Open Achilles Tendon Rerupture: A Case Report and Review of the Literature.

In this report, we describe a rare case of open rerupture of an Achilles tendon following primary surgical repair. The rerupture occurred 12 weeks postoperatively and was associated with a transverse open wound perpendicular to the original surgical incision. This complication was successfully managed utilizing the preexisting transverse wound and a minimally invasive repair technique, minimizing further risk to the soft tissues overlying the tendon. This rare complication has only been described a few times in the literature and is likely associated with adhesions between the tendon repair and the subcutaneous tissues.

Increased Complications in Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty.

The direct anterior (DA) approach for total hip arthroplasty (THA) has demonstrated successful short term outcomes in several studies. However, there is no consensus about which patients are appropriate candidates for DA total hip arthroplasty. It is also unclear if short term outcomes in obese patients undergoing THA through a DA approach are elevated in comparison to non-obese patients. The purpose of this study was to evaluate complication rates and short term outcomes of obese, pre-obese, and normal body mass index (BMI) patients undergoing THA with a DA approach in a consecutive group of patients. This study was a retrospective review of 210 consecutive patients who underwent unilateral THA through a DA approach for osteoarthritis or avascular necrosis during the early peri-operative period. The study included 61 patients with normal BMI, 70 pre-obese patients, and 79 obese patients according to World Health Organization (WHO) classification (49 class I obese, 22 class II obese, and 8 class III obese patients). Patient charts were reviewed to determine differences in surgical time, length of stay, disposition, major complications, wound complications, and short term outcome measures. When comparing normal and pre-obese patients (BMI <30) to a combined group of WHO class I, II, and III obese patients (BMI >30), the obese group demonstrated increased surgical times by 12.7 minutes (P<0.0001), as well as increased length of stay (P=0.0303), narcotic use (P=0.0037), and assistive device use at two weeks (P<0.0030). In addition, major complications and wound complications were both significantly increased in the obese group (odds ratio [OR], 8.8; P=0.0493 and OR, 3.6; P=0.0431, respectively). There was also a trend toward increased use of rehabilitation facilities in the obese group at disposition, 15.4% vs 7.6% (P=0.0774). This study demonstrates that obese patients undergoing a DA approach have a 8.8 and 3.6 times increase in major and wound complications, respectively, compared to patients with a BMI <30. Obese patients also demonstrated significant increases in operative time, use of narcotics, use of assistive devices, and length of stay. There was a trend toward higher use of rehabilitation placement. While significant, these findings are similar to complication rates in the literature for other THA operative approaches. This study further defines the risks associated with performing THA on obese patients regardless of approach.

Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases.

This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.

Irreducible longitudinal distraction-dislocation of the hallux interphalangeal joint.

Although volar and dorsal dislocations have been described in the literature, dislocation of the hallux interphalangeal joint is a disorder rarely encountered by orthopedic and foot surgeons. In this article, we report a case of a distinct irreducible longitudinal distraction-dislocation that originally presented to the emergency department but required open reduction in the operating room. We also describe the presentation, anatomy, and treatment of this unique disorder.

Full-thickness supraspinatus tears are associated with more synovial inflammation and tissue degeneration than partial-thickness tears.

BACKGROUND: The objective of this study was to determine whether the tear size of a supraspinatus tendon correlated with synovial inflammation and tendon degeneration in patients who underwent shoulder arthroscopy for rotator cuff repair. We hypothesized that increased synovial inflammation would correlate with greater tear size of the supraspinatus tendon at the time of surgery. MATERIALS AND METHODS: Tissue from the synovium, bursa, torn supraspinatus tendon, and subscapularis tendon was obtained from patients during shoulder arthroscopy to evaluate the messenger RNA expression of proinflammatory cytokines, tissue remodeling, and angiogenesis factors in the tendon, bursa, and synovium. Additional tissue was fixed to determine histologic changes including inflammation, vascular ingrowth, and collagen organization. RESULTS: Increased expression of interleukin 1ß, interleukin 6, cyclooxygenase 2, matrix metalloproteinase (MMP) 9, and vascular endothelial growth factor was found in the synovium of patients with full-thickness tears versus partial-thickness tears (P < .05). In the supraspinatus tendon, increased expression of MMP-1, MMP-9, MMP-13, and vascular endothelial growth factor was found in the full-thickness group. The upregulation of these genes in the full-thickness group was consistent with enhanced synovial inflammation, greater vascular ingrowth, and the loss of collagen organization in both supraspinatus and subscapularis tendons as determined by histology. CONCLUSION: Increased synovial inflammation and tissue degeneration correlate with the tear size of the supraspinatus tendon. A better understanding of the relationship between synovial inflammation and the progression of tendon degeneration can help in the design of novel and effective treatments to limit the advancement of rotator cuff disease and to improve their clinical outcomes.