Low-dose Preoperative Unshielded Radiation Is Effective in Heterotopic Ossification Prophylaxis and Does Not Affect Porous Fixation in Total Hip Arthroplasty at 2 Years Minimum Follow-up: A Radiographic Study.

BACKGROUND: Heterotopic ossification (HO) is a frequent complication of total hip arthroplasty (THA). HO can cause pain, limitation of range of motion, and instability. Radiation therapy (RT) for HO prophylaxis is well established but may interfere with early porous ingrowth and pullout strength of implants, as suggested by two animal studies. Although shielding of the bone from irradiation may theoretically protect ingrowth, it has been found to reduce RT effectiveness. Despite the popularity of porous implants in THA, the frequency of HO, and use of RT in its prophylaxis, the effect of RT on porous implant fixation in THA has not been previously reported. At our institution, we use unshielded, single-dose, preoperative 700 to 800 centigrays RT for HO prophylaxis in high-risk patients. We hypothesize that this RT protocol is effective and the press-fit technique protects porous implants during early ingrowth; therefore, long-term implant fixation is not compromised. METHODS: This was a retrospective study aiming to determine fixation of porous THA implants, healing of trochanteric osteotomies, and efficacy of HO prophylaxis with this RT protocol. RESULTS: Thirty-nine patients with follow-up of 24 to 144 months (average 59.7 months) were included. All 26 porous-coated femoral implants (11 revisions and 15 primary) were well fixed. There were 33 porous-coated acetabular implants (18 revisions and 15 primary). Thirty (91%) were well fixed, and three revision implants (9%) demonstrated radiolucent lines in two zones, but patients were clinically asymptomatic. All nine trochanteric osteotomies healed uneventfully. RT provided effective HO prophylaxis in 33 of 39 hips (85%). CONCLUSIONS: Single, low-dose, preoperative RT without shielding does not increase aseptic loosening of porous implants manufactured with plasma porous spray or nonunion of extended trochanteric osteotomies. This protocol provides effective HO prophylaxis in high-risk patients undergoing primary and revision THA.

Proximal Femoral Bone Cyst After Single Screw Fixation for Slipped Capital Femoral Epiphysis: A Case Report.

CASE: An 11-year-old female patient underwent bilateral in situ fixation for slipped capital femoral epiphyses using single, cannulated, stainless steel screws. She presented 12 years later with a large osteolytic lesion of the proximal femur, which only involved 1 side. Histological evaluation showed a foreign-body reaction and synovial lining. Infection was ruled out and dynamic hip screw stabilization, and bone grafting were performed. The bone graft healed, and the hardware was removed to prevent a similar reaction. In retrospect, postoperative radiographs at 7 weeks showed subtle osteolysis along the screw. CONCLUSION: Intra-articular drilling, vertical screw placement into the posterior epiphysis, and the prominent screw head may have led to this unexpected complication.

Intermediate-Term Results of 142 Single-Design, Rotating-Hinge Implants: Frequent Complications May Not Preclude Salvage of Severely Affected Knees.

Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary procedures and 131 revisions) at 57 months follow up. Implant survival was 73%. Successful two-stage reimplantation for prosthetic infection was 78.4% but new infection rate was 22%. The tibial component was durable while the femoral component was problematic. We observed only one patellar maltracking and no polyethylene wear. A third generation rotating-hinge arthroplasty reconstruction was reliable in complex problems. Outcomes in primary situations were excellent. Complications were the rule rather than the exception in revisions. With timely intervention, attention to soft tissue coverage, and realistic expectations, complications were contained and functional benefits were appreciable.

Anterior distal femoral osteotomy for removal of long femoral stems in revision knee arthroplasty.

Osteotomies of the proximal femur and proximal tibia in revision arthroplasty are well described while guidelines for distal femoral osteotomy are limited. Femoral stems are used with increasing frequency for fixation of revision components in knee arthroplasty and their removal is technically challenging particularly in the setting of infection. We describe a technique of anterior distal femoral osteotomy for revision knee arthroplasty to assist with removal of well-fixed long stemmed cemented or porous femoral components, as well as debridement of infection while preserving bone stock and soft tissue attachments.

Low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty.

Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose irradiation and Constrained Condylar or Rotating-hinge revision for severe, idiopathic arthrofibrosis. Irradiation may decrease fibro-osseous proliferation while constrained implants allow femoral shortening and release of contracted collateral ligaments. Fourteen patients underwent fifteen procedures for a mean overall motion of 46° and flexion contracture of 30°. One patient had worsening range of motion while thirteen patients had 57° mean gain in range of motion (range 5°-90°). Flexion contractures decreased by a mean of 28°. There were no significant complications at a mean follow up of 34 months (range 24 to 74 months).

Intramedullary rod and cement static spacer construct in chronically infected total knee arthroplasty.

Two-stage reimplantation, with interval antibiotic-impregnated cement spacer, is the preferred treatment of prosthetic knee joint infections. In medically compromised hosts with prior failed surgeries, the outcomes are poor. Articulating spacers in such patients render the knee unstable; static spacers have risks of dislocation and extensor mechanism injury. We examined 58 infected total knee arthroplasties with extensive bone and soft tissue loss, treated with resection arthroplasty and intramedullary tibiofemoral rod and antibiotic-laden cement spacer. Thirty-seven patients underwent delayed reimplantation. Most patients (83.8%) were free from recurrent infection at mean follow-up of 29.4 months. Reinfection occurred in 16.2%, which required debridement. Twenty-one patients with poor operative risks remained with the spacer for 11.4 months. All patients, during spacer phase, had brace-free ambulation with simulated tibiofemoral fusion, without bone loss or loss of limb length.

Cerclage wire-plate composite for fixation of quadrilateral plate fractures of the acetabulum: a checkrein and pulley technique.

Acetabular fractures with complete or incomplete quadrilateral plate separation frequently present with central displacement of the femoral head. Failure of stable fixation of medial wall fractures leaves residual subluxation despite reduction of other fracture components. Several fixation techniques may be either technically demanding or insufficient for stable fixation in conditions of comminution, osteoporosis, or neglected injuries. The proposed wire-plate composite uses a reconstruction spring plate over the pelvic brim for medial wall buttressing. One hole on its true pelvic limb provides a pulley to deviate a cerclage wire or cable passed through the greater sciatic notch into the true pelvis. This enhances buttressing against medial protrusion. Application through anterior approaches is simple and fixation is reliable in difficult fractures without the risk of joint penetration because all quadrilateral plate buttressing implants remain extraosseous.

Decancellation sacral osteotomy in iliosacral tumor resection: a technique for precise sacral margins.

En bloc resection of iliosacral sarcomas is a surgical challenge. There are substantial risks of inadequate margins, local recurrence, and nerve root loss when pelvic sarcomas involve sacral root canals and foramina. The decancellation technique uses principles similar to transpedicle decancellation in spinal deformity correction to perform the sacral osteotomy in iliosacral tumor resection. The technique aims at improving sacral margins and minimizing loss of neural function. We performed a decancellation osteotomy in five patients with sarcomas requiring difficult oblique or sagittal sacral osteotomies and selective root sacrifice. Through laminectomy and without anterior exposure, a precise full-thickness osteotomy of the sacrum was performed without major technique-related morbidities or complications. This was followed by formal pelvic resection and reconstruction. Surgical margins were adequate in all patients and all tumor-free nerve roots were preserved.

The subinguinal retroperitoneal approach for fractures of the acetabulum: a modified ilioinguinal approach.

The classic ilioinguinal approach is a standard procedure with reportedly high success rates in many displaced fractures of the acetabulum. Intraarticular visualization and exposure of the anterior wall and the quadrilateral plate are its main limitations. We propose a subinguinal approach based on the principle used for oncologic procedures that naturally require large exposures. The approach involves a retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allow ample exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the apparent magnitude of the procedure, closure is fairly simple and anatomical because repair of the inguinal canal floor is not required. This modification may compensate for the limitations of the classic approach without additional risks or morbidities.