Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study. INTERVENTION: Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities. MAIN OUTCOME MEASUREMENTS: Union rate, time to union. RESULTS: Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months. CONCLUSIONS: Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions.

OBJECTIVES: To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated. INTERVENTION: Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing. MAIN OUTCOMES MEASUREMENTS: The outcome measures were radiographic and clinical evidence of nonunion healing and time to union. RESULTS: All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months). CONCLUSIONS: Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons.

There are limited data to guide surgeon recommendations regarding activities after total joint arthroplasty. The present study aims to better clarify the current community standards. A questionnaire was distributed to the members of the American Association for Hip and Knee Surgeons attending the 2007 annual meeting inquiring about recommendations for 15 activities for patients with total hip arthroplasty or total knee arthroplasty. One hundred thirty-nine surveys were returned. Spearman rank correlation was used to analyze the data. More than 95% of the responses placed no limitations on low-impact activities including level surface walking, stair climbing, level surface bicycling, swimming, and golf. Higher-impact activities were more commonly discouraged, although there was considerable variability. Recommendations after total hip arthroplasty were more liberal compared to those after total knee arthroplasty. Higher-volume surgeons tended to be more liberal in their recommendations. No responder indicated that there was strong scientific evidence for their recommendations. Investigations are needed to elucidate the long-term effects of higher load and/or higher cycle activities on total joint arthroplasty.

Neurologic injuries after total hip arthroplasty.

Neurologic injuries are a potentially devastating complication of total hip arthroplasty (THA). Review of the literature reveals that these injuries are uncommon. The reported incidence ranges from 0.08% to 7.6%. The incidence in primary THA ranges from 0.09% to 3.7% and in revision THA from 0% to 7.6%. Reported etiologies include intraoperative direct nerve injury, significant leg lengthening, improper retractor placement, cement extravasation, cement-related thermal damage, patient positioning, manipulation, and postoperative hematoma. Risk factors include developmental dysplasia of the hip, the female sex, posttraumatic arthritis, and revision surgery. However, no single risk factor has been consistently reported to be significant, and many patients with no known risk factors incur neurologic injuries.