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There is renewed interest in bicruciate retaining (BCR) total knee arthroplasty (TKA), which preserves anatomy and more closely replicates native kinematics, theoretically allowing for improved functional results when compared to posterior stabilized (PS) TKA or cruciate retaining (CR) TKA. The purpose of this study is to report early clinical and radiographic results for a novel BCR TKA design.

Patellar crepitus and clunk (PCC) is a known complication in total knee arthroplasty (TKA) and the cause of dissatisfaction. Patellofemoral articulations have reportedly been optimized in newer TKAs. This study compared the incidence of PCC between a historical and modern TKA design. A single-surgeon retrospective review of primary PFC Sigma (DePuy Synthes, Warsaw, Indiana) or Attune TKA (DePuy Synthes) was performed. A total of 114 PFC Sigma and 103 Attune implants were analyzed at a mean 3.2 years follow-up for overall PCC, painful PCC, anterior knee pain (regardless of crepitus), and PCC necessitating revision. Similar rates of overall PCC (14.6% vs 20.2%, P =.803), painful PCC (8.7% vs 6.1%, P =.605), and anterior knee pain (15.5% vs 9.7%, P =.219) were observed in the Attune and PFC Sigma groups, respectively. No clinically significant differences in range of motion, pain, or Knee Society Scores were found between groups. Subgroup analyses of mobile vs fixed bearing PFC Sigma implants demonstrated higher rates of overall PCC (32.4% vs 15.0%, P =.043), painful PCC (20.6% vs 5.0%, P =.016), anterior knee pain (17.6% vs 1.3%, P =.003), and crepitus requiring revision surgery (17.6% vs 1.3%, P =.003) for mobile bearing PFC Sigma implants. No difference was found in the rates of anterior knee pain or PCC between the PFC Sigma and Attune implants. Subgroup analysis suggests that a mobile bearing PFC Sigma implant results in higher PCC. The authors believe the true incidence of anterior knee pain and PCC is underreported in the literature because many outcome measures do not capture these complications. [ Orthopedics . 2020;43(6):e508–e514.]

Background To help slow the rising costs associated with total joint arthroplasty (TJA), the Centers for Medicare and Medicaid Services introduced the Bundled Payments for Care Improvement (BPCI) initiative. The purpose of this study is to report our 1-year experience with BPCI in our 2 arthroplasty surgeon private practice. Methods In this series, a historical baseline group is compared with our first year under BPCI. We reviewed the cohorts with respect to hospital length of stay (LOS), readmission rates, discharge disposition, postacute care LOS, and overall savings on a per episode basis. Results The baseline group included 582 episodes from July 2009 to June 2012. The BPCI study group included 332 episodes from July 2015 to September 2016. We witnessed a substantial learning curve over the course of our involvement in the initiative. The total reduction in cost per episode for TJA was 20.0% (P = .10). Hospital LOS decreased from 4.9 to 3.5 days (P = .02). All-cause 90-day readmission rates decreased from 14.5% to 8.2% (P = .0078). Overall, discharges to home increased from 11.6% to 49.8% (P = .005). Conclusion Our small, private, 2 arthroplasty surgeon orthopedic practice has shown improvement in postoperative management for TJA patients in 1 year under the BPCI initiative, with increased discharges to home, decreased skilled nursing admissions, days in skilled nursing, and overall readmissions. Because BPCI includes fracture care arthroplasty, the model could be made more equitable if these patients were reimbursed a rate commensurate with their increased costs and risks.

Partial knee arthroplasty has had followers since the 1970s. As the implants for the patellofemoral and tibiofemoral articulations improved, surgeons began to combine the replacements in an attempt to spare the ligaments of the knee, to remove a minimal amount of bone, and above all, to get back the knee to the pristine kinematic conditions. Initially, the surfaces were replaced with individual implants. A monolithic femoral component was designed and has had some limited success. The chapter will review the experience of the European surgeons with the separate components and the American surgeons with the monolithic prostheses.

Extensor mechanism (EM) insufficiency after knee arthroplasty is a rare but devastating complication resulting in severe disability. To date, primary repair and allograft reconstructive options have produced suboptimal results. A synthetic mesh allograft reconstruction technique has recently been introduced with promising outcomes. A retrospective chart review was performed to identify all patients who experienced EM failure after total or unicompartmental knee arthroplasty and subsequently underwent synthetic mesh EM reconstruction using a previously described technique. Patient demographics, pre- and postoperative knee range of motion and residual extensor lag, pre- and postoperative pain and functional outcome scores, and complications were extracted during the chart review. Twelve patients met inclusion criteria: 3 with patellar tendon and 9 with quadriceps tendon defects. At mean follow-up of 27.0 months, all patients were ambulatory, with a mean residual extensor lag of 12.9° (range, 0°–30°). Mean visual analog scale pain score decreased significantly after EM reconstruction: 4.6±2.3 (range, 1–8) preoperatively vs 1.8±2.4 (range, 0–7) postoperatively ( P =.01). The mean Knee Society knee score improved from 41.5±11.1 (range, 21–57) preoperatively to 79.5±13.8 (range, 54–90) postoperatively ( P P Orthopedics. 2019; 42(4):e385–e390.]

Preservation of native knee anatomy may confer improved patient satisfaction, as suggested by patient satisfaction scores in unicondylar versus total knee replacement. Bicompartmental knee replacement (BKR) implants similarly promote native tissue preservation. We retrospectively reviewed 42 consecutive patients who underwent BKR from 2006 to 2007. Outcome measures were evaluated. At an average follow-up of 103 months (range 87-110), 34/42 (81%) of implants survived. Among the retained implants, the Knee Society Score (KSS) grade was excellent in 26/34 (76.5%), good in 5/34 (14.7%), fair in 3/34 (8.8%), and poor in 0/34 (0%) of cases. Midterm results of BKR demonstrated 81% survival and 76% with excellent KSS grading. Despite a 20% revision rate at the short-term follow-up, the retained implants functioned well at the midterm follow-up.

Total knee arthroplasty (TKA) in the presence of severe extra-articular deformity remains a challenging situation. Such deformities mainly occurring secondary to femoral or tibial fracture malunion, failed osteotomy, prior physeal injury, congenital deformity, metabolic bone disease, and skeletal dysplasia. In these situations, the standard principles of TKA still apply, including restoration of the mechanical alignment and soft tissue balance. The challenge relates to the implications of the distal femoral and proximal tibial bone resection in both the coronal and sagittal planes. The extra-articular deformity must in some way be corrected by the bone resection. There are several options for correction of the deformity; one is arthroplasty with intra-articular correction, or combined with an extra-articular corrective osteotomy, either as a staged or simultaneous procedure.

Total knee arthroplasty has become a very common procedure over the last decade. Patients are being treated earlier, and the severe deformities seen in previous decade are encountered less frequently. Despite this, there are occasions where the patient presents with a significant fixed deformity. A stepwise approach is required to safely deal with these severe deformities. Failure to do so may lead to skin compromise and further complicate the surgery. Once the arthrotomy is performed, in a stepwise fashion, tight structures need to be released to enable good surgical exposure. Quadriceps snip and an early lateral release are two techniques that can improve exposure. The bone cuts are also important, and often additional distal bone is resected to allow for full extension. A post-capsule release is also often required to enable achievement of full extension. Caution is needed, and patients need to be counseled when there is a severe flexion contracture as well as valgus deformity, since this deformity can be associated with a postoperative foot drop.

Osteonecrosis of the lunate was first described by Austrian radiologist Robert Kienbock in 19101. Presenting symptoms include pain, loss of carpal mobility, and prominence in the dorsal wrist. Theories about the pathogenesis of Kienbock disease include repetitive trauma, attritional rupture of the surrounding ligaments, and vascular compromise of the lunate. This causes osteonecrosis and progressive collapse of the lunate. It usually presents as idiopathic osteonecrosis or, alternatively, after high-energy trauma that may cause dislocation of the lunate. In this case report we describe a case of osteonecrosis following a low-energy fracture of the distal part of the radius. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A fifty-four-year-old woman sustained a fracture of the distal part of the right radius after falling on some ice (Figs. 1-A and 1-B). She was treated with closed reduction and splinting at an outside institution. Six days after the incident, she presented to us with persistent wrist pain. Repeat imaging showed a displaced fracture of the distal part of the right radius with unacceptable dorsal angulation. The lunate appeared normal with no fracture, collapse, or signs of osteonecrosis. The patient was taken to the operating room two days later for closed reduction; the arm was placed in a long-arm cast under intravenous sedation. Because of other medical problems, including severe hypertension, congestive heart failure, hepatitis C, and depression, a prolonged procedure under general anesthesia was contraindicated. Initial anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) radiographs showing the fracture of the distal part of the radius. Fig. 1-A Fig. 1-B At the first follow-up visit twelve days later, radiographs showed acceptable alignment of the fracture with maintenance of the reduction. The lunate had a normal appearance (Figs. 2-A and 2-B). One month after reduction, the patient was evaluated, and she reported no wrist pain. Radiographs revealed interval healing with some settling of the fracture. The radiographic …

The coverage of soft tissue defects in the lower extremity has proven to be challenging. The reverse sural flap provides reliable coverage with minimal complications. Six patients with sarcomas at the distal leg, ankle, and foot were treated with the reverse sural artery flap. Data was gathered for demographics, comorbidities, type of tumor, size of defect, flap viability, healing time, donor-site morbidity, recurrence, functional outcome, and range of motion. All patients possessed a primary sarcoma that traditionally would have required a free flap for coverage. The average size of defect was 94 cm2 (range 50–143) and was covered by flaps that ranged between 10 × 13 cm and 10 × 5 cm. Flap viability was 100 %, with healing occurring by 18 weeks (range 4–32 weeks). Donor-site morbidity was 0 %. Average revised MSTS score was 80 % or 24/40 (range 15–29). Average ROM for dorsi flexion was 0 ° and plantar flexion was 17.5 ° (range 10–25). Average time of follow-up was 8.75 months (range 4–14). In most patients without associated risk factors such as diabetes, the reverse sural flap can be performed safely. However, in patients with identifiable risk factors for partial flap failure, consideration should be given to alternative options such as free flap reconstruction in order not to delay or interrupt adjuvant radiotherapy. Level of Evidence: Level IV, therapeutic study.

Intra-articular fractures of the distal radius are common injuries. They are often the result of high-energy trauma in younger patients or falls in the elderly with osteopenia. While these injuries are difficult to treat, there are a variety of techniques that can be effectively used based on the pattern of fracture. Closed reduction and casting is sufficient for minor injuries, whereas external fixation, open reduction and internal fixation, pinning, bone grafting, or a combination of these techniques is indicated for more severe injuries. If there are bone or soft-tissue defects from open or penetrating injuries, then tissue grafting may also be necessary. Severe difficulties in treatment can be caused by loss of portions of the articular surface of the carpal bones or the distal radius. We present a case of a patient with a gunshot wound that resulted in a distal radius fracture with an unreconstructable lunate facet that was treated with a local osteochondral autograft.

A review of the literature often fails to uncover the best procedure for the treatment of cubital tunnel syndrome. This article compares 2 frequently used methods (subcutaneous anterior transposition vs decompression and medial epicondylectomy) for their effectiveness in relieving both subjective and objective symptoms of cubital tunnel syndrome. Between August 1991 and October 1993, nineteen patients underwent surgical decompression by a single surgeon for ulnar neuropathy at the elbow. Factors evaluated included upper extremity range of motion, elbow valgus stress, grip strength, pinch, 2-point discrimination, and pre- and postoperative nerve conduction. A standardized questionnaire was administered to assess subjective relief of symptoms. In the transposition group, grip strength averaged 71.2% of normal and pinch strength 86.6% of normal, and 2-point discrimination averaged 8.0 mm. The derived subjective assessment score was 23.2 of a possible 40. The average ulnar motor conduction velocity across the elbow was 50.1 m/sec preoperatively and 56.3 m/sec postoperatively. In the medial epicondylectomy group, grip strength averaged 79.5% of normal and pinch strength 81.7% of normal, and 2-point discrimination averaged 8.0 mm. The average ulnar motor conduction velocity across the elbow was 45.7 m/sec preoperatively and 55.7 m/sec postoperatively. No statistically significant difference existed between the 2 groups for the aforementioned indexes. These results do not indicate a difference between the outcomes of the patients undergoing either of the procedures. Because epicondylectomy is less technically demanding, with less soft tissue dissection of the nerve, it may be preferred over ulnar transposition.

Background High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns. Materials and methods Patients sustaining a radial head fracture from 2002−2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data. Results The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4°. Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %). Conclusion The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120° fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings. Level of evidence Diagnostic III.