Perioperative periprosthetic femur fracture associated with direct anterior total hip arthroplasty using metaphyseal fit and fill stem.

INTRODUCTION: This study aims to identify radiographic and clinical risk factors of perioperative periprosthetic femur fracture associated with the direct anterior approach (DAA) using a metaphyseal fit and fill stem. We hypothesize stem malalignment with this femoral implant places increased stress on the medial calcar region, which leads to an increased risk of periprosthetic fracture. METHODS: We compared patients with periprosthetic femur fractures following DAA total hip arthroplasty (THA) utilizing the Echo Bi-Metric Microplasty Stem (Zimmer Biomet, Warsaw, IN) to a cohort of patients who did not sustain a periprosthetic fracture from five orthopedic surgeons over four years. Postoperative radiographs were evaluated for stem alignment, neck cut level, Dorr classification, and the presence of radiographic pannus. Univariate and logistic regression analyses were performed. Demographic and categorical variables were also analyzed. RESULTS: Fourteen hips sustained femur fractures, including nine Vancouver B2 and five AG fractures. Valgus stem malalignment, proud stems, extended offset, and patients with enlarged radiographic pannus reached statistical significance for increased fracture risk. Low femoral neck cut showed a trend toward statistical significance. CONCLUSION: Patients undergoing DAA THA using a metaphyseal fit and fill stem may be at increased risk of perioperative periprosthetic fracture when the femoral stem sits proudly in valgus malalignment with extended offset and when an enlarged pannus is seen radiographically. This study identifies a specific pattern in the Vancouver B2 fracture cohort with regard to injury mechanism, time of injury, and fracture pattern, which may be attributed to coronal malalignment of the implant.

A Radiographic Abdominal Pannus Sign is Associated With Postoperative Complications in Anterior THA.

BACKGROUND: Numerous studies have shown that elevated BMI is associated with adverse outcomes in THA; however, BMI alone does not adequately represent a patient's adipose and soft tissue distribution, especially when the direct-anterior approach is evaluated. Local soft tissue and adipose, especially in the peri-incisional region, has an unknown impact on patient outcomes after direct-anterior THA. Moreover, there is currently no known evaluation method to estimate the quantity of local soft tissue and adipose tissue. The current study introduced a new radiographic parameter that is measurable on supine AP radiographs: the abdominal pannus sign. QUESTION/PURPOSE: Are patients who have an abdominal pannus extending below the upper (cephalad) border of the symphysis pubis more likely to experience problems after anterior-approach THA that are plausibly associated with that finding, including infections resulting in readmission, wound complications resulting in readmission, fractures, or longer surgical time, than patients who do not demonstrate this radiographic sign? METHODS: Between 2015 and 2020, five surgeons performed 727 primary direct-anterior THAs. After exclusion criteria were applied, 596 procedures were included. Of those, we obtained postoperative radiographs in the postanesthesia care unit in 100% of procedures (596 of 596), and 100% of radiographs (596) were adequate for review in this retrospective study. The level of the pannus in relation to the pubic symphysis was assessed on immediate supine postoperative AP radiographs of the pelvis: above (pannus sign 1), between the upper and lower borders (pannus sign 2), or below the level of the pubic symphysis (pannus sign 3). In this study, we combined pannus signs 2 and 3 into a single group for analysis not only because there was a limited number of patients in each group, but also because there was no statistically significant difference between the two groups. Pannus sign 1 was identified in 82% of procedures (486 of 596), and pannus sign ≥ 2 was identified in 18% (110). We compared the groups (pannus sign 1 versus pannus sign ≥ 2) in terms of the percentage of patients who experienced problems within 90 days of THA that might be associated with that physical finding, including infections resulting in readmission including subcutaneous, subfascial, and prosthetic joint infections; wound complications resulting in readmission, defined as dehiscence or delayed healing; and all fractures, and we compared the groups in terms of surgical time-that is, the cut-to-close time. RESULTS: Patients with a pannus sign of ≥ 2 were more likely than those with a pannus sign of 1 to have a postoperative infection (6.4% [seven of 110 procedures] versus 0.6% [three of 486], odds ratio 10.96 [95% confidence interval (CI) 2.83 to 42.38]; p < 0.01), wound complications (0.9% [one of 110] versus 0% [0 of 486] with an infinite odds ratio [95% CI indeterminate]; p = 0.18), and fractures (4.5% [five of 110] versus 0% [0 of 486], with an infinite odds ratio [95% CI indeterminate]; p < 0.01). The mean surgical time was longer in patients with a pannus sign of ≥ 2 than it was in those with a pannus sign of 1 (128 ± 25.3 minutes versus 118 ± 27.5 minutes, mean difference 10 minutes; p < 0.01). CONCLUSION: Based on these findings, patients who have an abdominal pannus that extends below the upper (cephalad) edge of the pubic symphysis are at an increased risk of experiencing serious surgical complications. If THA is planned in these patients, an approach other than the direct-anterior approach should be considered. Surgeons performing THA who do not obtain supine radiographs preoperatively should use a physical examination to evaluate for this finding, and if it is present, they should use an approach other than the direct-anterior approach to minimize the risk of these complications. Future studies might compare the abdominal pannus sign using standing radiographs, which are used more often, with other well-documented associated risk factors such as elevated BMI or higher American Society of Anesthesiologists classification. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Short-term Clinical Outcomes of Unexpected Culture-positive Cutibacterium acnes (Formerly Propionibacterium acnes) in Open Orthopaedic Surgery.

INTRODUCTION: The clinical significance and treatment recommendations for an unexpected positive Cutibacterium acnes (C acnes) culture remain unclear. The purpose of our study was to evaluate the clinical effect of a C acnes positive culture in patients undergoing open orthopaedic surgery. METHODS: Patients with a minimum of one positive C acnes intraoperative culture were retrospectively reviewed over a 7-year period. True C acnes infection was defined as culture isolation from ≥1 specimens in the presence of clinical or laboratory indicators of infection. RESULTS: Forty-eight patients had a positive intraoperative C acnes culture. 4.2% had a C acnes monoinfection, and 12.5% of the patients had a coinfection. The remainder was classified as indeterminate. Significant differences were identified between the indeterminate and true C acnes infection groups, specifically in patients with surgery history at the surgical site (P = 0.04), additional antibiotic therapy before surgery (P < 0 .001), and postoperative clinical signs of infection (P < 0 .001). DISCUSSION: Suspicion for true C acnes infection should be raised in patients with surgery site history, antibiotic therapy before surgery, and clinical infectious signs. The indeterminate unexpected positive culture patients had a low risk of developing a true clinical infection that required antibiotic therapy.

Triple Surgical Fixation Technique for an Isolated Greater Trochanter Fracture in an Amateur Weightlifter.

Isolated greater trochanter fractures have been infrequently described in the literature and are typically managed conservatively. Functional strength after injury to the abductor complex can be markedly affected resulting in a Trendelenburg gait and overall abductor weakness. We present a case of a 35-year-old athlete who underwent surgical fixation because of notable fracture displacement and function debility. This case vignette demonstrates the importance of using all available interdisciplinary orthopaedic surgery literature to provide a patient-specific surgical construct. Our patient benefitted from arthroscopic, arthroplasty, and trauma evidence-based medicine to successfully treat his displaced greater trochanteric hip fracture. Successful surgical fixation was enhanced by combining three different methods of fixation: osteosynthesis with partially threaded screws and washers (DePuy Synthes), suture anchor (Arthrex) direct fracture approximation and tendon reinforcement, and a knotless double-row suture bridge (Arthrex) tension band construct. The patient was able to return weightlifting at 4 months postoperatively with no evidence of weakness or trendelenburg gait.

Traumatic rupture of the posterior deltoid tendon during weight lifting: A case report and review of literature.

Deltoid tendon humeral sided avulsion leads to discomfort and functional limitation in the young active population. This report illustrates a case for surgical treatment with a simple suspensory device that allows for early return to activity.

Bilateral shoulder septic arthritis due to suspected bacterial endocarditis: A case report.

INTRODUCTION: Septic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment. It is typically caused by occult bacteremia which allows bacteria to seed the joint or local invasion of a soft tissue infection. Most cases of septic arthritis are caused by gram-positive bacteria, with the most common culprit being Staphylococcus Aureus. The reason septic arthritis is an orthopedic emergency is because of rapid destruction to cartilage. The mechanism of injury to cartilage is two-fold: bacterial enzymes are directly toxic to joint cartilage, and buildup of exudate can tamponade blood flow and cause anoxic injury. Typically, the knee is the most commonly involved joint. This is followed by the hip, ankle, elbow, wrist, and shoulder in descending order of occurrence. Polyarticular disease makes up a small percentage of these cases and if present, it is usually asymmetric and will involve at least one knee joint. PRESENTATION OF CASE: Bilateral joint septic arthritis is relatively rare. We present an uncommon case of atraumatic bilateral septic shoulders in an elderly man with a history of heart disease and insidious bilateral shoulder pain after golfing 18 holes. This presentation is unique not only in its rarity but also in its impact on our understanding of septic arthritis in the setting of medical comorbidities and a relatively unimpressive presentation. With a recent golfing day just prior to presentation, differential diagnoses other than septic arthritis included deltoid/rotator cuff muscle strain, acute on chronic rotator cuff tendinosis, acute on chronic rotator cuff tearing, acute flare up of osteoarthritis, rheumatoid arthritis, or crystalline arthropathy. With elevated inflammatory markers and an equivocal physical examination, our patient underwent advanced imaging via MRI and subsequent bilateral glenohumeral joint diagnostic aspirations that were consistent with septic arthritis due to his complaining of contralateral shoulder pain shortly after his admission. Immediately after said diagnosis was made, the patient was taken back for emergent bilateral open irrigation and debridement, as septic arthritis is an orthopedic emergency, and went on to recover appropriately on culture-directed intravenous antibiotic therapy. DISCUSSION/CONCLUSION: This case report is impactful with regard to clinical practice for multiple reasons. First and foremost it is a cautionary tale for all clinicians with regard to the level of suspicion one must have for polyarticular septic arthritis in the setting of the multiply painful patient. Second, it demonstrates the utility of advanced imaging in the equivocal patient. Lastly, it underscores the importance of prompt diagnosis and treatment, validating the existing algorithm for septic arthritis.

Patella Fractures: Approach to Treatment.

Patellar fracture morphology varies based on the mechanism of injury. Most fractures are either a result of direct impact or through an indirect eccentric extensor contraction injury. Each fracture pattern requires appropriate preoperative planning and individualization of the fixation method. Displaced fractures affect the extension apparatus, and often require surgical fixation. Surgical treatment is recommended in fractures with any of the following features: articular step-off > 2 mm, > 3 mm of fracture displacement, open fractures, and displaced fractures affecting the extensor mechanism. Meticulous handling of the soft-tissue envelope is of the utmost importance, given the patella's tenuous blood supply and limited soft-tissue envelope. Incongruent articular surface can result in detrimental long-term effects; therefore, surgical treatment is directed toward anatomic reduction and fixation. The evolution of patellar fracture fixation continues to maximize options to balance rigid fixation with low-profile fixation constructs. Improving functional outcomes, minimizing soft-tissue irritation, and limiting postoperative complications are possible by using the therapeutic principles of rigid anatomical fixation and meticulous soft-tissue handling.

An Unusual Case of Solitary Osteochondroma of the Iliac Wing.

INTRODUCTION: Osteochondromas represent one of the most common bone tumors accounting for 8% of all bone tumors. While most osteochondromas arise in the metaphysis of long bones, osteochondromas have been reported in atypical locations such as the scapula, metatarsals, and the pelvic region. Osteochondromas are capable of growing large enough to cause mass effects and can undergo malignant transformation, stressing the clinical importance of recognizing these tumors. Case Presentation. In this case, we present an 18-year-old skeletally mature Caucasian male with a symptomatic osteochondroma arising from the iliac wing. The osteochondroma increased in size since he reached skeletal maturity. This resulted in a mass effect that interfered with activities of daily living, including clothing wear and symptomatic impaction on hard surfaces. CONCLUSION: The majority of osteochondromas arise from the metaphysis of long bones, but case reports have shown that osteochondromas presenting in atypical locations such as the pelvis do occur. In the case of our patient, his asymptomatic pelvic tumor grew to the extent that it was causing interference with activities of daily living. Surgical excision of his tumor proved to be curative, and there was no recurrence at 6 months after excision. Osteochondromas in this region are capable of growing large enough to cause sexual dysfunction. Clinical suspicion must be high to properly diagnose osteochondromas in atypical locations. All providers, particularly those in primary care, should be aware of these locations as patients with symptomatic mass lesions will likely initially present here.

Repair of Proximal Hamstring Tear Utilizing a Suture Bridge Knotless Construct.

Proximal hamstring tendon injuries occur frequently in the athletic population resulting in varying degrees of functional disability depending on severity of injury. The purpose of our case vignette is to describe a surgical technique and clinical outcome for open proximal hamstring tendon repair with a confirmed biomechanically sound construct. We also describe and summarize the current literature recommendations for proximal hamstring injuries. We present a case and surgical technique report on a 27-year-old male who suffered a proximal hamstring tendon rupture. Utilizing a double row all-knotless suture bridge construct with a total of four anchors and six suture limbs allowed for anatomic footprint coverage and strength. Two years of clinical follow-up was obtained evaluating hip and knee range of motion, strength, and functional ability. Our patient underwent uncomplicated open surgical repair and returned to all activity at four months following surgery. Range of motion and strength returned to preoperative levels at the four-month postoperative mark. The use of a reproducible double row all-knotless suture bridge technique provided adequate strength and stability in the setting of a proximal hamstring tendon rupture. Open and endoscopic surgical techniques performed acutely both show positive postoperative subjective outcomes as well as a high likelihood of returning to sport. Controversy remains present in regard to the repair technique as well as postoperative bracing and physical therapy recommendations.

Chronic distal biceps avulsion treated with suture button.

BACKGROUND: Distal biceps tendon avulsions account for 3%-10% of all biceps ruptures. Treated nonoperatively, these injuries lead to a loss of endurance, supination strength, and flexion strength compared with operative repair or reconstruction. Operative management of chronic injury has classically been with graft tissue to augment the contracted muscle. We present our results for chronic distal biceps avulsions secured with suture button through a single transverse incision in high flexion without the need for allograft augmentation. MATERIALS AND METHODS: This was a retrospective review of 20 patients with 21 injuries who underwent primary surgical repair of chronic distal biceps tendon avulsions at an average of 10 weeks (range 4-42 weeks). All patients were treated with a single transverse incision with a suture button armed with nonabsorbable no. 2 core sutures. Postoperatively patients were found to have 50°-90° flexion contracture. All patients were placed in a simple sling postoperatively with gentle extension to gravity as tolerated immediately and no formal physical therapy. Patients were surveyed regarding pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and overall satisfaction. Range of motion (ROM), flexion, and supination strength compared to the contralateral uninjured extremity were evaluated at final follow-up. RESULTS: Mean clinical follow-up was 26 months. All patients regained full ROM and 5/5 flexion and supination strength at final follow-up. MEPSs were 100 for all responding patients compared with an average 47.5 preoperatively (P < .0001). The mean postoperative ASES score was 97.2 compared with 41.9 preoperatively (P < .0001). Mean OESs pre- and postoperatively were 24.2 and 48, respectively (P < .0001). The mean VAS score was 4.4 preoperatively and was reported as 0 by all patients at final follow-up (P < .0001). Two patients had transient sensory radial nerve neuropathy, and 1 patient has persistent palsy. No synostoses occurred. Four patients reported supination fatigue postoperatively compared with the uninjured extremity. CONCLUSION: Given these results, we feel that chronic distal biceps tendon ruptures can be repaired successfully with a single incision using suture button technique without the use of a graft. Though the flexion contracture is significant postoperatively, all patients regained full ROM and had excellent postoperative functional outcome scores.

Primary Repair of the Medial Collateral Ligament with a Double Row Suture Technique and Suture Tape Augmentation for Acute Tibial-Sided Injuries.

The management of medial collateral ligament (MCL) injuries has evolved during the past 30 years. Most heal reliably with conservative management. The treatment of MCL sprains with concomitant other ligamentous injuries continues to be controversial. Surgical management of chronic laxity of the medial structures can be quite difficult, and therefore anatomic repair of the medial support structures in the acute setting is preferred when indicated. Complete avulsion of the superficial and deep MCL from the tibia with disruption of the meniscal coronary ligament have a poor prognosis with non-operative treatment and may be optimally managed with acute surgical repair for improved valgus stability. A recent review demonstrated that there is a role for primary MCL repair for select patients. This technique addresses complete avulsions from the tibia, using multiple anchors for anatomic reattachment of the deep and superficial MCL, SutureBridge construct to enhance footprint compression, and suture tape to augment the MCL repair. Advantages of this technique include utilization of suture tape augmentation to allow for early range of motion, maintenance of the native MCL to preserve proprioception, and repair in the acute setting for faster recovery.