Faculty Bibliography

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 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.

INTRODUCTION: Total knee arthroplasty (TKA) is the preferred surgical treatment for end-stage osteoarthritis. However, substantial numbers of patients still experience poor outcomes. Consequently, it is important to identify which patient characteristics are predictive of outcomes in order to guide clinical decisions. Our hypothesis is that preoperative patient-reported outcome measures and radiographic measures may help to predict TKA outcomes. METHODS: Using cohort data from the Osteoarthritis Initiative, we studied 172 patients who underwent TKA. For each patient, we compiled pre- and postoperative Western Ontario and McMaster University Arthritis Index (WOMAC) scores. Radiographs were measured for knee joint angles, femorotibial angles, anatomical lateral distal femoral angles, and anatomical medial proximal tibial angles; Kellgren and Lawrence (KL) grades were assigned to each compartment of the knee. All studied measurements were compared to WOMAC outcomes. RESULTS: Preoperative WOMAC disability, pain, and total scores were positively associated with postoperative WOMAC total scores (P = .010, P = .010, and P = .009, respectively) and were associated with improvement in WOMAC total scores (P < .001, P < .001, and P < .001, respectively). For radiographic measurements, preoperative joint angles were positively associated with improvements in postoperative WOMAC total scores (P = .044). Combined KL grades (medial and lateral compartments) were negatively correlated with postoperative WOMAC disability and pain scores (P = .045 and P = .044) and were positively correlated with improvements in WOMAC total scores (P = .001). CONCLUSIONS: All preoperative WOMAC scores demonstrated positive associations with postoperative WOMAC scores, while among the preoperative radiographic measurements only combined KL grades and joint angles showed any correlation with postoperative WOMAC scores. Higher preoperative KL grades and joint angles were associated with better (lower) postoperative WOMAC scores, demonstrating an inverse correlation.

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.

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.

Deep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA. We report a large series by a single surgeon with a highly specialized revision TKA referral practice. We identified 84 patients treated by a two-stage revision. We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure. We defined "eradication of infection" on the basis of negative cultures and clinical diagnosis. After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision. Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases. The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.

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.

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.