The Effect of Mechanical Leg Alignment on Cartilage Restoration With and Without Concomitant High Tibial Osteotomy.

PURPOSE: To assess graft survivorship in patients who underwent autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) for the treatment of focal full-thickness cartilage lesions on the medial femoral condyle with and without concomitant high tibial osteotomy (HTO), depending on the preoperative lower-extremity alignment. A secondary purpose was to retrospectively evaluate associated factors for ACI and OCA graft failures. METHODS: A total of 168 patients who underwent cartilage repair with ACI or OCA with or without HTO for focal chondral defects on the medial femoral condyle by a single surgeon between March 2007 and February 2018 were included. Clinical notes, operative reports, and radiographic imaging were reviewed for each patient. Detailed Kaplan-Meier analyses were performed based on patient's mechanical axis alignment. In a subanalysis, failures and nonfailures in patients treated with ACI or OCA were comparatively evaluated. RESULTS: In ACI, neutral mechanical alignment resulted in a significantly longer graft survival compared with slight valgus alignment (P = .003 and P = .05, respectively). No significant differences in survivorship were seen based on mechanical axis alignment in OCA patients (P > .05). Patients who were considered failures after ACI presented significantly more often with valgus alignment (P = .002), whereas failures in the OCA group were more often female and smokers (P = .025; P = .034). CONCLUSIONS: In summary, the results of this study suggest that neutral mechanical axis alignment, regardless if physiologic or through HTO, improves survivorship in patients undergoing medial compartment ACI. Neutral alignment also showed a trend towards improved survivorship in patients after OCA, but this did not reach statistical significance. LEVEL OF EVIDENCE: Case-Series; Level of evidence, 4.

Validation of the Oswestry Risk of Knee Arthroplasty Index (ORKA-1) for Patients Undergoing Autologous Chondrocyte Implantation.

OBJECTIVE: The purpose of this study was first to externally validate the Oswestry Risk of Knee Arthroplasty index (ORKA-1) by applying it to an autologous chondrocyte implantation (ACI) patient cohort in the United States with a broader definition of failure than only arthroplasty, and second, to determine predictive factors for the risk of ACI failure as defined by the senior author. DESIGN: A total of 171 patients that underwent ACI were included to validate the ORKA-1 as all factors needed for calculation and outcomes were recorded. For Cox regression analysis, 154 patients were included as they completed preoperative Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm, International Knee Documentation Committee (IKDC), and 12-item Shor Form (SF-12) scores. Patient- and lesion-associated parameters were recorded for each patient. RESULTS: At final follow-up (maximum of 10 years post-ACI), a total of 27 patients (15.8%) were considered a failure by senior author's definition. With ACI failure as endpoint, the mean survival was 7.96 years in risk group 1 and 5.4 years in risk group 5. Cox regression analysis identified preoperative KOOS Sport/Recreation as the only significant predictive factor for ACI failure (P = 0.007). CONCLUSION: The ORKA-1 is a helpful tool for surgeons to estimate an individual patient's likelihood of ACI survival. Further studies with larger patient cohorts as well as a consensus definition of failure are needed to further refine predictors of ACI failure.

Effect of intrasite vancomycin powder on development of epidural fibrosis.

Placement of vancomycin powder into the surgical wound prior to closure has been shown to reduce postoperative infections in spine surgery. This study examines the effect of vancomycin powder on formation of epidural fibrosis (EF). Twenty-two rats underwent a two-level lumbar laminectomy. A control group, a low-dose and a high dose vancomycin powder (applied prior to closure) group was formed. Rats were sacrificed at 30 days and a blinded fellowshiptrained pathologist evaluated the laminectomy segments for EF. 50% of the samples in the high-dose vancomycin group were EF grade 3, compared to 20% of the low-dose and 16.7% of control samples. The average fibrosis grade for the high dose, low dose and control groups were 2.4, 1.4 and 1.8, respectively. There were more grade 3 EF specimens in the high dose vancomycin group. While the average EF grade was also higher in this group, there was not a statistical difference compared with the other groups.

Bilateral Hemiarthroplasty in a Patient with Below-Knee and Above-Knee Amputations: A Case Report.

CASE: This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. CONCLUSION: This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

Acute Both Bone Fracture in a Chronic Contracted Forearm.

INTRODUCTION: There is a paucity of information on management of forearm fractures through pre-existing ischemic contractures. The prevention of a Volkmann's contracture in forearm compartment syndrome requires vigilant clinical evaluation and emergent fasciotomy, but many of the patients who develop these contractures often do so as a result of delayed presentation due to substance abuse and intoxication. This case describes the first report and management of a severely displaced both bone (BB) forearm fracture through a chronic forearm Volkmann's contracture. CASE REPORT: A 39 year old female presented with an acute both bone forearm fracture in the setting of a Volkmann's contracture. Although very limited in use, the arm was functional for holding objects and was determined to be important in her activities of daily living. The surgical management involved open reduction internal fixation with radial and ulnar shortening osteotomies to restore cortical alignment secondary to the extensive overlying soft tissue contractures. CONCLUSION: Restoration of the radial bow and other standard principles of open reduction and internal fixation of BB fractures may not be as important as obtaining fracture union in patients with these complicated injuries due to the pre-existing functional limitations of the limb. The soft tissue envelope in a contracted forearm is commonly fibrotic and provides an abnormal fracture healing environment. Careful attention to osseous and soft tissue healing in the postoperative period is recommended. This report details the first case, technical difficulties, and subsequent management of a BB fracture in the setting of subsequent management of a both bone fracture in the setting of a chronic Volkmann's contracture.

Open perilunate injury with lunate revascularization after complete ligamentous avulsion.

Perilunate dislocations are a devastating injury to the carpus that carry a guarded long-term prognosis. Mayfield type 4 perilunate dislocations are rare, high-energy injuries that carry a risk for avascular necrosis (AVN) of the lunate. When AVN ensues and the carpus collapses, primary treatment with a proximal row carpectomy or arthrodesis has been advocated. This case reports a successful clinical result and revascularization of an extruded lunate with open reduction and internal fixation. This type 4, Gustilo grade 1 open perilunate dislocation exhibited complete avulsion of all lunate ligamentous attachments. Management included open reduction and internal fixation as well as carpal tunnel release through a combined dorsal and volar approach. Despite concerns for lunate AVN due to complete disruption of lunate vascularity, a 10-month postoperative clinical and radiographic examination demonstrated no pain with activities of daily living as well as a revascularized lunate.

National access to care for children with fractures.

BACKGROUND: Access to health care for many pediatric orthopaedic patients is becoming more difficult. In some communities, children with fractures have limited access to care regardless of insurance status. The purpose of this study was to determine the level of difficulty in obtaining access to care for children with fractures nationally and compare our results to the published results of a national survey in 2006. METHODS: Five orthopaedic offices were identified in each state using an internet search with Google maps by typing "general orthopedics" under the search heading for each state. Each office was contacted with a scripted phone call describing a fracture in a 10-year-old boy that does not involve the growth plate. The office was then told the patient has Medicaid insurance. If no appointment was given, the reason was recorded and the office was asked to refer us to another orthopaedic surgeon. A second phone call was made to the same office a few days later using the same script but the office was told the patient has a private preferred-provider organization insurance. If no appointment was given, the reason was recorded. RESULTS: Of the 250 (23.6%) offices across the country, 59 would see a pediatric fracture patient with Medicaid. 41.3% (79/191) of the offices refusing the patient stated that they do not accept Medicaid patients. Of the 250, 205 (82%) of the offices across the country would see a pediatric fracture patient with a private preferred-provider organization insurance. The 10 states with lowest Medicaid reimbursement offered an appointment 6% of the time, whereas the 10 best reimbursing states offered an appointment 44% of the time. DISCUSSION AND CONCLUSIONS: The access to care for children with fractures is becoming more difficult across the country. Compared with the published data in 2006, the number of offices willing to see a child with private insurance has decreased from 92% to 82%. The number of offices willing to see a child with a fracture and Medicaid insurance has decreased from 62% to 23% over the same time span.

Two-year outcome with the AperFix system for ACL reconstruction.

The purpose of the study was to assess the fixation durability of the AperFix System (Cayenne Medical, Inc, Scottsdale, Arizona) used in arthroscopic reconstruction of the anterior cruciate ligament. The AperFix System consists of a femoral and tibial component designed to secure either allograft or autograft. The outcomes of 185 knees (180 patients) were retrospectively reviewed at a minimum of 2 years postoperatively. Mean age at surgery was 31±12 years (range, 16-68 years). Of these, a convenience sample was seen prospectively to obtain radiographs and to assess functional status. No cases occurred of fixation failure involving loss of graft positioning or pullout. No patients required revision anterior cruciate ligament reconstruction. In 2 knees, the tip of the central fixation pin had to be modified as a result of hardware prominence and soft tissue irritation at 434 and 159 days postoperatively, respectively. In 4 knees, tibial screw removal occurred secondary to local discomfort (mean, 239 days; range, 105-371 days). No other recurring adverse events or problems associated with the implants were identified. Forty-four patients were evaluated prospectively at a mean follow-up of 32±7 months. Lysholm scores and patient satisfaction scores were positively and significantly correlated with Tegner activity scores (r=0.61; P<.0001). Eighty-two (82%) patients had a KT-1000 (Medmetric Corp, San Diego, California) side-to-side difference of less than 3 mm (average, 0.4 mm). No indications of femoral device migration existed when comparing follow-up and immediate postoperative radiographs. The AperFix System provides durable femoral aperture fixation during anterior cruciate ligament reconstruction with excellent clinical outcome scores and a low complication rate.

Selected anatomists: at the boundary of contemporary ethics.

Fascination with the interworkings of the human body has permeated scientific discovery for eons. Materials for dissection proved problematic for anatomists. Andreas Vesalius solved his dilemma by visiting local gallows where criminals had been executed. Eduard Pernkopf has been alleged to have taken some of his materials from victims of the Holocaust. Even today, executed criminals have served as subjects for anatomical educational purposes. These circumstances are explored and the contemporary ethics of each are compared.

Endovascular repair of infrarenal aortic aneurysms in octogenarians and nonagenarians.

OBJECTIVE: The purpose of this report was to present short and midterm results of endovascular aortic aneurysm repair (EVAR) of infrarenal aortic aneurysms in octogenarians and nonagenarians. METHODS: Between March 1994 and March 2011, elective EVAR was performed in 967 patients in our institution. This includes 279 patients older than 80 years at the time of the procedure (octogenarians: n = 252, nonagenarians: n = 27). Mean follow-up was 48.4 ± 34.5 months. A retrospective analysis was performed. Survival was calculated using Kaplan-Meier analysis and a survival comparison to patients who underwent EVAR <80 years old (n = 688) was performed. Cox hazard regression analysis was used to assess parameters that influence survival. RESULTS: Technical success was 96% in octogenarians and 85% in nonagenarians. Technical failure in 15 of 279 patients includes primary type I endoleak (n = 6), procedure abortion due to inability to pass the iliac vessels (n = 6), and emergency conversion (n = 3). Thirty-day mortality was significantly higher for patients >80 years old (2.8% vs 1.0%; P = .044). Morbidity rates were 11.5% for octogenarians and 7.4% for nonagenarians with predominately cardiopulmonary complications. High-risk patients >80 years old showed a comparable perioperative mortality rate to low-/medium-risk patients >80 years old (2.9% vs 2.5%;P = .717), but a significantly higher complication rate (22.5% vs 9.2%; P = .0275) and reduced midterm survival with 1-, 3-, and 5-year survival rates of 79% ± SE 7%, 55% ± SE 8%, and 38% ± SE 9% (log-rank test P = .03). In high-risk patients age >80 years old, their age did not influence 30-day mortality (2.5% vs 2.7%; P = .978) and midterm survival. Survival in octogenarians at 1, 3, and 5 years was 87.9 ± SE 2.1%, 70.9 ± SE 3.0%, and 55.6% ± SE 3.5%, respectively. Survival in nonagenarians at 1 and 3 years was 96.3% ± SE 4% and 60.6% ± SE 10.4%. Higher cardiac (hazard ratio [HR], 1.22; P = .038) and renal risk scores (HR, 1.59; P = .0016), chronic obstructive pulmonary disease (HR, 1.56; P = .032), and anemia (HR, 2.1; P < .001) influenced midterm survival. CONCLUSION: EVAR in octogenarians and nonagenarians is associated with a significantly higher but still low perioperative mortality compared to younger patients. Midterm survival in octogenarians and nonagenarians, although significantly lower than in younger patients, is still acceptable, indicating that age >80 years should not be an exclusion criteria for EVAR. Even high-risk patients >80 years can be treated safely with a low perioperative mortality and comparable midterm outcome to younger high-risk patients.