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.

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.

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.