Does Lack of Initial Collar-Calcar Contact Influence Performance of Collared Cementless Femoral Stems?

Background: Initial stability of cementless stems is important to minimize the risk of subsidence, pain, and periprosthetic fracture after total hip arthroplasty (THA). Collared stems improve initial component stability when contacting the femoral calcar. Direct contact is not always achieved, and collared stem performance has not been studied in this context. We hypothesized that collared stems achieving direct contact would demonstrate reduced subsidence. Methods: A single-surgeon retrospective study of 482 consecutive primary THAs implanted between February 2020 and May 2023 using collared cementless stems was performed. The 2 cohorts included stems with initial collar-calcar contact vs stems without. Subsidence was evaluated by comparing intraoperative fluoroscopy to postoperative 8-week radiographs. Binary logistic regression identified independent risk factors for subsidence. Chi-square tests were used for categorical variables and t-tests for continuous variables. Results: Of stems, 63.9% achieved initial collar-calcar contact, while 36.1% did not. The rate (1.3% vs 19.0%; P < .001) and magnitude (0.02 mm, range 0-3 mm vs 0.35 mm, range 0-3 mm; P < .001) of subsidence were significantly higher among stems without initial contact. Stems without initial collar-calcar contact (P < .001) and male gender (P = .007) were independent risk factors for subsidence. Two patients with initial contact had nondisplaced calcar cracks and <3 mm of subsidence at 4 weeks, which healed with protected weight-bearing. Stem survivorship was 100% in both groups, with all achieving osteointegration and none needing revision. Conclusions: Excellent performance of collared cementless stems was observed at 8 weeks after primary THA. Initial collar-calcar contact lowered the risk and magnitude of minor subsidence but did not affect survivorship or fracture risk. Level of Evidence: Level III.

Transient Osteoporosis of the Hip: A Case Report of a U.S. Soldier.

Transient osteoporosis of the hip is described as an uncommon, self-limiting condition that typically affects middle-aged men and pregnant women in their third trimester. Transient osteoporosis most commonly affects the hip, but cases have been described in the knee, ankle, and foot. Symptoms include pain, limited range of motion, and antalgic gait. A greater level of awareness of transient osteoporosis of the hip as a differential diagnosis for hip pain will obviate unnecessary, inefficient, or unproductive interventions and treatments. Transient osteoporosis of the hip is a self-limiting disease process that requires only symptomatic treatment such as basic analgesia, physical therapy, and activity modification. On average, recovery is seen within 6-12 months.

Utility of Intraoperative Fluoroscopic Positioning of Total Hip Arthroplasty Components Using a Posterior and Direct Anterior Approach.

INTRODUCTION: Positioning of implant components for total hip arthroplasty (THA) is important for polyethylene liner wear, prosthesis joint stability, and range of motion. The introduction of fluoroscopy for the direct anterior approach has been shown to improve physician accuracy for component positioning. Few studies compare the use of intraoperative fluoroscopy for THA component positioning in posterior THA. The purpose of this project is to retrospectively evaluate the effect of intraoperative fluoroscopy on component positioning for THA using posterior and direct anterior approach (DAA). MATERIALS AND METHODS: A retrospective review of postoperative weight-bearing X-ray films of THAs was performed over a 2-year period where a single fellowship-trained total joint surgeon introduced direct anterior approach into his practice while expanding the intraoperative use of fluoroscopy for all THA procedures, regardless of approach. Component position was evaluated through radiographic measurement of acetabular cup inclination (goal of 40 degrees), limb length discrepancy (goal of 0 mm), and femoral component offset difference (goal of 0 mm). Radiographic analysis was performed by two independent providers. Statistical analysis was performed using Student's t-tests. RESULTS: A total of 107 patients with an average age of 62 years were identified during the 2-year period surrounding the THA practice change, adding fluoroscopy to posterior and DAA THA. Three cohorts were identified: cohort A: 44 patients who underwent posterior THAs without the use of intraoperative fluoroscopy, cohort B: 35 patients who underwent direct anterior approach THAs with the use of intraoperative fluoroscopy, and cohort C: 18 patients who underwent posterior THAs with the use of intraoperative fluoroscopy. The use of intraoperative fluoroscopy for the posterior approach versus unguided posterior approach increased accuracy of both cup inclination (44 degrees vs 50 degrees, P < .05) and femoral offset (4 mm vs 7 mm, P < .05). A comparison of DAA with fluoroscopy versus posterior approach without fluoroscopy showed improvement in cup inclination (48 degrees vs 50 degrees, P < .05). Fluoroscopy with posterior approach versus fluoroscopy with DAA was found to have improved cup inclination (44 degrees vs 48 degrees, P < .05). CONCLUSION: Intraoperative use of fluoroscopy can improve component positioning for posterior THA.

Total Joint Arthroplasty at a Tertiary Military Medical Center in Hawai'i: Does Travel Distance Influence Short Term Complications?

As the health care delivery system in the United States changes, there has been an increase in the presence of specialized medical centers, translating into increased travel distance for patients. Tripler Army Medical Center in Honolulu, Hawai'i serves a unique population of local patients and those traveling from neighboring Hawaiian Islands and from across the Pacific Basin and Asia. Previous studies have examined the role of distance traveled, but no study has looked at patients routinely flying in the immediate postoperative period. The purpose of this study is to investigate if increased travel distance is associated with a higher probability of complications after a total joint arthroplasty (TJA). A retrospective review of all patients receiving TJA at a single medical institution was performed. After meeting the inclusion criteria, 126 consecutive patients were reviewed for 30-day complications. Sixty-four patients were local (from O'ahu, Hawai'i), and 13 from neighboring Hawaiian Islands, while 49 were international. There were no significant differences in complications between the groups. Length of stay was not affected by distance. A significant risk factor for short-term complications was having a higher score based on the American Society of Anesthesiologists Physical Status Classification System (ASA), ASA 3 vs ASA 1&2 (14% vs 1%, P = .015). There were no findings in our population to support inferior outcomes in patients traveling from the outer Pacific Basin during their initial postoperative course compared to the local population. No patient sustained a short-term complication after a patient returned to their island or country of origin. The results of this study will help to guide clinical decision making and effective resource management for patients seeking TJA traveling from a significant distance.

Does Clinical Exam and Ultrasound Compare With MRI Findings When Assessing Tendon Approximation in Acute Achilles Tendon Tears? A Clinical Study.

The purpose of this study was to determine if clinical palpation and ultrasound determination of apposition compares with magnetic resonance imaging (MRI) findings in patients with an acute Achilles tendon rupture. A review of 18 consecutive patients presenting with an acute Achilles tendon tear was performed. All tears were diagnosed by clinical exam and confirmed by ultrasound. Ankles were then plantarflexed to a point where tendon apposition was achieved as determined by palpation and ultrasound. Dorsally based equinus splints were applied, and approximation was reconfirmed by palpation and ultrasound. MRI was performed on all patients for comparison to the exam/ultrasound for any residual gapping after splinting. Demographic and clinical comparisons were made between those with <0.5 cm and ≥0.5 cm of residual gapping found on MRI. Eighteen patients with acute Achilles tears were splinted at a mean of 41° ± 11°, with presumed, complete tendon approximation confirmed with palpation and ultrasound. Post-splinting MRI demonstrated that 9/18 (50%) of these patients had residual gapping at a mean of 2.2 ± 1 cm. Mean time to MRI from splinting was not different between those with gapping (1.3 ± 2 days) and those without (1.2 ± 1 days). No other clinical or demographic differences were observed between these groups. In conclusion, clinical exam and ultrasound did not routinely relate to MRI in assessing tendon approximation after splinting of an acute Achilles tendon tear. For surgeons who use approximation as a determination of nonoperative treatment, varying results can be obtained depending on the clinical utility used.

Mouth in Foot Disease.

Toothpicks are commonly used household items that rarely cause serious injury or infection. Toothpick-related injuries often occur due to ingestion with subsequent trauma/infection at distal sites within the gastrointestinal tract; however, cardiovascular, pleural, and soft tissue infections have been reported. Eikenella corrodens is a gram-negative, facultative anaerobic bacillus found in oral flora associated with bite wound infections. A few case reports describe E. corrodens osteomyelitis from toothpick puncture wounds. We report a case of foot cellulitis and abscess in an elderly diabetic after toothpick puncture injury that was unresponsive to empiric antibiotics. Wound cultures grew E. corrodens and rare Peptostreptococcus species. E. corrodens is resistant to first-generation cephalosporins, macrolides, aminoglycosides, clindamycin, and metronidazole. This case highlights the insidious nature of E. corrodens infections and the need to tailor empiric antibiotics for skin and soft tissue infections based on the mechanism of injury. In addition, this case stresses the importance of protective footwear in diabetics and serves as a cautionary tale regarding the use of seemingly innocuous toothpicks.

Arthroscopic revision of Bankart repair.

The success of revision surgery for failed Bankart repair is not well known. This purpose of this study was to report the success rates achieved using arthroscopic techniques to revise failed Bankart repairs. Twelve arthroscopic revision Bankart repairs were performed on patients with recurrent unidirectional shoulder instability after open or arthroscopic Bankart repair. Follow-up was available on 11 of the 12 patients at a mean of 34.4 months (range, 25-56 months). The surgical findings, possible modes of failure, shoulder scores (Rowe score, University of California Los Angeles [UCLA], Simple Shoulder Test), and clinical outcome were evaluated. Various modes of failure were recognized during revision arthroscopic Bankart repairs. Good-to-excellent results were obtained in 8 patients (73%) undergoing revision stabilization according to Rowe and UCLA scoring. A subluxation or dislocation event occurred in 3 (27%) of the 11 patients at a mean of 8.7 months (range, 6-12 months) postoperatively. Arthroscopic revision Bankart repairs are technically challenging procedures but can be used to achieve stable, pain-free, functional shoulders with return to prior sport. Owing to limited follow-up and the small number of patients in this study, we were unable to conclude any pattern of failure or selection criteria for this procedure.

PKC regulates a farnesyl-electrostatic switch on K-Ras that promotes its association with Bcl-XL on mitochondria and induces apoptosis.

K-Ras associates with the plasma membrane (PM) through farnesylation that functions in conjunction with an adjacent polybasic sequence. We show that phosphorylation by protein kinase C (PKC) of S181 within the polybasic region promotes rapid dissociation of K-Ras from the PM and association with intracellular membranes, including the outer membrane of mitochondria where phospho-K-Ras interacts with Bcl-XL. PKC agonists promote apoptosis of cells transformed with oncogenic K-Ras in a S181-dependent manner. K-Ras with a phosphomimetic residue at position 181 induces apoptosis via a pathway that requires Bcl-XL. The PKC agonist bryostatin-1 inhibited the growth in vitro and in vivo of cells transformed with oncogenic K-Ras in a S181-dependent fashion. These data demonstrate that the location and function of K-Ras are regulated directly by PKC and suggest an approach to therapy of K-Ras-dependent tumors with agents that stimulate phosphorylation of S181.

Perforated duodenal diverticulitis: a report of three cases.

BACKGROUND: Duodenal diverticuli are present in up to 22% of the population. However, perforation of a duodenal diverticulum with spillage of enteric contents into the retroperitoneum is rare. METHODS: We report three cases of perforated duodenal diverticulitis. RESULTS: Clinical presentations varied widely from patients with acute abdominal findings and generalized sepsis to a patient with mild symptoms of abdominal discomfort. CT scanning was the imaging modality used to make an accurate diagnosis. Treatment approaches for the most stable patient included nonoperative management with antibiotics, bowel rest and parenteral alimentation, while the less stable patients underwent definitive surgery with complete diversion of gastric contents and biliary flow from the affected area of duodenum. CONCLUSIONS: This report highlights the salient issues in the presentation, diagnosis and modern management of patients with this potentially catastrophic disease.

Retroperitoneal perforation of the duodenum from biliary stent erosion.

Endoscopically placed biliary stents have supplanted surgical decompression as the preferred treatment option for patients with obstructive jaundice from advanced pancreatic cancer. An unusual complication of indewelling biliary stents is duodenal perforation into the retroperitoneum. We describe the case of a patient with end-stage pancreatic cancer who presented with an acute abdomen from erosion of a previously placed bile duct stent through the wall of the second portion of the duodenum. Although our patient presented with advanced symptoms, clinical presentations can vary from mild abdominal discomfort and general malaise to overt septic shock. Definitive diagnosis is best made with computed tomography (CT) imaging, which can detect traces of retroperitoneal air and fluid. Treatment options vary from nonoperative management with antibiotics, bowel rest, and parenteral alimentation in the most stable patients to definitive surgery with complete diversion of gastric contents and biliary flow from the affected area in patients with clinical symptoms or radiologic evidence suggesting extensive contamination. Complications of management can include duodenal fistulization, residual retroperitoneal or intrabdominal abscess, and ongoing sepsis. This report highlights the salient issues in the presentation, diagnosis, and modern management of patients with this rare complication of indwelling biliary stents.