Faculty Bibliography

BACKGROUND: Data regarding outcomes following intralesional curettage and cryosurgical treatment of low-grade chondrosarcoma of bone are limited. The aim of this study was to assess the long-term oncologic and functional outcomes of two different cryosurgery techniques. METHODS: Forty-three low-grade chondrosarcoma lesions (in forty-two patients) were treated with intralesional curettage and cryosurgery from June 1983 to October 2006. Eleven lesions were treated with cryoprobes and thirty-two were treated with the modified direct-pour Marcove technique. The mean patient age was 44.9 +/- 11.3 years (range, 21.8 to 66.4 years), and the mean duration of follow-up was 10.2 +/- 4.6 years (range, five to 22.5 years). Indications for treatment included a radiographic appearance consistent with a cartilage tumor with evidence of aggressive behavior. Pearson correlation and multivariate analyses were used to evaluate the relationships between predictive factors (including lesion size, soft-tissue extension, and location, patient age, cortical erosion, and presence of preoperative pain) and outcomes. RESULTS: The mean overall Musculoskeletal Tumor Society (MSTS) score was 26.5 +/- 3.1 (range, 17 to 30). There were four local recurrences, all in patients who had had tumor extension out of the bone with soft-tissue involvement at initial presentation. The mean time to recurrence was 2.4 +/- 2.3 years (range, 0.6 to 5.6 years). No patients developed metastatic disease during the follow-up period. There were no differences between the cryoprobe and Marcove techniques with respect to the MSTS score, fracture, or local recurrence. A significant correlation between tumor recurrence and soft-tissue extension was found (r = 0.79). Kaplan-Meier survivorship, with freedom from recurrence as the end point, was 90.7%. CONCLUSIONS: Intralesional curettage and cryosurgery for low-grade chondrosarcoma is safe and effective in selected patients. The presence of preoperative cortical breakthrough and soft-tissue extension was the strongest predictor of local recurrence following use of this technique. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

BACKGROUND: Ceramic femoral heads produce less wear of the opposing polyethylene than do metal femoral heads in wear simulation studies. This is a matched-pair analysis of the wear of ceramic and metal femoral heads on conventional polyethylene in uncemented total hip replacements in young, active patients at a minimum of fifteen years of follow-up. METHODS: From June 1989 to May 1992, thirty-one matched pairs of alumina ceramic or cobalt-chromium metal femoral heads were identified. Patients were matched on the basis of age, sex, body weight, diagnosis, and activity level. The mean age was 55 +/- 9 years (range, twenty-three to sixty-five years) at the time of surgery. All procedures were performed with a posterolateral surgical approach by a single surgeon using press-fit Ranawat-Bernstein femoral stems, Harris-Galante-II acetabular cups, GUR 4150 conventional polyethylene (sterilized in argon), and 28-mm-diameter femoral heads. Wear measurements were performed by two independent observers using the computer-assisted Roman software. RESULTS: The average duration of follow-up was 17 +/- 1.7 years (range, fifteen to twenty years). The mean Hospital for Special Surgery hip scores (and standard deviation) in the ceramic and metal groups were 39 +/- 4 and 40 +/- 3 at the time of final follow-up. The University of California Los Angeles activity score at the time of the final follow-up was 6 +/- 2 for both groups. The mean wear rates for the ceramic group and the metal group were 0.086 +/- 0.05 mm/yr and 0.137 +/- 0.05 mm/yr, respectively (p = 0.0015). There was one reoperation in the ceramic group because of distal femoral osteolysis. There were three failures in the metal group, requiring isolated liner exchange in two hips and revision of the acetabular component in one hip because of wear-induced osteolysis and/or loosening that caused symptoms. Five hips in the ceramic group and six hips in the metal group had radiographic evidence of acetabular or femoral osteolysis, but none were symptomatic. CONCLUSIONS: Ceramic femoral heads produced significantly less wear on conventional polyethylene liners at the time of long-term follow-up than did metal heads in this matched-pair analysis of young and active patients with uncemented fixation.

This is the first long-term (mean 11.6years), prospective, matched-pair study (based on age, gender, BMI and UCLA scores) using MAVRIC (multi-acquisition variable-resonance image combination) magnetic resonance imaging to analyze reactive synovitis and osteolysis between rotating-platform posterior-stabilized (RP-PS), fixed-bearing metal-back (FB-MB), and all-polyethylene tibial (APT) in active patients (24 total, 8 in each group, mean age of 64years, mean UCLA of 8.5) with identical femoral component and polyethylene. Reactive synovitis was observed in 6 RP-PS (75%), all 8 FB-MB (100%), and 6 APT (75%). There was a significant difference between the RP-PS and FB-MB knees in volumetric synovitis (P=0.023). Osteolysis with bone loss more than 4mm was seen in 3 FB-MB, 2 APT and none for RP-PS. These were not statistically significant.

The aim of this study was to assess peri-operative complications, safety and efficacy of non-cemented femoral fixation in total hip arthroplasty (THA) as compared to cemented femoral fixation in the elderly population. Fifty-two matched pair analysis of patients with 75 years of age and older (104 patients), who underwent primary THA from June 1997 to December 2004, was performed based on age, sex, BMI, and Charnley classification. Mean age was 81 years (75-101) and the average follow up was 3.1 +/- 2.9 years (1.2-6.4). There was no difference in peri-operative cardiopulmonary complications, pulmonary failures, deep venous thrombosis, pulmonary embolus, length of stay, or discharge deposition between the two groups. Non-cemented fixation is safe and effective in patients older than 75 years of age.

Cup positioning is an important variable for short and long term function, stability, and durability of total hip arthroplasty (THA). This novel method utilizes internal and external bony landmarks, and the transverse acetabular ligament for positioning the acetabular component. The cup is placed parallel and superior to the transverse ligament and inside the anterior wall notch of the true acetabulum, then adjusted for femoral version and pelvic tilt and obliquity based on weight bearing radiographs. In 78 consecutive THAs, the mean functional anteversion and abduction angles were 17.9 degrees +/- 4.7 degrees and 41.7 degrees +/- 3.8 degrees , respectively. 96% of the functional anteversion measurements and 100% of the functional abduction angles were within the safe zone. This technique is an easy, reproducible, and accurate method for functional cup placement.

Introduction/UNASSIGNED:The inside-out technique is a safe and reproducible method to effectively correct a fixed varus-flexion deformity during total knee arthroplasty by performing a posteromedial capsular release and so-called pie-crust lengthening of the superficial medial collateral ligament (sMCL). Step 1 Preoperative Planning/UNASSIGNED:Analyze preoperative radiographs as a key step in planning the surgery for the required amount of osseous cuts and soft-tissue release. Step 2 Exposure/UNASSIGNED:Obtain adequate exposure for proper visualization and assessment. Step 3 Tibial and Femoral Cuts/UNASSIGNED:Adequate bone cuts with proper alignment are an essential step of this technique. Step 4 Posteromedial Capsulotomy/UNASSIGNED:This is the most important step for extension balancing in knees with flexion contracture; the posteromedial aspect of the capsule in varus deformity should be safely incised at the level of the tibial cut. Step 5 Pie-Crusting of the sMCL/UNASSIGNED:Perform pie-crusting followed by serial manipulations in a controlled manner to avoid overrelease of the sMCL. Step 6 Flexion Gap Balancing/UNASSIGNED:This is a key step for proper balancing, femoral sizing, rotation, lateralization, and patellofemoral tracking. Results/UNASSIGNED:From October 2006 to December 2009, thirty-one consecutive patients (thirty-four knees) with a severe fixed varus-flexion deformity (varus alignment of ≥15° and flexion contracture of ≥5°) underwent total knee arthroplasty with the inside-out technique. What to Watch For/UNASSIGNED:IndicationsContraindicationsPitfalls & Challenges.

There has been a recent increase in interest for non-cemented fixation in total knee arthroplasty (TKA), however the superiority of cement fixation is an ongoing debate. Whereas the results based on Level III and IV evidence show similar survivorship rates between the two types of fixation, Level I and II evidence strongly support cemented fixation. United Kingdom, Australia, Sweden, and New Zealand registry data show lower failure rates and greater usage of cemented than non-cemented fixation. Case series studies have also indicated greater functional outcomes and lower revision rates among cemented TKAs. Non-cemented fixation involves more patellofemoral complications, including increased susceptibility to wear due to a thinner polyethylene bearing on the cementless metal-backed component. The combination of results from registry data, prospective randomised studies, and meta-analyses support the current superiority of cemented fixation in TKAs.

BACKGROUND: Traditional methods for correcting a severe varus and flexion deformity of the knee during total knee arthroplasty can often lead to excessive release of the medial collateral ligament, hematoma formation, and reliance on constrained implants. The "inside-out" technique for correction of varus deformities involves performing a posteromedial capsulotomy at the level of the tibial cut and incising the superficial medial collateral ligament in a pie-crust manner in extension followed by serial manipulations with valgus stress. Our hypothesis was that this technique effectively corrects severe knee varus and flexion deformity with a reduced risk of complications. METHODS: Thirty-one consecutive patients (thirty-four knees) with a severe fixed varus and flexion deformity (varus alignment of >/= 15 degrees and flexion contracture of >/= 5 degrees ) underwent total knee arthroplasty with use of the inside-out technique between October 2006 and December 2009. Physical examination, radiographs, and multiple outcome instruments were used to evaluate the results. RESULTS: The mean duration of follow-up was 3.1 +/- 1.1 years (range, 1.7 to 4.9 years). There were no cases of hematoma formation, excessive release of the medial collateral ligament, or acute or delayed instability. A semi-constrained TC3 implant was used in two cases. The mean preoperative coronal alignment was 21.1 degrees +/- 4 degrees of varus, which was corrected to 4.5 degrees +/- 1.6 degrees of valgus after surgery. The mean preoperative flexion contracture was 10 degrees +/- 3.5 degrees . Postoperatively, two patients (three knees) had a residual flexion contracture, which was