Faculty Bibliography

BACKGROUND:Gout is a common synovial pathology, but its prevalence in patients undergoing total knee arthroplasty (TKA) and potential association with complications such as periprosthetic infection (PJI) and revision are unknown. METHODS:Medicare data from 2009 to 2013 was retrospectively reviewed using PearlDiver. All patients 65 years of age or older and undergoing primary TKA with at least 3 years of pre-TKA records were included. The prevalence of gout was based on ICD-9 codes. Univariable associations of gout with PJI and revision at 1 year were assessed using odds ratios with 95% confidence intrervals (C.I.). To control for potential confounding, patients with a history of gout were matched on age, gender, smoking history, and Elixhauser Comorbidity Index (ECI) to patients without gout and associations reassessed. RESULTS:The prevalence of gout in Medicare patients undergoing primary TKA was 5.7%. On univariable analysis, patients with a history of gout were more likely to develop PJI (O.R., 1.58; 95% C.I., 1.45-1.72) and undergo revision (O.R., 1.33; 95% C.I., 1.25-1.41) at 1 year. After matching for confounders, a history of gout was no longer associated with developing PJI (O.R., 0.98; 95% C.I., 0.90-1.06) or undergoing revision (O.R., 0.94; 95% C.I., 0.89-1.00) at 1 year. CONCLUSIONS:Gout is a relatively common pathology in patients undergoing TKA. While gout is associated with increased complications, this appears to be driven by confounding through its association with other medical comorbidities. Gout does not appear to be an independent risk factor for complications following TKA.

Osteonecrosis of the femoral head most commonly arises from trauma or corticosteroid and alcohol use but is also associated with blood dyscrasias and metabolic and coagulation disorders. Initial evaluation includes a history and physical examination and plain radiographs. Early-stage osteonecrosis is best evaluated by MRI. The Ficat and Arlet classification system is the most widely used. Nonoperative treatment has been studied using bisphosphonates, anticoagulants, vasodilators, statins, and biophysical modalities. Operative treatment includes core decompression with or without adjuvants, such as autologous bone marrow, whereas total hip arthroplasty is reserved for advanced-stage osteonecrosis in older patients or those who have failed joint-preserving treatment.

Extensor mechanism disruption after total knee arthroplasty is a relatively rare but potentially devastating complication. One technique to address this problem involves reconstruction with synthetic mesh. Although there are reports of successful clinical outcomes using this technique, we are not aware of any histological analyses of removed mesh grafts. This case report of a failed mesh reconstruction includes a retrieval analysis demonstrating robust host soft-tissue incorporation into the mesh graft and supports the rationale for continued use of this off-label technique. This case report also highlights the need for careful operative technique when performing these procedures to increase the chance of a successful outcome.

BACKGROUND:We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture. METHODS:We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups. RESULTS:Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all). CONCLUSIONS:Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nursemaid's elbow and elbow fractures are both common causes of acute elbow pain, but the mechanism of injury is quite different. In children, falls frequently go unwitnessed and children are often inaccurate when recounting the sequences of a fall, making the mechanism difficult to ascertain. A common clinical mistake is to treat all elbow injuries as a nursemaid's elbow. When the mechanism of injury is unknown, radiographs should be used to help make the diagnosis. Occult fractures, also known as "hairline" elbow fractures, may not be visible on initial X-rays, but clues to the diagnosis, especially the posterior fat pad, can be helpful in evaluation. When an occult fracture is suspected based on history and radiographic findings, the patient's elbow should be immobilized, not manipulated. This article also reviews successful reduction maneuvers for nursemaid's elbow. [Pediatr Ann. 2016;45(6):e214-e217.].