Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 466 | Issue 2 | Feb, 2008
Articles

Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage

Richard A. Brand MD [object Object],Gathorne Robert Girdlestone was born in 1881, the son of the Rev. R.B. Girdlestone, Honorary Canon of Christ Church, Oxford [3]. His early education was at Charterhouse, then he read medicine at New College, Oxford. Girdlestone received his subsequent medical training at St. Thomas’ Hospital, London, completing his house appointment there. He subsequently went to Oswestry, where he was influenced by Sir Robert Jones. During WW I he returned to Oxford to assume charge of a military hospital that eventually had over 400 beds. The Wingfield Convalescent Home, an “old fashioned institution,” [3] was located in Headington, then a village near Oxford, and Girdlestone’s initial military hospital consisted largely of open air huts on the Wingfield grounds. Girdlestone continued to work there and at the Radcliffe Infirmary after the war. These huts were, through the benefaction of Sir William Morris (the founder of Morris Motors and later elevated to Lord Nuffield), replaced with modern buildings beginning in 1930 with a bequest of £70,000 [4]. These new buildings, initially named the Wingfield-Morris Orthopaedic Hospital, were opened by the Prince of Wales in 1933. As a result of his work and stature and perhaps his relationship with Lord Nuffield, Girdlestone was appointed in 1937 the first British Professor of Orthopaedic Surgery. (Oxford Medical School eventually received £2,000,000 from Lord Nuffield [3].) The Wingfield-Morris Orthopaedic Hospital became part of the National Health Service in 1948, then was renamed the Nuffield Orthopaedic Centre in 1950, the year of Girdlestone’s death. It is fair to say that Girdlestone was among the primary and most influential individuals creating a specialty of orthopaedic surgery in the first half of the 20th century.,Girdlestone wrote at least two articles describing excision arthroplasty of the hip. The first, from 1928, described a radical excision for draining tuberculous hips [1] and the second (reprinted here), from 1942, a related and perhaps at times even more radical operation for pyogenic infections [2]. Girdlestone emphasized these radical operations were intended only for severe infections, and readers are reminded these were both published in the preantibiotic era, when radical surgery was often required to save a patient’s life. In the first article, he also emphasized the principle of “removal of diseased and devitalized tissues, flattening down of dead spaces, and leaving drainage so complete and lasting as will allow the wound to heal from the bottom” [1]. He excised the greater trochanter and all involved muscles, suturing skin edges deep into the wound so as to achieve effective drainage. When necessary, he also “flattened” the edges of the acetabulum. In the second article he suggested less radical operations were often ineffective in pyogenic infections owing to the “miniature rabbit-warren of sinuses and cavities” [2]. The techniques were fundamentally similar to those he had earlier described for tuberculosis. He used a wide transverse incision (Fig. 2) to access the hip, excising all lateral musculature along with the trochanter and the lateral margin of the acetabulum (Fig. 1). In the presence of infection in the intermuscular planes, he avoided suturing the skin deeply, and rather packed the wound with Vaseline gauze and rubber drains (Fig. 4). The postoperative care included splinting either on a frame (if good nursing care was available) or spica casting with a large window. Readers familiar with operations for infected total hip arthroplasties will immediately recognize current procedures are far less radical than those typically used in Girdlestone’s time. Rarely would an infected arthroplasty be treated with such radical excision of bone and muscle, open packing, and secondary healing. For that reason, I suggest the name Girdlestone not be used for contemporary operations except as they apply to what he described: excision arthroplasty more accurately describes current procedures.,[object Object],[object Object]

The Etiology of Osteoarthritis of the Hip

Reinhold Ganz MD, Michael Leunig MD, Katharina Leunig-Ganz MD, William H. Harris MD, DSc The etiology of osteoarthritis of the hip has long been considered secondary (eg, to congenital or developmental deformities) or primary (presuming some underlying abnormality of articular cartilage). Recent information supports a hypothesis that so-called primary osteoarthritis is also secondary to subtle developmental abnormalities and the mechanism in these cases is femoroacetabular impingement rather than excessive contact stress. The most frequent location for femoroacetabular impingement is the anterosuperior rim area and the most critical motion is internal rotation of the hip in 90° flexion. Two types of femoroacetabular impingement have been identified. Cam-type femoroacetabular impingement, more prevalent in young male patients, is caused by an offset pathomorphology between head and neck and produces an outside-in delamination of the acetabulum. Pincer-type femoroacetabular impingement, more prevalent in middle-aged women, is produced by a more linear impact between a local (retroversion of the acetabulum) or general overcoverage (coxa profunda/protrusio) of the acetabulum. The damage pattern is more restricted to the rim and the process of joint degeneration is slower. Most hips, however, show a mixed femoroacetabular impingement pattern with cam predominance. Surgical attempts to restore normal anatomy to avoid femoroacetabular impingement should be performed in the early stage before major cartilage damage is present.,[object Object]

Hip Damage Occurs at the Zone of Femoroacetabular Impingement

M. Tannast MD, D. Goricki MD, M. Beck MD, S. B. Murphy MD, K. A. Siebenrock MD Although current concepts of anterior femoroacetabular impingement predict damage in the labrum and the cartilage, the actual joint damage has not been verified by computer simulation. We retrospectively compared the intraoperative locations of labral and cartilage damage of 40 hips during surgical dislocation for cam or pincer type femoroacetabular impingement (Group I) with the locations of femoroacetabular impingement in 15 additional hips using computer simulation (Group II). We found no difference between the mean locations of the chondrolabral damage of Group I and the computed impingement zone of Group II. The standard deviation was larger for measures of articular damage from Group I in comparison to the computed values of Group II. The most severe hip damage occurred at the zone of highest probability of femoroacetabular impact, typically in the anterosuperior quadrant of the acetabulum for both cam and pincer type femoroacetabular impingements. However, the extent of joint damage along the acetabular rim was larger intraoperatively than that observed on the images of the 3-D joint simulations. We concluded femoroacetabular impingement mechanism contributes to early osteoarthritis including labral lesions.,[object Object]

Measurement of Hip Range of Flexion-Extension and Straight-leg Raising

R. A. Elson FRCS, G. R. Aspinall FRCS We believe there is a degree of inaccuracy in the usual methods of evaluation of range at the hip in the sagittal plane, ie, flexion-extension. We describe a simple method of measuring more accurately the range of hip flexion-extension, presuming such ranges of motion should relate to the anatomic position of the pelvis. We used this technique for the measurement of flexion and extension of the left hip in a cohort of 200 healthy individuals; we found a wide range of both flexion (80°–140°) and extension (5°–40°). Especially with respect to extension, we believe more conventional methods underestimate the ranges of motion. As a corollary to this study, we suggest some reappraisal of the straight-leg–raising test by which pain from nerve root tension can be distinguished from a source of pain arising locally in intervertebral joints for mechanical reasons or from the hip itself. We recommend the method described as being useful in the consulting office.

Osteonecrosis after Allogeneic Bone Marrow Transplantation

Frederic Zadegan MD, Agnes Raould MD, Pascal Bizot MD, Remy Nizard MD, Laurent Sedel MD Osteonecrosis after bone marrow transplantation is usually severe. Most patients develop acute and chronic graft-versus-host disease requiring a high dose of steroids for a long period of time. Generally ineffective nonoperative treatment in the past has resulted in treatment primarily with total hip arthroplasty (THA). We asked whether THA (1) reliably improved functional status, (2) led to more complications, and (3) THA after bone marrow transplantation was as durable as THA for idiopathic ON. We retrospectively reviewed 77 patients (123 hips) with osteonecrosis. The mean age at surgery was 33 years (range, 15.7–56 years). We performed all arthroplasties with an alumina ceramic bearing coupled with an alumina head 32 mm in diameter. The minimum followup was 2 years (mean, 9.2 years; range, 2–26 years). We documented seven revisions: three for late septic loosening, four for late aseptic loosening. Considering loosening of any component as the end point, the survivorship was 74.8% (range, 58.7%–90.9%) at 10 years. In this difficult situation, we believe the results acceptable. Septic loosening affecting this specific population has to be considered a serious event.,[object Object]

Modified Posterior Approach to Total Hip Arthroplasty to Enhance Joint Stability

Yong Sik Kim MD, Soon Yong Kwon MD, Doo Hoon Sun MD, Suk Ku Han MD, William J. Maloney MD We modified the posterior approach by preserving the external rotator muscles to enhance joint stability after primary THA. We asked whether this modified posterior approach would have a lower dislocation rate than the conventional posterior approach, with and without a repair of external rotator muscles. We retrospectively divided 557 patients (670 hips) who had undergone primary THA into three groups based on how the external rotator muscles had been treated during surgery: (1) not repaired after sectioning, (2) repaired after sectioning, or (3) not sectioned and preserved. The minimum followup was 1 year. In the group with preserved external rotator muscles, we observed no dislocations; in comparison, the dislocation rates for the repaired rotator group and the no-repair group were 3.9% and 5.3%, respectively. This modified posterior approach, which preserves the short external rotator muscles, seemed effective in preventing early dislocation after primary THA.,[object Object]

Total THA in Adult Osteonecrosis Related to Sickle Cell Disease

Philippe Hernigou MD, Sebastien Zilber MD, Paolo Filippini MD, Gilles Mathieu MD, Alexandre Poignard MD, Frederic Galacteros MD Most previous studies of THA in sickle cell disease report high risks of medical and orthopaedic complications, including infections and a higher incidence of failure than observed after THA for osteonecrosis related to other conditions. Based on our experience (1245 orthopaedic procedures during the last 25 years), we questioned these conclusions and retrospectively reviewed 312 arthroplasties performed in 244 patients with sickle cell disease. The mean age of the 126 women and 118 men at the time of surgery was 32 years. The minimum followup was 5 years (mean, 13 years; range, 5–25 years). We revised 10 hips (3%) for infection at a mean 11 years (range, 7–15 years) after the primary procedure and revised 21 cups (8%) and 17 stems (5%) for aseptic loosening at a mean of 14 years. We observed medical complications after 85 operations (27%) and orthopaedic complications in 42 cases (13%). Although THA carries a high risk of complication in patients with sickle cell disease, the benefits for the patient are substantial, and the risk of revision for loosening or infection appeared less than described in previous literature.,[object Object]

Alumina-on-Alumina in THA

Eduardo Garcia-Cimbrelo MD, PhD, Eduardo Garcia-Rey MD, PhD, EBOT, Antonio Murcia-Mazón MD, PhD, Agustín Blanco-Pozo MD, PhD, Eduardo Martí MD Different bearing surfaces, including alumina-on-alumina, have been used to avoid osteolysis.,We prospectively followed 288 patients (319 hips) in which an alumina-on-alumina cup was used with a hydroxyapatite stem. The patients’ mean age was 52.7 (range, 14–70 years), and the minimum followup was 3 years (mean, 4.7 years; range, 3–8 years). At final followup, five cups (including one with an alumina liner fracture) and two stems underwent revision. The cumulative probability of not having a revision of one or both components for any cause was 97% (95% confidence interval, 94.7%–99.1%). No patient spontaneously reported any noises from the hip and none reported noises when specifically questioned. All patients who had not undergone revision had good clinical results, but five of these patients had radiographic cup loosening at last followup. These data suggest alumina-on-alumina prostheses had reasonable outcomes after 5 years. One acetabular component fractured from trauma. We observed no linear femoral head penetration. Continued followup will be required to determine if reduction in wear between the alumina-on-alumina bearings results in less osteolysis and loosening.,[object Object]

Alumina-on-Alumina Hip Arthroplasty in Patients Younger Than 30 Years Old

R. Nizard MD, D. Pourreyron MD, A. Raould MD, D. Hannouche MD, PhD, L. Sedel MD THA in patients younger than 30 years old presents challenges: the initial technical challenge relates to the initial disease that often causes deformities making reconstruction difficult, while the long-term challenge is wear and subsequent osteolysis and component loosening. Ceramic-on-ceramic prostheses may represent a valuable option to reduce wear. We retrospectively studied 101 patients (132 hips) with ceramic-on-ceramic prostheses implanted from 1977 to 2004. As a result of the long span of time, different implant designs and modes of fixation were used. The average age of the patients was 23.4 ± 5 years (range, 13–30 years), and the main indication for THA was femoral head necrosis. The minimum followup was 1 year (mean, 6.9 years; range, 1–26.5 years). We documented 17 revisions (13%) for aseptic loosening. Twelve were for isolated acetabular loosening, two for isolated femoral loosening, and three for loosening of both components. Survivorship was 82.1% at 10 years and 72.4% at 15 years. Inferior survivorship was observed for THA performed after secondary arthritis related to slipped capital epiphysis or trauma. Limited osteolysis was observed in one hip. The main limiting factor in this series was the fixation of the acetabular component. However, improvements in the design and in the mode of fixation of this component should enhance long-term results.,[object Object]

The Exeter™ Universal Hip in Patients 50 Years or Younger at 10–17 Years’ Followup

Simon C. Lewthwaite FRCS(Orth), Ben Squires FRCS(Orth), Graham A. Gie FRCSEd(Orth), Andrew J. Timperley D. Phil, FRCS, Robin S. M. Ling OBE, MA, BM(Oxon), FRCS The Exeter™ Universal hip (Stryker Inc., Newbury, UK) has reported survival rates of 91.74% at 12 years in all patients with reoperation as an endpoint. However, its performance in younger patients has not been fully established. We reviewed survivorship and the clinical and radiographic outcomes of this hip system implanted in 107 patients (130 hips) 50 years old or younger at the time of surgery. The mean age at surgery was 42 years. The minimum followup was 10 years (mean, 12.5 years; range, 10–17 years) with no patients lost to followup. Twelve hips had been revised. Of these, nine had aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation and one joint underwent revision for infection. Radiographs demonstrated 14 (12.8%) of the remaining acetabular prostheses were loose but no femoral components were loose. Survivorship of both stem and cup from all causes was 92.6% at an average of 12.5 years. Survivorship of the stem from all causes was 99% and no stem was revised for aseptic loosening. The Exeter™ Universal stem performed well, even in the young, high-demand patient.,[object Object]

Minimum 10-year Survival of Kerboull Cemented Stems According to Surface Finish

Moussa Hamadouche MD, PhD, François Baqué MD, Nicolas Lefevre MD, Marcel Kerboull MD The optimal surface finish for a cemented THA stem is still debated. We hypothesized surface finish would influence survival of Kerboull cemented hip arthroplasties and a matte finish would have lower survival. We reviewed survival of 433 total hip arthroplasties in 395 patients: 284 consecutive patients (310 hips) were enrolled in a prospective, randomized study of polished (165 hips) or matte finish stems (145 hips) and compared to a historical series of satin stems (123 hips) in 111 patients. The satin and matte finish implants had similar geometry but the polished was quadrangular rather than oval. Finish roughnesses were: polished (radius, 0.04 μm), satin (radius, 0.9 μm), and matte (radius, 1.7 μm). The mean age of the patients at the time of the index arthroplasty was 63.6 years. The survival rate at 13 years, using radiographic loosening as the end point, was 97.3% ± 2.6% for polished stems, 97.1% ± 2.1% for satin stems, and 78.9% ± 5.8% for matte stems. The data suggest survival of Kerboull stems was higher with a polished or satin surface finish than with a matte finish.,[object Object]

THA Using Metal-on-Metal Articulation in Active Patients Younger Than 50 Years

Christian P. Delaunay MD, François Bonnomet MD, Philippe Clavert MD, Philippe Laffargue MD, Henri Migaud MD The main concern of patients with longer life expectancies and of patients who are younger and more active is the longevity of their total hip arthroplasty. We retrospectively reviewed 83 cementless total hip arthroplasties in 73 patients implanted with metal-on-metal articulation. All patients were younger than 50 years old (average age, 41 years) at the time of the index procedure, and 80% of the patients had an activity level graded 4 or 5 when measured with the system of Devane et al. A 28-mm Metasul articulation was used with three different cementless titanium acetabular components. At the most recent followup (average, 7.3 years), the average Merle d’Aubigné-Postel score improved from a preoperative 11.1 points to 17.4 points. We observed no radiographic evidence of component loosening. Ten acetabular components had lucency limited to one zone. The 10-year survivorship with the end point of revision (ie, exchange of at least one prosthetic or bearing component) was 100% (95% confidence interval, 90%–100%). Metasul bearings with cementless acetabular components remain promising in this high-risk younger patient population. However, additional followup strategies are recommended to determine any possible long-term deleterious effects associated with the dissemination of metallic ions.,[object Object]

Oxidation and Wear of 100-Mrad Cross-linked Polyethylene Shelf-aged for 30 Years

Hironobu Oonishi MD, PhD, Sok Chol Kim MD, Hiroyuki Oonishi MD, Masayuki Kyomoto MSc, Shingo Masuda MSc [object Object]

Retroacetabular Stress-shielding in THA

Rocco P. Pitto MD, PhD, Akanksha Bhargava MBChB, Salil Pandit MBChB, Jacob T. Munro MBChB We conducted a randomized clinical trial to compare periacetabular bone density changes after total hip arthroplasty using press-fit components with soft and hard liner materials. Bone density changes were assessed using quantitative computed tomography-assisted osteodensitometry. Twenty press-fit cups with alumina ceramic liners and 20 press-fit cups with highly cross-linked polyethylene liners were included; the nonoperated contralateral side was used as the control. Computed tomography scans were performed postoperatively and 1 year after the index operation. At the 1-year followup, we found no differences of periacetabular bone density changes between the alumina and polyethylene liner cohorts. However, we observed marked periacetabular cancellous bone density loss (up to −34%) in both cohorts. In contrast, we observed only moderate cortical bone density changes. The decrease of periacetabular cancellous bone density with retention of cortical bone density after THA suggests stress transfer to the cortical bone.

Favorable Survival of Acetabular Reconstruction With Bone Impaction Grafting in Dysplastic Hips

Matthijs P. Somford MD, Stefan B. T. Bolder MD, PhD, Jean W. M. Gardeniers MD, PhD, Tom J. J. H. Slooff MD, PhD, B. Willem Schreurs MD, PhD Acetabular bone loss hampers implantation of a total hip arthroplasty in patients with developmental dysplasia of the hip. The bone impaction grafting technique in combination with a cemented total hip can restore the bone stock in these patients, but do these reconstructions yield satisfying long-term results? We used this technique in 28 hips (22 consecutive patients). The degree of dislocation was graded preoperatively as Crowe I in five hips, Crowe II in eight hips, Crowe III in nine hips, and Crowe IV in four hips. We present the long-term results of this bone impaction grafting technique a minimum of 10 years after surgery. Two patients died before the minimum followup of 10 years, leaving 20 patients (26 hips). Two cups were revised, one cup for a sciatic nerve palsy (at 2 years) and the other for aseptic loosening after 12 years. The cumulative survival of the cup with revision for any reason as the end point was 96% at 10 years and 84% at 15 years. There were no femoral revisions during followup. The bone impaction grafting technique in combination with a cemented cup is an effective technique for developmental dysplasia of the hip with favorable long-term results.,[object Object]

Long-term Radiographic Assessment of Cemented Polyethylene Acetabular Cups

Sophie Williams PhD, Graham Isaac PhD, Neil Porter MRCS, John Fisher DEng, John Older FRCS [object Object],[object Object]

THA with Hydroxyapatite Granules at Cement–Bone Interface

Hironobu Oonishi MD, PhD, Hirotsugu Ohashi MD, PhD, Hiroyuki Oonishi MD, Sok Chol Kim MD To augment cement–bone bonding, we interposed hydroxyapatite granules at the cement–bone interface (bioactive bone cement technique). Hydroxyapatite granules (2–3 g) were smeared on the bone surface of the acetabulum and femur just before cementing. We used porous hydroxyapatite granules 300 to 500 μm in diameter from 1986 to 1988 (first generation) and granules 100 to 300 μm in diameter from 1989 to 1991 (second generation). We followed 151 patients (222 hips) in the first generation and 170 patients (252 hips) in the second generation. The minimum followup was 15 years (mean, 17.3 years; range, 15–20 years). Radiolucent lines or spaces less than 1 mm were observed in four hips (1.8%) in the first generation and in 15 hips (6.2%) in the second generation. Osteolysis was observed in one hip (0.5%) in the first generation and six hips (1.6%) in the second generation. We observed loosening in two cups (0.8%) in the second generation. The long-term clinical results suggest the interface bioactive bone cement technique combined with our other techniques results in low incidences of radiolucent lines (spaces) and osteolysis, and may increase the longevity of cemented THA. The data suggest the larger hydroxyapatite granules performed better than smaller ones.,[object Object]

Fixation and Bone Remodeling Around a Low Stiffness Stem in Revision Surgery

Johan Kärrholm MD, PhD, Reza Razaznejad MD Femoral stems with reduced stiffness have the potential of decreasing stress shielding and could be an alternative in revision surgery when restoration of bone stock is required. We retrospectively reviewed 38 patients (40 stems) with a central core of cobalt-chromium surrounded by a polymer and an outer titanium mesh layer containing a proximal coating of hydroxyapatite/tricalcium phosphate; 30 of the 38 patients (32 hips) had a minimum 2-year followup. We impacted morselized allograft around the stem in 28 of 32 revisions. Repeated radiostereometric examinations showed medial, distal, and posterior migration (median, 0.21 mm, 0.17 mm, and 0.96 mm, respectively) of the femoral head center for up to 6 months followed by stabilization. Measurements of bone mineral density in the seven Gruen zones at 6 months revealed either a decrease (down to a median of 3%), no change, or a slight increase (up to 5%) followed by a further increase up to 2 years in three of the regions (2, 3, and 5). Conventional radiography at 2 years demonstrated graft remodeling and incomplete radiolucent lines in 19 hips, mainly in Regions 1 and 7. Two hips were reoperated on as a result of dislocation, but none of the stems had been revised.,[object Object]

Dual Mobility Cemented Cups Have Low Dislocation Rates in THA Revisions

Frantz L. Langlais MD, Mickaël Ropars MD, François Gaucher MD, Thierry Musset MD, Olivier Chaix MD THA revisions using standard cups are at risk of dislocation (5.1% to 14.4% incidence), especially in patients over 70 years of age. Constrained tripolar cups have reduced this risk (6% incidence) but are associated with substantial loosening rates (9%). The nonconstrained dual mobility cup was designed to improve prosthetic stability (polyethylene head ≥ 40 mm diameter) without increasing loosening rates by reducing wear and limiting impingement (rotation range of 108°). We implanted 88 cemented dual mobility cups for THA revisions in 82 patients at high risk of dislocation. Average patient age was 72 years (range, 65–86 years). Eighty-five of the 88 hips were reviewed at 2 to 5 years followup. One patient (1.1%) had a traumatic dislocation at 2 years postoperatively. Two patients (2.3%) had asymptomatic early loosening and three patients (3.5%) had localized radiographic lucencies. These results confirm those with press-fit dual mobility cups suggesting a low dislocation rate at 5 years and a cup survival of 94.6%. At middle term followup, cemented dual mobility cup achieved better results than constrained cups in cases at risk of dislocation and recurrent loosening.,[object Object]

Cartilage-retaining Wafer Resection Osteotomy of the Distal Ulna

Jason A. Barry MD, Wadih S. Macksoud MD Ulnar-sided wrist pain resulting from ulnar impaction is common. We describe a new cartilage-retaining wafer resection osteotomy designed to keep the cartilage intact and decompress the ulnocarpal articulation without requiring internal fixation. We retrospectively reviewed seven patients with ulnar impaction who had the procedure. The minimum followup was 14 months (mean, 30 months; range, 14–38 months). The mean change in ulnar variance was −1.29 mm. Patients showed radiographic healing by a mean of 11 weeks. Our preliminary results suggest the cartilage-retaining wafer resection osteotomy may be an effective way to unload the ulnocarpal joint without requiring internal fixation or destruction of the distal ulna cartilage.,[object Object]

Sequential Changes of Bone Metabolism in Normal and Delayed Union of the Spine

Tsuyoshi Ohishi MD, PhD, Masaaki Takahashi MD, PhD, Akihiro Yamanashi MD, PhD, Daisuke Suzuki MD, Akira Nagano MD, PhD [object Object],[object Object]

Orthopaedic Surgeons’ Cardiovascular Response During Total Hip Arthroplasty

Marko Bergovec MD, Dubravko Orlic MD, PhD The literature contains limited and contradictory information regarding the amount of physical effort and/or emotional stress needed to perform surgery. We therefore investigated cardiovascular response to psychophysical stress in orthopaedic surgeons while they were performing surgery. We monitored 29 male orthopaedic surgeons from four university centers while they performed total hip arthroplasties. Changes in their cardiovascular parameters were recorded by ambulatory monitoring methods. Exercise stress testing of each participant was used as a control state. We compared the cardiovascular response during surgery to energy requirements of everyday activities. Preoperative and postoperative testing showed lower values of cardiovascular parameters than during physically less difficult parts of the operation; physically more difficult phases of the operation additionally increased the values of parameters. We concluded performing total hip arthroplasty increases surgeons’ cardiovascular parameters because of psychologic stress and physical effort. Excitement of the cardiovascular system during total hip arthroplasty appears similar to the excitement during moderate-intensity daily activities, such as walking the dog, leisurely bicycling, or climbing stairs.

The Asymmetric Profile of the Acetabulum

Eric Vandenbussche MD, PhD, Mohammed Saffarini MEng, Fabienne Taillieu MD, Céline Mutschler MD Despite the curvaceous profile of the acetabulum, orthopaedic surgeons have continued to implant hemispheric cups since the introduction of total hip arthroplasty. The geometric discrepancies between the natural acetabulum and implant can result in painful iliopsoas impingement attributable to prosthetic overlap at the anterior acetabular ridge over which the iliopsoas tendon extends to leave the pelvis. We expanded on previous in vitro observations of acetabular morphology using a large in vivo sample and quantified the dimensions of the psoas valley. We studied computed tomographic scans of 200 healthy hips from 50 men and 50 women. The acetabular ridges were digitized on three-dimensional bone reconstructions and their coordinates were manipulated in spreadsheets to deduce acetabular diameter, anteversion, and inclination and to plot the rim profile. Our results confirm the acetabular rim is an asymmetric succession of three peaks and three troughs. The psoas valley has the following shape distribution: 79% curved, 11% angular, 10% irregular, and 0% straight. The mean depth of the psoas valley is 5 mm and the latitude of its trough is on average 6 mm below the acetabular equator. The use of side-specific cups that replicate the curvaceous acetabular profile could prevent prosthetic overlap and reduce the incidence of iliopsoas impingement.

Randomized Trials to Modify Patients’ Preoperative Expectations of Hip and Knee Arthroplasties

Carol A. Mancuso MD, Suzanne Graziano RN, Lisa M. Briskie RN, Margaret G. E. Peterson PhD, Paul M. Pellicci MD, Eduardo A. Salvati MD, Thomas P. Sculco MD Patients have multiple expectations of THA and TKA. We asked whether preoperative educational classes addressing recovery during the first year could modify patients’ expectations of their 12-month postoperative recovery. Participants were enrolled consecutively in two randomized, controlled trials, one for THA (177 patients) and one for TKA (143 patients). Control patients preoperatively received a standard THA or TKA class addressing recovery immediately after surgery. Intervention patients preoperatively received the standard class plus a joint-specific module addressing recovery during the first 12 months. Before and after the class, patients completed either a hip-specific or knee-specific validated expectations survey. The main outcome was the within-patient change in expectation scores (maximum increase, +100; maximum decrease, −100) before and after the class but preoperatively. Mean changes in hip scores were +3.3 ± 8 for intervention patients (range, −22–+32) and +4.9 ± 8 for control patients (range, −13–+29). Mean changes in knee scores were −3.4 ± 10 for intervention patients (range, −26–+33) and +2.4 ± 10 for control patients (range, −30–+30). Patients’ preoperative expectations of their recovery from THA or TKA can be modified by preoperative educational classes.,[object Object]

How Effective is a Saline Arthrogram for Wounds Around the Knee?

Paul Tornetta MD, Matthew T. Boes MD, Anthony A. Schepsis MD, Timothy E. Foster MD, Mohit Bhandari MD, Enrique Garcia BS Traumatic arthrotomies may predispose patients to subsequent septic arthritis and therefore are regarded as serious injuries requiring emergent treatment. The saline arthrogram is a commonly used test to determine if a patient has a traumatic arthrotomy. We determined the sensitivity of the saline arthrogram to identify known intraarticular wounds in 78 patients (80 knees) undergoing elective arthroscopic procedures. There were 66 infrapatellar and 14 suprapatellar incisions. The average length of the incision was 7.5 mm. Intraarticular position was confirmed with a blunt probe. A saline arthrogram then was performed using 60 mL normal saline. The known arthrotomy (operative wound) was observed during the injection for evidence of saline leakage (positive static test). If no leakage was observed, the knee was brought through a range of motion with continued observation for leakage from the arthrotomy (positive dynamic test). Twenty-two of 80 knees had a positive test without passive range of motion of the knee (static sensitivity, 36%). Eight additional knees had a positive test with subsequent passive motion (dynamic sensitivity, 43%). Our data suggest a saline arthrogram has low sensitivity for detecting known small traumatic arthrotomy wounds of the knee.,[object Object]

5- to 9-year Survivorship of Single-radius, Posterior-stabilized TKA

Ormonde M. Mahoney MD, Tracy L. Kinsey RN, MSPH We studied 1030 consecutive cemented primary TKAs performed by the primary author (OMM) using a single-radius, posterior-stabilized total knee prosthesis with 5 years’ minimum followup to determine whether an accelerated early failure rate was associated with this design. At 5 to 9.5 postoperative years, 32 knees had been revised at an average of 2.4 postoperative years (range, 0.1–8.2 years) because of infection (11), periprosthetic fracture (10), aseptic loosening (eight), stiffness (two), and late hemarthrosis (one). Four had only the tibial insert revised. One-half of all failures occurred within 1.5 years. The cases of aseptic loosening involved the femoral component in one patient, tibial component in five, and both components in two. With only seven patients (0.7%) having unknown outcomes, the overall failure rate was 4.9 per 1000 person-years for the study period. The Kaplan–Meier survivorship using any part of the prosthesis removed or revised for any reason as the end point was 95.8% (95% confidence interval, 93.7%–95.5%), and with aseptic loosening as the end point, it was 98.6% (95% confidence interval, 96.5%–99.4%). The midterm survivorship rates were comparable to those of other posterior-stabilized total condylar designs and are not suggestive of excessive risk of early failure.,[object Object]

Surgical Treatment of Isolated Patellofemoral Osteoarthritis

Roland Becker MD, PhD, Martin Röpke MD, Anja Krull MD, Volker Musahl MD, Wolfgang Nebelung MD, PhD Isolated patellofemoral osteoarthritis in the healthy middle-aged population is a challenging problem. Fifty-one knees in 50 patients with isolated patellofemoral osteoarthritis were treated by partial lateral facetectomy, lateral release, and medialization of the tibial tubercle. The minimum followup was 7 months (mean, 20.2 months; range, 7–32 months). Preoperative radiographs showed Ahlbäck Grades III and IV lateral patellofemoral joint space narrowing. The mean age of the patients was 60.1 years (range, 46–81 years). The subjective outcome was based on the WOMAC and the McCarroll score. Posteroanterior flexion weightbearing views, lateral views, and 45° axial views were taken. According to the WOMAC score, the scores improved considerably by 2.34 points with respect to pain and by 1.63 points with respect to function. The Insall-Salvati index decreased considerably but still remained in the physiologic range. The majority of these patients experienced improvement in their patellofemoral symptoms. However, the clinical outcome was not better in comparison to other surgical procedures. After the short followup, we would not recommend combined lateral facetectomy, lateral release, and medialization of the tibial tubercle until longer results are available.,[object Object]

Three-dimensional In Vivo Quantification of Knee Kinematics in Cerebral Palsy

Frances T. Sheehan PhD, Andrea R. Seisler MBE, Katharine E. Alter MD Cerebral palsy is the most common disabling condition in childhood, involving a diverse group of movement and posture disorders of varying etiologies. Yet, much is unknown about how cerebral palsy affects individual joints because currently applied techniques cannot quantify the three-dimensional kinematic parameters at the joint level. We quantified the effects of cerebral palsy at the knee using fast phase contrast MRI, with the ultimate intent of improving the assessment of joint impairments associated with cerebral palsy, improving clinical outcomes, and reducing the impact of cerebral palsy on function. We addressed three questions: (1) Can patients with cerebral palsy perform the required repetitive extension task? (2) Which of the 12 degrees of freedom defining complete knee kinematics are abnormal in individual patients with cerebral palsy and is the patellar tendon moment arm abnormal in these patients? (3) Are the individual kinematic differences consistent with clinical observations? All patients were able to perform the required task. We found kinematic differences for each patient with cerebral palsy consistent with clinical findings, in comparison to an able-bodied population. Fast phase contrast MRI may allow differentiation of patellofemoral and tibiofemoral function in various functional subtypes of cerebral palsy, providing insights into its management.

Allograft-Prosthetic Composite in the Proximal Tibia After Bone Tumor Resection

Davide Donati MD, Marco Colangeli MD, Simone Colangeli MD, Claudia Bella MD, Mario Mercuri MD We consider an allograft-prosthesis composite in the proximal tibia one of the better reconstructive options in this site because it combines the mechanical stability of a prosthesis with the biologic reconstruction of the extensor mechanism. We retrospectively reviewed 62 patients who had proximal tibia reconstructions with allograft-prosthesis composites to ascertain the complications and functional outcomes. By combining an allograft with a prosthesis, placing cement in the graft, and press-fitting the prosthesis in the tibial diaphysis, we obtained satisfactory Musculoskeletal Tumor Society scores in 90.4% of patients, with a 5-year survival rate (73.4%) comparable to that of reconstruction with a modular prosthesis. However, we observed high infection rates (24.2%) and rotation of the medial gastrocnemius seemed not to reduce this complication. For this reason, we do not recommend using this reconstructive technique in patients who will receive postoperative chemotherapy or in patients in whom a previous reconstructive method failed. We believe the ideal candidate is the young patient with a benign aggressive or malignant low-grade tumor who has not undergone previous surgery.,[object Object]

Acute Infections After Fracture Repair

Eric Rightmire MD, David Zurakowski PhD, Mark Vrahas MD Managing infections in fractures treated with open reduction and internal fixation is an ongoing dilemma. Little published data exist to support the current practice of treating these infections with retained hardware, irrigation, débridement, and antibiotic suppression. We evaluated the effectiveness of this approach. We identified potential subjects from a central trauma database and selected them based on chart review and specific inclusion and exclusion criteria. We divided the patients into two groups. Patients achieving successful union with original hardware in place were considered as having successful results and patients who required hardware removal before healing were considered to have failed results. Data, including age, gender, tobacco use, diabetic status, site of fracture, Orthopaedic Trauma Association class, open grade, type of fixation, joint involvement, and organism, were gathered and compared between the groups by analysis of variance. Sixty-nine cases were available for analysis. Forty-seven (68%) were successful and 22 (32%) were unsuccessful. Average time to healing was 130 days. Most of the failures occurred within 120 days from the time of injury. Smoking was a major risk factor with a 3.7 times greater likelihood of procedures being unsuccessful per month than procedures among nonsmokers. Treating infected fractures with hardware in place is less successful than widely believed.,[object Object]

Femoral Nailing-related Coagulopathy Determined by First-hit Magnitude

Peter V. Giannoudis MD, EEC (Ortho), Martijn Griensven MD, PhD, Frank Hildebrand MD, Christian Krettek MD, FRACS, Hans-Christoph Pape MD We asked whether coagulopathy worsened during femoral intramedullary nailing in the presence of lung contusion and hemorrhagic shock and whether reamed or unreamed nailing influenced these results. In 30 Merino sheep, we induced hemorrhagic shock and/or standardized lung contusion followed by femoral nailing. Six groups of five each were assigned as follows: thoracotomy control groups treated with reamed or unreamed nailing, lung contusion groups treated with reamed or unreamed nailing, and shock and lung contusion groups treated with reamed or unreamed nailing. After lung contusion alone (first hit), the serum values of antithrombin III, factor V, and fibrinogen were considerably altered after reamed and unreamed femoral nailing (second hit) 4 hours postoperatively. In the lung contusion and shock groups, we found a substantial reduction for all serum coagulative parameters between baseline and fixation after reamed and unreamed nailing. The magnitude of the first hit is increased if hemorrhagic shock is added to a lung contusion determined by hemostatic reactions. The magnitude of the injury appears equally important as the type of subsequent surgery and should be considered in planning for fracture fixation in patients at high risk for complications.

Infection Rates and Healing Using Bone Wax and a Soluble Polymer Material

Tadeusz Wellisz MD, Yuehuei H. An MD, Xuejun Wen MD, PhD, Qian Kang MD, Christopher M. Hill VMD, Jonathan K. Armstrong PhD [object Object]

Development of Partial-thickness Articular Cartilage Injury in a Rabbit Model

Edwin J. Jansen MD, Pieter J. Emans PhD, MD, Lodewijk W. Rhijn PhD, MD, Sjoerd K. Bulstra PhD, MD, Roel Kuijer PhD In humans, partial-thickness cartilage lesions frequently result in premature osteoarthritis. While rabbits often are used as a model for partial-thickness cartilage lesions, the natural course of cartilage surrounding such a lesion is largely unknown. We developed a rabbit model of a chronic partial-thickness cartilage defect and asked whether these defects led to (1) deterioration of surrounding cartilage macroscopically and microscopically (increased Mankin score) and (2) disturbances in proteoglycan metabolism. In 55 rabbits, we created a 4-mm-diameter partial-thickness cartilage defect on one medial femoral condyle. The surrounding cartilage was characterized during the course of 26 weeks. Contralateral knees were sham-operated. In experimental knees, we found cartilage softening and fibrillation at 13 and 26 weeks. High Mankin scores observed at 1 week were partially restored at 13 weeks but worsened later and were most pronounced at 26 weeks. Mankin scores in the experimental groups were worse at 1 and 26 weeks when compared with the sham groups. Mankin scores at 26 weeks improved compared with 1 week in the sham groups. Disturbances in proteoglycan metabolism were less evident. In this rabbit model, a partial-thickness cartilage lesion resulted in early markers of degenerative changes resembling the human situation.

Case Reports

Nazzar Tellisi MD, Austin T. Fragomen MD, Svetlana Ilizarov MD, S. Robert Rozbruch MD Congenital limb deficiencies with severe shortening and/or deformity can be difficult to fit with a prosthesis. We report two patients in whom gradual lengthening and deformity correction with the Ilizarov/Taylor spatial frame™ was used to improve prosthesis fit, comfort, and gait.

Richard von Volkmann

Christian Willy MD, Peter Schneider MD, Michael Engelhardt MD, Alan R. Hargens MD, Scott J. Mubarak MD [object Object]
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