Medical Missions in Jordan: A Series of Upper-Extremity Orthopedic Injuries.

Worldwide, a great deal of disability is caused by musculoskeletal injuries from high-energy trauma. In nations affected by war, blast injuries associated with mines, missiles, high-powered gunshots, and bombings are one cause of these injuries. Medical missions carried out by those from developed nations is one way to address this. Therefore, it is critical that those who participate in these missions maintain a basic understanding the injuries that may be encountered in nations affected by war and violent conflict. We describe a small number of upper-extremity injuries seen by one orthopedic surgeon during his volunteer medical mission to Jordan. Many of these injuries resulted in the loss of function and/or limb, as these patients were treated without appropriate instrumentation or facilities in a suboptimal environment and in a delayed manner by surgeons who lacked optimal training. It is our hope that this case series will encourage studies that can offer guidance in the ways to treat such complex injuries with optimal safety and efficacy.

Medical Missions in the Middle East: An Orthopaedic Surgeon's Experience of a Series of Lower Extremity Cases.

Orthopaedic trauma accounts for a great deal of disability worldwide. There are many impoverished nations affected by war wherein victims suffer blast injuries associated with mines, missiles, high-powered gunshots, and bombings. One way to address this is through international medical missions sponsored by industrialized nations. It is imperative that practitioners have a basic understanding of the type of injuries that may be encountered in these nations impacted by war and conflict. Therefore, we described a small number of various lower extremity injuries seen by one orthopaedic surgeon during his volunteer medical mission to Jordan. Frequently, these injuries did result in the loss of a limb and/or function as the patients were treated without appropriate instrumentation or facilities in a suboptimal environment. Treatment was frequently delayed, and many of the surgeons involved lacked optimal training. It is our hope that this case series will lead to studies which may give guidance regarding how to best treat these complex injuries with optimal outcomes and minimal complications.

Ochronosis as Etiology of Requiring Total Knee Arthroplasty-A Case Series.

Alkaptonuria is a rare hereditary metabolic disorder that leads to the accumulation of homogentisic acid accumulation and weakens the collagen, creating fissuring and articular cartilage degeneration. Therefore, we are reporting a multicenter case series of three patients (four arthroplasties) who presented with signs and symptoms of ochronotic arthropathy-and eventually underwent total knee arthroplasty (TKA)-and provide a review of the current literature on total joint arthroplasty in ochronotic osteoarthritis. Each patient achieved excellent Knee Society Scores (KSS) after at least a five-year follow-up-regardless of receiving cemented or cementless prostheses-and suffered no complications. There have been a number of case reports published on patients who had TKA and were found to have a diagnosis of ochronosis. We believe that surgery for symptomatic patients who are surgical candidates for TKA should not be delayed for concerns of complications. However, future studies should compare outcomes to those who undergo TKA without ochronotic arthropathy.

Patient-Specific Instrumentation in Total Knee Arthroplasty: What Is the Evidence?

With a steady increase in the demand for primary and revision total knee arthroplasty (TKA), any potential reduction in the number of failures can be a topic of significant clinical importance. Patient-specific instrumentation (PSI) is introduced to potentially achieve more reproducible alignment with reduced outliers by creating more accurate and patient-specific femoral and tibial cuts based on neutral mechanical axis. However, there is no widely accepted consensus on the efficacy and indication of using PSI in TKA. The purpose of this review was to assess the current literature on patient-specific TKA and its effect on perioperative outcomes, including templating and preoperative planning, mechanical alignment, clinical outcomes, perioperative blood loss, and economic evaluations. Based on the current literature, more prospective studies are necessary to evaluate the routine use of PSI in TKA.

Bilateral femur fractures associated with short-term bisphosphonate use.

Bisphosphonates are the most commonly prescribed drugs to treat osteoporosis because they have been proposed to prevent bone loss. Nevertheless, in up to 0.1% of patients, long-term use may cause atypical stress or insufficiency femoral fractures. Bilateral femoral shaft fractures have been reported after long-term use of bisphosphonates; however, there is limited evidence of the effect of short-term use. The current study reports a case of bilateral femoral fractures after a low-energy fall in a 56-year-old woman and provides a review of the literature on bilateral femoral shaft fractures after long-term use of bisphosphonates. Patients should be educated about the potential for stress fractures with the use of this treatment. In patients with thigh pain, a thorough history and physical examination, including the contralateral thigh, may be beneficial to detect bilateral traumatic or atypical stress fracture patterns. More studies with larger sample sizes are necessary to better identify patients who may be at risk for fracture, including histomorphometric evidence of low bone turnover in patients with unfortunate bilateral cases.

Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty?

BACKGROUND: One of the most important goals of primary total knee arthroplasty (TKA) is to achieve a functional range of motion (ROM). However, up to 20% of patients fail to do so, which can impair activities of daily living. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the effect of various (1) demographic factors; (2) comorbidities; and (3) knee-specific factors on the frequency of manipulation under anesthesia, which was used as an indicator of knee stiffness after a primary TKA. METHODS: We evaluated the registries of two high-volume centers and reviewed all 3182 TKAs that were performed between 2005 and 2011 to identify all patients who had undergone manipulation under anesthesia (MUA). A total of 156 knees in 133 patients underwent MUA after an index arthroplasty. These patients were compared in a one-to-four ratio with a group of patients with satisfactory ROM drawn from the same database who met prespecified criteria and who had not undergone MUA. Effects of various factors, including age, sex, body mass index, race, comorbidities, and the underlying cause of knee arthritis, were compared between these two cohorts using multivariable logistic regressions. RESULTS: After controlling for various confounding, nonwhite race was associated with an increase (odds ratio [OR], 2.01; p=0.03), and age≥65 years (OR, 0.17; 95% confidence interval [CI], 0.04-0.74; p=0.0179) was associated with a reduction in the incidence of MUA. In comorbidities, diabetes (OR, 1.72; 95% CI, 1.02-2.32; p=0.03), high cholesterol levels (OR, 2.70; p=0.03), and tobacco smoking (OR, 1.59; 95% CI, 1.03-2.47; p=0.03) were associated with an increase in frequency of MUA. In knee-specific factors, preoperative knee ROM of less than 100° (OR, 0.80; p<0.0001) and knee osteonecrosis (p=3.61; 95% CI, 1.29-10.1; p=0.014) were associated with increased frequency of MUA. CONCLUSIONS: We identified several demographic, medical, and knee-specific factors that were associated with poor postoperative ROM in our patients undergoing TKA. Patients who have multiple risk factors may benefit from preoperative counseling to set realistic ROM expectations. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Blood management strategies in primary and revision total knee arthroplasty for Jehovah's Witness patients.

Primary or revision total knee arthroplasties (TKAs) may be associated with a marked amount of intraoperative or postoperative blood loss that potentially may lead to the need for blood transfusions. However, Jehovah's Witnesses usually refuse blood transfusions because of their religious beliefs. This may create clinical or ethical challenges for the treating physicians. Therefore, following established blood management protocols specifically designed for these patients may be beneficial for the performance of safe and transfusion-free procedures with minimal complications. In this report, we provide an overview of various potential preoperative, intraoperative, and postoperative blood management measures that may be used for the care of Jehovah's Witnesses who undergo knee arthroplasty procedures. In addition, we review reported outcomes of primary and revision TKAs in these patients.

Reliability of templating with patient-specific instrumentation in total knee arthroplasty.

Magnetic resonance imaging (MRI) or computed tomography-based patient-specific instrumentation (PSI) may allow for reliable alignment and fewer outliers when compared with conventionally instrumented total knee arthroplasty (TKA). However, some authors have suggested that frequent intraoperative surgeon-directed changes may still be required. This study evaluated the accuracy of PSI to predict component sizing and alignment during TKA. A total of 84 patients (89 knees) who underwent a TKA using a PSI system were evaluated. An MRI-based preoperative plan of every knee was provided and approved by the surgeons. This demonstrated the proposed prosthetic component alignment, as well as the femoral, tibial, and bearing insert component size and position. Intraoperative changes to these components were prospectively recorded and compared with the computerized preoperative plan. Major changes were defined as any changes in femoral or tibial resection, size, and position of the components. Minor changes were defined as any change in the size of the polyethylene bearing insert. The preoperative plan was able to correctly predict the size of the implanted tibial and femoral component in 93 and 95.5% of the cases, respectively. Thirteen major intraoperative changes were made. In one knee, the proposed femoral resection was not acceptable (because of the presence of significant amount of osteophytes) and was abandoned in favor of a manual extramedullary guide. In another patient, the proposed femoral and tibial components were upsized. In two other patients, the femoral components were downsized, in four patients, the tibial components were downsized, and in another patient, it was upsized. There were also 16 minor changes, which included 2-mm upsizing of the polyethylene liner in 13 knees and 4-mm upsizing in 3 knees. Surgical experience is necessary to recognize improper component size, incorrect surgical resection, or nonideal alignment when performing TKA using PSI. The authors believe that the design and manufacture of PSI combined with a comprehensive templating resulted in excellent intraoperative concordance of the preoperative plan at the default settings with minimal changes.

Total knee arthroplasty for osteonecrosis.

BACKGROUND: A patient with collapse of a femoral condyle caused by osteonecrosis has few treatment options other than total knee arthroplasty. The purpose of this study was to report the clinical and radiographic outcome of total knee arthroplasty for osteonecrosis. METHODS: Between 1987 and 1996, thirty-two total knee arthroplasties were performed with cement in thirty patients with osteonecrosis of the femoral condyle and/or tibial plateau. The study group included twenty-forty women and five men with a mean age of fifty-four years (range, thirty-one to seventy-seven years) at the time of the arthroplasty. Twenty-two patients had atraumatic osteonecrosis associated with corticosteroid use, and eight had spontaneous osteonecrosis. All patients had a complete clinical and radiographic evaluation at a mean of 108 months (range, forty-eight to 144 months) postoperatively. RESULTS: Overall, thirty-one (97%) of the thirty-two knees had a successful clinical outcome. The mean Knee Society score improved from 54 points preoperatively to 95 points at the time of the latest follow-up. No evidence of progressive radiolucency was found around any prosthetic component. CONCLUSIONS: Previous studies have demonstrated less-than-optimal results following total knee arthroplasty in patients with osteonecrosis. The excellent results found in the present study may have been secondary to the use of cemented implants in all cases and ancillary stems when appropriate.