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Extended-spectrum beta-lactamase-producing Enterobacteriaceae have increasingly become a public health issue in a variety of infections, including urinary tract infections and postoperative infections. The complications that occur due to these organisms in bone, joint, and prosthetic joints have not been well defined. This study reviewed the clinical characteristics, risk factors, and outcomes of patients with extended-spectrum beta-lactamase-producing Enterobacteriaceae infections of prosthetic joints or orthopedic-related hardware. Six infections met the inclusion criteria that resulted in a 100% failure rate when the hardware or prosthetic joint was not replaced initially. However, when the hardware or prosthetic joint was replaced, all of the patients did well. The use of carbapenems remains effective in these cases. [Orthopedics. 2016; 39(4):e668-e673.]. [ABSTRACT FROM AUTHOR]

Internal and external fixation techniques have been described for realignment and arthrodesis of Charcot midfoot deformity. There currently is no consensus on the optimal method of surgical reconstruction. This systematic review compared the clinical results of surgical realignment with internal and external fixation, specifically in regard to return to functional ambulation, ulcer occurrence, nonunion, extremity amputation, unplanned further surgery, deep infection, wound healing problems, peri- or intraoperative fractures, and total cases with any complication. A search of multiple databases for all relevant articles published from January 1, 1990, to March 22, 2014, was performed. A logistic regression model evaluated each of the outcomes and its association with the type of fixation method. The odds of returning to functional ambulation were 25% higher for internal fixation (odds ratio [OR], 1.259). Internal fixation had a 42% reduced rate of ulcer occurrence (OR, 0.578). External fixation was 8 times more likely to develop radiographic nonunion than internal fixation (OR, 8.2). Internal fixation resulted in a 1.5-fold increase in extremity amputation (OR, 1.488), a 2-fold increase in deep infection (OR, 2.068), a 3.4-fold increase in wound healing complications (OR, 3.405), and a 1.5-fold increase in the total number of cases experiencing any complication (OR, 1.525). This was associated with a 20% increase in the need for unplanned further surgery with internal fixation (OR, 1.221). Although internal fixation may decrease the risk of nonunion and increase return to functional ambulation, it had a higher rate of overall complications than external fixation for realignment and arthrodesis of Charcot midfoot deformity. [ABSTRACT FROM AUTHOR]

The current study analyzed changes in anterior cruciate ligament (ACL) and lateral collateral ligament stress as a result of mechanical varus. In an exploratory pilot study, progressive mechanical varus was introduced to a male finite element model of the lower limb at different knee flexion angles. Nine situations were analyzed (combinations of 0°, 30°, and 60° knee flexion and 0°, 5°, and 10° varus). The ACL stress was measured via changes in section force, von Mises stress, and fiber stress. Lateral collateral ligament stress was measured via changes in section force. For all 3 measures of the ACL, maximum stress values were found in extension, stress decreased with flexion, and the effect of varus introduction was most significant at 30° flexion. With 60° flexion, varus introduction produced a decrease in section force and von Mises stress and a small increase in fiber stress. In all situations and stress measures except fiber stress at 60° flexion, stress was concentrated at the posterolateral bundle. For the lateral collateral ligament, the introduction of 5° and 10° varus caused an increase in section force at all degrees of flexion. Stress in the ligament decreased with flexion. Mechanical varus of less than 10° was responsible for increased ACL stress, particularly at 0° and 30° knee flexion, and for increased lateral collateral ligament stress at all degrees of flexion. Stress was mostly concentrated on the posterolateral bundle of the ACL. [Orthopedics. 2016; 39(4):e729-e736.]. [ABSTRACT FROM AUTHOR]

A 50-year-old woman with a chronic polyarthropathy was seen by her orthopedist for long-standing back and shoulder and worsening hip pain. A lateral labral tear and chronic trochanteric bursitis were diagnosed on hip magnetic resonance imaging, which was otherwise unremarkable. Hip arthroscopy was performed revealing an unusual bluish-tinged femoral head articular surface. Computed tomography scans of the spine were also obtained. [ABSTRACT FROM AUTHOR]

Ligamentous laxity correlates with shoulder instability. Relaxin is a hormone that has been linked to laxity in the knee and has been shown to be a risk factor for anterior cruciate ligament (ACL) injury. This study prospectively evaluated the association between relaxin and acute shoulder instability. A prospective cohort study of 1050 young athletes was performed between 2006 and 2010. The authors conducted a nested case-control analysis within this cohort to evaluate the association between preinjury serum relaxin concentration and the likelihood of subsequent shoulder instability. The study compared 53 patients who had shoulder instability and 53 control subjects who were matched for sex, age, height, and weight. The serum relaxin concentration in preinjury baseline samples was tested with enzyme-linked immunosorbent assay analysis in duplicate. Independent t tests were performed to identify differences in mean serum relaxin concentration between patients with shoulder instability and uninjured control subjects. Logistic regression was used to evaluate whether preinjury baseline serum relaxin concentration was associated with the subsequent likelihood of shoulder instability. Of the 53 patients with instability, 13 (25%) had a detectable serum relaxin concentration compared with 9 (17%) of uninjured control subjects (P=.34). Mean serum relaxin concentration in the injury group was 3.69±1.78 pg/mL and 2.20±0.97 pg/mL in uninjured control subjects (P=.02). Increased serum relaxin concentration was associated with the subsequent likelihood of acute shoulder instability. Subjects were 2.18 times (odds ratio, 2.18; 95% confidence interval, 1.01-4.76) more likely to have acute shoulder instability during the follow-up period for every 1-pg/mL increase in serum relaxin concentration at baseline. The findings suggest that serum relaxin concentration is associated with a risk of subsequent shoulder instability in young athletes. Further research on the role of relaxin in shoulder instability is warranted. [Orthopedics. 2016; 39(4):e724-e728.]. [ABSTRACT FROM AUTHOR]

The aim of the study was to examine the effects of rotational component alignment on outcome after total knee arthroplasty (TKA) with a minimum follow-up of 5 years. For this study, 96 patients were available for follow-up at a mean of 5.7 years after TKA. Computed tomography scans were available in 55 patients. Outcome (Oxford Knee Score [KSS], Knee Injury and Osteoarthritis Outcome Score [KOOS], 36-item Short Form Health Survey) was correlated with postoperative femoral and tibial component malrotation or femorotibial rotational alignment mismatch. Results showed that femoral or tibial component malrotation or femorotibial mismatch were present in 15.5%, 38.2%, and 29.1% of patients, respectively. Although femoral componoent malrotation was associated with significantly poorer, KSS and KOOS scores, outcome was comparable for patients with or without tibial component malrotation or femorotibial mismatch. In conclusion, both internal and external rotational femoral malalignment exceeding 3° is associated with significantly poorer subjective and objective outcome 5 to 7 years after TKA. Tibial component malrotation and femorotibial mismatch were more common, but did not significantly compromise outcome. [Orthopedics. 2016; 39(3):S50-S55.]. [ABSTRACT FROM AUTHOR]

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being replaced by metal-backed tibial (MBT) components, as well as more recent considerations of newer APT designs. Modern APT components have been shown to have similar or superior outcomes than MBT components. Despite their limitations, APT components can be used to reduce the economic burden to the provider, medical institution, and health care system as a whole. There is a paucity of evidence-based literature directly comparing the cost associated with APT and MBT components. The purpose of this report is to review the literature to assess the available data regarding direct and indirect costs of both designs so that orthopedic surgeons can account for economic differences in everyday practice. [Orthopedics. 2016; 39(3):S61-S66.]. [ABSTRACT FROM AUTHOR]

The computer-assisted navigation of total knee arthroplasty (TKA) offers a radiologically demonstrated higher precision of implantation than conventional implantation in relation to the axis alignment. The impact on long-term clinical outcomes is currently unknown. In 1999, 217 consecutive TKAs were performed in a total of 213 patients (113 navigated and 104 conventional). After 10 years, it was possible to follow up on 94 patients with 96 TKAs, of which 46 were conventional and 50 were navigated. The radiographs were evaluated using the Knee Society protocol. In addition to the Hospital for Special Surgery Score and Knee Society Score, the current authors also used the patient-focused 36-item Short Form Health Survery. After 10 years, 8 TKAs were revised because of aseptic loosening, 7 in the conventional group and 1 in navigated group. This equates to an 87% survival rate for conventional and 98% for navigated implantation. This difference was statistically significant (P<.05). After conclusion of the follow-up, 17% of the conventional and 9.8% of the navigated TKAs were found to have undergone aseptic loosening. All of the TKAs subject to aseptic loosening presented a mechanical femorotibial angle outside the optimal zone of ±3° around neutral axis. The study indicates a clinically significant advantage of the navigation technique compared with the conventional procedure. [Orthopedics. 2016; 39(3):S72-S76.]. [ABSTRACT FROM AUTHOR]

Post-cam designs for posterior-stabilized total knee arthroplasy (TKA) implants have evolved over the last 2 decades. These designs have evolved from symmetric post and cam to asymmetric designs that include anterior post interactions to affect a kinematic change in full extension. All design changes have consequences on the resulting femorotibial contact kinematics and, depending on the amount of constraint built into the design, these changes may have significant consequences on the wear patterns on the tibial polyethylene insert. The current authors review the kinematic effects of symmetric and asymmetric cam designs and use a retrieval database of TKA implants obtained at the time of necropsy to show how different design variables may affect polyethylene wear patterns after 10 or more years of implantation or from modeled wear in simulators. More modern designs seem to have moved the post posteriorly and sloped the anterior aspect to avoid impingement of the anterior post in terminal flexion on the inferior aspect of the patella button. [Orthopedics. 2016; 39(3):S45-S49.]. [ABSTRACT FROM AUTHOR]

Crouch gait deformity is common in children with cerebral palsy and often is associated with patella alta. Patellar tendon advancement typically is used to correct patella alta and restore normal knee mechanics. The purpose of this study was to determine the mechanical strength of surgical constructs used for fixation during patellar advancement procedures. This study used a cadaveric model to determine which of 3 surgical techniques is biomechanically optimal for patellar tendon advancement in treating patella alta. Twenty-four human cadaveric knees (8 per group) were prepared using 1 of 3 different common surgical techniques: tibial tubercle osteotomy, patellar tendon partial resection and repair at the distal patella, and patellar tendon imbrication. The patella was loaded from 25 to 250 N at 1 Hz for 1000 cycles. A significant difference in patella displacement under cyclical loading was found between surgical techniques. Tibial tubercle osteotomy exhibited significantly less displacement under cyclical loading than distal patella excision and repair (P<.0001) or imbrication (P=.0088). Imbrication exhibited significantly less displacement than distal patella excision and repair (P=.0006). Tibial tubercle osteotomy survived longest. Based on failure criteria of 5 mm of displacement, tibial tubercle osteotomy lasted between 250 and 500 cycles. The other 2 techniques failed by 25 cycles. This study offers quantitative evidence regarding the relative mechanical strength of each construct and may influence choice of surgical technique. [Orthopedics. 2016; 39(3):e492–e497.] [ABSTRACT FROM AUTHOR]

Although the majority of North American surgeons perform total knee arthroplasty by cementing both the femoral and the tibial components, hybrid fixation with a press-fit femur and cemented tibia is an alternative form of total knee arthroplasty performed by some. Currently, there is a paucity of literature evaluating long-term outcomes after hybrid total knee arthroplasty. As such, the purpose of the current study was to describe the long-term results of total knee arthroplasty performed using the hybrid technique. The authors retrospectively reviewed a total of 77 hybrid total knee arthroplasties with at least 12 years of follow-up. Clinical and radiographic evaluations were performed to determine patient function and the incidence of femoral component failure after hybrid total knee arthroplasty. At the time of last follow-up, 76 of 77 (99%) of the femoral components remained in place without evidence of loosening. One femoral component failed due to aseptic loosening and was ultimately revised to a cemented femoral component without further complication. In addition, 1 tibial component and 2 patellar components failed due to aseptic loosening. Four tibial polyethylene liners were revised for polyethylene wear. In conclusion, press-fit fixation of the femoral component is a reliable and durable alternative to cemented fixation. [Orthopedics. 2016; 39(3):181–186.] [ABSTRACT FROM AUTHOR]

A once annealed highly cross-linked polyethylene (HXLPE) was introduced in 1998. Concerns regarding its long-term performance and oxidative resistance exist because of the presence of retained free radicals. The authors studied 48 patients with 50 hip implants having an average age of 62 years. They were followed for 9 to 15 years. The purpose of this study was to determine linear wear rate and the incidence of osteolysis and/or mechanical failure. At an average follow-up of 12.2 years, the annual linear wear rate was 0.018 mm (SD, 0.024 mm). No mechanical failures or osteolysis have been found to date. The clinical performance of this HXLPE continues to meet expectations despite the presence of free radicals. [Orthopedics. 2016; 39(3):e565–e571.] [ABSTRACT FROM AUTHOR]

During arthroscopic Bankart repair, penetration of suture anchors through the far cortex can compromise the initial biomechanical characteristics of anchor stability and repair integrity. This study compared the placement of suture anchors through a low anterior-inferior rotator interval portal (AI) vs a trans-subscapularis portal to evaluate the rate of anchor perforation as well as biomechanical strength. Ten matched pairs of cadaveric shoulders were randomized to an AI or a trans-subscapularis portal for placement of suture anchors at the 3 o'clock and 5:30 positions. The following measurements were obtained: (1) distance from the portal to the cephalic vein; (2) presence and length of anchor penetration through the inferior glenoid; and (3) ultimate failure strength of the anchors. The distance from the portal to the cephalic vein was significantly greater with the AI vs the trans-subscapularis portal across all specimens (29.9 vs 11.2 mm, P<.05). The rate of anchor penetration was significantly increased in the AI group vs the trans-subscapularis group at the 5:30 position (60% vs 10%, P=.014) but not at the 3 o'clock position (P=.33). Mean pullout strength of the anchors at the 5:30 position trended higher in the trans-subscapularis group, but the difference was not significant (132.8 vs 112.6 N, P=.18). The cephalic vein is closer to the trans-subscapularis portal than to the AI, but is at a safe distance. Both the rate and the degree of glenoid suture anchor penetration were lower with the trans-subscapularis portal compared with the AI at the 5:30 position. Placing anchors through the trans-subscapularis portal provides a safe alternative method, with improved positioning of the inferiormost anchor compared with the traditional AI. [ABSTRACT FROM AUTHOR]

Sarcopenia is a loss of skeletal muscle mass in the elderly that is an independent risk factor for falls, disability, postoperative complications, and mortality. Although its cause is not completely understood, sarcopenia generally results from a complex bone-muscle interaction in the setting of chronic disease and aging. Sarcopenia cannot be diagnosed by muscle mass alone. Diagnosis requires 2 of the following 3 criteria: low skeletal muscle mass, inadequate muscle strength, and inadequate physical performance. Forty-four percent of elderly patients undergoing orthopedic surgery and 24% of all patients 65 to 70 years old are sarcopenic. Although dual-energy x-ray absorptiometry and bioelectrical impedance analysis may be used to measure sarcopenia and are relatively inexpensive and accessible, they are generally considered less specific for sarcopenia compared with computed tomography and magnetic resonance imaging. Sarcopenia has been shown to predict poor outcomes within the medical and surgical populations and has been directly correlated with increases in taxpayer costs. Strengthening therapy and nutritional supplementation have become the mainstays of sarcopenia treatment. Specifically, the American Medical Directors Association has released guidelines for nutritional supplementation. Although sarcopenia frequently occurs with osteoporosis, it is an independent predictor of fragility fractures. Initiatives to diagnose, treat, and prevent sarcopenia in orthopedic patients are needed. Further investigation must also explore sarcopenia as a predictor of surgical outcomes in orthopedic patients. [ABSTRACT FROM AUTHOR]

The stability of a total knee arthroplasty is determined by the ability of the prosthesis components in concert with supportive bone and soft tissue structures to sufficiently resist deforming forces transmitted across the knee joint. Constrained prostheses are used in unstable knees due to their ability to resist varus and valgus transformative forces across the knee. Constraint requires inherent rigidity, which can facilitate early implant failure. The purpose of this study was to describe the comparative indications for surgery and postoperative outcomes of varus valgus constrained knee (VVK) and rotating-hinge knee (RHK) total knee arthroplasty prostheses. Seven retrospective observational studies describing 544 VVK and 254 RHK patients with an average follow-up of 66 months (range, 7-197 months) were evaluated. Patients in both groups experienced similar failure rates (P=.74), ranges of motion (P=.81), and Knee Society function scores (P=.29). Average Knee Society knee scores were 4.2 points higher in VVK patients compared with RHK patients, indicating minimal mid-term clinical differences may exist (P<.0001). Absent collateral ligament support is an almost universal indication for RHK implantation vs VVK. Constrained device implantation is routinely guided by inherent stability of the knee, and, when performed, similar postoperative outcomes can be achieved with VVK and RHK prostheses. [ABSTRACT FROM AUTHOR]

The use of early mobilization of the ankle joint without orthosis in the treatment of Achilles tendon rupture has been advocated as the optimal management. The goal of this study was to compare outcomes in a postoperative rabbit model of Achilles tendon rupture between early mobilization and immobilized animals using a differential proteomics approach. In total, 135 rabbits were randomized into the control group (n=15), the postoperative cast immobilization (PCI) group (n=60), and the early mobilization (EM) group (n=60). A rupture of the Achilles tendon was created in each animal model and repaired microsurgically, and tendon samples were removed at 3, 7, 14, and 21 days postoperatively. Proteins were separated using 2-dimensional polyacrylamide gel electrophoresis and identified using peptide mass fingerprinting, tandem mass spectrometry, NCBI database searches, and bioinformatics analyses. A series of differentially expressed proteins were identified between groups, some of which may play an important role in Achilles tendon healing. Notable candidate proteins that were upregulated in the EM group were identified, such as CRMP-2, galactokinase 1, tropomyosin-4, and transthyretin. The healing of ruptured Achilles tendons appears to be affected at the level of protein expression with the use of early mobilization. The classic postoperative treatment of Achilles tendon rupture with an orthosis ignored the self-protecting instinct of humans. With a novel operative technique, the repaired tendon can persist the load that comes from traction in knee and ankle joint functional movement. In addition, kinesitherapy provided an excellent experimental outcome via a mechanobiological mechanism. [ABSTRACT FROM AUTHOR]

Mobile devices are increasingly becoming integral communication and clinical tools. Monitoring the prevalence and utilization characteristics of surgeons and trainees is critical to understanding how these new technologies can be best used in practice. The authors conducted a prospective Internet-based survey over 7 time points from August 2010 to August 2014 at all nationwide American Council for Graduate Medical Education-accredited orthopedic programs. The survey questionnaire was designed to evaluate the use of devices and mobile applications (apps) among trainees and physicians in the clinical setting. Results were analyzed and summarized for orthopedic surgeons and trainees. During the 48-month period, there were 7 time points with 467, 622, 329, 223, 237, 111, and 134 responses. Mobile device use in the clinical setting increased across all fields and levels of training during the study period. Orthopedic trainees increased their use of Smartphone apps in the clinical setting from 60% to 84%, whereas attending use increased from 41% to 61%. During this time frame, use of Apple/Android platforms increased from 45%/13% to 85%/15%, respectively. At all time points, 70% of orthopedic surgeons believed their institution/hospital should support mobile device use. As measured over a 48-month period, mobile devices have become an ubiquitous tool in the clinical setting among orthopedic surgeons and trainees. The authors expect these trends to continue and encourage providers and trainees to be aware of the limitations and risks inherent with new technology. [ABSTRACT FROM AUTHOR]

The article reports on the use of radiofrequency generated energy for the treatment of lesions in cartilage, joint capsules and ligaments. Laser or mono- and bipolar production of radiofrequency energy can be used to deliver the thermal energy. The effects of concentrated energy on joint tissue was examined. In conclusion, radiofrequency energy for the treatment of articular cartilage problems should be used with caution, pending evaluation of the long-term effects.

Patient-controlled analgesia (PCA) is regularly used to manage pain following major surgery. The fentanyl hydrochloride iontophoretic transdermal system (ITS) was developed to overcome some of the limitations of intravenous (IV) PCA. The small, self-adhesive, needle-free disposable system is applied to the skin on the upper arm or chest and is controlled by patients clicking a button on the device. The authors identified patients who were underwent spinal surgery from 2 prior multicenter, randomized studies and analyzed their data. Of the 1296 patients in the original trials, 170 underwent spine surgery procedures: 90 were randomized to the fentanyl ITS (40 mcg/activation) and 80 to IV PCA morphine (1 mg/dose). More patients treated with the fentanyl ITS rated their method of pain control as "excellent" across all time points, but differences did not reach statistical significance. However, investigators' ratings of "excellent" satisfaction with study treatment were significantly higher for the fentanyl ITS. Discontinuation rates and overall adverse event rates were similar between groups. The only significant difference was that patients treated with the fentanyl ITS had a higher rate of application site reactions than infusion site reactions in the IV PCA morphine group; the reactions were typically mild-to-moderate erythema that resolved shortly after removal of the fentanyl ITS device and did not require further treatment. Ratings of satisfaction with pain control method were consistently higher for the fentanyl ITS than the IV PCA morphine. The 2 groups had a similar safety profile. These results suggest that the fentanyl ITS appears to be a safe, efficacious alternative to IV PCA in spine surgery patients. [ABSTRACT FROM AUTHOR]

This study evaluated the utility of optical coherence tomography (OCT) in imaging porcine and human rotator cuff (RTC) tissue, analyzed its effectiveness in identifying clinical pathology, and correlated these findings with histologic examination. Twelve human cadaveric and 6 porcine shoulders were evaluated. Six-millimeter-wide bone sections were harvested from the proximal humerus of each specimen, with each containing the entire enthesis of the respective RTC tendon, as well as 2 cm of tendon medial to the enthesis. Only the supraspinatus tendon was evaluated in the human specimens, whereas the enthesis of multiple RTC tendons were evaluated in the porcine model. All specimens were imaged using OCT and correlated with histologic evaluation. Optical coherence tomography evaluation of macroscopically healthy tissue consistently showed an easily identifiable banding pattern (birefringence) in contrast to a disorganized, homogeneous appearance in grossly diseased tissue. Optical coherence tomography was more effective for qualitative evaluation of RTC tissue, identification of bursal-sided RTC tears, and localization of calcific deposits, whereas intrasubstance tendon delaminations and partial articular-sided tendon avulsion lesions were relatively more difficult to identify. Optical coherence tomography correlated well with histologic evaluation in all specimens. Optical coherence tomography provides high-resolution, subsurface imaging of rotator cuff tissue in real-time to a depth of up to 4 mm with excellent correlation to histology in a cadaveric model. Optical coherence tomography could be an effective adjunctive tool for the identification and localization of rotator cuff pathology. The use of OCT in arthroscopic shoulder surgery potentially provides a minimally invasive modality for qualitative assessment of rotator cuff pathology. This may allow for a decrease in soft tissue dissection, improved qualitative assessment of cuff tissue, and improved patient outcomes. [ABSTRACT FROM AUTHOR]

The extra-articular impingement of the greater trochanter against the ileum is an underrated cause of early dislocation in total hip arthroplasty. In this preliminary study, the authors assess the effectiveness of an anterior longitudinal osteotomy of the greater trochanter for preventing dislocation. A total of 115 patients underwent a total hip arthroplasty through a posterolateral approach. All patients underwent clinical and radiological follow-up at 1, 3, and 6 months. No dislocation was reported. All patients demonstrated fast recovery of range of motion and walking. No trochanter fractures were observed. The osteotomy of the greater trochanter is an effective surgical technique that decreases anterior impingement and consequently lowers the dislocation rate in primary total hip arthroplasty. [Orthopedics. 2015; 38(8):490-493.]. [ABSTRACT FROM AUTHOR]

Access to musculoskeletal consultation in the emergency department (ED) is a nationwide problem. In addition, consultation from a subspecialist may be delayed or may not be available, which can slow down the ED flow and reduce patient satisfaction. The purpose of this study was to review the 1-year results of a change in the authors' institutional practice to reduce subspecialty consultation for select musculoskeletal problems while still ensuring adequate patient follow-up in orthopedic or plastic surgery clinics for patients not seen by these services in the ED. The authors hypothesized that select injuries could be safely managed in the ED by using an electronic system to ensure appropriate follow-up care. Using Kaizen methodology, a multidisciplinary group (including ED staff, orthopedics, plastic surgery, pediatrics, nursing, radiology, therapy, and administration) met to improve care for select musculoskeletal injuries. A system was agreed on in which ED providers managed select musculoskeletal injuries without subspecialist consultation. Follow-up was organized using an electronic system, which facilitated communication between the ED staff and the secretarial staff of the subspecialist departments. Over a 1-year period, 150 patients were treated using this system. Charts and radiographs were reviewed for missed injuries. Radiographic review revealed 2 missed injuries. One patient had additional back pain and a lumbar spine fracture was found during the subspecialist follow-up visit; it was treated non-operatively. Another patient appeared to have scapholunate widening on the injury radiograph that was not appreciated in the ED. Of the 150 patients, 51 were seen in follow-up by a subspecialist at the authors' institution. An electronic system to organize follow-up with a subspecialist allowed the ED providers to deliver safe and effective care for simple musculoskeletal injuries. [ABSTRACT FROM AUTHOR]

The goal of this study was to review the authors' initial experience with arthroscopic transosseous rotator cuff repair. Thirty-one patients with full-thickness rotator cuff tears underwent arthroscopic transosseous rotator cuff repair over a 15-month period. Preoperatively, demographics and subjective scores were recorded. Postoperatively, pain levels, subjective shoulder values, satisfaction scores, American Shoulder and Elbow Surgeons (ASES) scores, complications, and reoperations were noted with a minimum 2-year follow-up. The relationships between pre- and intraoperative variables and outcome scores were determined with univariate analysis. Average patient age was 56 years, and 23 patients (74%) were men. Twenty patients (65%) underwent primary rotator cuff repair, and 11 patients (35%) underwent revision repair. Average time to follow-up was 26 months. Average preoperative pain level and subjective shoulder value were 5.1 of 10 and 35%, respectively. Average postoperative scores included pain level of 0.9 of 10, subjective shoulder value of 84%, satisfaction score of 90.6 of 100, and ASES score of 86.3 of 100. There were 3 (9.7%) major and 2 (6%) minor complications. Patients undergoing revision rotator cuff repair had significantly worse outcomes (pain level, subjective shoulder value, ASES score; P<.05) compared with those undergoing primary repair, and cortical augmentation did not significantly affect outcome. Overall, outcomes after arthroscopic transosseous rotator cuff repair are good, although patients undergoing revision repair do not have the same outcomes as those undergoing primary cuff repair. The procedure is not without complications (9.7% major, 6% minor complications). Cortical augmentation may be used to supplement fixation, although it does not necessarily affect outcomes. Patients without such augmentation may be at increased risk for suture cutout through the bone. [ABSTRACT FROM AUTHOR]

Pertrochanteric femur fractures are successfully treated by orthopedic surgeons worldwide, but maintaining the reduction status or fixation of the greater trochanter is sometimes difficult in unstable cases in elderly patients. Several biomechanical advantages have been reported in locking plates when compared with conventional plates; locking plates provide angular and axial stability, better rigidity, and no toggling, and they preserve periosteal blood supply. The authors describe the use of auxiliary locking plates in unstable pertrochanteric femur fractures in elderly patients. Mini locking plates are simple, straightforward, and versatile enough to be used in elderly patients. [ABSTRACT FROM AUTHOR]

Patient-specific instrumentation (PSI) has recently been introduced to improve the alignment following total knee arthroplasty (TKA). However, controversy remains between PSI and conventional instrumentation. The aim of this study is to compare the accuracy of PSI with conventional instruments for total knee arthroplasty (TKA). A systematic literature search was performed in databases including PubMed, the Cochrane Library, EMBASE, and Web of Science. All of the available randomized, controlled trials (RCTs) or non-randomized, controlled trials (nRCTs) comparing PSI with conventional instruments for TKA were identified. A statistical analysis was performed of this meta-analysis. Eighteen studies with 241 7 patients were included in the authors' final analysis. The results of the meta-analysis demonstrated that there were no statistical differences in outliers of the mechanical axis (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.61-1.11), the femoral component in the coronal (RR, 0.56; 95% CI, 0.32-1.05) and sagittal (RR, 0.83; 95% CI, 0.60-1.14) plane, the tibial component in the coronal (RR, 0.84; 95% CI, 0.52-1.35) and sagittal (RR, 1.04; 95% CI, 0.69-1.55) plane, and the femoral component rotation (RR, 1.02; 95% CI, 0.57, 1.83) between the 2 groups. In addition, subgroup analysis showed that the study design and imaging used for preoperative scanning did not affect the outcome of the alignment, but a different PSI system might. The authors' meta-analysis indicated that the accuracy of PSI was not superior to conventional instruments for patients undergoing TKA. Future RCTs should focus on functional outcomes and component survivorship with mid- to long-term follow-up. [ABSTRACT FROM AUTHOR]

The number of times an article has been cited in the peer-reviewed literature is indicative of its impact on its respective medical specialty. No study has used citation analysis to determine the most influential studies pertaining to the anterior cruciate ligament (ACL). The primary aims of this study were to identify the classic works in ACL research using citation analysis and to characterize these articles to determine which types of studies have had the most influence on the field. A systematic query of ISI Web of Science (Thomson Reuters, Philadelphia, Pennsylvania) was performed for articles pertaining to the ACL, and the 50 most-cited articles were selected for evaluation. The following characteristics were determined for each article: number of citations, citation density, journal, publication year, country of origin, language, article type, article subtype, and level of evidence. The number of citations ranged from 219 to 1073 (mean, 326), and the citation densities ranged from 4.9 to 55.6 citations per year (mean, 18.2). All articles were published in 1 of 11 journals, with the most being published in The American Journal of Sports Medicine (46%) and The Journal of Bone and Joint Surgery American (30%). The most common decades of publication were the 1990s (34%), 1980s (28%), and 2000s (26%). The majority (68%) of articles originated from the United States, and all were written in English. By article type, 42% were basic science, and 58% were clinical. Of the clinical articles, 3% were Level I, 17% were Level II, 28% were Level III, and 52% were Level IV. The articles were heterogeneous with regard to article type, article subtype, and level of evidence and tended to have the following characteristics: high-impact journal of publication, recent publication year, US origin, English language, and low level of evidence. These works represent some of the most popular scientific contributions to ACL research. This list may aid residency and fellowship programs in the compilation of articles for trainee reading curriculums. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) prophylaxis after total joint arthroplasty is considered best practice. However, over the past 5 years, there has been considerable debate about the ideal prophylactic regimen or modality. The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians published their most recent clinical practice guidelines about VTE prophylaxis in 2011 and 2012, respectively. In addition, the Surgical Care Improvement Project published their latest recommendations in 2014. In this review, commonly used VTE prophylaxis options and the latest clinical guidelines will be discussed. [ABSTRACT FROM AUTHOR]

Various short hip stems have been introduced with differing implant concepts of femoral fi xation and implant length. There is a lack of proper classifi cation for short hip stems, with a clear and accepted defi nition for implant length and extent of bone preservation in the metaphyseal and diaphyseal femur. This study analyzed the length of short hip stems. Stems were divided into collum, partial collum, and trochantersparing implants. An additional category was added, trochanter harming, which was defi ned as interruption of the circumferential integrity of the femoral neck. For all of the femoral components described, the designs were compared, excluding stems with insuffi cient clinical data. The 15 fi nally selected stems were classifi ed as collum (1 stem), partial collum (7 stems), trochanter sparing (4 stems), and trochanter harming (3 stems). Mid-term results (>5 years of follow-up) were available for only 3 designs in the partial collum group. Taking into account the results of short-term studies (<5 years of follow-up), the femoral revision rate per 100 observed component years was <1 for most total hip arthroplasties. However, the studies varied greatly regarding level of signifi cance, and short hip stems without published results are available commercially. Short hip stems cannot be circumscribed by a simple length limit. For some designs, clinical data collected from large patient cohorts showed a survivorship comparable to traditional stems. In cases that must be revised, this often can be performed with a conventional primary stem, fulfi lling the promise to preserve bone for potential future revisions in younger patients. [ABSTRACT FROM AUTHOR]

Since 1998, short stem total hip arthroplasty (THA) has been performed at the authors' institution. Currently, 30% of THAs are performed with short stems. This article reports on complications that required revision of a short stem THA. Between September 2005 and February 2012, a total of 1953 Metha short stem THAs were performed; of these, 38 required revision due to mechanical complications. In 12 cases, the modular titanium neck adapter failed. In 19 cases, aseptic implant loosening occurred; of these, 11 cases were due to major stem subsidence. In 2 cases, via falsa (cortical penetration) implantation occurred. In 5 cases, periprosthetic fractures led to revision. This corresponds to an aseptic total revision rate of 1.3% for 26 short stems and 1.9% including the cases of all 38 documented revision cases. Thirty-four cases were revised with cementless standard hip stems, 2 cases were revised with short stems, and 2 cases were revised with long revision stems. Undersizing was analyzed in 58% of aseptic revisions. Fifty-four percent of revisions were performed in male patients — 23% with osteonecrosis of the femoral head, and 7% with short hip stems positioned in varus in coxa vara deformities. Seventy-two percent of revisions after marked early stem subsidence and position change into valgus were performed in female patients. Dysplastic hips with coxa valga did not show elevated revision rates. No revisions were performed for dislocation or femoral thigh pain. Short stem THA with the Metha implant is a bone-preserving option for various indications in select patient groups. [ABSTRACT FROM AUTHOR]

Because of the recent trend for total hip arthroplasty in younger patients, more bonepreserving implants have been designed, based partly on the premise that maintenance of more bone stock would allow revision with standard primary implants. Another possible advantage of an implant that retains the femoral neck is that it may allow anatomical recreation of the center of the femoral head, femoral neck anteversion, anterior tilt, and caput-collum-diaphysis (CCD) angle, as well as femoral offset and leg length, without the use of modular implants. To determine whether the proximal femoral anatomy could be recreated, this study used computed tomography data and 3-dimensional modeling from 10 cadaver hips in 6 whole body specimens. Three femoral neck resection levels were investigated: 2 mm, 5 mm (recommended resection), and 10 mm from the base of the femoral neck. Results showed that the center of the femoral head, femoral neck anteversion, and CCD angle could all be recreated with available implant sizes, without modularity, within 2° and 1 mm on average. The addition of a modular neck provided no advantage in recreation of the hip center or other anatomical parameters. Use of a short metaphyseal femoral neck retaining-type of stem should allow restoration of anatomical parameters without the use of an exchangeable modular femoral neck. [ABSTRACT FROM AUTHOR]

Bleeding after total knee arthroplasty can result in significant morbidity and increases the need for blood transfusion. The proper use of intraoperative adjunctive topical hemostatic agents can enhance hemostasis perioperatively, potentially reducing blood transfusions. In this prospective study, 157 consecutive patients undergoing primary total knee arthroplasty received FLOSEAL (FLOSEAL Hemostatic Matrix; Baxter Healthcare Corporation, Hayward, California), a gelatin thrombin hemostatic matrix, 5 mL (74 patients) or 10 mL (83 patients). All patients received warfarin as thrombopro-phylaxis starting the day after surgery. Data were extracted via hospital chart review from 100 consecutive patients who underwent total knee arthroplasty and immediately preceded the FLOSEAL groups and did not receive FLOSEAL (control group). Postoperative drainage was significantly lower in the FLOSEAL 5 mL (236.9 mL) and 10 mL (120.5 mL) groups compared with the control group (430.8 mL; P<.0001 for both). The FLOSEAL 10 mL group had significantly less drainage than the FLOSEAL 5 mL group (P<.0001). The predicted probability of transfusion in the FLOSEAL 5 mL group was not significantly different compared with the control group (6.0% vs 7.6%, P=.650). The predicted probability of transfusion was lower in the FLOSEAL 10 mL group compared with the control group (0.5% vs 5.5%; P=.004). Within the FLOSEAL 10 mL group, application of FLOSEAL either before or after tourniquet release had a similarly significant effect on drainage volume and predicted probability of blood transfusion. No differences in outcomes were observed by type of anesthesia used. No adverse events occurred related to FLOSEAL use. [Orthopedics. 2015; 38(2):e118-e123.] [ABSTRACT FROM AUTHOR]

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2-19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins (P=.140) or site (P=.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft (P=.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed. [Orthopedics. 2015; 38(2):87-93.] [ABSTRACT FROM AUTHOR]

A 17-year-old adolescent boy presented with progressive lower back pain and fatigue. [ABSTRACT FROM AUTHOR]

After lower-extremity orthopedic trauma and surgery, patients are often advised to restrict weight bearing on the affected limb. Conventional training methods are not effective at enabling patients to comply with recommendations for partial weight bearing. The current study assessed a novel method of using real-time haptic (vibratory/vibrotactile) biofeedback to improve compliance with instructions for partial weight bearing. Thirty healthy, asymptomatic participants were randomized into 1 of 3 groups: verbal instruction, bathroom scale training, and haptic biofeedback. Participants were instructed to restrict lower-extremity weight bearing in a walking boot with crutches to 25 lb, with an acceptable range of 15 to 35 lb. A custom weight bearing sensor and biofeedback system was attached to all participants, but only those in the haptic biofeedback group were given a vibrotactile signal if they exceeded the acceptable range. Weight bearing in all groups was measured with a separate validated commercial system. The verbal instruction group bore an average of 60.3±30.5 lb (mean±standard deviation). The bathroom scale group averaged 43.8±1 7.2 lb, whereas the haptic biofeedback group averaged 22.4±9.1 lb (P<.05). As a percentage of body weight, the verbal instruction group averaged 40.2±19.3%, the bathroom scale group averaged 32.5±16.9%, and the haptic biofeedback group averaged 14.5±6.3% (P<.05). In this initial evaluation of the use of haptic biofeedback to improve compliance with lower-extremity partial weight bearing, haptic biofeedback was superior to conventional physical therapy methods. Further studies in patients with clinical orthopedic trauma are warranted. [ABSTRACT FROM AUTHOR]

The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of realtime augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery. [ABSTRACT FROM AUTHOR]

Studies have shown the effectiveness of cervical disk replacement. However, clinical outcomes, particularly by radiographic assessment during the 36-month follow-up visit, have not been reported for cervical disk replacement with Mobi-C (LDR, Austin, Texas) disk prostheses. A retrospective study was conducted at 10 centers across China and included 65 patients who underwent single-level Mobi-C disk prosthesis replacement from October 2009 to July 2010. Clinical and radiographic data were collected before replacement, 7 days postoperatively, and 1, 3, 6, 12, 24, and 36 months postoperatively. Clinical and neurologic outcomes were assessed by the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS), Neck Disability Index (NDI), and Odom's criteria. Static and dynamic radiographs were measured to determine intervertebral height and range of motion (ROM) of the cervical spine, the functional spinal unit, the treated segment, and adjacent segments. JOA, VAS, and NDI scores showed statistically significant improvement 36 months after replacement (P<.05). The ROM of the cervical spine, functional spinal unit, treated segment, and adjacent segments did not show a significant difference before and after replacement (P>.05). The intervertebral height of the treated segment increased significantly, and the intervertebral height of adjacent segments showed no statistical significance between time points and at follow-up. Clinical outcomes indicated that Mobi-C artificial cervical disk replacement is reliable. Radiographic data showed that it plays a role in reconstruction or maintenance of intervertebral height and ROM of the cervical spine, functional spinal unit, treated segment, and adjacent segments after Mobi-C cervical disk replacement. [ABSTRACT FROM AUTHOR]

The mini C-arm has become increasingly popular in the practice of orthopedics. To the authors' knowledge, its use in the pediatric orthopedic outpatient clinic has not been reported. The purpose of this study was to evaluate the practice efficiency and radiation exposure to the patient when the mini C-arm was used in the pediatric orthopedic outpatient clinic. One hundred consecutive midshaft and distal forearm fractures were evaluated by one orthopedic surgeon in follow-up using a mini C-arm. For each case, the radiation physicist calculated the amount of skin exposure in milligray (mGy). The average skin exposure to the patient from the mini C-arm was 0.58 mGy, compared with 0.2 mGy for anteroposterior view and lateral view radiographs. Use of the mini C-arm, in place of plain radiographs obtained in the radiology department, decreased time waiting during clinic visits by 23 minutes. This study reports 2 important findings. First, surprisingly, the mini C-arm used a slightly higher radiation dose than standard imaging with plain radiographs. Second, use of the mini C-arm saved time and improved the efficiency of the clinic visit. Overall, the mini C-arm improves quality and efficiency in the pediatric orthopedic outpatient clinic. [The mini C-arm has become increasingly popular in the practice of orthopedics. To the authors' knowledge, its use in the pediatric orthopedic outpatient clinic has not been reported. The purpose of this study was to evaluate the practice efficiency and radiation exposure to the patient when the mini C-arm was used in the pediatric orthopedic outpatient clinic. One hundred consecutive midshaft and distal forearm fractures were evaluated by one orthopedic surgeon in follow-up using a mini C-arm. For each case, the radiation physicist calculated the amount of skin exposure in milligray (mGy). The average skin exposure to the patient from the mini C-arm was 0.58 mGy, compared with 0.2 mGy for anteroposterior view and lateral view radiographs. Use of the mini C-arm, in place of plain radiographs obtained in the radiology department, decreased time waiting during clinic visits by 23 minutes. This study reports 2 important findings. First, surprisingly, the mini C-arm used a slightly higher radiation dose than standard imaging with plain radiographs. Second, use of the mini C-arm saved time and improved the efficiency of the clinic visit. Overall, the mini C-arm improves quality and efficiency in the pediatric orthopedic outpatient clinic. [Orthopedics. 2016; 39(6):e1097–e1099.] [ABSTRACT FROM AUTHOR]

Despite advances in surgical techniques, 20% to 90% of rotator cuff (RTC) repairs fail. They tend to fail at the suture-tendon junction due to tension at the repair and gap formation prior to healing. This study evaluated the gap formation and ultimate tensile failure loads of a RTC repair with a decellularized human dermal allograft. Augmentation of a RTC repair with an extracellular matrix graft decreased gap formation and increased load to failure in a human RTC repair model. [ABSTRACT FROM AUTHOR]

In completely displaced pediatric distal radial fractures, achieving satisfactory reduction with closed manipulation and maintenance of reduction with casting is difficult. Although the Kapandji technique of K-wiring is widely practiced for distal radial fracture fixation in adults, it is rarely used in pediatric acute fractures. Forty-six completely displaced distal radial fractures in children 7 to 14 years old were treated with closed reduction and K-wire fixation. One or 2 intrafocal K-wires were used to lever out and reduce the distal fragment's posterior and radial translation. One or 2 extrafocal K-wires were used to augment intrafocal fixation. Postoperative immobilization was enforced for 3 to 6 weeks (with a short arm plaster of Paris cast for the first half of the time and a removable wrist splint for the second half), after which time the K-wires were removed. Patients were followed for a minimum of 4 months. Mean patient age was 9.5 years. Near-anatomical reduction was achieved easily with the intrafocal leverage technique in all fractures. Mean procedure time for K-wiring was 7 minutes. On follow-up, there was no loss of reduction; remanipulation was not performed in any case. There were no pin-related complications. All fractures healed, and full function of the wrist and forearm was achieved in every case. The Kapandji K-wire technique consistently achieves easy and near-anatomical closed reduction by a leverage reduction method in completely displaced pediatric distal radial fractures. Reduction is maintained throughout the fracture-healing period. The casting duration can be reduced without loss of reduction, and good functional results can be obtained. [ABSTRACT FROM AUTHOR]

Tranexamic acid was intra-articularly injected in total knee arthroplasty (TKA) to reduce blood loss and transfusion. However, no single study has been large enough to definitively determine whether it is safe and effective. To determine the safety and efficacy of intra-articular tranexamic acid in TKA, the authors searched various databases for relevant randomized controlled trials. Mean difference (MD) in total blood loss, risk ratio (RR) for transfusion, and complication rate in the tranexamic acid-treated group vs the placebo group were calculated. Seven randomized controlled trials, including 622 patients (174 men and 448 women), were identified. All 7 placebo-controlled randomized trials had a low risk of bias. The pooled results showed a positive effect of tranexamic acid in all treatment groups, with significant reduction in total blood loss (MD, -396.42 mL [95% confidence interval (CI), -629.64 to -163.20]; P=.0009). However, there was significant heterogeneity in the finding (chi-square=27.16, i²=3, P=89%; P<.00001) among studies. The pooled results indicated that 5.8% (18 of 309) of tranexamic acid-treated patients required transfusion compared with 27.2% (85 of 313) of placebo-treated patients. This difference was significant (RR, 0.22; 95% CI, 0.14-0.35; P<.00001). There was no significant difference between the groups in the incidence of deep venous thrombosis (RR, 0.83; 95% CI, 0.35-1.98; P=.68) or pulmonary embolism (RR, 0.54; 95% CI, 0.10-2.85; P=A6). In all, intra-articular tranexamic acid significantly reduced total blood loss, drainage, reduction of hemoglobin, and the need for transfusion without increasing the incidence of deep venous thrombosis and pulmonary embolism. Intra-articular tranexamic acid is safe and efficacious in TKA. [ABSTRACT FROM AUTHOR]

Despite advances in surgical techniques, 20% to 90% of rotator cuff (RTC) repairs fail. They tend to fail at the suture-tendon junction due to tension at the repair and gap formation prior to healing. This study evaluated the gap formation and ultimate tensile failure loads of a RTC repair with a decellularized human dermal allograft. Augmentation of a RTC repair with an extracellular matrix graft decreased gap formation and increased load to failure in a human RTC repair model. [ABSTRACT FROM AUTHOR]

Modular femoral heads have been used successfully for many years in total hip arthroplasty. Few complications have been reported for the modular Morse taper connection between the femoral head and trunnion of the stem in metal-on-polyethylene bearings. Although there has always been some concern over the potential for fretting, corrosion, and generation of particulate debris at the modular junction, this was not considered a significant clinical problem. More recently, concern has increased because fretting and corrosive debris have resulted in rare cases of pain, adverse local tissue reaction, pseudotumor, and osteolysis. Larger femoral heads, which have gained popularity in total hip arthroplasty, are suspected to increase the potential for local and systemic complications of fretting, corrosion, and generation of metal ions because of greater torque at the modular junction. A less common complication is dissociation of the modular femoral heads. Morse taper dissociation has been reported in the literature, mainly in association with a traumatic event, such as closed reduction of a dislocation or fatigue fracture of the femoral neck of a prosthesis. This report describes 3 cases of spontaneous dissociation of the modular prosthetic femoral head from the trunnion of the same tapered titanium stem because of fretting and wear of the Morse taper in a metal-on-polyethylene bearing. Continued clinical and scientific research on Morse taper junctions is warranted to identify and prioritize implant and surgical factors that lead to this and other types of trunnion failure to minimize complications associated with Morse taper junctions as hip implants and surgical techniques continue to evolve. [ABSTRACT FROM AUTHOR]

Heterotopic ossification (HO), acquired or hereditary, is featured by the formation of bone outside of the normal skeleton. Typical acquired HO is a common, debilitating condition associated with traumatic events. Cardiovascular calcification, an atypical form of acquired HO, is prevalent and associated with high rates of cardiovascular mortality. Hereditary HO syndromes, such as fibrodysplasia ossificans progressiva and progressive osseous heteroplasia, are rare, progressive, life-threatening disorders. The cellular origins of HO remain elusive. Some bona fide contributing cell populations have been found through genetic lineage tracing and other experiments in vivo, and various other candidate populations have been proposed. Nevertheless, because of the difficulties in establishing cellular phenotypes in vivo and other confounding factors, the true identities of these populations are still uncertain. This review critically evaluates the accumulating data in the field. The major focus is on the candidate populations that may give rise to osteochondrogenic lineage cells directly, not the populations that may contribute to HO indirectly. This issue is important not solely because of the clinical implications, but also because it highlights the basic biological processes that govern bone formation. [ABSTRACT FROM AUTHOR]

The advantages of anterior surgery for severe ossification of the posterior longitudinal ligament in the cervical spine have been reported. However, it is more technically demanding and associated with a high risk of surgery-related complications. The purpose of this study was to evaluate the feasibility of longitudinal decompression techniques in anterior surgery for severe ossification of the posterior longitudinal ligament in the cervical spine. Between June 2008 and December 2011, twenty-two patients (16 men and 6 women; average age, 58 years [range, 45-72 years]) who underwent anterior corpectomy and fusion for severe ossification of the posterior longitudinal ligament were studied retrospectively. The clinical efficacy, canal narrowing ratio, fused segment height, and complications were investigated. After a mean 25.4-month follow-up, mean Japanese Orthopaedic Association score increased from 8.8±1.4 preoperatively to 14.0±1.2 at final follow-up (P<.05), an improvement rate of 63.5%±12.5%. Mean canal narrowing ratio decreased from 62.0%±6.0% preoperatively to 8.2%±4.9% postoperatively (P<.05). Mean fused segment height increased 2.3±0.5 mm from pre- to postoperatively and decreased 2.8±0.4 mm from postoperatively to final follow-up (P>.05). Five patients developed cerebrospinal fluid leakage, and 1 patient experienced hematoma. No instrument failure was observed, and all patients had successful fusion. Anterior longitudinal decompression is a relatively effective procedure in the management of severe ossification of the posterior longitudinal ligament in the cervical spine. It can be applied to treat closed-base ossification of the posterior longitudinal ligament (defined as no space between the lateral margin of the ossified base and the spinal canal lateral wall), but it is associated with a high risk of cerebrospinal fluid leakage. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the sensitivity and positive predictive value of magnetic resonance imaging (MRI) in the identification of full-thickness articular cartilage defects in the porcine knee. Seventy-two full-thickness chondral defects (small or large; circular, oval, or triangular) were created in 12 porcine knees. The authors used 3.0-T MRI with 3-dimensional gradient echo water-selective/fluid (WATSf) sequences acquired in axial, coronal, and sagittal planes. Sensitivity and positive predictive value parameters were calculated for 2 readers. Magnetic resonance imaging was highly sensitive for detection of full-thickness defects in the knee (85%). The highest sensitivity was observed at the medial femoral condyle (93%), while the lowest was observed at the medial patella (71%). The sensitivities for detecting different shapes were unique to each shape, with oval lesions identified with greatest sensitivity (93%). Small lesions (86%) were detected at a similar sensitivity as large lesions (83%). The positive predictive values for accurate true-positive reads were low for all lesion shapes (18%-57%) and moderate for small (69%) and large (59%) sizes, with significant differences observed between the 2 readers. Magnetic resonance imaging has a high sensitivity in the detection of full-thickness articular cartilage defects in the porcine knee. Variability in defect shape and intra-articular location affects MRI sensitivity, while size does not. Magnetic resonance imaging was not effective in describing lesion shape or size. Further, there was subjectivity in reading defect shape and size between 2 radiologists. [ABSTRACT FROM AUTHOR]

The authors describe a tactile surgical navigation system using custom 3-dimensional (3D) models of the bony pelvis for complex acetabular fracture surgery. The bone area of interest was extracted from the Digital Imaging and Communications in Medicine (DICOM) data of computed tomography scans. A standard triangulated language file was used to create 3D models of the bony pelvis by layered manufacturing using a 3D printer and non-cytotoxic, sterilizable, acrylic-based photopolymers. No infections and no toxic or other adverse events were observed. The models were useful for preoperative assessment, planning, and simulation; intra-operative assessment; obtaining informed consent; and education. [Orthopedics. 2014; 37(4):xx-xx.] [ABSTRACT FROM AUTHOR]

Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management. [Orthopedics. 2014; 37(3):151-157.] [ABSTRACT FROM AUTHOR]

High tibial osteotomy may be indicated in the treatment of varus knee in young, active patients. The preservation of proprioception and native joint and biomechanics is crucial for functional recovery in these patients. However, deterioration of initial good results can occur with time. In such cases, revision with total knee arthroplasty is indicated. However, this is a more surgically demanding option compared with a primary prosthesis. Accurate preoperative planning is mandatory to decrease the risk of intraoperative complications. A precise surgical technique, which is crucial to improving functional outcomes, includes hardware removal, joint exposition, tibial deformities due to previous osteotomy, and managing soft tissue mismatches. Possible technical challenges and surgical solutions exist for each of these aspects. However, several studies report lower functional results compared with primary implants. Thus, patients should be informed before high tibial osteotomy about its failure rate, the difficult surgical aspects of an additional prosthesis, and less satisfactory clinical results. [Orthopedics. 2014; 37(3):191-198.] High tibial osteotomy (HTO) is a reliable option in the management of constitutional varus deformity of the knee in young adults and in arthritic varus knees. High tibial osteotomy is considered the best choice in young, active patients in whom the preservation of proprioception and native joint and biomechanics is crucial for functional recovery. Moreover, there are legitimate concerns regarding the results and survivorship of total knee arthroplasty (TKA) in young, high-demand patients. Recently, HTO has been proposed in association with ligament reconstruction and the management of cartilage defects.[1,2] In such patients, HTO protects the cartilage and/or ligament graft by changing the lower limb mechanical axis. [ABSTRACT FROM AUTHOR]

Viscosupplementation is the intra-articular administration of preparations containing hyaluronic acid or hyaluronate intended to restore the normal biological properties of hyaluronic acid normally found in synovial fluid. Infiltration of hyaluronic acid in the arthritic hip is a more recent technique than viscosupplementation of the knee due to the greater technical difficulty of infiltration to the hip, which requires fluoroscopic or ultrasound guidance. The introduction of high-molecular-weight hyaluronic acid in the treatment permits a single administration and has helped diffuse hip infiltration treatment. A single infiltration reduces patient discomfort caused by the procedure and allows treatment of a larger number of patients. Although the literature has unequivocally proven the possibility of reducing pain in patients affected by hip arthritis following infiltration, the molecular weight and density, the number of infiltrations required for long-term results, and the most appropriate indications for infiltration treatment have yet to be clarified. Selecting the patient is the first obstacle to be overcome. Therefore, infiltration should be considered as an option for patients with initial pain symptoms who have not yet been listed for joint prosthesis surgery. The radiographic criteria require at least a partly preserved joint space, and the clinical criteria of persistent hip pain and full joint mobility seem to be sufficiently effective for selection. [ABSTRACT FROM AUTHOR]