Distribution of Subchondral Bone Puncture Strength in the Talus and Tibial Plafond: A Biomechanical Study.

We investigated talus and tibial plafond subchondral bone puncture strength based on surface location. Puncture tests of the subchondral bone were performed in 9 equal zones on the articular surface of 12 cadaver specimens aged 49.1 years (range, 36-56 years). Compressive load was applied through a microfracture awl at 2 mm/min. Puncture strength was defined as the first load drop in load-deflection curves. In the talus, zone 1 (215 ± 91 N) and zone 2, the anterior medial and anterior middle zones, had significantly greater puncture strength than zones 7, 8, and 9, the posterior medial, middle, and lateral zones (104 ± 43 N, 115 ± 43 N, and 102 ± 35 N, respectively; P < .001). In the tibial plafond, zone 3, the anterior-lateral zone, and zone 7, the posterior medial zone, had significantly greater strength than zone 8, the posterior middle zone (202 ± 72 N, 206 ± 121 N, and 112 ± 65 N, respectively; P < .001) These results suggest that the subchondral bone is significantly weaker to penetrative force in the posterior region than in the anterior region of the talar dome and of the tibial plafond. These findings may have implications for microfracture awl design and for understanding the complex anatomy and physiology of the ankle joint. LEVELS OF EVIDENCE: Controlled laboratory study.

Use of Shorter Intramedullary Guide for Ipsilateral Total Knee Arthroplasty following Prior Total Hip Arthroplasty.

Alignment after total knee arthroplasty (TKA) plays an important role with respect to patient satisfaction and implant survivorship. In patients undergoing ipsilateral TKA with prior total hip arthroplasty (THA), the femoral intramedullary (IM) guide cannot be fully inserted into the femoral canal because of the prior THA. The purpose of this study was to determine the effect of femoral component alignment using a shorter IM guide during TKA in patients with an ipsilateral THA. We identified 42 patients undergoing ipsilateral TKA with the use of a short IM guide in the setting of a prior THA. A matched cohort group was identified from our total joint registry that included 42 patients who underwent primary TKA. The surgical goal was to achieve 5 degrees of valgus on the femoral side and 0 degree on the tibial side with an overall postoperative tibial-femoral angle of 5 degrees of valgus. Patients were evaluated clinically using Knee Society pain scores (KSSs), function scores, and with radiography. Both the tibial-femoral limb alignment and the femoral component alignment were compared using Student's t-test. There were no significant differences between the two groups with respect to sex, age, body mass index (BMI), pre- and postoperative KSSs. There was a statistically significant difference between the two groups with respect to radiographic tibial-femoral limb alignment, 4.33 degrees of valgus in the short stem THA-TKA group versus 5.4 degrees of valgus in the TKA group (p < 0.04); however, this difference did not correlate to a difference in postoperative outcomes. An adequate tibial-femoral component alignment was achieved in patients undergoing ipsilateral TKA with prior THA using a shortened IM femoral guide.

Assessment of static progressive stretch for the treatment of shoulder stiffness: a prospective case series.

INTRODUCTION: The purpose of this study was to evaluate the use of a patient-directed static progressive stretch orthosis for the treatment of shoulder stiffness. METHODS: Twenty-three patients who had limitations in range of motion of the shoulder and who had failed conventional physical therapy methods were studied. This cohort included 15 women and 8 men with a mean age of 53 years. Treatment comprised one to three 30- to 60-minute sessions per day with a patient-controlled orthosis utilizing static progressive stretch. The patients adjusted the degree of stretch at 5-minute intervals as tolerated. Compliance, range of motion, patient satisfaction, and complications were assessed, and a two-way repeated measure ANOVA was performed to assess the effects of age or gender. RESULTS: After a mean treatment duration of 10 weeks (range, 4 to 19 weeks), the patients gained a mean of 22° (range, -47 to 57°) of external rotation, 18° (range, -19 to 55°) of internal rotation, 46° (range, 3 to 97°) of abduction, and 23° (range, 3 to 40°) of forward flexion. In total, 22 of 23 patients (96%) experienced increases in range of motion that were maintained at 1 year following treatment. Statistically significant increases in range of motion and clinical function scores were noted; age and gender did not appear to influence the outcomes. DISCUSSION: This device compared favorably to other treatment methods for shoulder stiffness. An orthosis utilizing static progressive stretch was a useful adjunct for the treatment of shoulder stiffness refractory to conventional therapy.

Peroneal nerve dysfunction after total knee arthroplasty: characterization and treatment.

The purpose of this study was to report on the presentation, evaluation, treatment, and outcome of patients who had a peroneal nerve dysfunction after total knee arthroplasty. Six patients were unable to achieve adequate range of motion after physical therapy, and the remaining 5 patients had sensory symptoms that interfered with daily activities despite adequate range of motion. All 11 patients had abnormal electrodiagnostic testing but had intact motor strength and were treated with surgical decompression of the nerve. The patients with motion problems had a mean increase in range of motion of 40 ° (range, 20 °-70 °) at final follow-up. All patients with dominant sensory symptoms had a resolution of leg and foot pain after treatment. Orthopedic surgeons should be aware of peroneal nerve dysfunction as a possible cause of unsatisfactory rehabilitation and/or persistent atypical lateral leg pain after total knee arthroplasty.

Strategies to reduce blood loss in lower extremity total joint arthroplasty.

Concerns about blood loss and the safety of allogenic blood transfusion have led to the development of many transfusion options for lower extremity joint arthroplasty. Techniques for dealing with such blood loss include allogenic blood transfusion, autologous donation and transfusion, hemodilution, perioperative blood salvage, intraoperative cell savers, bipolar sealers, and pharmacological agents. A blood management strategy must consider both the patient and the surgical procedure, assess the transfusion risks, and formulate a plan to address them appropriately. This article is an overview of the blood management techniques for lower extremity joint arthroplasty. The purpose of this review is to report our opinion regarding the use of alternative blood management strategies and to discuss the possible advantages and disadvantages of each technique. The results of this review indicate that a patient-focused algorithm using one or more strategies such as preoperative administration of erythropoietin, preoperative autologous blood donation, use of a bipolar sealer, intraoperative blood collection and reinfusion, as well as postoperative reinfusion drains may reduce the need for allogenic blood transfusions in patients undergoing primary and revision lower-extremity joint arthroplasties. The authors believe that a patient-specific algorithm utilizing the aforementioned techniques can lead to a substantial decrease in morbidity and mortality and an overall cost saving for both patients and medical institutions.

A comparison of subvastus and midvastus approaches in minimally invasive total knee arthroplasty.

BACKGROUND: The mini-subvastus and the mini-midvastus approaches are among the most common alternatives to the medial parapatellar approach for total knee arthroplasty. The purpose of this study was to compare the early clinical outcomes of these two approaches. METHODS: In this prospective, randomized study of fifty-one patients who underwent bilateral total knee arthroplasty, the mini-subvastus approach was used in one knee and the mini-midvastus approach, in the contralateral knee. There were forty-two women and nine men who had a mean age of seventy years at the time of the index arthroplasties, and they were followed for two years postoperatively. Clinical outcome was assessed and compared with use of the Knee Society pain and function scores, the straight-leg-raising test, range of motion, and isokinetic strength testing. Operating time and blood loss for each approach were also compared. In addition, patients were surveyed concerning which knee they preferred. RESULTS: Comparisons of postoperative Knee Society scores between both approaches at the time of the two-year follow-up did not yield a significant difference in outcome. Isokinetic strength testing at twelve weeks postoperatively revealed no significant differences in muscle strength, with a mean extensor peak torque-to-body weight ratio of 0.14 Nm/kg for both groups. No significant difference was found with respect to total blood loss, straight-leg-raising test, range of motion, or patient preference. There was no clinically relevant difference in operative times between the two approaches. CONCLUSIONS: The minimally invasive subvastus and midvastus approaches for total knee arthroplasty were both associated with excellent short-term clinical results. Some surgeons believe that the subvastus approach completely avoids damage to the quadriceps mechanism and therefore would be associated with improved muscle function. This prospective series did not identify a substantive difference between the two approaches. We believe that the decision between these surgical approaches should be based on surgeon preference and experience.

Percutaneous drilling for the treatment of atraumatic osteonecrosis of the ankle.

Atraumatic osteonecrosis of the ankle can be severely debilitating and can lead to joint collapse. A relatively new technique of percutaneous drilling has previously been used to relieve the symptoms of osteonecrotic hips and knees. The purpose of the present study was to examine the results of this technique when used to treat osteonecrosis of the ankle. Between September 2002 and June 2005, the senior author (M.A.M.) treated and prospectively followed 44 symptomatic osteonecrotic ankles (31 patients) using this drilling technique. The series included 23 (74.2%) women and 8 (25.8%) men with a mean age of 43 +/- 11 years. Arthrodesis had been recommended for 14 (45.2%) of these patients (20 [45.5%] ankles). At a mean follow-up duration of 45 +/- 12 months, 40 (91%) ankles had achieved a successful clinical outcome. The mean American Orthopaedic Society of Foot and Ankle Society Ankle and Hindfoot score increased from 42 +/- 5 points preoperatively to 88 +/- 10 points postoperatively, and this difference was statistically significant (P < .0001). There were no perioperative complications, although 3 ankles subsequently collapsed and required arthrodesis. The percutaneous drilling technique appears to be a useful method for the relief of symptomatic ankle osteonecrosis.

Total hip arthroplasty: comparison of two-incision and standard techniques at an AOA-accredited community hospital.

CONTEXT: The two-incision approach to total hip arthroplasty (THA) has received increasing attention in recent years. However, the benefits of this procedure have been debated. OBJECTIVES: To evaluate the two-incision THA technique compared to the standard anterolateral THA approach in a community hospital setting. METHODS: A retrospective review of records from patients who had THA at Memorial Hospital of York in Pennsylvania. Outcomes for patients who received the two-incision THA technique were compared to those who had a standard anterolateral THA approach. Perioperative parameters included operation duration and complication rates. Early function was evaluated by hospital length of stay and whether patients were discharged home or to a rehabilitation center. RESULTS: Twenty-eight patients had 30 THAs with a two-incision technique, and 30 patients had a standard anterolateral THA. Demographic parameters were similar among both groups. The two-incision THA group had a longer mean operation time by 34 minutes but shorter hospital stay by 0.8 days. Patients in the two-incision THA group were discharged to home 87% of the time compared to 43% in the anterolateral group. In addition, 4 patients (13%) in the two-incision group had an orthopedic complication compared to no complications in the anterolateral group. CONCLUSION: There were longer operative times, shorter hospital stays, and higher complication rates among patients who received the two-incision THA. Patients who receive the two-incision THA should be selected carefully and advised about the potential for increased complications.

Restoring range of motion via stress relaxation and static progressive stretch in posttraumatic elbow contractures.

HYPOTHESIS: Loss of range of motion after injury or surgery of the elbow is a common complication. We hypothesized that an orthosis that used progressive stretch and stress relaxation principles would improve elbow range of motion. METHODS: This study evaluated the result of a patient-directed, bidirectional orthosis that uses static progressive stretch and stress relaxation principles to improve elbow range of motion in patients who had posttraumatic elbow contractures. Treatment in 37 elbows consisted of a 30-minute stretching protocol performed in 1 to 3 sessions daily for a mean of 10 weeks (range, 2-22 weeks). RESULTS: The mean gain in range of motion was 26 degrees (range, 2 degrees -60 degrees ). Gains of motion were noted in 35 of 37 elbows. Patients lowered their analgesic use and were highly satisfied with the device (mean satisfaction score of 8.5 of 10 points possible). DISCUSSION: This device compared favorably with reports of other devices. Consistent improvements in restoring range of motion can be achieved with short treatment times by using a device based on the principles of static progressive stretch and stress relaxation in patients with posttraumatic elbow contractures.

Minimally invasive total knee arthroplasty: pitfalls and complications.

Despite reports of complications, there has been tremendous interest in using minimally invasive surgery (MIS) for total knee arthroplasty (TKA). Over the past 10 years, we have used an MIS approach for all TKAs. In the study described here, we examined the complications of the first 1000 of these TKAs. These cases involved a minimal incision (mean, 10 cm), a quadriceps muscle-sparing approach, and a non-patellar-everting technique. The complications assessed included manipulations, reoperations, and component revisions. We also analyzed for deviations in radiographic alignment or radiographic failures. There were 45 clinical complications-25 manipulations under anesthesia, 12 arthroscopic procedures for painful patellofemoral crepitus (mostly for an initially nonvisualized retained lateral band), and 8 operative explorations for various component problems. Radiographically, there were 3 impending component failures-2 tibial and 1 femoral. Excluding manipulations, there was a significant decrease in operative complication rate from the first 200 cases (6.0%) to the next 800 cases (1.0%), with overall complication rates similar to those of a control cohort treated with traditional surgical techniques. From this analysis, the major concern was potential tibial component loosening, which may be related to decreased exposure and possibly poor cement pressurization. Despite the low complication rate, this study yielded insights into further potential improvements in using this MIS technique for TKAs.

An arthroscopic technique to enhance visualization during total hip arthroplasty.

This technical note describes the use of an arthroscope or endoscope to enhance visualization during minimally invasive total hip arthroplasty. The arthroscope/endoscope is used to verify seating of the components and to look for potential impingements, loose bodies, or fractures. This technique was successfully used to identify and address 2 bony or soft tissue impingements as well as a calcar fracture that might otherwise have been missed. Although further study is necessary, we believe that this technique might reduce postoperative complications and improve clinical outcomes of total hip arthroplasty.

Incidence and cost of intraoperative waste of hip and knee arthroplasty implants.

Many strategies have been reported for decreasing the cost of orthopedic procedures, but prosthetic waste has not been investigated. The purpose of this study was to characterize the cost of intraoperative waste of hip and knee implants. A regional prospective assessment was performed, evaluating the reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Implant waste occurred in 79 (2%) of 3443 procedures, with the surgeon and operating room staff bearing primary responsibility in 73% of occurrences. The annualized cost was $109 295.35, with 67% absorbed by hospitals. When extrapolated to the whole of the United States, the annual cost to hospitals would be $36,019,000 and is estimated to rise to $112,033,000 by 2030, representing a potential target for educational programs and other cost containment measures.

Intraoperative waste of trauma implants: a cost burden to hospitals worth addressing?

OBJECTIVES: The purposes of this study were to assess the incidence of intraoperative trauma implant waste in a regional territory of the United States and to assess its impact on costs. METHODS: The total number of procedures using a single device manufacturer's orthopaedic trauma implants in one geographic region and number of occurrences of intraoperative orthopaedic trauma implant waste were recorded prospectively from 74 contiguous hospitals over a period of 18 months along with the individual responsible for the waste (surgeon, vendor representative, or operating room staff), the cost of the wasted implant, and whether the hospital paid for the implant. Hospitals were stratified into teaching or community institutions. The collected data were then aggregated and analyzed for overall incidence and cost as well as cost per trauma procedure. RESULTS: Implant waste occurred in 37 of 6531 procedures (0.6%) with 16 of the centers (21.6%) reporting at least one occurrence and 95% attributed to the surgeon or operating room staff. Community hospitals were found to have a significantly higher incidence of implant waste as compared with teaching hospitals. Hospitals absorbed 74% of the wasted implant costs ($20,357 over the study period). This expense represented a mean additional cost of $3.12 per orthopaedic trauma procedure performed. CONCLUSIONS: There is a small but notable annual incidence and cost of orthopaedic trauma implant waste in the study region with the majority of this cost borne by the hospitals. However, implant waste occurs infrequently and represents a very small cost to hospitals per procedure. Educational programs and other strategies to reduce its incidence are unlikely to yield any substantial cost savings.

Small-diameter percutaneous decompression for osteonecrosis of the shoulder.

Core decompression of the humeral head has previously been used as a joint-preserving procedure for treatment of symptomatic osteonecrosis of the shoulder. In this article, we describe a new decompression technique, which involves multiple small-diameter (3-mm) percutaneous perforations. In our study population (early-stage disease), shoulder arthroplasty was avoided in all 15 patients (26 shoulders) for a mean follow-up of 32 months (range, 24-41 months). Of the 26 shoulders, 25 had successful clinical and functional outcomes (University of California Los Angeles shoulder score, >24 points), and 1 showed radiographic progression of the disease but has not needed further operative treatment. We compared our decompression results with those of a nonoperative historical control group, identified through a literature search. There was a 48% (143/299) rate of progression to arthroplasty in the control group at a follow-up ranging from 2 to 4.5 years. This outpatient, percutaneous perforations technique appears to be a low-morbidity method for relieving symptoms and deferring shoulder arthroplasty in patients with symptomatic osteonecrosis of the humeral head.

Botulinum toxin type A injections for the management of muscle tightness following total hip arthroplasty: a case series.

BACKGROUND: Development of hip adductor, tensor fascia lata, and rectus femoris muscle contractures following total hip arthroplasties are quite common, with some patients failing to improve despite treatment with a variety of non-operative modalities. The purpose of the present study was to describe the use of and patient outcomes of botulinum toxin injections as an adjunctive treatment for muscle tightness following total hip arthroplasty. METHODS: Ten patients (14 hips) who had hip adductor, abductor, and/or flexor muscle contractures following total arthroplasty and had been refractory to physical therapeutic efforts were treated with injection of botulinum toxin A. Eight limbs received injections into the adductor muscle, 8 limbs received injections into the tensor fascia lata muscle, and 2 limbs received injection into the rectus femoris muscle, followed by intensive physical therapy for 6 weeks. RESULTS: At a mean final follow-up of 20 months, all 14 hips had increased range in the affected arc of motion, with a mean improvement of 23 degrees (range, 10 to 45 degrees). Additionally all hips had an improvement in hip scores, with a significant increase in mean score from 74 points (range, 57 to 91 points) prior to injection to a mean of 96 points (range, 93 to 98) at final follow-up. There were no serious treatment-related adverse events. CONCLUSION: Botulinum toxin A injections combined with intensive physical therapy may be considered as a potential treatment modality, especially in difficult cases of muscle tightness that are refractory to standard therapy.

Anatomic and physiologic rationale for various technologies for primary total hip arthroplasty.

A number of patients have anatomic or physiologic variations that may adversely affect the performance of a primary total hip arthroplasty. Various technologies have been utilized in an attempt to improve the outcomes for these patients; however, some of these potential solutions are controversial. The authors examined the complete body of literature for scientific evidence regarding the use of these new technologies. The anatomic and physiologic anomalies that were studied include extra-articular deformities, developmental dysplasia, Perthes disease, Type C femoral bone, acetabular bone deficiency, femoral rotational abnormalities, variations that increase the risk of hip dislocation, sickle cell anemia, and extremely small or large bone sizes. This article presents the current scientific evidence and imparts an unbiased view of the use of various technologies to provide individualized solutions for patients who have anatomic or physiologic variations.

Total knee arthroplasty using cementless keels and cemented tibial trays: 10-year results.

The problem of early mechanical stability of cemented and cementless keels of the tibial component in total knee arthroplasty (TKA) is controversial. The purpose of this study was to assess clinical and radiographic outcomes of a cohort of 51 TKAs using a cemented platform with cementless keel fixation. At a mean follow-up of 10.4 years (range, 7 to 14 years), the mean Knee Society Score (KSS) was 93 points (range, 59 to 100 points), and the mean functional score was 73 points (range, 0 to 100 points). Only one patient demonstrated progressive tibial radiolucencies at 13.1 years follow-up, which resolved with a revision with an exchange of components. The results of this study suggest that a proximally cemented tibial tray with a press-fit keel TKA provides excellent mean 10-year outcomes.

Hemostasis using a bipolar sealer in primary unilateral total knee arthroplasty.

Previous studies have shown that, compared with standard electrocautery, a bipolar sealer reduces tissue damage and smoke production during surgery. We conducted a multicenter, prospective, randomized study to compare a bipolar sealer with standard electrocautery for hemostasis. Sixty-nine primary total knee arthroplasties were performed. Cohorts were evaluated for intraoperative and postoperative blood loss, blood transfusion requirements, postoperative hemoglobin and pain levels, length of hospital stay, range of motion, and Knee Society scores. Amount of blood loss and decrease in postoperative hemoglobin were significantly lower in the bipolar sealer group than in the standard electrocautery group. Need for autologous blood transfusions was decreased in the bipolar sealer group compared with the electrocautery group. There were no between-groups differences in clinical knee scores. The bipolar sealer was an effective coagulation alternative for total knee arthroplasties in reducing blood loss and transfusion requirements without affecting clinical outcome.

Perioperative management for orthopaedic patients with sickle cell anaemia.

PURPOSE: To compare outcomes of 2 types of perioperative optimisation for patients with sickle cell anaemia (SCA) undergoing various orthopaedic surgeries. METHODS: 12 female and 11 male patients aged 13 to 40 (mean, 18) years with SCA underwent 31 separate orthopaedic procedures for osteonecrosis of the femoral head. They were referred to a haematologist for 2 types of perioperative optimisation, based on the choice of the attending paediatrician. In the aggressive management group, patients received packed red blood cells preoperatively to increase the haemoglobin level to 9 to 11 g/dl and to lower the haemoglobin S level to <30%. Fresh frozen plasma was given when their Factor VII level was <30%. In the conservative management group, patients received packed red blood cells preoperatively to increase the haemoglobin level to a minimum of 10 g/dl. Fresh frozen plasma or packed red blood cells were given intra-operatively only when excessive bleeding occurred. The length of hospital stay, the number of perioperative complications, the number of transfusions, and episodes of alloimmunisation and/or vaso-occlusive crises in the two groups were compared. RESULTS: No patient in the aggressive management group received supplemental oxygen or had an estimated intra-operative blood loss of >400 ml. Three patients in the conservative management group received multiple intra- and post-operative transfusions and supplemental oxygen. CONCLUSION: Both aggressive and conservative protocols may be safely used in SCA patients. The more aggressive protocol resulted in lower rates for postoperative complications, transfusions, and resorting to supplemental oxygen.