Clinical Orthopaedics and Related Research

Published by Springer Verlag
Online ISSN: 1528-1132
Publications
Article
Piriformis syndrome is an uncommon condition characterized by sciatic nerve entrapment at the greater sciatic notch. Nonoperative treatment such as physical therapy, nonsteroidal antiinflammatory drugs, and local injections often results in relief of symptoms. For patients who do not benefit from nonoperative therapy, surgical exploration and decompression of the sciatic nerve has been effective. However, the success of surgery may be diminished by scar formation or hematoma in the anatomically restricted sciatic notch. We report two patients with piriformis syndrome who responded primarily to surgical decompression and had recurrent symptoms resulting from scar tissue formation in the sciatic notch. On revision surgery, polytetrafluoroethylene pledgets were placed around the sciatic nerve to avoid compression and entrapment by scar tissue. Both patients had satisfactory outcomes at 3 years followup.
 
Patient characteristics 
An ultrasound image inferior to the inguinal ligament shows a hypoechoic space deep to the fascia iliaca (demonstrated by white arrows) created by the injection of bupivacaine. The femoral artery (FA) and femoral nerve (FN) are visible. After injection, the FN is visible on the surface of the iliopsoas (IS) muscle. 
Comparisons in the literature of patients undergoing TKA and receiving femoral nerve block for postoperative multimodal pain management 
Article
Continuous femoral nerve block has been shown to decrease opioid use, improve postoperative pain scores, and decrease length of stay. However, several studies have raised the concern that continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period. This study sought to determine whether continuous femoral nerve block with a single-shot sciatic block prevented early ambulation after total knee arthroplasty (TKA) and whether the technique was associated with adverse effects. Between January 2011 and January 2013, 77 consecutive patients undergoing primary TKAs at an orthopaedic specialty hospital received a continuous femoral nerve block for perioperative analgesia. The femoral block was placed preoperatively with an initial bolus and 76 (99%) patients received a single-shot sciatic nerve block performed at the same time. Fifty-eight percent (n = 45) received an initial bolus of 0.125% bupivacaine and 42% (n = 32) received 0.25% bupivacaine. All 77 patients received 0.125% bupivacaine infusion postoperatively with the continuous femoral nerve block. All patients were provided a knee immobilizer that was worn while they were out of bed and was used until 24 hours after removal of the block. All patients also used a front-wheeled walker to assist with ambulation. All 77 patients had complete records for assessing the end points of interest in this retrospective case series, including distance ambulated each day and whether in-hospital complications could be attributed to the patients' nerve blocks. Thirty-five patients (45%) ambulated for a mean distance of 19 ± 22 feet on the day of surgery. On postoperative Days 1 and 2, all 77 patients successfully ambulated a mean of 160 ± 112 and 205 ± 123 feet, respectively. Forty-eight patients (62%) had documentation of ascending/descending stairs during their hospital stay. No patient fell during the postoperative period, required return to the operating room, or readmission within 90 days of surgery. One patient experienced a transient foot drop related to the sciatic nerve block, which resolved by postoperative Day 1. Continuous femoral nerve block with dilute bupivacaine (0.125%) can be successfully used after TKA without preventing early ambulation. By taking active steps to prevent in-hospital falls, including the use of a knee immobilizer for ambulation while the block is in effect, patients can benefit from the analgesia provided by the block and still ambulate early after TKA. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
 
Article
It has been nearly 40 years since John Insall helped usher in the modern era of TKA with his preliminary report in CORR® on total condylar knee arthroplasty [2], yet we still don’t know if we should perform this operation singly or in pairs. Same-day bilateral TKA appears to offer a shorter recovery period and, perhaps, decreases in costs or charges [6]. But these benefits may come at a serious cost to patient safety, as well-designed studies have identified greater likelihoods of serious complications occurring in patients having same-day, bilateral surgeries compared to those having staged, bilateral surgeries [4, 5]. The topic itself, like so many others in medicine and surgery, is a moving target, so studying this subject is a challenge. Knee arthroplasty patients are getting younger [3], and hospitalists and preoperative screening protocols are making these interventions safer [1]. Offsetting this, though, are large decreases in postoperative lengths of stay, leaving open the questions of if we even know how many complications exist and in which patients they are occurring. In light of this, we welcome new ways of looking at the problem. In their study, “Have Bilateral Total Knee Arthroplasties Become Safer? A Population-Based Trend Analysis” (DOI: 10.1007/s11999-012-2608-9), Memtsoudis and colleagues looked at the largest all-payer database available of hospital discharges to try to draw some inferences. From their work, we learned that the frequencies of many severe complications after same-day, bilateral TKA actually increased over the 10-year study period when adjusted for length of stay. By contrast, the risk of death appeared to have gone down over time. Although the literature remains conflicted about the safety of same-day, bilateral TKA, Memtsoudis and colleagues found that surgeons use this approach more frequently now than ever before. Again, this is a hard subject to study; no single study design (and certainly no single study) can answer all the questions surgeons have. For example, studies such as this one that use large administrative databases cannot tell us much about complications that occur after hospital discharge, even when risk is adjusted for length of stay. Because of this, we most likely are seeing a “safest-case scenario” here, with the actual morbidity of the procedure probably being higher than the observed morbidity. The authors shed some light on a procedure that is done tens of thousands of times per year, even though we don’t know whether it benefits patients or puts them at increased risk. As specialists, we should consider ourselves under some pressure to sort this out. The work of Memtsoudis and colleagues represents a good step in that direction.
 
Article
File this one under “science is fun.” This manuscript has it all: a hot topic, a young investigator, some early success in terms of extramural funding, and a high-tech approach to quantifying a problem—cam lesions in femoroacetabular impingement (FAI)—that is too often discussed using seat-of-the-pants estimations. The “Emerging Ideas” section of Clinical Orthopaedics and Related Research® is not the part of the journal that contains the answers. It is the place where some of the most interesting questions are approached by some of the best minds in our specialty. In this report, Dr. Richard Kang and colleagues demonstrate a promising approach to quantifying the femoral-sided pathology in patients with FAI. Several groups [2, 3] have presented other advanced imaging approaches; what makes Dr. Kang’s technique particularly attractive is its apparent ability to characterize location, height, and volume of cam lesions in a way that is both visually intuitive and readily quantified. Of course, this was an “Emerging Ideas” piece, so the results presented were very preliminary. Still, the technology is fascinating, and we look forward to further studies from this program in the future. This science is not just fun; it is important. We need consistent, reliable, quantifiable methods for diagnosing FAI. While there remains some disagreement within our specialty over the degree to which FAI causes symptoms or progresses to arthritis, few specialists deny that it exists. Outside of our specialty, in minds of payors and perhaps others, there appears to be doubt, which may turn into pressure if we can’t “amp up” the science on the subject. A recent, massive meta-analysis from the Washington State Health Care Authority (WSHCA) [1] found “no evidence for the efficacy of open or arthroscopic approaches for FAI compared with no surgical intervention.” Even more importantly, for purposes of this “Emerging Ideas” report, WSHCA characterized the strength of the evidence, even for agreement on how to make the diagnosis, as “very low.” The tool that Kang and colleagues are developing may be an important step towards changing that. We wish them well in this endeavor, and, in the “Take 5” interview that follows, we explore with Dr. Kang the challenges of discovery, program building, and starting out as a clinician-scientist.
 
Article
During the period 1957 to 1976, 1,015 Jewett nails were inserted for intertrochanteric hip fractures. This is one of the largest series of intertrochanteric fractures studied at one institution using one method of treatment. Anatomic reduction was attempted in almost all cases regardless of comminution. Medial or valgus displacement was rarely carried out on purpose. The average delay to surgery was 2.1 days after admission. Most parients were on bed-chair status on the first postoperative day and began toe-touching ambulation 10 to 14 days after surgery. Routine anticoagulation was not employed. The reduction and nail placement were critical factors for fracture healing. Only 3.3% of patients with satisfactory nailings had nail-related complications, such as penetration or cutting out. Eighty-seven per cent of patients with poor nailings had these problems. Ninety-eight and seven-tenths per cent of fractures united, 1.3% went to nonunion, and necrosis was seen in 2 united fractures (0.4%).
 
Article
Forty male New Zealand white rabbits were treated with immobilization and forcible manipulation of the right knee known to cause ectopic bone formation in the quadriceps muscle. The animals were also treated with either: A) A total radiation dose of 1840 rad (18.4 Gy); B) A 0.5 mg/kg/day oral dose of prednisolone; C) 10 mg/kg/day of indomethacin, given in two oral doses; D) Ethane-1-hydroxy-1,1-diphosphonate (EHDP) given in a 20-mg/kg/day oral dose; or E) with the vehicle given alone as a control. The experimental period was four weeks, and the amount of ectopic bone was determined by planimetry of serial transverse sections of the femur. The degree of knee stiffness was recorded during the experiment. The amount (mean +/- SEM) of ectopic bone was 1.412 +/- 0.264 cm3 in controls; it was insignificantly higher in the EHDP-treated group, but significantly lower (p less than 0.01) in rabbits treated with radiation (0.390 +/- 0.094 cm3), prednisolone (0.181 +/- 0.076 cm3), and indomethacin (0.314 +/- 0.112 cm3). In control animals and those given EHDP, the treatment invariably led to almost complete stiffness of the right knee. The rabbits treated with prednisolone and indomethacin offered the least resistance to the manipulations, and the group treated with radiation showed intermediate stiffness. Semiquantitative histologic evaluation demonstrated less inflammation in the group treated with prednisolone than in the control group.
 
Article
Paget's disease of bone in 51 patients was treated with ethane-1, hydroxy-1,1 diphosphonate (EHDP) for six months at a dosage of 5 mg/kg/day. Clinically, the analgesic effect on bone pain is clear, with parallel reduction in radioisotope uptake observed by quantitative bone scintigraphy. There is also a reduction of about 70% of the excess level of serum alkaline phosphatase and total 24-hour urinary hydroxyproline. Histologically, there is a significant reduction in both the osteoclastic resorption surfaces and the number of osteoclasts. In contrast to that obtained by calcitonin, these clinical, biologic, and histologic changes continue for at least one year beyond the end of the treatment. That is the main characteristic of this treatment, of which the clinical and biologic tolerance is admittedly very satisfactory. Accumulation of osteoid tissue, which is indicative of a mineralization defect, does not appear at low dosages under the prescribed conditions. EHDP (5 mg/kg/day) can be regarded as effective treatment for some patients with Paget's disease of bone.
 
Article
Adult male rats were treated for six weeks by prednisolone and/or 1,25-(OH)2D3 and given a diet containing either 0.5% calcium or 0.01% Ca and 0.6% phosphorus. Both prednisolone administration and a low-Ca diet were associated with a lower bone mass than that observed in control rats given a 0.5% Ca diet. The percentage of osteoid surface was decreased in rats given prednisolone; these rats also had a lower osteoclast number. The results were consistent with a lower bone turnover during prednisolone treatment. Administration of 1,25-(OH)2D3, resulting in a slightly higher mean level of 1,25-(OH)2D3 in serum, had a positive effect on bone mass, which may be related to increased osteoblastic activity; no increase in the osteoclast number occurred.
 
Article
Low doses of 1,25-DHCC cause a significant increase in trabecular and cortical bone mass of the mature rat skeleton by stimulated endosteal bone formation. The increased serum contents of calcium and inorganic phosphate give rise to a moderate nephrocalcinosis. An increased bone resorption occurs upon toxic dose levels causing profound nephrocalcinosis. Similar doses of 25-HCC do not affect the mature bone.
 
Article
The progress of spinal bone loss was monitored by measurements of the vertebral body height of T6 to L5 in seventy 70-year-old women who participated in a controlled, double-blind therapeutic trial. They were treated for one year by 1,25(OH)2D3, 0.50 micrograms a day (or less if hypercalcemia occurred) and cyclical estrogen/gestagen, alone or combined, or placebo. Sufficient calcium intake was ensured in all. The vertebral body height decreased significantly, by 1%, in both of the 1,25(OH)2D3 groups, whereas it remained unchanged in the hormone and the placebo + calcium group. This observation does not encourage the use of 1,25(OH)2D3 for prevention or treatment of postmenopausal bone loss.
 
Article
Calcitonin and 1.25(OH)2D3 have opposite effects on the serum concentrations of Ca and P, as well as on bone resorption, and can be observed in the process of healing of standardized fracture in adult rats. The rats given 1.25(OH)2D3 had a stronger fracture callus and slightly less pronounced postfracture osteopenia. Calcitonin did not significantly influence the fracture healing but had a pronounced effect in preventing the osteopenia. The effects of 1.25(OH)2D3 are believed to be indirect, i.e., through the changes in the serum Ca X P product, whereas the osteopenia preventing action of calcitonin may come from direct effect on bone.
 
Article
This study reviews the clinical and radiographic results of 138 consecutive cementless acetabular revisions in 131 patients performed for aseptic loosening at a mean of 10.5 years followup. Kaplan-Meier survivorship of these components was 84% at 11.5 years. Two components (1.8%) in two patients were considered aseptically loose based on radiographic criteria; one patient was symptomatic but the component was not revised because of the patient's poor health, and the other patient was asymptomatic. Pelvic osteolysis was present in 19 hips (17%), appearing at a mean of 103 months. All but two of these were small lesions (< 2 cm) at the periphery of the components. Nevertheless, the incidence of osteolysis has increased with time, and continued followup is warranted. Separation or fragmentation of the fiber-metal porous pads was uncommon (8.3%), but was significantly associated with pelvic osteolysis; this finding has not been reported before with this component. Five patients underwent late revision surgery (after 100 months), one for deep infection, one for periprosthetic femur fracture, and three for late recurrent dislocation. Harris hip scores averaged 81 points (good) at final followup, which is unchanged from the authors' last report on this group. Acetabular revision with a fiber-metal hemispherical component appears durable at a mean followup of more than 10 years.
 
Article
This is a report of a retrospective study of 1000 consecutive, cemented total knee arthroplasties performed by one surgeon from January 1976 to August 1989. Eighty-five percent of the patients were available after a mean of 51 months. Using The Knee Society Clinical Rating System, a good to excellent result was found in 95% of the knees; function was good to excellent in 54% of the knees. By using an actuarial method, 94% of the knees can be expected to survive 13 years. A deep venous thrombosis or pulmonary embolus was found in 1.7% and was no less common in the 25% of the patients who received pharmacologic anticoagulation. The mortality rate was 0.4%. The infection rate was 0.7% and did not correlate with intraoperative cultures. There were 14 failures for a variety of reasons, and six unsuccessful knees were revised. Preoperative medical problems did not generally predict the postoperative complications. The average duration of hospitalization during the last five years of the study was 9.7 days. Careful and consistent preoperative, intraoperative, and postoperative care is responsible for the low complication rate. The cemented knee arthroplasty consistently continues to yield good results.
 
Article
We examined factors affecting survivorship, and reasons for reoperation and revision of a cemented modular condylar total knee arthroplasty (TKA). One thousand and eight consecutive primary cemented cruciate-retaining TKAs performed at one institution were studied. At the time of review, 411 patients (562 knees) had died, 43 patients (45 knees) had their knee components revised or removed, and 47 patients (62 knees) were lost to followup. Mean followup of living patients with their TKA components in situ (244 patients, 331 knees) was 15.7 years. Survivorship at 15 years for revision for any reason, revision for mechanical failure, and revision for aseptic loosening were 95.9%, 97.0%, and 98.8% respectively. Survivorship was poorer among patients aged less than 60. Forty-five knees had components removed or revised; approximately one-third were removed for infection, one-third for aseptic loosening or tibial polyethylene wear, and one-third for other causes. Mechanical implant failures accounted for less than one-half of the reoperations and revisions, while infection and periprosthetic fractures accounted for a substantial portion of revisions and reoperations. Because mechanical arthroplasty failures have become less common, other complications related to arthroplasty have become proportionately more frequent.
 
Article
Our experience with 101 consecutive T.H.A.'s in 91 patients was examined in an attempt to identify preoperative risk factors for postoperative medical complications, especially pulmonary embolism and thrombophlebitis. Six per cent of patients developed postoperative clinical thrombophlebitis, and 8% a pulmonary embolism. Advancing age and previous venous thrombosis served as predictors for pulmonary embolism and thrombophlebitis, respectively (p less than 0.01), but obesity, venous varicosities, diabetes mellitus, cigarette smoking, previous pulmonary embolism, and length of surgery did not, for either. Fifty per cent of the patients with preoperative abnormal kidney function developed some form of medical complication postoperatively, a significant increase in risk (p less than 0.05) over patients with normal kidney function. We were unable to identify an increase in postoperative atelectasis or pneumonia associated with smoking or obesity in these patients. No consistent decrease in post-operative medical morbidity could be assigned to preoperative medical consultations, suggesting that we have not yet identified all significant risk factors. A thorough preoperative preparation and improvement in intra- and postoperative techniques and management may account for differences found in this study from traditionally held risk factors.
 
Article
In a consecutive series of 103 patients with soft tissue sarcoma, operated on from 1987 through 1990, clinical and perioperative factors were assessed for the development of wound complications. Local excision was performed in 98 cases and amputation in five. None had preoperative radiation therapy or chemotherapy. The overall incidence of wound complication was 40%. There were 16 infections, 13 necroses, and 12 hematomas. The complication rate was significantly lower in the upper extremity (17%) as compared with the trunk and lower extremity (45%). Superficially located and deep tumors had equal incidences of wound complications. Regarding deep tumors, wound complication was significantly related to large tumor size, old age, long operating time, and excessive blood loss. No such correlations could be found for superficial tumors. The median hospitalization time for patients with deep tumors who developed complications was 23 days, as compared with 11 days for those without. Complications in patients with superficial tumors did not lead to a lengthened hospital stay. A considerable complication rate was associated with limb-sparing surgery for soft tissue sarcomas. This incidence could probably be reduced by taking into account risk factors associated with wound complications, better preoperative planning, and close cooperation with plastic surgeons for adequate wound coverage.
 
Article
One hundred and three consecutive total condylar knee prostheses in patients with gonarthrosis inserted from 1979 to 1981 have been prospectively followed for four to six years. According to the New York Hospital for Special Surgery Knee Rating Scale, 58 knees (56%) were rated excellent; 34 (33%), good; seven (7%), fair; and four (4%), poor at the latest follow-up evaluation. The median preoperative score was 57 points and the median postoperative score 87 points. Thirteen knees (13%) had a radiolucency with a width of 2 mm or more beneath one or more of three tibial zones. In only one case did this represent a clinical loosening. Six knees (6%) had complications requiring reoperation. One deep infection was treated with an arthrodesis, one patellar button was revised after a traumatic patellar fracture, and three superficial skin necroses were surgically managed. Moreover, in one mechanically loosened tibial component, a revision has been planned. No complications were fatal. The modified total condylar I prosthesis is an excellent prosthetic design with a low failure rate in gonarthrosis.
 
Article
A close relation exists among the alterations in the lumbosacral spine designated as spondylolysis, isthmic spondylolisthesis, degenerative spondylolisthesis, and prespondylolisthesis. While the former two conditions are probably caused by faulty development and subsequent minor traumata or repeated stresses, the third condition is caused by degenerative changes associated with anatomic variations; the fourth condition is a static insufficiency leading to faulty alignment. In 105 patients, the initial preferred management of these conditions was conservative. Thirty-four patients who developed persistent symptoms of spinal instability and/or intractable neurologic deficits were treated surgically. The results were generally successful.
 
Article
One hundred five patients were treated for slipped capital femoral epiphyses during the period from 1964 to 1976. Attempts were made to evaluate the differences in results of multiple pinning and open epiphysiodesis performed to treat this problem. Pinning in situ was performed in 61 hips, and open epiphysiodesis was performed in 33 hips. The average follow-up period was seven years four months for pinning in situ and six years seven months for open epiphysiodesis. The average slippage was 22 degrees for patients treated by pinning in situ and 30 degrees for patients treated by open epiphysiodesis. At follow-up evaluation 91.7% of the patients treated by pinning in situ had good or excellent results, as compared with 71.6% of the patients treated by epiphysiodesis. For the patients treated by pinning in situ, 5% had poor results, and 3.3% were considered failures. For the patients treated by epiphysiodesis, 3.4% had poor results, while 25% were considered failures. Pinning in situ is the treatment of choice. It is more predictable, has less complications, and provides better long-term results.
 
Article
One hundred five consecutive patients with a diagnosis of delayed union (61 patients) or nonunion (44 patients) of the femoral shaft from February 1968 to November 1983 were managed by intramedullary reaming and nailing. The procedure was accomplished by closed techniques in 82 of the cases. Adequate follow-up study was obtained in 101 patients; all but four showed clinical and radiologic union at an average of 20 weeks following the procedure, with an overall union rate of 96%. The four patients whose fractures failed to consolidate with this treatment had repeat procedures with placement of thicker nails, and all subsequently healed.
 
Article
Although arthroscopic surgery of the hip is becoming a more frequently done operation, there is relatively few data in the literature regarding the frequency of complications. In the current prospective study of 1054 consecutive hip arthroscopies, the authors report an overall complication rate of 1.4%. Complications included neurapraxia, portal wound bleeding, portal hematoma, trochanteric bursitis, and instrument breakage. The only major complication was one case of septic arthritis. It is concluded that, done properly, hip arthroscopy can be a considered a low-risk procedure.
 
Article
Fractures of the hip and its resultant mortality are a reflection of age more than any other factor. The death and morbidity in this poor risk patient group with multiple medical problems can be significantly lowered by the generalized use of prophylactic antibiotics and thromboembolic protection. Stabilization of intertrochanteric fractures at the time of surgery with stronger implants, displacement osteotomy, and the judicious use of bone cement, along with primary replacement of displaced subcapital fractures allows the patient earlier ambulation before the skills of walking have been forgotten.
 
Article
Secondary chondrosarcomas are rare; recognition and diagnosis are difficult. Slow growth and late recurrence require long-term followup to understand the clinical course. In the current study, 107 patients had secondary chondrosarcoma arising in a solitary osteochondroma (61 patients) or multiple exostoses (46 patients). All histologic slides were reviewed without knowledge of the outcome, and radiologic studies were available for review in 71 cases. Patients with secondary chondrosarcoma were one to two decades younger than those with primary chondrosarcoma. Male preponderance and a predilection for flat bones were observed. The radiologic signs of sarcomatous degeneration included irregularity of the margin, inhomogeneous mineralization, and an associated soft tissue mass. The tumors generally were well-differentiated. Only 10 tumors were classified as Grade 2. Five-year and 10-year local recurrence rates were 15.9% and 17.5%, respectively, and 5- and 10-year mortality rates were 1.6% and 4.8% for patients having initial treatment at the authors' institution. Metastasis developed in five patients: in the lung in four patients and in the groin region in one patient. Most patients who died of tumor died of local recurrence. Wide excision had the lowest local recurrence rate. With successful surgical treatment, patients may have long-term disease-free survival.
 
Article
Three independent seminal papers published in 1911 by Arthur Legg [9, 10], Jacque Calve [3, 4], and Georg Perthes [12, 13] described what we now know as “Legg-Calve-Perthes disease” (LCPD) and distinguished the entity from other forms of a deforming arthritis that affected children. At that time, arthritis deformans (as it was frequently known) was sometimes not recognized until adolescence and young adulthood. Others [1, 2, 11, 14] had earlier described the entity but had not so clearly distinguished it from other disorders, particularly tuberculosis of the hip. (The earliest apparent descriptions by Baker [2] and Wright [14] appear as brief notes for the “Section of Diseases of Children” in the British Medical Journal.) By the mid 20th century, the entity was well known.
 
Article
In spondylolisthesis, it is believed that as L5 slips on S1, the pedicle may become elongated in response to the instability in an attempt to bridge the defect. Whether patients with spondylolysis, which is largely developmental, also develop elongation of the pedicles is unknown. The purpose of this study is to evaluate and quantify the increase in L5 pedicle length in subjects with spondylolysis as compared with normal healthy subjects. Nine hundred fifty-two human cadaveric specimens without spondylolysis and 120 specimens with spondylolysis from the Hamann-Todd Osteological Collection were examined by a single examiner. Baseline data, including age, sex, and race of specimens, were collected. Digital calipers were used to measure the pedicle lengths at the L5 level. Linear regression analysis was performed to compare the L5 pedicle lengths in healthy patients and patients with spondylolysis. Linear regression showed a significant association of increased L5 pedicle length in subjects with spondylolysis. The average L5 pedicle length in subjects with spondylolysis was greater compared with subjects without spondylolysis. In spondylolytic specimens, pedicles start to elongate after the age of 40 years. The pedicle lengths increase progressively from 5.6 mm at 40 years to 6.7 mm at 80 years with a 1% to 3% increment every decade. The pedicle lengths showed little variation in specimens from healthy subjects. In spondylolytic specimens, there is progressive elongation of L5 pedicle length after the third decade. An increase in L5 pedicle length in all age groups compared with the specimens from healthy subjects suggests that pathologic changes occur in bony anatomy of L5 vertebrae as early as adolescence when the condition develops.
 
Article
Chondrosarcoma is the second most common malignant bone tumor and is relatively unresponsive to chemotherapy and radiation regimens. In addition, the clinical course of chondrosarcoma is difficult to predict. The purpose of this study was to review the authors' experience with chondrosarcoma and ascertain any factors related to prognosis and clinical outcome. The medical records of 108 patients followed up for a minimum of 2 years were retrospectively reviewed. There were 31 low-grade and 77 high-grade chondrosarcomas. One hundred one patients underwent surgical resection. There was a statistically significant association between positive margins and local recurrence, metastasis, and death. Tumor grade was not predictive of outcome. Proliferation indices (MIB-1 expression determination through immunohistochemistry) were quantitated in 39 patients. A significant association was seen between MIB-1 expression and recurrence and death. Thus, objective quantitation of tumor proliferation was more predictive than was histologic grade of outcome in chondrosarcoma. Although histologic grade continues to be the standard grading system for chondrosarcoma, the current study contributes to ongoing research and validation of alternative techniques that may be more reliable in guiding prognosis and treatment of chondrosarcoma.
 
Article
One hundred twenty-three total hip arthroplasties were performed in 85 patients with osteonecrosis of the femoral head. There were 51 males and 34 females with an average age of 45 years. The average followup time was 4.6 years with a range of 2 to 10 years. All femoral stems and 71 sockets were fixed with acrylic cement. Fifty-two of the sockets used were placed without cement. The average Harris hip score improved from 45 points preoperatively to 92 points at the time of last followup. Of the 246 components used, 6 acetabular and 4 femoral prostheses in 7 patients have been revised (4%). Two components (0.8%) were revised for infection, 2 (0.8%) for repeated dislocation, and 6 (2.5%) for aseptic loosening. There is current radiographic loosening in 3 acetabular and 2 femoral components (2%). None of the noncemented acetabular components was either radiographically loose or revised. Within the subset of the 36 patients (52 hips) with a minimum 5-year followup (average, 6.6 years), 5 components (5%) were revised and 4 (4%) components are radiographically loose. The overall revision rate for cemented and hybrid hips at 2 to 10 years followup was 4%. The revision rate for hybrid hips alone was 2.5% in the entire series and 2% for hips with a minimum followup of 5 years. These results seem significantly better than previously reported. Using modern cement techniques and components, total hip arthroplasty can give excellent results in the young patient with avascular necrosis and may be the treatment of choice when reconstructive surgery is required.
 
Article
A comparison of the clinical and radiographic results of patients with metal-backed monoblock Insall-Burstein I and modular Insall-Burstein II Posterior Stabilized Knee Prostheses was done. The minimum followup was 10 years. The clinical results were comparable with a similar average Hospital for Special Surgery knee score of 85 and 84 points, respectively. Likewise, the Knee Society Knee and Functional Scores showed no statistical difference. Radiographically, the incidence of minor radiolucent lines was 11% for the Insall-Burstein I prostheses and 29% for the Insall-Burstein II prostheses, but their presence was of no clinical significance. There was no clinical or radiographic evidence of tibial component loosening with either prosthetic design and there were no revisions for polyethylene wear or osteolysis in either cohort of patients.
 
Article
A consecutive prospective series of 102 knees (90 patients) had unicompartmental knee arthroplasty (St. Georg "sledge") between 1973 and 1979 for gonarthrosis, Stages 2-4. Total clinical and roentgenographical evaluation was undertaken after 5-11 years (mean, 8.1 years) and included all 75 surviving patients. Fully comparable results were encountered in the 15 patients who died during the observation period. There were no early revisions but five late revisions; two due to loosening, one late infection, one instability, and one intractable pain. Complete loosening occurred in four patients (4%). Functional score (Hospital for Special Surgery method) averaged 77 points (preoperative, 43) with no tendency of deterioration with time. Loss of initially achieved alignment was generally associated with bone resorption around the tibial component. Minor arthrotic changes of the non-operated compartment occurred in 4% of the cases.
 
Article
Background: Various authors have proposed flaps to reconstruct traumatic forefoot skin and soft tissue defects, especially with exposure of tendon and/or bone although which is best for particular circumstances is unclear. Description of technique: The indications for the technique were a forefoot defect area of no more than 8-cm × 8-cm and a well-preserved lateral tarsal (LT) donor site. The injured tendons were repaired using tendon grafts. The free dorsalis pedis flap was outlined by centering it on the cutaneous branch of the LT artery and tailoring it to the size of the wound, allowing 0.5-cm margins in length and width. The flap was rotated around the plantar perforating branch of the dorsalis pedis artery (DPA) to cover the forefoot defect. The lateral dorsalis pedis cutaneous nerve was anastomosed with the recipient plantar nerve stump. The donor site was covered with an inguinal, full-thickness skin graft. Patients and methods: Traumatic forefoot skin and soft tissue defects with exposure of the tendon and/or bone involving 11 feet in 11 patients (mean age, 32 years) were covered using a LT flap with a reversed DPA pedicle. Three patients with forefoot defects underwent emergency repair within 8 hours of injury, whereas eight patients required delayed repair. All patients were followed up for at least 6 months (mean, 13 months; range, 6-24 months). Results: All flaps survived uneventfully, except for two that had superficial marginal necrosis or severe venous insufficiency. All skin grafts covering the donor sites survived and all wounds healed. None of the patients had restricted standing or walking at followups. The two-point discrimination was 4 mm to 10 mm at 6 months postoperative. The mean hallux-metatarsophalangeal-interphalangeal scale score was 93 points (range, 87-98 points). Conclusions: Our observations suggest the LT flap with a reversed DPA pedicle is a reasonable option for repair of traumatic forefoot skin and soft tissue defects with exposure of tendon and/or bone but a well-preserved LT donor site and is associated with minimal morbidity.
 
Article
Many studies suggest patient factors influence TKA outcomes, but the reported data are controversial, due perhaps in part to using only postoperative scores rather than change in scores from pre- to postoperatively. We examined the effect of gender, age, diagnosis, and obesity on changes in pre- to postoperative outcome measures (Knee Society clinical rating, WOMAC, and SF-12) in a cohort of 843 consecutive knee arthroplasties in 728 patients who received the same implant (Genesis II, Smith & Nephew, Memphis, TN). Minimum followup was 5 years (mean, 9.5 years; range, 5-11 years). Kaplan Meier survivorship was 98% +/- 0.007 with any reoperation as an end point. Male and female patients had similar increases in postoperative scores. Diagnosis and obesity made no difference in postoperative increases. However, less improvement occurred in health-related quality-of-life outcomes scores with advancing age.
 
Article
This study deals with survivorship of total condylar knee arthroplasties in 87 consecutive patients (112 knees) with follow-up periods of up to 11 years. The end point of the survivorship was defined as: (1) the need for revision due to septic or aseptic loosening; (2) roentgenographic loosening evidenced by a shift of component position; or (3) radiolucency extending under the condyle of the tibial component and partially along the peg, when associated with clinical symptoms. Life table calculations predict 88.7% survivorship of total condylar knee arthroplasty. Using revision for septic or aseptic loosening and recommendation for surgery as an end point, the survivorship was 94.1% 11 years after operation in this series. Seventy-two patients (90 knees) of 87 were available for clinical and roentgenographic study at eight to 11 years. Eight patients (12 knees) had died and seven patients (ten knees) were lost to follow-up study. The results were excellent to good in 93%, fair in 3%, and poor in 4%. Roentgenographic evaluation revealed well-fixed components in 36 knees (40%). Radiolucencies of varying degrees were present in 54 knees (60%). Of the 54 knees, seven had radiolucency under the tibial condyle in Zones I-IV and partially along the peg in Zones V and VI. Two knees had component loosening, one with a loose patella and the other a loose tibial component; both of these patients were symptomatic. Variables such as the patient's age, sex, diagnosis, alignment and position of the prosthesis, and level of bone cut did not correlate with the development of radiolucencies at the cement-bone interface.(ABSTRACT TRUNCATED AT 250 WORDS)
 
Top-cited authors
Javad Parvizi
  • Rothman Orthopaedic Institute
Kevin Bozic
  • Dell Medical School at the University of Texas at Austin
Steven M Kurtz
  • Drexel University
Kevin Ong
  • Exponent
Edmund Lau
  • Exponent