Superior Pubic Ramus Screw Placement During Complex Acetabular Revision: Acetabular Distraction for Treatment of Pelvic Discontinuity.

Insertion of a superior pubic ramus screw may be indicated for the treatment of a chronic pelvic discontinuity when utilizing acetabular distraction in revision total hip arthroplasty (THA), especially in the setting of severe bone loss in the ischium. The aim of this procedure is to stabilize and prevent abduction failure of the acetabular component when utilizing acetabular distraction. Description: With the patient in the lateral decubitus position, the acetabulum is exposed from a standard posterior approach for a revision THA. The location of the superior pubic root is identified after making a recess within the anteroinferior capsule. In order to ensure that the appropriate trajectory is obtained, C-arm imaging (inlet view and orthogonal obturator outlet views) is utilized to safely predrill the screw trajectory into the superior pubic ramus. A Kirschner wire (K-wire) is then placed into the hole. With use of a metal-cutting burr on the back table, customized peripheral screw holes are placed and then the acetabular component is slid and impacted into place over the K-wire. After cup insertion, the K-wire is removed and the superior pubic ramus screw can be placed and confirmed on fluoroscopy. Alternatives: In general, chronic pelvic discontinuity requires surgical management with revision THA and has historically employed the use of a cup-cage construct, custom triflange implants, and/or jumbo acetabular cups with modular porous metal augments1-5. With these treatment options, it is typically necessary to insert "kickstand" screws, which function to prevent abduction failure of the acetabular cup4,5. However, in many cases of discontinuity, there may be severe ischial osteolysis, making ischial screw placement difficult or impossible. The superior pubic ramus, however, remains a reliable option that can be utilized for inferior screw fixation, even in cases of severe acetabular bone loss, and thus is especially beneficial in these difficult cases. Rationale: The technique of acetabular distraction was developed because of limitations with alternative techniques. This procedure achieves cementless biologic fixation and eventual discontinuity healing as a result of lateral or peripheral acetabular distraction and resultant medial or central compression across the pelvic discontinuity. Acetabular distraction allows for intraoperative customization and cement unitization of the acetabular construct. This procedure requires the use of a "kickstand" screw or of inferior screw fixation in order to prevent abduction failure of the cup. These screws may be placed into either the ischium or superior pubic ramus. If the patient has substantial ischial osteolysis, ischial screw fixation may not be possible. If not placed in a systematic manner, pubic ramus screws can be technically challenging, and incorrect placement can result in neurovascular injury. The present video article demonstrates a reproducible technical method for safely placing a screw in the superior ramus to aid in optimal fixation of the acetabular component in cases of pelvic discontinuity. Expected Outcomes: Thus far, short-term survivorship of acetabular distraction with use of a jumbo cup and kickstand screws has been about 95%. In the largest study to date assessing patients with chronic pelvic discontinuity who underwent revision THA with use of the acetabular distraction technique, only 1 of 32 patients required revision for aseptic loosening6. An additional 2 patients had evidence of radiographic loosening but did not undergo revision, and 3 had migration of the acetabular component into a more stable configuration. Radiographically, 22 of 32 patients in the study demonstrated healing of the discontinuity6. In another study assessing the survivorship of porous tantalum acetabular shells in revision THA to treat severe acetabular defects, patients with inferior screw fixation with superior pubic ramus or ischial screws had a significantly lower incidence of proximal translation of components compared with those without inferior screw fixation7. Important Tips: For reproducible, successful execution of this technique, it is important to confirm correct placement of the acetabular retractors at the correct anatomical locations to ensure adequate surgical visualization of the acetabulum for easy identification of the superior pubic root.It is also critical to check placement of the drill via fluoroscopy with an inlet and obturator outlet views prior to drilling.The drill should be advanced on the oscillate setting to avoid inadvertently perforating the cortical bone and damaging surrounding neurovascular structures. Acronyms and Abbreviations: OR = operating roomf/u = follow-upvac = vacuum-assisted closureRSA = radiostereometric analysis.

Significant Reduction of Pulmonary Embolism in Orthopaedic Trauma Patients.

OBJECTIVES: To report results of a protocol to lessen incidence of pulmonary embolism (PE) among orthopaedic trauma patients. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENT/PARTICIPANTS: Orthopaedic trauma inpatients were included in the study. INTERVENTION: On arrival, an orthopaedic trauma patient's PE risk is calculated using a previously developed tool. If possible, patients at high risk are given their first dose of enoxaparin before leaving the emergency room. If other injuries preclude enoxaparin, then chemoprophylaxis is held for 24 hours. Twenty-four hours after arrival, the patient's ability to receive enoxaparin is reassessed. If possible, enoxaparin is started, with dosing twice a day. If enoxaparin is still contraindicated, a removable inferior vena cava filter is placed. Adequacy of enoxaparin dosing is tested using anti-factor Xa assay, drawn 4 hours after the third dose of enoxaparin. If the anti-factor Xa result is less than 0.2 IU/mL, a removable inferior vena cava filter is placed. If the result is 0.2-0.5 IU/mL, enoxaparin dosing is continued. If greater than 0.5 IU/mL, the dose of enoxaparin is reduced. OUTCOME MEASURE: The main outcome measure was rate of PE. RESULTS: From September 1, 2015 to December 31, 2015, our hospital admitted 420 orthopaedic trauma patients. Fifty-one patients were classed as high risk for PE. In September through December 2015, 9 sustained PE, 1 of which was fatal. From September 1, 2016 to December 31, 2016, our hospital admitted 368 orthopaedic trauma patients with comparable age and Injury Severity Score to 2015. Forty patients were at high risk for PE, 1 sustained a nonfatal PE. PE incidence from September to December 2016 was significantly lower than in 2015 (P = 0.02). Overall, 26 patients managed under the new protocol had IVCFs placed, 21 had their filters removed, and 3 died with filters in place. There were no complications during filter placement or removal. One patient had hemorrhage felt to be attributable to enoxaparin. CONCLUSIONS: Our protocol emphasizes more robust enoxaparin dosing, and more frequent use of IVCF, but only among those at high risk. We lessened the incidence of PE, with a low complication rate. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sleep Quality in Patients With Rotator Cuff Disease.

BACKGROUND: Little is known about the influence of rotator cuff pathology on sleep. The purpose of this study was to determine which patient-reported factors correlate with sleep disturbance in patients with rotator cuff disease. METHODS: A nonrandomized, cross-sectional cohort study was performed to evaluate the effects of rotator cuff disease on sleep quality. Data collected at time zero (before any treatment) included the Single Assessment Numeric Evaluation rating, the American Shoulder and Elbow Surgeons score, the Pittsburgh Sleep Quality Index, patient demographics, and medical comorbidities. Statistical analysis included the Pearson correlation and multiple regression analysis to determine which patient-reported factors were associated with sleep disturbance. RESULTS: Nocturnal pain was reported by 91% of the 391 participants (274 with tendinitis and 117 with rotator cuff tears). Participants had a mean age of 57 years. Pearson correlation coefficients determined that poor sleep quality in one group or both the tendinitis and the rotator cuff tear groups was associated with higher pain visual analog scale scores (0.27 and 0.31; P = 0.004 and P < 0.0001, respectively), depression (0.27 and 0.30; P < 0.01), female sex (0.24 and 0.27; P < 0.001), presence of low back pain (0.25 and 0.27; P < 0.01), diabetes mellitus (0.24 in the rotator cuff tear group; P < 0.01), and increased body mass index (0.22 and 0.27; P = 0.02). DISCUSSION: The status of the rotator cuff did not correlate with increasing symptoms of shoulder pain or with worse sleep quality as measured by the Pittsburgh Sleep Quality Index. These results support the theory that worsening symptoms of shoulder pain may not be clearly associated with rotator cuff disease severity. CONCLUSION: Worse sleep quality scores in patients with rotator cuff disease are associated with pain, depression, female sex, low back pain, diabetes mellitus, and high body mass index. Overall, sleep quality did not differ among patients with varying rotator cuff disease severity. Only hypertension (in patients with rotator cuff tears) and concurrent cervical pathology (in patients with tendinitis) were uniquely related to the disease classification. Further investigation is needed to better define how these factors interact and influence nocturnal shoulder pain and sleep quality in patients with rotator cuff disease. LEVEL OF EVIDENCE: Level III prognostic cohort study.

Sleep quality and nocturnal pain in patients with shoulder disorders.

BACKGROUND: Nocturnal shoulder pain resulting in poor sleep quality is a common finding in patients with shoulder disease. The purpose of this paper was to describe and to compare the sleep quality, pain, and function in adult subjects who have been diagnosed with rotator cuff disorders, osteoarthritis, or adhesive capsulitis (AC). METHODS: Patients completed a clinical assessment and comprehensive questionnaire regarding their current medical health history, shoulder symptoms, and impact of their symptoms on activities of daily living and quality of sleep. RESULTS: The study analyzed 343 patients with an average age of 57.4 years. The mean Single Assessment Numeric Evaluation score for AC was 34%, which was significantly lower than the score for the subacromial impingement syndrome group of 53% (P = .007). The mean American Shoulder and Elbow Surgeons scale score for AC was 38, which was also significantly lower than the score for the subacromial impingement syndrome group of 51 (P = .007). There were no significant differences in pain, with mean scores ranging from 4.90 to 5.82 for diagnostic subgroups on a visual analog scale (P = .28). Sleep quality was significantly poorer in the AC group (P = .008), with a mean Pittsburgh Sleep Quality Index score of 12.07. Specific subcomponents of the Pittsburgh Sleep Quality Index that had a significant impact on sleep interruption included sleep quality, sleep duration, and habitual sleep efficiency in the AC group (P < .05). CONCLUSION: This study shows that whereas many patients with shoulder disease may have sleep-related issues, patients with adhesive capsulitis are particularly vulnerable to reduced sleep quality.