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Background: Short-term benefits of perioperative corticosteroid injections (CSIs) for bilateral total knee replacement (BTKR) include suppressed inflammation, improved knee motion, and reduced pain. Very little is known about the long-term benefits, complications, and safety of corticosteroids administered in the perioperative period. Purpose: We sought to compare 3-year follow-up outcomes of BTKR patients who received perioperative CSI with those who received placebo. We hypothesized that there would be no statistically significant differences in functional outcomes or adverse events based on whether or not CSIs were administered in the perioperative period. Methods: We conducted a retrospective review of chart and registry data of BTKR patients from a prior randomized controlled trial to compare outcomes in patients who received hydrocortisone vs placebo injections after BTKR (ClinicalTrials.gov: NCT01399268 and NCT01815918). Outcomes were compared at 6 and 12 weeks and at 1, 2, and 3 years. The Knee Injury and Osteoarthritis Outcome Scores (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate clinical outcomes. Cochran-Mantel-Haenszel tests were used to compare the risk of complications between treatments after adjustment for trial. When possible, summary relative risk estimates were calculated using the Mantel-Haenszel method. Results: No BTKR patients in the treatment group developed an infection. The risk of complications did not increase in patients who received CSI compared with those who received placebo. Patients in the CSI group experienced greater reductions in pain and stiffness, though these results were not statistically significant. There were no statistically significant differences in the KOOS-Symptoms, KOOS-Activities of Daily Living, KOOS-Sports, KOOS-Quality of Life, or WOMAC Function scores. Conclusions: Low-dose corticosteroids can be administered in selected patients who undergo BTKR without increasing the risk of adverse events. At 3-year follow-up, administration of low-dose corticosteroids did not result in superior clinical outcomes scores when compared with placebo.

New 3-dimensional digital technologies are revolutionizing orthopedic clinical practice, allowing structures of any complexity to be manufactured in just hours. Such technologies can make surgery for complex cases more precise, more cost-effective, and possibly easier to perform. Applications include pre-operative planning, surgical simulation, patient-specific instrumentation and implants, bioprinting, prosthetics, and orthotics. The basic principles of 3- dimensional technologies, including imaging, design, numerical simulation, and printing, and their current applications in orthopedics are reviewed. [ Orthopedics. 2018; 41(1):12–20.]

Nanomedicine is based on the fact that biological molecules behave similarly to nanomolecules, which have a size of less than 100 nm, and is now affecting most areas of orthopedics. In orthopedic oncology, most of the in vitro and in vivo studies have used osteosarcoma or Ewing sarcoma cell lineages. In this article, tumor imaging and treatment nanotechnology applications, including nanostructure delivery of chemotherapeutic agents, gene therapy, and the role of nano-selenium–coated implants, are outlined. Finally, the potential role of nanotechnology in addressing the challenges of drug and radiotherapy resistance is discussed. [ Orthopedics. 2016; 39(5):280–286.]

Although percutaneous needle fasciotomy for Dupuytren’s contracture is a simple, inexpensive procedure, it is a blind procedure with risks including injury to nerves, arteries, and tendons. The authors describe a novel technique using ultrasound as an adjunct to percutaneous fasciotomy for Dupuytren’s contracture. Generally, patients have no postoperative restrictions other than to avoid submerging their hands for 48 hours. To date, the authors have noted, in 66 cases, no permanent complete nerve dysfunction following needle aponeurotomy using ultrasound assistance. Recurrence of the disease is the most common complication, occurring at a higher rate than with open procedures. Ultrasound mapping of the digital neurovascular structures can be successfully used as an adjunct to help prevent these neurovascular complications. [ Orthopedics. 2015; 38(5):299–303.]

Our purpose was to identify the success rate and factors predicting outcome of irrigation and debridement (ID) in patients with deep periprosthetic joint infection (PJI) of the hip.We retrospectively reviewed clinical characteristics of patients with deep PJI after primary/revision total hip arthroplasty (THA) between January 2000 and May 2013 treated with ID. Implant retention was the outcome of interest. Sixty patients (29 men and 31 women; mean age 64.9 years) were identified. Mean follow-up was 59 months (range, 12-168).The implants were retained in 42 patients (70%). Failure of ID treatment correlated with duration of symptomsfive days (p0.001) and obesity [body mass index (BMI) ≥ 30)] (p = 0.0289). Treatment outcome was affected by the type of pathogen (p = 0.0482), with patients with methicillin-resistant staphylococci having significantly lower odds of success.ID can be a feasible option in THA patients presenting with acute deep PJI. Duration of symptomsfive days, isolation of methicillin-resistant staphylococci and obesity should be taken into consideration in pre-operative decision making.

To determine the incidence and to identify potential risk factors for in-hospital and late infections, as well as for deep periprosthetic joint infection (PJI) following TKA. We identified 17,959 patients treated with primary TKA between 2000 and 2009. We recorded patient demographics, comorbidities and in-hospital complications. The rates of in-hospital, late, and deep PJIs were determined. Different logistic regression models were built to identify risk factors for each of the above types of infection. The rates for in-hospital, post-discharge, and deep PJI were 0.65%, 0.41%, and 0.26%, respectively. Younger age, allogeneic blood transfusion, liver disease, and unilateral or staged bilateral TKA were risk factors for in-hospital infection. Renal and pulmonary disease, urinary tract infection, wound dehiscence, and prior in-hospital infection were risk factors for post-discharge infection. Male gender, history of in-hospital infection, prolonged length of stay, and pulmonary disease were identified as risk factors for deep PJI. Despite low infection rates after primary TKA, there are patients at higher risk that would benefit by addressing modifiable risk factors for both in-hospital or post-discharge infections, including deep PJIs.

With increases in both life expectancy and the number of patients with endoprosthetic replacements, more periprosthetic fractures are expected to occur. Periprosthetic fractures related to megaprostheses present a treatment challenge, with a high incidence (one-third of affected patients) of secondary revision as a result of prosthetic loosening, infection, nonunion, refracture, or even amputation. Efforts to improve endoprosthetic reconstruction should focus on preventing postoperative complications. Understanding the causes of complications and strategies to avoid them could lead to significant improvements in implant survival, limb function, and patient outcomes. This article presents a concise review of the current literature and an algorithmic approach to reconstruction of these complex injuries. [ Orthopedics. 2017; 40(3):e387–e394.]

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18-59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2-12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18-68 months). Range of motion and grip strength were measured. Cooney's scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney's clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.

Long-term results after total knee replacement (TKR) with conventional and compression-molded polyethylene (PE) have been excellent. The introduction of highly cross-linked polyethylene (XLPE), which has demonstrated superior wear properties in total hip replacement (THR), has led to its recent use in TKR. However, the knee has a unique biomechanical environment characterized by large contact stresses and shear forces and differs from the highly conforming articulation (and primarily abrasive and adhesive wear) found in THR. For this reason, XLPE, with its decreased fatigue resistance and toughness compared to PE, may not be the best material to withstand these unique forces.This review and evaluation of the literature aims to answer the following questions. What are the advantages and disadvantages of XLPE in TKR? Does its success in THR ensure a favorable outcome in TKR? Does the increased cost of XLPE justify its use in TKR?A systematic literature review of MEDLINE, Science Direct, and Google Scholar databases was performed searching for advantages and disadvantages of XLPE in TKR. We found 18 biomechanical in vitro investigations and 3 clinical studies comparing conventional and XLPEs. We included levels I through IV published articles in peer-reviewed journals in English language.Several in vitro studies found XLPE to have significantly better wear properties compared to conventional PE. However, the two clinical investigations that directly compared conventional PE and XLPE found no difference in clinical or radiographic outcomes. Additionally, clinical studies with long-term follow-up on TKR with conventional PE did not find wear-induced osteolysis to be a major cause of failure. Four studies did find cost to be significantly higher for XLPE compared to conventional PE.Based on our review, we concluded that (1) the material properties of XLPE reduce adhesive and abrasive wear, but not the risk of crack propagation, deformation, pitting, and delamination found in TKR; (2) wear-induced osteolysis in TKR has not been found to be a major cause of failure at long-term follow-up; (3) mid-term follow-up studies show no difference in any recorded outcome measure between conventional PE and XLPE; and (4) XLPE is two to four times the cost of conventional PE without an improvement in clinical or radiographic outcomes. For these reasons, we currently cannot recommend the use of XLPE in TKR. Conventional compression-molded polyethylene with its outstanding long-term results should remain the material of choice in TKR.

Total hip arthroplasty (THA) has been associated with excellent functional outcomes and survival rates (Cushner et al., 2010 [1]). Selection of acetabular shell and technique of implantation is an important factor as is the stem for a successful THA. Both cemented all-polyethylene cups and cementless sockets have benefited from improvements in surgical techniques, cup designs, and bearing surfaces. This paper is a review of the current literature that focuses on the options for the acetabular components of a modern total hip replacement, aiming to answer common questions and controversies on this topic.

Herein, we present the case of a 75-years-old male—a retired sales engineer—with a 10-year history of progressive contracture of the ring finger of his dominant right hand. The chief complaint was a right ring finger contracture and diminished dexterity. The patient denied pain. However, he did have difficulty with activities such as putting on gloves and shaking hands, which worsened significantly over the last 2 years. He also complained of bilateral basal thumb pain and difficulty with grip related activities.

The objective of the current study was to compare quantitative data on the biomechanical analysis of different techniques for fixation of intercalary bone defects of the humerus, by means of consistently applied methodology on composite models. A total of 25 humeral specimens of composite models were used. An intercalary defect was created and reconstructed using plates, intramedullary nails, external fixators and segmental prosthetic implants. The specimens were loaded under axial compression, four-point bending and torsion within the linear elastic region. Modular segmental implants and intramedullary nails were able to compensate significantly greater amounts of compressive loads compared to locking plates and external fixators. However, in flexion and torsion, the modular segmental implants and the external fixators were significantly better load-bearing devices compared to the intramedullary nails and plates. Early mobilization of the upper limb in patients with diaphyseal bone defects of the humerus could probably be more safe and tolerable when reconstructed with modular segmental implants.

This study is a randomized prospective study comparing two fracture fixation implants, the extramedullary sliding hip screw (SHS) and the dual lag screw cephalomedullary nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and sixty-five patients with low-energy intertrochanteric fractures, classified as AO/OTA 31A, were prospectively included during a 2-year period (2005–2006). Patients were randomized into two groups: group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails. Delay to surgery, duration of surgery, time of fluoroscopy, total hospital stay, implant-related complications, transfusion requirements, re-operation details, functional recovery, and mortality were recorded. The mean follow-up was 36 months (24–56 months). The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred. There was no statistically significant difference in the functional recovery score, reoperation, and mortality rates between the 2 groups. A new type of complication, the so-called Z-effect phenomenon, was noticed in the cephalomedullary nail group. There are no statistically significant differences between the two techniques in terms of type and rate of complications, functional outcome, reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures. Our data do not support recommendations for the use of one implant over the other.

Background: Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the long-term results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. Methods: Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. Results: Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. Conclusion: Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity. Level of Evidence: IV, Retrospective Case Series

We report the results of 62 hips in 62 patients (17 males, 45 females) with mean age of 62.4 years (37 to 81), who underwent revision of the acetabular component of a total hip replacement due to aseptic loosening between May 2003 and November 2007. All hips had a Paprosky type IIIa acetabular defect. Acetabular revision was undertaken using a Procotyl E cementless oblong implant with modular side plates and a hook combined with impaction allografting. At a mean follow-up of 60.5 months (36 to 94) with no patients lost to follow-up and one died due to unrelated illness, the complication rate was 38.7%. Complications included aseptic loosening (19 hips), deep infection (3 hips), broken hook and side plate (one hip) and a femoral nerve palsy (one hip). Further revision of the acetabular component was required in 18 hips (29.0%) and a further four hips (6.4%) are currently loose and awaiting revision. We observed unacceptably high rates of complication and failure in our group of patients and cannot recommend this implant or technique.

OBJECTIVE To evaluate the effect of negative-pressure wound therapy in musculoskeletal tumor surgery patients. MATERIALS AND METHODS The authors analyzed the medical records of 32 patients treated at the authors' institution for bone and soft-tissue sarcomas and secondary wound-healing complications, from 2005 to 2008; there were 11 men and 21 women, with a mean age of 56 years (range, 35-72 years). RESULTS A statistically significant difference (P = .036) was found regarding the length of hospitalization in the conventional wound treatment group, group A (mean, 25.2 days; range, 15-52 days), compared with the negative wound pressure therapy group, group B (mean, 16.5 days; range, 12-33 days). CONCLUSIONS The use of negative-pressure wound therapy for the management of complicated wound healing in sarcoma patients following tumor surgery is safe and effective and is associated with lower overall complications rates, infection rate, and the need for further surgery and a lower total cost of wound-healing treatment.

Tumor-induced or oncogenic osteomalacia is a rare paraneoplastic syndrome characterized by overproduction of fibroblast growth factor-23 as a phosphaturic agent and renal phosphate wasting. A range of predominantly mesenchymal neoplasms have been associated with tumor-induced osteomalacia and classified as phosphaturic mesenchymal tumor mixed connective tissues. However, phosphaturic mesenchymal tumor mixed connective tissues could be nonphosphaturic in the first stage of the disease, either because the tumors are resected early in the clinical course or because the patient’s osteomalacia was attributed to another cause. This article presents a case of a 42-year-old woman with a 2-year history of low back and right leg pain. Laboratory examinations including serum and urine calcium and phosphorous were within normal values. Imaging of the lumbar spine and pelvis showed an osteolytic lesion occupying the right sacral wing. Histology was unclear. Reverse-transcription polymerase chain reaction analysis for fibroblast growth factor-23 was positive and confirmed the diagnosis of phosphaturic mesenchymal tumor mixed connective tissues. Preoperative selective arterial embolization and complete intralesional excision, bone grafting, and instrumented fusion from L4 to L5 to the iliac wings bilaterally was performed. Postoperative recovery was uneventful. Neurological deficits were not observed. A lumbopelvic corset was applied for 3 months. At 12 months, the patient was asymptomatic. Serum and urine values of calcium and phosphorous were normal throughout the follow-up evaluation.

Background Total scapulectomy and intra-articular resection of the glenohumeral joint indicates the Malawer Type III shoulder girdle resection. Materials and Methods The modified Tikhoff-Linberg total scapulectomy and constrained reverse total shoulder reconstruction for a Ewing's sarcoma of the scapula is presented. A combined approach has been used. The deltoid, trapezius, rhomboids, levator scapulae, latissimus dorsi, and serratus anterior were preserved. the tumor was removed en bloc by disarticulation of the acromioclavicular and the glenohumeral joints. The scapular prosthesis was suspended by the muscles. A constrained reverse humeral prosthesis was implanted after osteotomy of the humeral head. Results There were no intraoperative or postoperative complications; surgical margins were clear. At 12 months postoperatively, the patient has a stable and painless shoulder. Conclusion The goal of shoulder reconstructions is to provide a stable and painless joint that allows positioning of the arm and hand in space. Compared to those patients left without a scapula reconstruction, prosthetic replacement of the scapula and shoulder partially restores abduction and external rotation and improves cosmesis. J. Surg. Oncol. 2009;100:611–615. © 2009 Wiley-Liss, Inc.

Resume Un homme âge de 72 ans souffrait de douleurs du rachis lombaire et des membres inferieurs evoluant depuis six mois. Dans les antecedents, on retenait une resection trans-uretrale d’un cancer de la vessie realisee 12 ans auparavant, suivie par des instillations intravesicales repetees de BCG. L’imagerie du rachis dorsolombaire mettait en evidence une osteolyse des vertebres L3 et L4 avec atteinte du disque intervertebral L3-L4 et une volumineuse masse des parties molles dont les anomalies de signal etaient celles d’un abces. Une biopsie guidee par scanner a mis en evidence une infection a Mycobacterium bovis . Le traitement antibiotique a consiste en une tritherapie par isoniazide, rifampicine et ethambutol, administree pendant 12 mois. Le traitement chirurgical a comporte le drainage de l’abces et une arthrodese vertebrale L2-L5 avec fusion et instrumentation. La BCG-therapie intravesicale peut se compliquer d’une infection mycobacterienne tardive atteignant l’os et ce meme plusieurs annees apres sa realisation. En consequence, les patients ayant eu une BCG-therapie devrait etre evalues avec precision compte tenu de la survenue possible d’une dissemination hematogene de la mycobacterie vers des sites a distance.

A 72-year-old man presented with a 6-month history of low back and leg pain. Past medical history revealed transurethral resection of bladder cancer followed by multiple intravesical BCG instillation 12 years ago. Imaging studies of the thoracolumbar spine showed osteolysis of the L3 and L4 vertebrae and the associated intervertebral disc space, and a large soft tissue mass with signal abnormalities suggesting of an abscess. CT-guided needle biopsy showed Mycobacterium bovis infection. A triple anti-tuberculous chemotherapy regimen including isoniazid, rifampicin, and ethambutol was administered for 12 months. Surgical treatment included drainage of the abscess and L2-L5 spinal instrumentation and fusion. Intravesical BCG therapy may be complicated by late disseminated disease to the bone even many years after initial BCG therapy. Patients having BCG therapy should be closely evaluated thereafter for the possibility of hematogenous spread of mycobacteria to distant sites.

Six patients underwent segmental bone resection and limb salvage surgery for primary or metastatic bone tumors involving the diaphysis of the femur, the tibia, and the humerus using a modular intramedullary diaphyseal segmental defect fi xation system. Th ere were four men and two women with a mean age of 62 years (range: 40-77 years). Histological diagnosis included adamantinoma, synovial sarcoma, multiple myeloma, met- astatic renal cell carcinoma, myeloid carcinoma of the thyroid gland, and adenocarcinoma of the stomach. Th e mean follow-up was 17 months (range: 11-28 months). At the latest examination, fi ve patients were free of local or distant disease and one patient had deceased with distant disease, without evidence of local recurrence. Revision surgery was necessary in one patient because of mechanical loosening of the proximal fi xation of the prosthesis at 24 months. Th e mean postoperative increase of the Enneking rating score was 87.8%. Th e intramedullary diaphyseal segmental defect fi xation system used herein is associated with a satisfactory functional and oncological outcome after wide resection of diaphyseal bone tumors.

Background: Forty-six patients (38 females and 8 males) with infected knee arthroplasties were included in this study. In 31 patients (group A) an antibiotic-impregnated articulating spacer was used, whereas in 15 patients (group B) a combination of spacer and antibiotic carrier was used. Methods: All patients were reviewed weekly with laboratory examinations (white blood cell count [WBC], erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) prior to re-implantation. At a mean follow-up of 36 mo (range, 8–60 mo) no patient was lost to follow-up or had died. Results: White blood cell count and ESR showed no differences at any time interval. C-reactive protein values had a statistically significant difference between the two groups after the second week (third week p = 0.042) and group B had significantly lower CRP values at every checkpoint thereafter. The re-infection rate was 16.12% in group A and 6.6% in group B (p = 0.192).

Background The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) treated with external fixation and Kirschner wires (K-wires). Materials and Methods Twenty patients (18 males and 2 females) with a mean age of 38 years (range 18–59) with an acute PLD or PLFD were treated with external fixator and K-wires. There were 12 PLDs and seven transscaphoid and one transstyloid PLFDs. The median time from trauma to operation was 8 hours (range 2–12 hours). Indirect reduction via ligamentotaxis was achieved in 17 patients with a mean age of 38years (range 18–59). There were 12 PLDs and 5 trans-scaphoid PLFDs; however, in three cases (two transscaphoid and one transstyloid PLFDs), indirect reduction failed and an open reduction was required. The intercarpal ligaments were not repaired even after open reduction. Results The mean follow-up was 39 months (range 18–68 months). The flexion-extension range of motion (ROM) and grip strength of the injured wrist averaged 80% and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney's scoring system, overall functional outcomes of the 17 patients were rated as excellent in 4 patients, good in 8, fair in 4, and poor in 1. Fifteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid, and two developed posttraumatic arthritis. Conclusion External fixation plus percutaneous K-wires for the treatment of acute PLDs has satisfactory midterm functional and radiographic outcomes. When successful, this minimally invasive technique is simple and provides restoration of the carpal alignment. It may especially be useful in the polytrauma patient, thanks to its decreased operative time and diminished blood loss, when other emergent surgical procedures may be necessary. An open reduction with possible fixation may be necessary for PLDs and PLFDs, especially in the presence of polytrauma and scaphoid comminution. Level of evidence: IV.

The estimated prevalence of patients who report minor or no improvement of their symptoms and pain after total knee arthroplasty (TKA) remains high, ranging from 5% to 40%. The authors sought to determine whether chronic pain and functional health are related to specific variations in demographic data, surgical techniques, or radiographic pre- and postoperative findings. They also sought to identify independent risk factors for persistent moderate-to-severe chronic pain after TKA. A total of 273 patients who underwent primary TKA from October 2007 to March 2010 with a minimum follow-up of 1 year were identified from electronic medical records. A questionnaire to identify persistent postoperative pain (36-item Short Form Health Survey [SF-36]) was mailed to these patients. Linear regression and logistic regression were used to identify predictors for SF-36 and chronic pain, respectively. Thirty-nine percent of patients reported persistent pain after TKA, with a median average pain score of 3 out of 10 and worst pain score of 5 out of 10. Independent risk factors for persistent pain are the length of the operative procedure (odds ratio [OR]=1.013), medical history of diabetes mellitus (OR=0.430), presence of preoperative flexion contracture (OR=1.089), and patellofemoral joint overstuffing (OR=0.915). Persistent postoperative pain is a common finding after TKA. Nonmodifiable risk factors could be used for risk stratification, whereas modifiable risk factors could be used as a clinical guidance for modification of some aspects of existing surgical techniques. [ Orthopedics. 2016; 39(1):55–62.]

We retrospectively reviewed the medical records of 31 patients with periprosthetic hip infections attempting to evaluate the outcome of a two-stage revision protocol characterized by prolonged interim period (mean=9.2 months, range 8-12 months) prior to the final re-implantation. In 3 cases (9.6%) the 1st stage was repeated after a mean period of 12.3 weeks due to relapse of infection. Five spacer dislocations occurred, not affecting the final clinical outcome after reimplantation, as evaluated by the Harris Hip Score. No protrusions or additional acetabular bone loss was noticed. Our proposed protocol is a simple, safe, efficient and reproducible treatment approach that may be successfully utilized predominantly when dealing with multidrug resistant pathogens.

We retrospectively reviewed 110 patients who underwent two-stage revision surgery in order to identify potential risk factors for recurrence of periprosthetic infection. We found that patients with inflammatory arthritis (P=0.0125), perioperative hematoma formation (P=0.0422), wound dehiscence (P=0.042), and those who are chronic Staphylococcus carriers (P=0.0177) were associated with an increased incidence of re-infection. The duration of intravenous antibiotic therapy less than 6 weeks was associated with a reduced risk of reinfection to greater than 6 weeks (P=0.03). Multivariate analysis indicated that wound dehiscence (odds ratio [OR], 5.119; 95% confidence interval [CI], 1.367-19.17), and Staphylococcus carriers (OR, 11.419; 95% CI, 1.376-94.727) are significant predictors of recurrence (P=0.0153 and 0.0241, respectively).

Developmental dysplasia of the hip (DDH) or congenital hip dysplasia (CDH) is the most prevalent developmental childhood hip disorder. It includes a wide spectrum of hip abnormalities ranging from dysplasia to subluxation and complete dislocation of the hip joint. The natural history of neglected DDH in adults is highly variable. The mean age of onset of symptoms is 34.5 years for dysplastic DDH, 32.5 years for low dislocation, 31.2 years for high dislocation with a false acetabulum, and 46.4 years for high dislocation without a false acetabulum. Thorough understanding of the bony and soft tissue deformities induced by dysplasia is crucial for the success of total hip arthroplasty. It is important to evaluate the existing acetabular deformity three-dimensionally, and customize the correction in accordance with the quantity and location of ace tabular deficiencies. Acetabular reconstruction in patients with DDH is challenging. Interpretation of published data is difficult and should be done with caution because most series include patients with different types of hip disease. In general, the complication rate associated with THA is higher in patients with hip dysplasia than it is in patients with osteoarthritis. Overall, clinical and functional outcomes following THA in patients hip dysplasia (DDH) differ from those treated for primary hip osteoarthritis, possibly due to the lower age and level of activity. Although function scores decline with age, the scores for pain and range of motion presented with a statistically significant improvement in the long-term.

Cauda equina syndrome is an uncommon complication of ankylosing spondylitis characterized by the slow and insidious development of severe neurologic impairment related to dural ectasia. This report describes a unique case of cauda equina syndrome in a patient with ankylosing spondylitis after hip revision surgery. A 70-year-old man with long-standing ankylosing spondylitis underwent standard hip revision surgery; combined spinal and general anesthesia was administered. Pain was controlled with intravenous opioids postoperatively (patient-controlled analgesia). As per routine protocol, on the first postoperative day, the patient remained supine on a hip abduction pillow; mobilization was initiated on the second postoperative day. On postoperative day 1, the patient had severe low back pain that was controlled with patient-controlled analgesia. On postoperative day 2, the Foley catheter was removed and the patient sat and dangled. Back pain persisted while supine; in addition, the patient noticed involuntary loss of urine. On postoperative day 3, the patient had below-the-knee numbness that progressed to saddle anesthesia and foot flexor and extensor weakness. An epidural hematoma was suspected and urgent magnetic resonance imaging was performed, which showed severe degenerative stenosis at the L4-L5 level (mainly by dense ligamentum flavum). An L4-L5 decompression and instrumented fusion was performed; intraoperatively, L4-L5 was found to be the sole mobile segment. The extension of the spine in the supine position that completely obliterated the spinal canal was considered the mechanism of cauda equina syndrome. The intensity of back pain is a good indicator of a severe spinal lesion; however, pain can be dampened by intravenous opioids. High suspicion is required in patients with preexisting spinal pathology, such as ankylosing spondylitis.

This is a technical note of pelvic reconstruction performed by an advanced multidisciplinary team. The authors report a new 3-stage reconstruction of the hemipelvis after Type 3 sacrectomy involving instrumented spinoiliac arthrodesis and pedicled fibula grafting in 2 patients. The anterior stage of the procedure begins with a transabdominal approach to mobilize the viscera and to free up the tumor from the vessels. The posterior divisions of internal iliac vessels, the middle sacral vessels, and the lateral sacral vessels are then ligated. An anterior vertebrectomy is done at the appropriate level, followed by an anterior osteotomy through the lateral planed surgical margin of the sacrum close to the salvaged sacroiliac joint. The second stage includes a major sacral resection with lower-extremity amputation from the pubic symphysis through the intact side of the sacrum, ipsilateral pedicled fibula harvesting, and closure with an ipsilateral pedicled quadriceps flap. The final stage involves reconstruction with lumboiliac instrumentation. The pedicled fibular graft left from the second stage is then placed distally within the previously created iliopectineal docking site and proximally within the L-5 docking site. The authors believe that this is a feasible and reproducible technique with theoretical advantages that have to be proved in the long-term follow-up.

The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.

Understanding of the anatomy of the proximal part of the fifth metatarsal helps to differentiate the types of fractures and recognize variables affecting healing. The proximal part of the fifth metatarsal includes the head, the metaphyseal region, the tuberosity and the proximal part of diaphysis, with the tuberosity being the most proximal and plantar structure. The proximal part of the 5th metatarsal is articulated with the base of the 4th metatarsal and the cuboid bone. Dorsal, plantar, and interosseus ligaments are attaching the base of the fourth and fifth metatarsals. The most prominent part of the tuberosity is connected with the lateral process of the tuberosity of the calcaneus with a strong band of the plantar aponeurosis.

Although the clinical and biomechanical advantages of pedicle screws are well documented, the accuracy of their insertion is always a concern.Injury of neurovascular structures could be devastating. Perforation of the aorta from posteriorly placed screws is fortunately rare but could end up being lethal. We present a review of the current literature along with two illustrative cases with aorta perforation from posterior pedicle screws. An 82-year-old female with a history of thoracic kyphosis and a 26-year-old female with scoliotic deformity were referred to our institution owing to back pain. Both patients had undergone correction of their deformities and posterior fixation using posterior pedicle screws and rods 5 years previously. During the diagnostic work-up, which included CT scans, we incidentally found one pedicle screw to be malpositioned, exiting the vertebral body and perforating the aorta. The patients were offered a combined orthopaedic and vascular procedure, including screw removal and endovascular stenting of the aorta. Potential complications from the presence of a screw inside the pulsatile aorta, and the complexity of revision surgery should be well considered before proceeding to such a difficult surgical procedure. Systemic postoperative follow-up imaging and safer intraoperative practices during screw placement are important.

The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries.

Backround This retrospective study was undertaken to determine the incidence of kidney dysfunction (KD) and to identify potential risk factors contributing to development of KD in orthopaedic population following an elective or emergency surgery. Methods A total of 1025 patients were admitted in our institution over a period of one year with various indications. Eight hundred and ninety-three patients (87.1%) had a surgical procedure. There were 42 (52.5%) male and 38 (47.5%) female with a mean age of 72 years (range: 47 to 87 years). We evaluated the following potential risk factors: age, comorbidities, shock, hypotension, heart failure, medications (antibiotics, NSAIDs, opiates), rhabdomyolysis, imaging contrast agents and pre-existing KD. Results The overall incidence of KD was 8.9%. Sixty-eight patients developed acute renal injury (AKI) and 12 patients developed acute on chronic kidney disease (CKD). In sixty-six (82.5%) patients renal function was reversed to initial preoperative status. Perioperative dehydration (p = 0.002), history of diabetes mellitus (p = 0.003), pre-existing KD (p = 0.004), perioperative shock (p = 0.021) and administration of non-steroid anti-inflammatory drugs (NSAIDs) (p = 0.028) or nephrotoxic antibiotics (p = 0.037) were statistically significantly correlated with the development of postoperative KD and failure to gain the preoperative renal function. Conclusion We conclude that every patient with risk factor for postoperative KD should be under closed evaluation and monitoring.

Focal posttraumatic shoulder dystonia is a rare and not easily identifiable entity. Its true pathophysiologic nature, predisposing factors, and disease course remain debatable. This article describes a rare case of a 40-year-old man with late symptoms of focal shoulder dystonia after peripheral trauma of his left shoulder girdle. The shoulder was indirectly injured from the impact of a fall off his motorbike 3 years earlier. He was referred to the authors’ institution because remarkable reduction of arm abduction, muscle spasms, and circumscribed hypertrophy of the trapezius muscle were noted while his head and neck were in neutral position and had a full range of motion. The left shoulder had a fixed elevated posture compared with the contralateral shoulder. A continuous burning pain was localized over the area of the hypertrophied trapezius muscle, radiating to the ipsilateral side of the head and neck. Dystonic movements of the trapezius, rhomboid, and supraspinatus muscles were observed. The abduction of the shoulder was significantly decreased, and any repetitive effort for arm abduction induced an exaggeration of his movement disorder, leading to a more pronounced shoulder elevation. Plain radiographs and magnetic resonance imaging of the left shoulder revealed a suprascapular tendinitis with no other abnormalities. Repeated needle electromyography of the left trapezius muscle and neurography of the accessory nerve on both sides were normal. Injections of botulinum toxin A were effective in the resolution of muscle hypertrophy and abnormal posture.

In periarticular knee resections, the relative lack of soft tissue coverage and need to reattach the extensor mechanism after en bloc resection of the tibial tuberosity with the tumor specimen complicate reconstructions and decrease postoperative function and stability of the knee joint. Distal femoral reconstructions are less problematic; muscular attachments are relatively few, neurovascular structures are not immediately adjacent to bone, and the knee extensor mechanism is usually not compromised from bone tumors. In the proximal tibia, the close proximity of the neurovascular structures in the popliteal fossa and peroneal nerve at the lateral aspect of the leg make reconstruction more difficult. Poor function is mostly related to unreliable options for knee extensor mechanism reattachment and poor soft tissue coverage. Successful and reliable attachment of the soft tissues has been a significant advance that improved functional outcomes. This article describes techniques for the reconstruction of the extensor mechanism of the knee after proximal tibia resections. Combined reconstruction techniques using direct reattachment of the patellar tendon with synthetic materials to megaprosthetic or allograft reconstructions for immediate stability, augmentation with autologous bone graft or substitutes at the attachment site, and coverage with the medial gastrocnemius muscle flap and supplementary flaps for long-term stability of the reattachment are currently considered the gold standard.

This article describes a case of a 58-year-old man with no significant underlying disease who had chronic pain due to osteonecrosis of the hamate. Following physical examination, imaging, and laboratory findings, he underwent surgical exploration via a limited dorsal approach. The hamate bone did not have a normal anatomical appearance or structure. It was marble-like in appearance, soft, friable, and lacking physiologic contour and bone strength. We removed the dorsal aspect of the hamate piecemeal. The articular surfaces of the adjacent carpal bones (capitate and lunate) were excised, and the lesion was packed with iliac autograft. Three months postoperatively, fusion of the remaining hamate and the adjacent capitate and lunate carpal bones was evident, and the patient reported mild wrist pain, moderate grip strength improvement, and mild improvement of wrist range of motion and stiffness. Currently, no standard treatment algorithm exists for patients with avascular necrosis of the hamate. However, delayed diagnosis of this clinical entity can be debilitating. A high index of clinical suspicion and an early course of treatment offers considerable benefits to patients with osteonecrosis of the hamate.

Background Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies. Case Description A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection. Literature Review Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition. Purposes and Clinical Relevance Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.

Aim To present foot salvage for osteosarcoma of the navicular bone with en bloc resection and reconstruction using bone allograft and talus-cuneiform arthrodesis. Patient and surgical technique A 20year-old male with a history of osteosarcoma of the distal femur presented to our department 5years later with a metastatic lesion of the navicular bone of the contralateral foot. The patient received 4 cycles of neo-adjuvant chemotherapy with satisfactory response. Tumor shrinkage allowed en bloc excision of the navicular bone with clear margins. Reconstruction was done using a tricortical allograft and talus-allograft-cuneiform arthrodesis, secured with a mini-fracture plate (Synthes). Weight bearing protection was advised for 2months and partial weight bearing for another 4months. Patient received 4 cycles of adjuvant chemotherapy. Results Three years postoperatively, the patient was free of local recurrence or distant metastasis. There were no signs of allograft resorption, fracture or non union. The patient was asymptomatic and full weight bearing. Ankle and subtalar joint motion was within normal limits. Conclusion Foot salvage after excision of osteosarcoma of the navicular bone could be possible if en bloc resection of the lesion could be performed. Talus-cuneiform fusion with allograft interposition is a viable reconstructive option.

This article presents a case of a painless fluctuant mass on the volar aspect of the wrist and forearm of an immunocompetent 45-year-old man with no history of significant underlying disease. This mass proved to be a chronic tenosynovitis associated with Mycobacterium kansasii infection. The patient, who had a history of multiple minor cuts and abrasions plus exposure to an aquatic environment, had a wide resection of the lesion and elective tenosynovectomy. Operative findings revealed a marked tenosynovitis of flexor tendons. Several rice bodies lesions were also observed along the course of the involved flexor tendons. Biopsy showed a granulomatous inflammatory reaction. Specimens of affected tissue were sent to a laboratory for solid (at 30°C and at 37°C) and liquid (at 37°C) mycobacterial culture. The initial Ziehl-Neelsen stain for acid-fast bacilli was positive. After 8 days of incubation, acid-fast bacilli were recovered. In accordance with the diagnosis of M kansasii tenosynovitis and the results of antibiotic susceptibility testing, triple therapy with rifampicin, isoniazid and clarithromycin was initiated. After 3 months of therapy, the patient experienced improvement in the swelling and is due to receive 12 months of antibiotic therapy. Despite awareness of atypical mycobacterial infections, diagnosis is frequently delayed, leading to increased morbidity. Patients with exposure to these atypical pathogens require a broadened differential to include appropriate testing and culture of specimens to obtain an accurate diagnosis.

A secondary high-velocity trauma to a previously stabilized femoral fracture with intramedullary nailing is rare. In this paper, we present the management of a 40-year-old man presented with a bent intramedullary nail due to secondary trauma. A lateral longitudinal femoral osteotomy was used for the resection of the distorted nail. The femur was reconstructed with a new nail, and the fixation of the osteotomy was achieved with plate and cerclage wires. Five months postrevision surgery, callus formation was evident and the patient regained a normal range of motion and gait, walking with a single cane.

Primary osteoarthritis (OA) of the hip joint • Secondary OA following acetabular dysplasia [hip • dysplasia, developmental dysplasia of the hip (DDH), or congenital disease of the hip (CDH)] Rheumatoid arthritis (RA) • Osteonecrosis (ON) • Legg-Calve-Perthes’ disease (LCP disease) • Slipped capital femoral epiphysis (SCFE) • Deteriorated or failed pelvic osteotomy (deterio• rated cases) Traumatized hip with deformity and malalignment • (posttraumatic arthritis)

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

We conducted a thorough search of all the English language literature and carried out a meta-analysis in an attempt to reveal potential differences on the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) between one stage bilateral and unilateral total hip replacements, and to provide, if possible, recommendations on thromboembolic prophylaxis. We identified 37 citations eligible for inclusion. A total of 5868 bilateral simultaneous THR patients were identified. Analysis of data was performed with the Mantel-Haenszel method. Meta-analysis of homogeneous data revealed no statistically significant differences in the rates of deep vein thrombosis (p = 0.40) and pulmonary embolism (p = 0.39) when comparing staged with bilateral simultaneous THR procedures as well as the rates of pulmonary embolism when comparing bilateral simultaneous THR with unilateral procedures (p = 0.69). However, deep vein thrombosis rate was in favor of bilateral two-stage compared to unilateral THR (p = 0.00001). Definite recommendations regarding the prevention of thromboembolic events in bilateral simultaneous THR could not be produced as the literature was limited and the data heterogenic. Conclusively, deep vein thrombosis and pulmonary embolism is not increased in bilateral simultaneous THR, provided that appropriate prophylactic measures are taken. More data are needed in order to clarify if additional measures or altered protocols of thromboembolic prophylaxis should be followed.

IntroductionIn patients who have undergone a total joint replacement, any mass occurring in or adjacent to the joint needs thorough investigation and a wear debris-induced cyst should be suspected.Case presentationAn 81-year-old man presented with a painful and enlarging mass at the popliteal fossa and calf of his right knee. He had had a total right knee replacement seven years previously. Plain radiographs showed narrowing of the medial compartment. Magnetic resonance imaging showed a cystic lesion at the postero-medial aspect of the knee joint mimicking popliteal cyst or soft tissue sarcoma. Fine needle aspiration was non-diagnostic. A core-needle biopsy showed metallosis. Intraoperative findings revealed massive metallosis related to extensive polyethylene wear, delamination and deformation. Revision knee and patella arthroplasty was carried out after a thorough debridement of the knee joint.ConclusionLong-term follow-up is critical for patients with total joint replacement for early detection of occult polyethylene wear and prosthesis loosening. In these cases, revision arthroplasty may provide a satisfactory knee function.

We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60–80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time.