Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 468 | Issue 5 | May, 2010

Minimally Invasive Subvastus Approach: Improving the Results of Total Knee Arthroplasty: A Prospective, Randomized Trial

José Ramón Varela-Egocheaga PhD, Miguel Angel Suárez-Suárez PhD, María Fernández-Villán MD, Vanessa González-Sastre MD, José Ramón Varela-Gómez MD, Carlos Rodríguez-Merchán PhD

Minimally invasive knee arthroplasty seeks to diminish the problems of traditional extensile exposures aiming for more rapid rehabilitation of patients after surgery.

Outcomes of Meniscal Preservation Using All-inside Meniscus Repair Devices

Sujith Konan MRCS, Fares S. Haddad MCh, FRCS (T&O)

The thrust of meniscal surgery has now moved toward meniscal preservation. Repair is particularly indicated on the lateral side where the sequelae of resection are severe even in an older patient population.

Functional Performance with a Single-radius Femoral Design Total Knee Arthroplasty

Enrique Gómez-Barrena MD, PhD, Carmelo Fernandez-García MD, PhD, Almudena Fernandez-Bravo MD, Raquel Cutillas-Ruiz MD, Gloria Bermejo-Fernandez MD

Better muscular recovery of the extensor mechanism after TKA is claimed by femoral designs based on a sagittal single radius.

Midterm Assessment of Causes and Results of Revision Total Knee Arthroplasty

Fahad Hossain MRCS, Shelain Patel MRCS, Fares Sami Haddad FRCS (Tr & Orth)

There is limited information regarding revision total knee arthroplasty (TKA) with respect to etiology, outcome, and long-term survival comparing different implant types.

Results after Late Polymicrobial, Gram-negative, and Methicillin-resistant Infections in Knee Arthroplasty

José Cordero-Ampuero MD, PhD, Jaime Esteban MD, PhD, Eduardo García-Rey MD, PhD

Previous studies of knee arthroplasty infections caused by high-virulence organisms suggest poor outcomes. Polymicrobial and Gram-negative infections are less studied.

Computer Assistance Increases Precision of Component Placement in Total Knee Arthroplasty with Articular Deformity

Daniel Hernández-Vaquero MD, PhD, Abelardo Suarez-Vazquez MD, PhD, Manuel A. Sandoval-Garcia MD, PhD, Alfonso Noriega-Fernandez MD

The accuracy of computer navigation applied to total knee arthroplasty (TKA) in knees with severe deformity has not been studied.

Postoperative Analgesia in TKA: Ropivacaine Continuous Intraarticular Infusion

Primitivo Gómez-Cardero MD, E. Carlos Rodríguez-Merchán MD, PhD

Postoperative pain control is a challenge in patients undergoing TKA due to side effects and technical limitations of current analgesic approaches. Local anesthetic infiltration through continuous infusion pumps has been shown to reduce postoperative pain in previous studies.

Hinged Total Knee Arthroplasty in the Presence of Ligamentous Deficiency

Daniel Hernández-Vaquero PhD, Manuel A. Sandoval-García PhD

Rotating-hinge total knee prostheses may be used for the treatment of global instability about the knee. The designs of previous generations were associated with suboptimal outcomes.

The Outerbridge Classification Predicts the Need for Patellar Resurfacing in TKA

E. Carlos Rodríguez-Merchán MD, PhD, Primitivo Gómez-Cardero MD Patellar resurfacing (PR) in total knee arthroplasty (TKA) is controversial. The Outerbridge classification of cartilage defects in the patella is commonly used in the literature. The purpose of this study was to determine if the Outerbridge classification can predict the need for PR as part of total knee arthroplasty. Between 1995 and 2000, we performed a prospective, randomized study of 500 TKAs. We carried out PR depending on the Outerbridge classification of the patella at the time of surgery. Patients with Outerbridge Grades I, II, and III formed Group A, whereas patients with Grade IV formed Group B. Within each group, resurfacing was completed on half of the patients. Group A had 328 patients (164 with PR, 164 without PR). In Group B, there were 172 patients (86 with PR, 86 without PR). An identical prosthetic design was used for both groups. The minimum followup was 5 years (average, 7.8 years) for both Group A and Group B. At the end of followup, we assessed the number of patients in each group that required secondary resurfacing as a result of patellofemoral pain. Patients in Group A required fewer revisions for PF pain. In Group A, only one patient required a secondary PR (0.6% rate), whereas in Group B, 10 patients needed PR (11.6% rate). In Group B, the risk of need of a patellar resurfacing was 21.5 times greater than in Group A. On the basis of these findings, we recommend PR in Outerbridge Grade IV patellae, but not in Grades I, II, and III.,[object Object]

The 5-year Results of an Oxidized Zirconium Femoral Component for TKA

Massimo Innocenti MD, Roberto Civinini MD, PhD, Christian Carulli MD, Fabrizio Matassi MD, Marco Villano MD Osteolysis secondary to polyethylene wear is one of the major factors limiting long-term performance of TKA. Oxidized zirconium is a new material that combines the strength of a metal with the wear properties of a ceramic. It remains unknown whether implants with a zirconium femoral component can be used safely in TKA. To answer that question, we reviewed, at a minimum of 5 years, the clinical outcome and survivorship of a ceramic-surfaced oxidized zirconium femoral component implanted during 98 primary TKAs between April 2001 and December 2003. Survivorship was 98.7% at 7 years postoperatively. No revision was necessary and only one component failed because of aseptic loosening. Mean Knee Society score improved from 36 to 89. No adverse events were observed clinically or radiologically. These results justify pursuing the use of oxidized zirconium as an alternative bearing surface for a femoral component in TKA.,[object Object]

A New Incision Technique to Reduce Tibiofemoral Mismatch in Rotationplasty

Christian Ossendorf MD, MS, Gerhard U. Exner MD, Bruno Fuchs MD, PhD Rotationplasty provides stable and durable biologic reconstruction after tumor resection around the knee and renders reliable results, in young patients. However, after resection of the tumor, there is often a mismatch between the circumference of the proximal (femoral) and the distal (tibial) parts. Because rotationplasty includes an intercalary amputation where the ends are readapted, there is always a mismatch of the proximal and distal circumferences of the soft tissue envelope. To facilitate skin closure without tension and to avoid impaired wound healing and subsequent infections, the type of incision is critical and must be carefully planned. We present a new incision technique for rotationplasty about the knee. Half of the difference of the incision length of the proximal and distal circumferences represents the base of the triangle proximally, medially and laterally of the thigh. After adapting both ends, the peak of this flat triangle is distally adapted via a vertical incision which allows it to match unequal circumferences. This technique was used in eight patients, in all of whom the wounds healed uneventfully.

Fresh Osteochondral Allografting for Steroid-associated Osteonecrosis of the Femoral Condyles

Simon Görtz MD, Allison J. Young BS, William D. Bugbee MD

Osteonecrosis is a complication of corticosteroid therapy with limited treatment options in young, active patients. These options include debridement, core decompression, osteotomy, allografting, and partial or total knee replacement. Few studies exist regarding the use of osteochondral allografts for treatment of steroid-associated osteonecrosis.

A Useful Radiologic Method for Preoperative Joint-line Determination in Revision Total Knee Arthroplasty

Jose Romero MD, Burkhardt Seifert PhD, Olaf Reinhardt MD, Oliver Ziegler MD, Oliver Kessler MD, MS Intraoperative joint-line determination during revision TKA is difficult and no method exists to plan the position preoperatively. Two questions need to be answered: to which extent does the joint line differ from its anatomic position after revision TKA if it has only been determined intraoperatively, and can the joint line be calculated preoperatively based on the transepicondylar width. Of 22 consecutive patients with complete preoperative (before and after primary TKA) and postoperative (after revision TKA) radiograph documentation, the joint-line position was measured on plane radiographs using the medial epicondyle as a reference. On another set of 45 consecutive patients with no knee disorders other than meniscal lesions, the transepicondylar axis width (TEAW) and the perpendicular distance from the medial and lateral epicondyles to the joint line were measured twice by two independent observers on plane AP radiographs of the knee. Significant joint-line alterations were observed after primary and revision TKA, implicating that a method for preoperative planning is needed. Because a linear correlation between the TEAW and the perpendicular distance from the epicondyles to the joint-line tangent was found, the ratio is useful to calculate the true joint-line position from the TEAW before revision TKA.,[object Object]

Tantalum is a good bone graft substitute in tibial tubercle advancement

Mariano Fernandez-Fairen PhD, MD, Virginia Querales MD, Alexander Jakowlew MD, Antonio Murcia PhD, MD, Jorge Ballester PhD, MD

Porous tantalum is reportedly a good substitute for structural bone graft in several applications. So far, its use has not been reported in tibial tuberosity anteriorization (TTA) for treatment of isolated degenerative chondral lesions of the patellofemoral joint.

Weight of Polyethylene Wear Particles is Similar in TKAs with Oxidized Zirconium and Cobalt-chrome Prostheses

Young-Hoo Kim MD, Jun-Shik Kim MD, Wansoo Huh PhD, Kwang-Hoon Lee MS

The greater lubricity and resistance to scratching of oxidized zirconium femoral components are expected to result in less polyethylene wear than cobalt-chrome femoral components.

Anatomic Study of the Abductor Pollicis Longus: A Source for Grafting Material of the Hand

Elena Bravo MD, PhD, FEBOPRAS, Raul Barco MD, FEBOT, Adrian Bullón MD Interposition grafting material is used frequently to treat osteoarthritis of the base of the thumb or tendinous and ligamentous injuries of the hand. The observation of duplicated tendons in the first dorsal compartment of the hand prompted us to explore the possibility of using the accessory abductor pollicis longus (AAPL) tendon as grafting material. Based on dissections of 78 cadaveric upper limbs, we describe the number of tendons in the first dorsal compartment of the hand, the number of muscle bellies, their innervation, their insertion site, and the tendon dimensions to determine whether the AAPL can be considered a true tendon. The AAPL was present in 85% of the hands. Average length, width, and thickness (in millimeters) of the APL were of 69.3, 5.2, and 2.1, respectively. Average length, width, and thickness (in millimeters) of the AAPL were of 69.2, 3.3, and 1.6, respectively. No differences in dimension of the tendons were found between the APL and the AAPL. The dimensions of the tendinous portion of the AAPL are similar to those of the APL and can be considered a true tendon. When present, the AAPL is a suitable source of local grafting material.

Revision Total Hip Arthroplasty with a Porous-coated Modular Stem: 5 to 10 Years Followup

Dror Lakstein MD, David Backstein MD, MEd, FRCSC, Oleg Safir MD, FRCSC, Yona Kosashvili MD, MHA, Allan E. Gross MD, FRCSC [object Object],[object Object]

Will a Vascularized Greater Trochanter Graft Preserve the Necrotic Femoral Head?

Dewei Zhao PhD, MD, Benjie Wang PhD, Lin Guo PhD, Lei Yang PhD, Fengde Tian PhD

Various head-preserving procedures have been used for young patients with osteonecrosis of the femoral head (ONFH) to avert the need for THA. However, none of these techniques are accepted universally because of the technical difficulties, complications, or mixed results that often are difficult to reproduce.

Back Pain and Total Hip Arthroplasty: A Prospective Natural History Study

Javad Parvizi MD, Aidin E. Pour MD, Alan Hillibrand MD, Grigory Goldberg MD, Peter F. Sharkey MD, Richard H. Rothman MD, PhD

Many patients with degenerative joint disease of the hip have substantial degeneration of the lumbar spine. These patients may have back and lower extremity pain develop after THA and it may be difficult to determine whether the source of the pain is the hip or spine.

Subchondral Insufficiency Fracture of the Femoral Head may be Associated with Hip Dysplasia: A Pilot Study

Kohei Ishihara MD, Keita Miyanishi MD PhD, Hidetoshi Ihara MD, Seiya Jingushi MD PhD, Takehiko Torisu MD PhD

Subchondral insufficiency fracture of the femoral head occurs mainly in elderly patients with osteoporosis. Spontaneous resolution is observed after nonoperative treatment in some patients whereas other show progressive joint destruction requiring THA. Several studies report the occurrence of subchondral insufficiency fracture of the femoral head in dysplastic hips.

Neuromuscular Function after Arthroscopic Partial Meniscectomy

Julia F. Glatthorn MSc, Andreas M. Berendts MSc, Mario Bizzini MSc, PT, Urs Munzinger MD, Nicola A. Maffiuletti PhD

Quadriceps muscle strength, which is essential for the function and stability of the knee, has been found to be impaired even years after arthroscopic partial meniscectomy. However, the neuromuscular alterations that could account for such muscle weakness remain unclear.

Which is the Best Method to Determine the Patellar Height in Children and Adolescents?

Moon Seok Park MD, Chin Youb Chung MD, Kyoung Min Lee MD, Sang Hyeong Lee MD, In Ho Choi MD Patellar height is associated with various clinical syndromes. We asked which of three methods was the most appropriate for measuring patellar height for different age groups in terms of applicability, validity, and reliability. We evaluated 108 children and adolescents with available MR images and lateral knee radiographs using Insall-Salvati (IS), Blackburne-Peel, and Koshino-Sugimoto (KS) methods. Subjects were divided equally into three age groups (A, 5–10.9 years; B, 11–12.9 years; C, 13–18 years). The applicabilities of the three methods were evaluated using bony landmarks identified on lateral radiographs. For validation testing, standardized patellar tendon lengths determined by MRI were used as reference standards, and concurrent validity was analyzed by performing correlation tests. Intraobserver and interobserver reliability were determined using intraclass correlation coefficients. Of the three methods used to measure patellar height in this study, the IS appeared to be the most reliable and valid in patients older than 13 years with nearly complete ossification. Before this stage of ossification had been achieved, the KS was the only applicable and most reliable but less valid method in younger children.,[object Object]

Does the Taylor Spatial Frame Accurately Correct Tibial Deformities?

S. Robert Rozbruch MD, Kira Segal BA, Svetlana Ilizarov MD, Austin T. Fragomen MD, Gabriel Ilizarov MD

Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) and the Ilizarov method enable gradual realignment of angulation and translation in the coronal, sagittal, and axial planes, therefore, the term six-axis correction.

Decancellation Sacral Osteotomy in Iliosacral Tumor Resection: A Technique for Precise Sacral Margins

Yasser R. Farid MD, PhD En bloc resection of iliosacral sarcomas is a surgical challenge. There are substantial risks of inadequate margins, local recurrence, and nerve root loss when pelvic sarcomas involve sacral root canals and foramina. The decancellation technique uses principles similar to transpedicle decancellation in spinal deformity correction to perform the sacral osteotomy in iliosacral tumor resection. The technique aims at improving sacral margins and minimizing loss of neural function. We performed a decancellation osteotomy in five patients with sarcomas requiring difficult oblique or sagittal sacral osteotomies and selective root sacrifice. Through laminectomy and without anterior exposure, a precise full-thickness osteotomy of the sacrum was performed without major technique-related morbidities or complications. This was followed by formal pelvic resection and reconstruction. Surgical margins were adequate in all patients and all tumor-free nerve roots were preserved.

Cryoimmunologic Antitumor Effects Enhanced by Dendritic Cells in Osteosarcoma

Masanori Kawano MD, Hideji Nishida MD, PhD, Yasunari Nakamoto MD, PhD, Hiroshi Tsumura MD, PhD, Hiroyuki Tsuchiya MD, PhD

We previously reported a limb-salvage technique by treating tumor-bearing bone with liquid nitrogen. We also reported systemic antitumor immunity was enhanced by cryotreatment in a murine osteosarcoma (LM8) model. We therefore combined the cryotreatment of tumor with dendritic cells to promote tumor-specific immune responses.

Intramuscular Granular Cell Tumor in the Lower Extremities

Eisuke Arai MD, Yoshihiro Nishida MD, PhD, Satoshi Tsukushi MD, PhD, Hideshi Sugiura MD, PhD, Naoki Ishiguro MD, PhD Granular cell tumors are uncommon but typically histologically benign neoplasms that occasionally behave as malignant tumors. Differentiation of benign granular cell tumors from malignant counterparts with radiographic and/or histologic analysis is crucial for physicians. We retrospectively studied five cases of intramuscular granular cell tumors arising in the lower extremities. All tumors had been histologically diagnosed as benign and were resected with a wide surgical margin. The minimum followup was 1 year (mean, 45 months; range, 12–119 months) after surgery. Four patients had no local recurrence or distant metastasis (at a minimum of 18 months followup), whereas one patient with lymph node metastasis had a recurrence and distant metastasis 3 months after surgery resulting in death. Intramuscular granular cell tumors can be diagnosed based on their characteristic MRI features, such as peripheral high intensity on T2-weighed images, and histologic evaluation. The histologic criteria described by Fanburg-Smith et al. can differentiate malignant granular cell tumors from benign tumors. A wide resection seems suitable for most granular cell tumors in the extremities.,[object Object]

Single Ray Amputation for Tumors of the Hand

Mark Edward Puhaindran MBBS, John H. Healey MD, Edward A. Athanasian MD Single ray amputation after hand trauma or infection can result in good aesthetic and functional outcomes. The role of this procedure in the management of aggressive benign or malignant hand tumors has been described only in case reports and small case series. We retrospectively reviewed the records of all 25 patients who underwent single ray amputations at our center during a 10-year period; there were seven index, five middle, six ring, and seven small ray amputations performed. The minimum followup was 2 months (mean, 36 months; range, 2–120 months), with four patients having a followup of 1 year or less. No patients had local recurrences, although two patients had positive resection margins. One underwent repeat resection followed by radiotherapy. The other was treated with radiotherapy alone, as local tumor control would have required a hand amputation. Functional assessment based on the Musculoskeletal Tumor Society staging system showed an average of 27.5 (range, 21–30). Patients who underwent perioperative radiotherapy experienced a decrease in functional ability. Grip strength was an average of 66% (range, 38%–100%) of the contralateral side. Our study suggests single ray amputation for hand tumors has a low local recurrence rate and high functional scores. However, function can be compromised by radiotherapy and a decrease in grip strength by a mean of 34% is to be expected.,[object Object]

Proximal Tibia Osteoarticular Allografts in Tumor Limb Salvage Surgery

D. Luis Muscolo MD, Miguel A. Ayerza MD, German Farfalli MD, Luis A. Aponte-Tinao MD

Resection of large tumors of the proximal tibia may be reconstructed with endoprostheses or allografts with fixation. Endoprosthetic replacement is associated with high failure rates and complications. Proximal tibia osteoarticular allografts after tumor resection allows restoration of bone stock and reconstruction of the extensor mechanism, but the long-term failure rates and complications are not known.

A New Technique for Removal of an Incarcerated Expandable Femoral Nail

Emmanouil Liodakis MD, Christian Krettek MD, FRACS, FRCSEd, Mohamed Kenawey MSc, MRCS, Stefan Hankemeier MD Removal of intramedullary nails often is relegated to younger surgeons but may be difficult and challenging. We describe difficulties with removal of an incarcerated expandable femoral nail and a new technique for retrograde mobilization of an intramedullary nail through a small infrapatellar incision. No special device was necessary for successful implant removal.,[object Object]

Is There a Role for Tissue Biopsy in the Diagnosis of Periprosthetic Infection?

Geert Meermans MD, Fares S. Haddad BSc, MCh (Orth), FRCS (Orth)

Successful treatment of an infected joint arthroplasty depends on correctly identifying the responsible pathogens. The value of a preoperative biopsy remains controversial.

Cost Analysis of Outpatient Anterior Cruciate Ligament Reconstruction: Autograft versus Allograft

Sameer H. Nagda MD, Grant G. Altobelli BS, Kevin A. Bowdry RN, Clive E. Brewster MS, PT, Stephen J. Lombardo MD

Prior studies suggest the cost of allograft anterior cruciate ligament (ACL) reconstruction is less than that for autograft reconstruction. Charges in these studies were influenced by patients requiring inpatient hospitalization.

Cartilage Degeneration is Associated with Augmented Chemically-induced Joint Pain in Rats: A Pilot Study

Meguru Okamoto MD, Yuji Atsuta MD

Osteoarthritis arising from cartilage degeneration is the most common cause of joint pain. However, the relationship between joint pain and cartilage degeneration is not well understood.

Publication Rates of Presentations at an Annual Meeting of the American Academy of Orthopaedic Surgeons

Derek J. Donegan MD, Tae Won Kim MD, Gwo-Chin Lee MD

The Program Committee of the American Academy of Orthopaedic Surgery (AAOS) continually tries to improve the quality of the scientific program at AAOS meetings. However, according to the most recent study, the publication rate of papers presented at the 1996 annual meeting was only 34%.

Necrotizing Fasciitis of the Extremity Caused by Haemophilus influenzae Serotype b in a Healthy Adult

Ellen Y. Lee MD, Wing Yuk Ip MD, FRCS (Ed), FHKAM (Ortho) Haemophilus influenzae is a rare cause of necrotizing fasciitis with only a few previously reported cases. We describe the case of a 44-year-old man who had necrotizing fasciitis of the right lower extremity develop after intramuscular injections of paracetamol on his right buttock. The causative organism isolated was Haemophilus influenzae serotype b. This unusual infection was treated with repeated débridement and culture-guided antibiotics. There was no recurrence of infection at last followup 1 year after the initial surgery. Wound coverage was achieved with the use of a full-thickness skin graft after application of platelet-rich plasma and a dermal regeneration template. This resulted in a cosmetically acceptable appearance of the involved extremity for our patient.

Case Report: Unicameral Bone Cysts in a Young Patient with Acquired Generalized Lipodystrophy

James M. Gregory MD, Alexandre Arkader MD, Aqiba Bothari MD, John P. Dormans MD We report the case of a 13-year-old boy with bilateral distal femoral unicameral bone cysts (UBCs) associated with acquired generalized lipodystrophy. As opposed to congenital generalized lipodystrophy, cystic bone lesions in acquired generalized lipodystrophy are rare. After radiographic and histologic confirmation of the UBCs, we performed percutaneous intramedullary decompression, curettage, and grafting. UBCs can be an important manifestation of acquired generalized lipodystrophy. Cystic bone lesions appear to be less common in acquired generalized lipodystrophy than in congenital generalized lipodystrophy, and intramedullary adipose tissue loss may be a predisposing factor for the development of bone lesions in patients with acquired generalized lipodystrophy. When evaluating a patient with lipodystrophy, doctors should recognize the clinical course may include the development of UBCs.

Erratum to: One Intraoperative Dose of Tranexamic Acid for Patients Having Primary Hip or Knee Arthroplasty

Fiona E. Ralley BSc, MBChB, FRCA, FRCSC, Donna Berta RN, Valerie Binns RN, James Howard MD, MSc, FRCSC, Douglas D. R. Naudie MD, FRCSC

Chest Wall Mass in a 50-year-old Woman

Deep S. Chatha MD, Leon D. Rybak MD, James C. Wittig MD, Panna Desai MD
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