Patient Reported Outcomes from Sacroiliac Joint Fusion.

STUDY DESIGN: Retrospective, case series. PURPOSE: The purpose of this study is to determine morbidity, complications, and patient reported outcomes from minimally invasive sacroiliac joint (SIJ) fusion. OVERVIEW OF LITERATURE: Lumbar back pain emanating from the SIJ can be surgically treated via a percutaneous approach in the appropriately selected patient with minimal morbidity and acceptable functional outcomes. METHODS: Patients diagnosed by >2 physical examination maneuvers and subjective relief from a computed tomography-guided lidocaine-bupivacaine-steroid injection underwent SIJ fusion after failing conservative management with a combination of oral anti-inflammatory medications, physical therapy, and pelvic belt stabilization. Perioperative data collected include estimated blood loss (EBL) and operative time. Oswestry disability index, 12-item short form health survey (SF-12), visual analogue score, and functional status were analyzed. All complications were noted. RESULTS: The study cohort of 45 cases (69% female) achieved postoperative survey follow-up at 9.9 and 32.3 months. SF-12 physical component summary statistically improved while all other scores were equivalent. Mean EBL and operative time were 22 mL and 36 minutes, respectively. Initial survey showed that 64% of patients discontinued narcotics (29/45), 71% do not use an assistive device (32/45), and 15.6% do not work due to pain (7/45). 73% of patients stated they would have the surgery again (33/45). For the second survey, 65% of patients discontinued narcotics (26/40), 70% did not use an assistive device (28/40), and 17.5% did not work due to pain (7/40). A history of thoracolumbar instrumentation (16/45) did not significantly affect outcomes. Three complications described by screw malposition with neurologic deficit (6.7%) were treated with screw repositioning (1 case) and removal of a single superior implant (2 cases) with time to revision of 2.2 months. All three ultimately had resolution of radicular pain. CONCLUSIONS: Percutaneous SIJ fusion offers minimal morbidity and acceptable functional outcomes. While women and those with a prior history of lumbar instrumentation may be at increased risk of having SIJ dysfunction requiring surgical intervention, it was not found to affect postoperative functional outcomes when compared to the non-instrumented group.

A Review of Atypical Femoral Fractures From a Tertiary Care Teaching Hospital: An Alarming Trend?

OBJECTIVE: To evaluate the experience of a single tertiary care teaching hospital with the association between use of bisphosphonates and atypical femoral fractures, and to identify potential risk factors and chronologic incidence. DESIGN: Retrospective review. SETTING: Tertiary-care teaching hospital. PATIENTS: Thirty-two patients with a total of 43 fractures met inclusion criteria. INTERVENTION: Treatment for atypical femur fractures. MAIN OUTCOME MEASUREMENTS: Radiographic assessments, duration of bisphosphonate therapy, prodromal symptoms, associated medications/comorbidities. RESULTS: Thirty-one female patients and 1 male patient, with a total of 43 fractures, with an average age of 71.0 (47-92 years) ± 11.01 years at time of fracture, had an average duration of bisphosphonate therapy of 7.57 (1-12 years) ± 3.07 years. Prodromal thigh pain was reported in 20 of 43 fractures (46.5%). Eleven of the forty-three (25.5%) fractures occurred between 2001 and 2005. From 2006 to May 2011, however, 32/43 (74.5%) were reported. Beta-blockers, ACE/ARBs, and Statins (43.8%) were the most common concomitant medications, whereas Levothyroxine (21.8%), H-2 blockers (15.6%), and Glucocorticoids (12.5%) were less common. CONCLUSIONS: There is an increasing trend of atypical femur fractures in the current adult population. Bisphosphonate therapy beyond 7 years may place patients at increased risk. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Coracoid fracture after reverse total shoulder arthroplasty: a report of 2 cases.

Although reverse total shoulder arthroplasty is largely successful, there are still complications that require appropriate diagnostic workup and treatment. These 2 cases of patients with a coracoid fracture were encountered at 3 months and 15 months after reverse total shoulder arthroplasty. One patient presented with new-onset pain in the coracoid region without significant functional deficit, and the other presented with functional deficit and complaint of a strange noise at the anterior aspect of the operative shoulder. While standard radiographs did not detect the fracture, computed tomography imaging was sufficient to establish the diagnosis. Ultimately, nonoperative management led to resolution of these symptoms.

The treatment of periprosthetic femur fractures after total knee arthroplasty.

Periprosthetic femur fractures after total knee arthroplasty are a rising concern; however, when properly diagnosed, they can be managed nonoperatively or operatively in the form of locking plate fixation, intramedullary nailing, and arthroplasty. The degree of osteoporosis, stability of the femoral implant, and goals of the patient are a few critical variables in determining the ideal treatment. Despite excellent outcomes from each of these operative choices, the risk of nonunion, malunion, instability, and refracture cannot be ignored.

Elbow injuries in the throwing athlete.

High valgus and extension loads imparted to the athlete's elbow during repetitive overhead throwing can lead to acute and chronic pathology. Over time, normal soft tissue and bony stabilizing structures of the elbow undergo progressive structural changes and can succumb to injury. Modern diagnostic modalities, including plain radiographs, computed tomography, and magnetic resonance imaging, in addition to arthroscopy, can aid in diagnosis. Although nonoperative management is often successful, surgical intervention may be necessary before allowing return to play.

Utility of trephine reamers in revision hip arthroplasty.

Powered trephines used over a femoral component to disrupt the bone component interface can yield acceptable clinical and radiographic outcomes while minimizing direct mechanical injury and indirect thermal necrosis. Thirty-six patients required trephining for fractured stems (16), infection (8), malposition (7), modular junction failure (4), and acetabular exposure (1). Harris Hip Scores (HHS), radiographic healing, and complications were assessed at a follow-up of 50.01 mo. Mean HHS increased from 46.61 preoperatively to 87.78 postoperatively (p<.0001). Two patients suffered spontaneous postoperative periprosthetic fractures in the region of the trephined bone at 3 mo and 4 mo postoperatively. Despite undergoing ORIF with locked plates, they both re-fractured with necrotic bone observed at the time of revision. There is a 5.6% incidence of femoral shaft fractures near the region of trephined bone within 1 year of surgery. Given the location of these fractures, thermal necrosis may have occurred and consideration should be given to distally bypassing the region of the femur that has been trephined.

Posterolateral rotatory instability of the elbow.

Symptomatic posterolateral rotatory instability (PLRI) results from a lateral collateral ligament complex injury and presents with pain, clicking, and subluxation within the flexion and extension arcs of elbow motion. Often, symptoms and examination characteristics are subtle and can be easily misdiagnosed. Therefore, a thorough history and provocative physical examination maneuvers are important to correctly establish the diagnosis. Patients frequently have a history of elbow trauma such as an episode(s) of elbow dislocation, prior surgery, or previous cortisone injections. Radiographs and advanced imaging can aid in the diagnosis, and examination under anesthesia, manipulation with arthroscopic visualization, and/or stress radiographs can be confirmatory. Symptomatic cases of PLRI can be effectively treated with a repair or isometric ligament reconstruction.

Acetabular distraction: an alternative for severe defects with chronic pelvic discontinuity?

BACKGROUND: Stabilization of a pelvic discontinuity with a posterior column plate with or without an associated acetabular cage sometimes results in persistent micromotion across the discontinuity with late fatigue failure and component loosening. Acetabular distraction offers an alternative technique for reconstruction in cases of severe bone loss with an associated pelvic discontinuity. QUESTIONS/PURPOSES: We describe the acetabular distraction technique with porous tantalum components and evaluate its survival, function, and complication rate in patients undergoing revision for chronic pelvic discontinuity. METHODS: Between 2002 and 2006, we treated 28 patients with a chronic pelvic discontinuity with acetabular reconstruction using acetabular distraction. A porous tantalum elliptical acetabular component was used alone or with an associated modular porous tantalum augment in all patients. Three patients died and five were lost to followup before 2 years. The remaining 20 patients were followed semiannually for a minimum of 2 years (average, 4.5 years; range, 2-7 years) with clinical (Merle d'Aubigné-Postel score) and radiographic (loosening, migration, failure) evaluation. RESULTS: One of the 20 patients required rerevision for aseptic loosening. Fifteen patients remained radiographically stable at last followup. Four patients had early migration of their acetabular component but thereafter remained clinically asymptomatic and radiographically stable. At latest followup, the average improvement in the patients not requiring rerevision using the modified Merle d'Aubigné-Postel score was 6.6 (range, 3.3-9.6). There were no postoperative dislocations; however, one patient had an infection, one a vascular injury, and one a bowel injury. CONCLUSIONS: Acetabular distraction with porous tantalum components provides predictable pain relief and durability at 2- to 7-year followup when reconstructing severe acetabular defects with an associated pelvic discontinuity. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of modified 2-incision technique with use of indomethicin in treatment of distal biceps tendon rupture.

Multiple surgical techniques for distal biceps tendon ruptures exist. Heterotopic ossification is an associated omplication of the 2-incision technique. The purpose of this study was to review the results of distal biceps tendon repairs via the modified 2-incision technique using indomethacin chemoprophylaxis. A retrospective review of 34 2-incision repairs of the distal biceps tendon was performed. All patients received 6 weeks of indomethacin treatment postoperatively to prophylax against heterotopic ossification. Outcome measures included disabilities of the arm, shoulder, and hand (DASH) scoring, incidence of heterotopic ossification, and forearm range of motion. Of the 34 elbows, 2 had minor complications that resolved within 6 weeks of presentation. The average DASH score at final follow-up was 3.8. No cases of heterotopic ossification, nerve palsies, reruptures, or radioulnar synostoses were observed. At final follow-up, no significant difference was noted in range of motion between the injured and uninjured extremity in all planes. The Morrey modification of the 2-incision technique can be safe and provide full functional recovery in patients with ruptured distal biceps tendons when performed in conjunction with indomethacin prophylaxis.