Faculty Bibliography

Despite the increasing volume of revision total hip arthroplasty (THA) being performed in the United States, there are few studies reporting mid-term clinical and radiographic outcomes of modular fully porous-coated femoral stems. We retrospectively studied a consecutive series of patients who underwent revision THA with a modular extensively porous-coated femoral component at a single institution and by a single surgeon. The final study group included 54 hips (52 patients) followed for an average of 84 months. Ten-year survival rates with revision for any reason and revision for femoral loosening as endpoints were 94% and 100%, respectively. No complications regarding the modular junction were encountered. Of the 50 hips with adequate radiographs, all showed proximal ingrowth and 42 (84%) had both proximal and distal ingrowth. The modular, fully porous-coated femoral stem studied demonstrated excellent survivorship and bone ingrowth at mid-term follow up.

The frequency of unicompartmental knee arthroplasty (UKA) procedures has increased rapidly over the past decade. Some conflicting evidence exists concerning UKA revision. Some studies have found UKA revisions to be comparable with primary total knee arthroplasty, whereas others have found that UKA revisions require a higher need for tibial stems and augments and have more complications and worse results. This study seeks to determine the effect of a conservative tibial resection in UKA on the ease of revision and its outcomes in a consecutive patient cohort.Thirty-five patients underwent 37 conversions of a medial UKA to a total knee arthroplasty. Clinical, functional, and radiological data were evaluated. At revision, a primary total knee arthroplasty implant was used in 24 (88.8%) patients who underwent a conservative tibial resection during their UKA compared with only 3 (30%) patients who underwent an aggressive tibial resection (P<.001). The odds ratio of needing an augment or stem was 26.8 (95% confidence interval, 3.71-194) when an aggressive resection was performed compared with a conservative resection during the UKA.The results indicate that revision of a medial UKA can be comparable with a primary TKA when a conservative tibial resection is performed at the time of the primary UKA. It is possible to preoperatively predict which patients might need the use of augmentation and stems during UKA revision. This data should guide surgeons to strive for the most conservative UKA tibial resection possible in patients undergoing medial UKA.

Rising implant prices and evolving technologies are important factors contributing to the increased cost of arthroplasty. Assessing how patients value arthroplasty, new technologies, and their perceived outcomes is critical in planning cost-effective care, as well as evaluating new-technologies. One hundred one patients undergoing arthroplasty took part in the survey. We captured demographics, spending practices, knowledge of implants, patient willingness to pay for implants, and preferences related to implant attributes. When patients were asked if they would be satisfied with "standard of care" prosthesis, 80% replied "no". When asked if they would pay for a higher than "standard of care" prosthesis, 86% replied "yes". The study demonstrated that patients, regardless of their socio-economic status, are not satisfied with standard of care implants when newer technologies are available, and they may be willing to share in the cost of their prosthesis. Patients also prefer the option to choose what they perceive to be a higher quality or innovative implant even if the "out of pocket" cost is higher.

We report the case of a woman in the third trimester of pregnancy who sustained an ankle fracture dislocation that could not be adequately closed reduced. After discussions with the patient, her obstetrician, and the anesthesiologists, she was indicated for surgical fixation. A heart tone monitor was used to assess fetal health during the procedure. During surgical incision, the fetus went into distress, and an emergency caesarian section was performed. After delivery of the infant and abdominal closer, surgery was completed. Due to a cohesive team effort, both the patient and her infant had excellent outcomes. There are many important considerations in the surgical management of the pregnant patient with traumatic orthopaedic injuries. Of especial importance to the orthopaedic surgeon is the impact of patient positioning on uteroplacental blood flow. This report discusses factors that should be taken into account by any orthopaedist who plans to operate on a pregnant patient.

Periprosthetic fractures of the femur after total hip replacement can present some unique challenges to the treating reconstructive orthopedic surgeon. Treatment may differ depending on fracture location, bone condition, implant stability, patient characteristics, and surgeon experience. It is imperative that adequate and sufficient mechanical fixation be achieved in the treatment of these patients. It is crucial that the treating orthopaedic surgeon have a clear and effective treatment plan to manage these complex cases. The patient's final outcome is dependent on fracture union, implant stability, early functional recovery, and return to pre-injury independence. This review presents an overview of the current diagnostic and treatment approaches, with the goal of providing a template for optimal decision-making when dealing with these complex injuries.

Insufficiency fractures present a significant problem in patients with osteoporosis. We report a case of bilateral iliac wing insufficiency fracture following low energy injury in an 87-year-old osteoporotic woman occurring 2 weeks after primary total hip arthroplasty. There are only a few reports of insufficiency fractures involving the ilium in the literature, and diagnosis has proven challenging, as radiographs are often negative at symptom onset. Magnetic resonance or radionuclide imaging is generally necessary for definitive diagnosis. This case highlights the importance of careful perioperative management of patients with osteoporosis.

BACKGROUND: Shoulder arthroplasty provides predictable pain relief and functional improvement of the shoulder for glenohumeral disease. With recent emphasis on health economic planning and rising patient expectation, physicians are encouraged to adopt more evidence-based strategies for decision-making. In the context of shoulder arthroplasty, surgeon preference and bias may play a large role in the choice of the procedure performed. The purpose of this study is to objectively examine the perceived differences and similarities, from the surgeon's perspective, between total shoulder arthroplasty (TSA) and hemiarthroplasty anticipated outcomes. METHODS: We conducted a web-based survey that asked surgeons to weigh the relative values of these procedures in relation to one another. Within the survey, there were numerous variables in which the surgeon was asked to choose the preferred surgical outcome. Ninety-eight surgeons responded to the survey. The average age was 51.7 years. RESULTS: Surgeons in our study chose pain relief and improved ROM as a more likely outcome in TSA than any level of complication and as a more likely out-come than improved strength compared to hemiarthroplasty. These results emphasized the perception amongst the polled surgeons that TSA is a preferred treatment option for patients who expect a high level of pain relief and ROM even at the expense of a decreased strength. CONCLUSION: This study is a first step in the construction of a patient oriented model for treatment decisions. With this information, we may be better able to tailor our patients' needs and wishes to the procedures that most predictably result in the outcomes they desire.

A 50-year-old male patient sustained a supination-adduction type ankle fracture with an associated sagittal split fracture of the talus. The patient was treated initially in a short leg splint, and upon presentation to an orthopaedic surgeon, an external fixator was applied. After the soft tissue swelling improved enough to permit open reduction and internal fixation, the patient was brought back to the operating room for definitive treatment with removal of the external fixator and open reduction and placement of internal fixation. The patient's postoperative course was uncomplicated. At the 6-week follow-up visit, he was noted to have a radiographic Hawkin's sign in the dome of the talus. At 3 months postoperatively, he was weightbearing as tolerated with radiographic evidence of fracture healing, and his ankle range of motion was from 30 degrees of plantar flexion to 15 degrees of dorsiflexion. At 6 months postoperatively, the patient had no complaints and was ambulating in a regular shoe. His plantar flexion was 35 degrees and his dorsiflexion was 15 degrees . His subtalar motion was from 5 degrees of eversion to 10 degrees of inversion. He returned for his one-year follow-up doing well without complaints, and he had returned to his previous activities.

The rotating hinge knee prosthesis is a popular intervention in patients lacking stability with highly constrained total knee arthroplasty. Despite improvements in design, nonmechanical and mechanical complications continue to be a problem. Dislocation of the hinge has been widely described, mainly due to the component fracture. Few reports describe isolated dislocation of the rotating stem. We report a case of isolated disengagement of the rotating hinge mechanism, due to severe flexion gap imbalance, leading to subsequent posterior dislocation of the hinge and anterior knee dislocation, in a patient with a history of multiple total knee arthroplasty revisions. This case suggests the importance of the soft tissue balancing, the adequate patellar tracking, and use of a long cylindrical, minimally tapered rotating stem in hinge arthroplasty to minimize hinge dislocation.