Faculty Bibliography

BACKGROUND: Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. METHODS: A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. RESULTS: All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. CONCLUSIONS: In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment.Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.

BACKGROUND: Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis. METHODS: A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion. RESULTS: All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B. CONCLUSIONS: In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment. Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated

The optimal choice for the treatment of end-stage primary glenohumeral osteoarthritis remains controversial, with alternatives including total shoulder replacement (TSR) and humeral head replacement (HHR). The objective of this review was to analyze the effect of TSR compared with HHR on rates of pain relief, range of motion, patient satisfaction, and revision surgery in patients with primary glenohumeral osteoarthritis. We searched computerized databases for clinical studies published between 1966 and 2004 that reported on shoulder replacement for primary glenohumeral osteoarthritis. Pain data were converted to a 100-point score. Outcome assessment data were pooled when possible, and analyses via normal test statistics were performed. We identified 23 studies, with a total of 1952 patients and mean follow-up of 43.4 months (range, 30-116.4 months). The mean level of evidence was 3.73. Among the 23 studies, 7 different outcome instruments were used. Of the 23 studies, 14 (n = 1185) reported pain relief, 15 (n = 1080) reported range of motion, 12 (n = 969) reported patient satisfaction, and 14 (n = 1474) reported revision surgery. Compared with HHR, TSR provided significantly greater pain relief (P < .0001), forward elevation (P < .0001), gain in forward elevation (P < .0001), gain in external rotation (P = .0002), and patient satisfaction (P < .0001). Furthermore, only 6.5% of all TSRs required revision surgery, which was significantly lower than the percentage for all patients undergoing HHR (10.2%) (P < .025). Only 1.7% of all-polyethylene glenoid components required revision. On the basis of this review and analysis, in comparison with HHR, TSR for the treatment of primary glenohumeral osteoarthritis significantly improves pain relief, range of motion, and satisfaction and has a significantly lower rate of revision surgery. Inconsistent outcome reporting and poor study design may warrant standardization of outcome instruments and improved study design in the future.

Trabecular metal augmentation has added new treatment options for severe proximal tibial bone defects in revision knee arthroplasty. Porous tantalum tibial cones provide mechanical support for the tibial component and have the potential for long-term biologic fixation. These cones facilitate restoration of the proximal tibia metaphysis in Type 2 and 3 defects. Ten tantalum tibial cones were press-fit into the prepared cavitary defect of a series of revision knee arthroplasties. Voids between the cone and host bone were filled with morselized grafting material. The core tibial component was cemented into the implanted tibial cone; fixation was enhanced with stem extensions, which were press-fit in four knees and cemented in six knees. Extensions ranged from 75-200 mm with length dependent upon the residual bone quality. Offset stems were used in 3 tibias. At follow-up (average 10 months), radiographic evaluation revealed no evidence of loosening or change in position. Strength, range of motion, and stability were comparable to previously reported series of revision arthroplasties. Trabecular metal cones can help reconstruct large cavitary defects and, along with stem extensions and offset stems, may eliminate the need for extensive bone grafting or structural allograft in revision knee arthroplasty. Level of Evidence: Therapeutic study, level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.