A Case Report of Giant Cell Tumor in the Thumb Distal Phalanx.

INTRODUCTION: The following report describes a rare case of giant cell tumor (GCT) of the bone that presented in the distal phalanx of the thumb. GCT of the bone is a relatively rare, and typically benign condition that presents most frequently in the metaphysis of long bones in women age 30-50 years old. There are only three other instances in the literature describing GCT of the bone presenting in the distal phalanx of the thumb. Although rare, delayed or missed diagnosis can be very debilitating to the patient. CASE REPORT: A 28-year-old male laborer who is right hand dominant and works with his hands for a living presented to the emergency department (ED) with swelling and pain at the distal aspect of his left thumb with no known injury. The patient was seen 4 weeks previously and was treated for cellulitis of the hand with antibiotics. At that time, no radiographs were taken. Despite this treatment, the patient reported increased swelling and pain over the next 2 weeks. He then sought treatment in the ED where a hand surgeon was consulted and radiographs were obtained that displayed a lytic, disruptive, and mildly expansile lesion of the distal phalanx of the first finger concerning for sarcoma. The risks and benefits of surgery were discussed with the patient and surgical intervention was planned. CONCLUSION: Due to how rarely this condition presents clinically, the patient was initially misdiagnosed and definitive treatment was delayed. Although rare, this is an important diagnosis to consider in patients presenting similarly. The patient ultimately received adequate treatment, but the delay in diagnosis in combination with the locally aggressive nature of this tumor could have led to extensive surgical intervention with impairment in hand function. As a laborer whose income relies on daily use of his hands a delayed diagnosis; in this case could have had a catastrophic impact.

Improved outcomes in patients with positive metal sensitivity following revision total knee arthroplasty.

BACKGROUND: Metal sensitivity as a cause for painful joint replacement has become increasingly prevalent; however, there is a lack of reported clinical outcome data from total knee arthroplasty patients with metal allergies. The purpose of this study was to determine whether patients presenting with a painful total knee arthroplasty with a positive metal sensitivity have improved outcomes following revision to a hypoallergenic implant. METHODS: A retrospective review was conducted for patients that underwent a revision total knee arthroplasty after metal sensitivity testing over a 3-year period from January 1, 2015, to December 31, 2017. Based on the results of sensitivity testing, patients underwent revision total knee arthroplasty to a hypoallergenic component or a standard component. Following revision, patients returned to the clinic at an interval of 6 weeks, 5 months, and 12 months for functional, pain, and satisfaction assessment. Outcomes were compared within and between sensitivity groups. RESULTS: Of the included patients, 78.3% (39/46) were positive for metal sensitivity. The most common metal sensitivity was to nickel (79.5%, 32/39). Both non-reactive and reactive patients significantly improved in range of motion after revision arthroplasty. The reactive group saw a 37.8% decrease in pain at 6 weeks post-revision (p < 0.001) Whereas, the non-reactive group only saw a moderate, non-significant improvement in pain reduction at 6 weeks post-revision (27.0%; p = 0.29). Frequency of pain experienced did not vary significantly between groups. Maximum metal lymphocyte transformation test (LTT) sensitivity score did not correlate with pain level at the time of revision (R2 = 0.02, p = 0.38) or percent improvement after revision (R2 = 0.001, p = 0.81). Overall, all patients reported being very satisfied after revision total knee arthroplasty; there was no difference between positive and negative sensitivity groups (W = 62, p = 0.89). CONCLUSIONS: Patients presenting with a painful knee arthroplasty and positive metal LTT have improved pain scores, walking function, and range of motion following revision to a hypoallergenic component. This study also provides a treatment algorithm for patients presenting with a painful knee replacement, in order to provide effective and timely diagnosis and management.

Arthroscopic Treatment of Popliteal Cysts.

Popliteal cysts, often referred to as Baker's cysts, are a common occurrence in the adult knee. Although controversy exists as to the exact indications for treatment, these structures can cause extreme discomfort and morbidity, including pain from rupture and symptoms from neurovascular compromise. Prior to the development of the arthroscope, open treatment of popliteal cysts was not uncommon. Complications such as poor wound healing, cyst recurrence, and knee flexion contractures were reported after such treatment. Owing to the presence of a valve-type structure, also called the posterior transverse synovial infold, there is 1-way flow of synovial fluid into the cyst. Although seldom described, there is a reproducible and relatively straightforward arthroscopic treatment for this pathology. This technical report will describe the arthroscopic treatment of popliteal cysts and clarify the posterior knee anatomy that gives the surgeon the landmarks to perform safe and effective arthroscopic treatment of popliteal cysts.

Catastrophic failure of a dual mobility bearing in a revision total hip arthroplasty.

The following case demonstrates an example of a catastrophic failure of a dual mobility (DM) bearing used in the setting of a revision total hip arthroplasty for an acetabular component with an excessive abduction angle. Currently, in the literature, it has been demonstrated that DM bearings have decreased polyethylene wear at abduction angles up to 65°; however, this has only been shown in in vitro studies. To our knowledge, there have been no reports of in vivo DM bearings that have demonstrated these same results. In this case, a DM bearing was used in a revision surgery with a retained acetabular component that had an abduction angle of approximately 70°-75° which ultimately led to catastrophic polyethylene failure.

Superior rim fracture of a vitamin E-infused highly cross-linked polyethylene (HXLPE) liner leading to total hip arthroplasty revision.

This case report looks at the failure of a vitamin E-infused highly cross-linked polyethylene acetabular liner that fractured at the superior rim of the locking mechanism. This calls to question whether there is a problem with the vitamin E-infused product or a flaw in the design of the liner or possibly a combination of the 2. Although there has been discussion of a possible minimum rim polyethylene thickness, there has not been a minimum thickness established. In addition, in the case of offset liners, indentations which are a part of a locking mechanism can cause the minimum rim dimension to be much less than the specified nominal thickness. This case serves as an interesting observation and contributes to the discussion of rim liner polyethylene thickness and minimum rim thickness.

Topical Tranexamic Acid Reduces Postoperative Blood Loss in Primary Total Hip and Knee Arthroplasty.

CONTEXT: The purpose of this study was to assess the effectiveness of topical pre-closure application of tranexamic acid (TXA) to reduce postoperative blood loss and blood transfusion rates in primary total hip and knee arthroplasty (THA and TKA) in a private, high-volume orthopedic specialty hospital setting. METHODS: This was a retrospective study examining 140 consecutive patients undergoing primary hip or knee arthroplasty at the sample setting by a single surgeon. The first 70 patients did not receive topical TXA (2 gm./20ml.), the final 70 did receive topical TXA. We compared the postoperative hemoglobin levels of both sample subgroups at postoperative days 1, 2, and 3. RESULTS: Overall, the postoperative hemoglobin levels were significantly higher in the TXA group on postoperative days 1, 2, and 3 (p < 0.05). When patients who underwent THA (n = 70) were investigated separately, the hemoglobin levels were significantly higher on postoperative days 1, 2, and 3 in the group that received TXA. In the TKA group (n = 70), there was not a significantly higher hemoglobin level in patients who received TXA. There were no blood transfusions in the entire study cohort. Possibly due to the more restrictive transfusion criteria employed in this study, the total estimated prospective cost savings from use of TXA was calculated at about $116 per patient. CONCLUSIONS: Based on these results from a high volume orthopedic specialty hospital, pre-closure topical TXA application may prove effective in reducing postoperative blood loss for some patients but have a relatively small impact on cost outcomes.