Distal femoral fracture during primary total knee arthroplasty.

PURPOSE: To review 6 cases of periprosthetic distal femoral fracture during total knee arthroplasty (TKA). METHODS: Of 778 women and 691 men who underwent primary TKAs using posterior-stabilised (n=1240), cruciate-retaining (n=165), or semiconstrained (n=64) implant, 5 women and one man with a mean age of 73.3 years and a mean body mass index of 31.6 kg/m(2) sustained an intra-operative periprosthetic distal femoral fracture and were followed up for a mean of 12.8 (range, 2-39) months. RESULTS: Respectively in patients with a posterior-stabilised, cruciate-retaining, or semi-constrained implant, the intra-operative fracture rates were 0.32%, 0%, and 3.13%. For women, the respective rates were 0.46%, 0%, and 5.10%. Intra-operative fracture was 9.69 times (p=0.03) more likely to occur in patients with a semi-constrained implant than those with a posterior-stabilised implant, and was 4.44 times (p=0.22) more likely to occur in women than in men. Half of the fractures occurred during the trial phase when the tibia was reduced onto the femur, and half during final prosthesis implantation. CONCLUSION: Distal femoral fracture during primary TKA is rare and associated with the use of a semiconstrained implant. Preserving as much bone in the distal femur is advised.

Thoracic renal artery: a rare variant. A case study and literature review.

BACKGROUND: Variations in the course of paired renal arteries are common and are known causes of iatrogenic injury. However, a thoracic origin of the renal artery is rare and poses a greater risk for iatrogenic injury especially during thoracic endovascular or surgical interventions. PURPOSE: To describe a renal artery variant, its clinical implications in the context of procedural interventions, and to provide a literature review on renal artery variations. METHODS: An abdominal CT scan with IV contrast was obtained using a GE 64-slice helical CT scanner with subsequent sagittal, coronal, and 3-D reformations. A literature review was performed using Index Medicus. RESULTS: Right renal artery variant arising from the thoracic aorta at the lower aspect of the T10 vertebral body, coursing posteroinferiorly through the right diaphragmatic crux before reaching the right kidney hilum. CONCLUSION: A thoracic origin of the renal artery is an uncommon but important risk factor for vascular injury during endovascular and surgical interventions especially in the thorax. 3-D CT or CT angiography prior to an indicated procedure may prove useful for pre-interventional planning.

Surgical treatment of a brown recluse spider bite: a case study and literature review.

Spider bite envenomation can cause local, constitutional, and/or systemic symptoms. The present case study reports on 5 years of follow-up for a "probable" brown recluse spider bite of the foot and ankle that was refractory to conservative treatment and was subsequently treated with surgery. The present case study reports the atypical occurrence of long-term peripheral neuropathy after necrotic arachnidism induced by "probable" brown recluse (Loxosceles recluse) envenomation, in a 46-year-old male. The state of published data suggests to minimize inflammation and tissue necrosis, prevent bacterial superinfection, and control pain levels. For patients with long-term peripheral neuropathy refractory to conservative therapy, surgical intervention may further improve their symptoms.

Extensor mechanism reconstruction with achilles tendon allograft in TKA: results of an abbreviate rehabilitation protocol.

Various treatment alternatives address extensor mechanism failure after total knee arthroplasty. We present the results of a protocol utilizing Achilles tendon allograft followed by an abbreviated immobilization program to treat extensor mechanism disruptions after TKA in 29 knees (27 patients). Failed reconstruction was defined as mechanical allograft failure requiring re-intervention, extension lag >30°, recurrent falls, regression to a lower ambulatory status, and revision due to infection. With mean follow-up of 3.5 years, seventeen cases (58.6%) had satisfactory results, eleven cases (37.9%) were considered failures, and one case was lost to follow-up. Among failures, eight (27.5%) underwent reoperation with four (13.8%) due to late infections. Our observational data suggest that 1) a shortened immobilization protocol yields less favorable results than expected, and 2) continuous monitoring of patients who had allograft reconstruction for possible development of late infection is recommended.

Change in spinal alignment after total hip arthroplasty.

OBJECTIVE: The study hypotheses were that: (i) there would be a difference in sagittal plane alignment between patients with symptomatic osteoarthritis of the hip and those with lumbar degenerative disk disease; and (ii) that sagittal plane lumbar alignment would change following total hip arthroplasty (THA). METHODS: In this prospective study, a series of patients without back pain or lumbar complaints who were scheduled to undergo THA underwent lateral lumbar radiography prior to and nine months after elective THA. Radiographic measurements of lumbar alignment included sacral slope, lumbar lordosis, and L1 axis S1 distance (L1 ASD). All measurements were performed on upright, standing, lateral radiographs. A control group of patients underwent serial radiography over the same period for evaluation of lumbar degenerative disease. The independent sample t-test was used to compare the mean sacral slope, lumbar lordosis, and L1 ASD in the THA and control groups. RESULTS: There were 12 patients in the THA group and 34 in the control group. Mean follow-up was 9 months. Average age in the control group was 63 years and in the THA group 64.2 years. The sacral slope was greater in the THA group (mean, 23°) than in the lumbar patients (control group) and this difference was statistically significant (mean, 11°, P = 0.001). There were no statistically significant differences between THA and control patients in lumbar lordosis or L1 ASD. Change before and after THA was measured. There were no statistically significant differences in assessed radiographic variables preoperatively versus postoperatively. CONCLUSION: There is no significant change in spinal alignment after unilateral THA. At baseline, patients with symptomatic spine complaints have less sacral slope than their hip arthroplasty counterparts.

Hyperbaric oxygen for osteomyelitis in a compromised host.

Post-traumatic osteomyelitis is a rare but debilitating complication of closed fractures. Most infections can be resolved with aggressive debridement, intravenous antibiotics, and hardware removal. However, the eradication of infection can be challenging in a patient with multiple comorbidities. Refractory infection may require suppressive therapy or amputation to control the disease. Improvements in care have led to improved survival for this population, posing new challenges in their post-traumatic care. We report on the successful use of hyperbaric oxygen therapy as an adjunct in a compromised host with recurrent post-traumatic osteomyelitis despite aggressive debridement, removal of instrumentation, and several courses of intravenous antibiotic therapy. Hyperbaric oxygen may be considered as an adjunct to standard treatment protocols for refractory osteomyelitis in compromised hosts.

Should We Use Preoperative Epoetin-α in the Mildly Anemic Patient Undergoing Simultaneous Total Knee Arthroplasty?

Simultaneous knee arthroplasty is associated with significant blood loss. To prevent transfusion, three preoperative doses of epoetin-α were offered to mildly anemic simultaneous knee arthroplasty patients. A retrospective review, using ICD-9 codes, identified twenty patients from 2007-2009. Epoetin-α increased hemoglobin levels preoperatively (12.6 to 13.9, p<0.01). Twenty patients who did not receive epoetin-α were matched to study patients. Study patients were transfused less (55% vs 95%, p=0.012) and had similar inpatient length of stay. The average blood loss without transfusion was 4.6g/dL. The mildly anemic patient is at high-risk for packed red cell transfusion during simultaneous knee arthroplasty. Three preoperative doses of epoetin-α in the mildly anemic patient decreased total transfusions; however, it did not affect inpatient length of stay.

Comparison of open and minimally invasive techniques for posterior lumbar instrumentation and fusion after open anterior lumbar interbody fusion.

BACKGROUND CONTEXT: Minimally invasive techniques for spinal fusion have theoretical advantages for the reduction of iatrogenic injury. Although this topic has been investigated previously for posterior-only interbody surgery, such as transforaminal lumbar interbody fusion, similar studies have not evaluated these techniques after anteroposterior spinal fusion, a study design that can more accurately determine the effect of pedicle screw placement and decompression via a minimally invasive technique without the confounding effect of simultaneous interbody cage placement. PURPOSE: To compare process measures that provide insight into the morbidity of surgery, such as surgical time and the length of postoperative hospital stay between open and minimally invasive anteroposterior lumbar fusion; and to compare the complications during the intraoperative and early postoperative period between open and minimally invasive anteroposterior lumbar fusion. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: One hundred sixty-two patients. OUTCOME MEASURES: Estimated blood loss, length of surgery, intraoperative fluoroscopy time, length of postoperative hospital stay, malpositioned instrumentation on postoperative imaging, and postoperative complications, including pulmonary embolus and surgical site infection. METHODS: Patients who underwent open anterior lumbar interbody fusion followed by either traditional open posterior fusion (Open group) or minimally invasive posterior fusion (minimally invasive surgery [MIS] group) were matched by the number of surgical levels. A chart review was performed to document the intraoperative and postoperative process measures and associated complications in the two groups. Secondary analyses were performed to compare the subgroups of patients, who did and did not undergo a posterior decompression at the time of posterior instrumentation to determine the effect of decompression. RESULTS: Baseline characteristics were similar between the Open and MIS groups. Estimated blood loss and postoperative transfusion rate were significantly higher in the Open group, differences that the subanalyses suggested were largely because of those patients who underwent concomitant decompression. Length of stay was not significantly different between the groups but was significantly shorter for MIS patients treated without decompression than for Open patients treated without decompression. Intraoperative fluoroscopy time was significantly longer in the MIS group. There was no difference in the infection or complication rates between the groups. CONCLUSIONS: Our case-control study comparing patients who underwent anterior lumbar interbody fusion followed by open posterior instrumentation with those who underwent anterior lumbar interbody fusion followed by minimally invasive posterior instrumentation demonstrated that patients undergoing MIS fusion without decompression had less blood loss, less need for transfusion in the perioperative period, and a shorter hospital stay. In contrast, most outcome measures were similar between MIS and Open groups for patients who underwent decompression.

The Use of Epoetin-α in Revision Knee Arthroplasty.

Introduction. To evaluate the efficacy of epoetin-α prior to revision total knee arthroplasty, we hypothesized that epoetin-α will reduce blood transfusion. Methods. Eighty-one patients were compared in this retrospective review; twenty-eight patients received our dosing regimen. All patients were mildly anemic. Epoetin-α to control (1 : 2) patient matching occurred so that one of two attending surgeons, gender, BMI, complexity of surgery, ASA score, and age were similar between groups. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used. Results. Blood transfusion and length of stay were lower in the study group. None of the patients who received epoetin-α underwent transfusion. Hemoglobin increased from 11.97 to 13.8, preoperatively. Hemoglobin at day of surgery and time of discharge were higher. Gender, BMI, ASA score, total and hidden blood losses, calculated blood loss, preop PLT, PT, PTT, and INR were similar between groups. One Epogen patient had an uncomplicated DVT (3.6%). Conclusions. Epoetin-α may have a role in the mildly anemic revision knee patient. It may also decrease patient length of stay allowing for earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted.

The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial.

BACKGROUND: The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment. METHODS: One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group). RESULTS: There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001). CONCLUSIONS: Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

The Use of Preoperative Epoetin-α in Revision Hip Arthroplasty.

PURPOSE: To evaluate the efficacy of preoperative epoetin-α on the revision hip arthroplasty patient. We hypothesized that epoetin-α will reduce blood transfusion. A pertinent review of the literature is provided. METHODS: Forty-six patients were retrospectively reviewed. Sixteen patients received epoetin-α. Patients were case matched by age, preoperative hemoglobin, surgery, gender, and BMI. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used. RESULTS: Blood transfusion and length of stay were decreased in the epoetin-α group. Hemoglobin in the intervention group increased from 12.0 to 14.5, preoperatively. Patients who received epoetin-α were 0.78 (RR=0.225) times as likely to receive a transfusion. Number Needed to Treat (NNT) to avoid one allogeneic transfusion was 1.84. Age, Gender, BMI, ASA, total and hidden blood loss, preoperative Iron supplements, preop Hct, preop PLT, PT, PTT, and INR were similar. One (6.0%) patient developed an uncomplicated deep venous thrombosis in the intervention group. CONCLUSIONS: The mildly anemic revision hip arthroplasty patient is at increased risk for transfusion. Epoetin-α increased preoperative hemoglobin counts and reduced transfusions in this study; it also decreased patient length of hospital stay likely allowing for an earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted.

What are young patients doing after hip reconstruction?

We assessed primary hip arthroplasty patients younger than 50 years in terms of activity and function. We hypothesized that young patients are more active than previously thought. Physician activity recommendations were compared with patient-reported participation levels in activities. Sixty-one patients (65.3%) were reached by telephone. Average age was 43.18 years; body mass index, 29.46. "Recommended activities" increased by 33%. High-Activity Arthroplasty Score and University of California at Los Angeles scores were 11.69 and 6.87, respectively. Patients were 98% satisfied with their postoperative function, and 95% would redo the procedure. Activities stopped due to fear of injury (29%), physician recommendation (26%), hip pain (14%), early fatigue (17%), and decreased interest (14%). The average period to postoperative survey administration was 30.06 months (range, 10-81 months). Postoperative recommendations for the young total hip arthroplasty patient should be a balance between joint prosthesis preservation and regular activity participation.

Aberrant iliac artery: far lateral lumbosacral surgical anatomy.

A 44-year-old man presented after 3 weeks of progressively worsening atraumatic onset pain in the right anteromedial thigh. The pain was sharp and radiated to the anteromedial shin and medial foot. The patient had no associated weakness, numbness, or bowel/bladder dysfunction. Nonsteroidal anti-inflammatory, pain, and neuropathic-relieving drugs had limited effect. He underwent interlaminar injections, which provided transient relief of his shin symptoms. After conservative management failed, a spine surgeon (not affiliated with our practice) recommended an anterior lumbar interbody fusion via far lateral approach. The patient presented to our spine clinic for a second opinion. Closed magnetic resonance imaging revealed an aberrant iliac artery impinging on the lumbar plexus and a foraminal herniation at L4-L5 on the right, an orientation more lateral than expected or seen on the contralateral side. We recommended physical therapy that focused on core strength and adequate stretching prior to considering surgery. The patient's symptoms have since resolved. Common iliac artery anomalies are rare. No known incidence exists. The finding in this case was incidental and, if missed, could have led to vascular compromise. To prevent such an injury during minimally invasive (transpsoas lateral approach) spine surgery, we recommend careful examination of radiographs for aberrant vessels.

Current management review of thoracolumbar cord syndromes.

BACKGROUND CONTEXT: Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES). PURPOSE: To review the current management of thoracolumbar spinal cord injuries. STUDY DESIGN: Literature review. METHODS: Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options. RESULTS/CONCLUSIONS: After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.

Total knee arthroplasty using a hybrid navigation technique.

The use of computer navigation is becoming a well-recognized technical alternative to conventional total knee arthroplasty (TKA). However, computer navigation has a substantial learning curve and the use of commercially available navigation systems increases surgical time. In addition, the potential risks associated with the navigation TKA, such as, registration errors, notching of the anterior femoral cortex, oversizing of the femoral component, and overresection must be taken into consideration. On the other hand, conventional techniques are familiar and intuitive to most practicing surgeons, and thus, are easier to perform and are less prone to anterior notching and femoral component oversizing. However, conventional techniques have greater risks of inaccurate and inconsistent component alignment than computer navigation. This paper describes a novel technique that combines computer navigation and conventional TKA.

Pulmonary cement embolization after kyphoplasty: a case report and review of the literature.

BACKGROUND CONTEXT: Kyphoplasty is performed for the treatment of osteoporotic compression fractures. A theoretical advantage of this technique is the reduced risk of embolization of cement. STUDY DESIGN/SETTING: Case report of an incidental finding of cement pulmonary embolization after kyphoplasty of an osteoporotic vertebral compression fracture. METHODS/RESULTS: Here we report a patient who presented with an incidental finding of pulmonary embolization after kyphoplasty and review the relevant literature. CONCLUSIONS: Patients who present with symptoms of respiratory distress after kyphoplasty should undergo workup for pulmonary embolism. Clinicians may consider routine postoperative chest radiographs after kyphoplasty to screen for embolic disease. Further research is necessary to identify the risk factors and possible long-term sequelae of cement embolization.