An articulating antibiotic spacer controls infection and improves pain and function in a degenerative septic hip.

BACKGROUND: Treating septic arthritis of the hip with coexisting advanced degenerative disease is challenging. The use of primary total hip arthroplasty (THA) has led to postoperative infection rates as high as 22%. Insertion of antibiotic spacers with subsequent reimplantation of a THA controls infection and improves pain and function in patients with periprosthetic infections. QUESTIONS/PURPOSES: We asked whether two-stage exchange for patients with degenerative joint disease (DJD) and coexisting septic arthritis would control infection and improve pain relief and function both during the period after insertion of the spacer and after conversion to THA. METHODS: We retrospectively reviewed 14 patients with severe DJD and either active or recent septic arthritis treated with débridement and insertion of a primary antibiotic-loaded cement spacer between 1996 and 2008. Ten patients underwent subsequent exchange to a permanent hip arthroplasty. Four patients did not undergo exchange to a permanent THA: two died from unrelated causes and two elected not to proceed with exchange because their spacer provided adequate function. We obtained a modified Harris hip score. The minimum clinical followup was 7 months (average, 28 months; range, 7-65 months) after insertion of the spacer. RESULTS: Mean pain scores improved from 6 to 34, and overall Harris hip scores improved from 11 to 67 at last followup with the spacer. Those who underwent definitive THA had further improvement in their mean Harris hip scores to 93. CONCLUSIONS: Articulating antibiotic spacers offer acceptable pain relief and function while the infection is treated in this unique group of patients. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hip arthroplasty with minimally invasive surgery: a survey comparing the opinion of highly qualified experts vs patients.

In recent years, there has been an increasing debate regarding the possible role of minimally invasive (MIS) total hip arthroplasty (THA). We conducted a questionnaire survey of the Hip Society members and compared the responses of the surgeons with those of patients who were being considered for THA. 80% of surgeons who completed the survey admitted to performing MIS THA, of whom two thirds defined MIS as small incision. Of surgeons, 74% had encountered some complication related to MIS THA; 67% of patients had not heard of MIS THA. The knowledge regarding MIS THA expressed by 80% of patients was either inaccurate or not substantiated by any studies. This survey highlights the inadequacy of our current understanding of MIS THA and lack of education on the part of the patients.

Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score.

STUDY DESIGN: Prospective study of 5 spine surgeons rating 71 clinical cases of thoracolumbar spinal injuries using the Thoracolumbar Injury Severity Score (TLISS) and then re-rating the cases in a different order 1 month later. OBJECTIVE: To determine the reliability of the TLISS system. SUMMARY OF BACKGROUND DATA: The TLISS is a recently introduced classification system for thoracolumbar spinal column injures designed to simplify injury classification and facilitate treatment decision making. Before being widely adopted, the reliability of the TLISS must be studied. METHODS: A total of 71 cases of thoracolumbar spinal trauma were distributed on CD-ROM to 5 attending spine surgeons, including clinical/radiographic data, details of the TLISS, and a scoring sheet in which cases would be scored using the system. The surgeons were later assigned the task with the cases reordered. Intraobserver and interobserver reliability was calculated for TLISS components, total score, and surgeon's treatment decision using the Cohen unweighted kappa coefficients and Spearman rank-order correlation. RESULTS: Interrater reliability assessed by generalized kappa coefficients was 0.33 +/- 0.03 for injury mechanism, 0.91 +/- 0.02 for neurologic status, 0.35 +/- 0.03 for posterior ligamentous complex status, 0.29 +/- 0.02 for TLISS total, and 0.52 +/- 0.03 for treatment recommendation. Respective results using the Spearman correlation were 0.35 +/- 0.04, 0.94 +/- 0.01, 0.48 +/- 0.04, 0.65 +/- 0.03, and 0.51 +/- 0.04. Surgeons agreed with the TLISS recommendation 96.4% of the time. Intrarater kappa coefficients were 0.57 +/- 0.04 for injury mechanism, 0.93 +/- 0.02 for neurologic status, 0.48 +/- 0.04 for posterior ligamentous complex status, 0.46 +/- 0.03 for TLISS total, and 0.62 +/- 0.04 for treatment recommendation. Respective results using the Spearman correlation were 0.70 +/- 0.04, 0.95 +/- 0.02, 0.59 +/- 0.05, 0.77 +/- 0.04, and 0.59 +/- 0.05. CONCLUSIONS: The TLISS has good reliability and compares favorably to other contemporary thoracolumbar fracture classification systems.

Revision hip arthroplasty for late instability secondary to polyethylene wear.

We evaluated the outcome of revision arthroplasty for polyethylene wear presenting as late dislocation. The computerized databases at two institutions were reviewed to identify all patients presenting with first time dislocation five or more years after total hip arthroplasty. Records and radiographs were then evaluated, and patients whose late dislocation occurred in the presence of greater than two millimeters of polyethylene liner wear with no other etiology for dislocation were identified. There were 22 patients with a mean age of 57.8 years at primary procedure. The average time from initial arthroplasty to dislocation was 9.0 years. Revision surgery to address polyethylene wear and instability was performed at a mean of 11.1 years (range 5.8 to 23 years). Revision surgery restored stability to eighteen patients (eighty-two percent). Polyethylene wear can and is associated with late dislocation after hip arthroplasty. Exchange of polyethylene lining of a metal backed implant or revision of the all polyethylene acetabular component can successfully address late instability in the majority of patients.

Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery.

UNLABELLED: Resurfacing the patella during primary total knee arthroplasty is controversial. The objective of this meta-analysis was to evaluate the outcome of total knee arthroplasty with or without resurfacing of the patella with particular attention to patient satisfaction, incidence of anterior knee pain, patellar complications, and the need for secondary operations. Computerized databases were searched for citations and published randomized clinical trials relevant to patellar resurfacing from 1966-2003. Of 158 citations identified as related to patellar resurfacing during total knee arthroplasty, 14 articles met all inclusion criteria for this study. The incidence of anterior knee pain was greater in knees with nonresurfaced patellas. Secondary resurfacings for anterior knee pain was needed in 8.7% of nonresurfaced knees. No difference in reported complications existed. Total knee arthroplasty resulted in improvement of functional outcome regardless of whether the patella was resurfaced. Based on the results of this meta-analysis, nonresurfacing of the patella during primary total knee arthroplasty is likely to result in a greater incidence of anterior knee pain, the need for secondary resurfacing in almost one in 10 patients, and possibly less patient satisfaction. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Proximal femoral replacement for the treatment of periprosthetic fractures.

BACKGROUND: A periprosthetic fracture around the femoral component is a rare but potentially problematic complication after total hip arthroplasty. Reconstruction can be challenging, especially when severe bone stock deficiency is encountered. Proximal femoral replacement is one method of treating the severely deficient proximal part of the femur. The present report describes the outcomes of revision total hip arthroplasty with use of a proximal femoral replacement in a cohort of patients who had a Vancouver type-B3 periprosthetic fracture. METHODS: With use of a computerized institutional database, all patients in whom a Vancouver type-B3 fracture (characterized by severe proximal bone deficiency and a loose femoral stem) had been treated with a proximal femoral replacement were identified. A modular femoral replacement with proximal porous coating had been used in all cases. The twenty-one patients who were identified had had a mean age of 78.3 years (range, fifty-two to ninety years) at the time of the index operation. The clinical and radiographic records of these patients were reviewed. RESULTS: At the time of the latest follow-up (mean, 3.2 years), all but one of the patients were able to walk and had minimal to no pain. Complications included persistent wound drainage that was treated with incision and drainage (two hips), dislocation (two hips), refracture of the femur distal to the stem (one hip), and acetabular cage failure (one hip). CONCLUSIONS: Despite a relatively high complication rate, we believe that proximal femoral replacement is a viable option for the treatment of periprosthetic fractures in older patients with severe bone deficiency. If a proximal femoral replacement is used, the stability of the hip must be tested diligently intraoperatively and a constrained acetabular liner should be utilized if instability is encountered. In order to enhance the bone stock, the proximal part of the femur, however poor in quality, should be retained for reapproximation onto the implant.

Bilateral simultaneous fasciotomy for chronic exertional compartment syndrome.

BACKGROUND: Chronic exertional compartment syndrome (CECS) occurs bilaterally in approximately 60% of patients. Fasciotomy is the primary corrective treatment. We hypothesized that bilateral fasciotomy can be done during the same operative procedure with early return to sports and low complication rates METHOD: Sixteen patients had simultaneous bilateral lower extremity fasciotomies for CECS confirmed by compartment pressure testing before and after exercise. Ten patients had concomitant superficial peroneal neurolysis for associated numbness. All patients who were athletes (six runners; nine ball sports) (average age 25 years) had sports related pain limiting participation. RESULTS: Patients were followed for an average of 16.4 (range 6 to 48) months. Full return to sports participation occurred at an average of 10.7 weeks. Three patients continued to have mild, but much improved, pain with active sports participation, while 13 were pain free. All 11 patients with exertional related numbness had resolution after operative release. All patients were satisfied and all patients stated that they would have simultaneous fasciotomies again if required. As a nonmatched comparison, three patients who had staged fasciotomies for bilateral CECS were also evaluated, but because of the small number no statistical comparison was made. All three also returned to their previous levels of sports participation, however, at an average of 22.7 months as compared to 10.7 weeks in patients with simultaneous bilateral releases. CONCLUSION: Bilateral simultaneous fasciotomies for CECS can be done safely and effectively with early return to sports participation and low complication rates.

The effect of tibial polyethylene insert design on range of motion: evaluation of in vivo knee kinematics by a computerized navigation system during total knee arthroplasty.

Computer-assisted navigation for total knee arthroplasty offers the unique opportunity to assess in vivo knee kinematics during surgery and implement changes whenever appropriate. Using a computerized navigation system, the effect of 2 tibial polyethylene insert designs on knee kinematics in general and knee range of motion (ROM) in particular was evaluated in 37 knee arthroplasties in 30 patients. The Scorpioflex tibial insert was found to provide a significant increase in mean extension, mean flexion, and overall ROM of the knee compared with the standard tibial insert (P<.005) without affecting knee ligamentous balance. Navigation is a very effective and useful tool for intraoperative assessment of knee kinematics and accurate recording of ROM. Based on the information obtained from the navigation software, the surgeon can implement changes in selection of the knee components with beneficial effects in knee kinematics in general and knee ROM in particular. This may, in turn, translate to better clinical outcome of the knee arthroplasty.

Isolated acetabular polyethylene exchange through the anterolateral approach.

Isolated exchange of an acetabular liner, in the presence of a well-fixed acetabular component, has become an established method for the management of polyethylene wear. Various experienced adult-reconstruction surgeons have noted a high incidence of instability following isolated liner exchange. We report the results of isolated liner exchange in 35 patients with polyethylene wear and osteolysis (16 patients) or polyethylene wear and instability (19 patients) with a minimum follow-up of 2 years. Isolated liner exchange was performed through an anterolateral approach in all cases. Postoperative dislocation occurred in 2 of the 35 patients (6%), both with polyethylene wear and osteolysis. Isolated liner exchange was successful in addressing instability in all 19 patients who presented with polyethylene wear and dislocation. Isolated acetabular liner exchange performed through an anterolateral approach carries an acceptable dislocation rate.