Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 469 | Issue 4 | Apr, 2011

Current Concepts for Clean Air and Total Joint Arthroplasty: Laminar Airflow and Ultraviolet Radiation: A Systematic Review

Richard P. Evans MD

With the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room.

Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

Margret Oethinger MD, PhD, Debra K. Warner MT(ASCP), Susan A. Schindler MT(ASCP), Hideo Kobayashi MD, PhD, Thomas W. Bauer MD, PhD

Intraoperative Gram stains have a reported low sensitivity but high specificity when used to help diagnose periprosthetic infections. In early 2008, we recognized an unexpectedly high frequency of apparent false-positive Gram stains from revision arthroplasties.

Can Implant Retention be Recommended for Treatment of Infected TKA?

Ho-Rim Choi MD, Fabian Knoch MD, David Zurakowski PhD, Sandra B. Nelson MD, Henrik Malchau MD, PhD

Retention treatment is reportedly associated with lower infection control rates than two-stage revision. However, the studies on which this presumption are based depend on comparisons of historical rather than concurrent controls.

Can This Prosthesis Be Saved?: Implant Salvage Attempts in Infected Primary TKA

Jeremy Gardner MD, Terence J. Gioe MD, Penny Tatman MPH

Open débridement with polyethylene liner exchange (ODPE) remains a relatively low morbidity option in acute infection of total knee arthroplasty (TKA), but concerns regarding control of infection exist. We sought to identify factors that would predict control of infection after ODPE.

Treatment Based on the Type of Infected TKA Improves Infection Control

Young-Hoo Kim MD, Yoowang Choi MD, Jun-Shik Kim MD

A classification system with four types of infected TKAs has been commonly used to determine treatment, especially with regard to whether the prosthesis should be removed or retained.

Durable Infection Control and Function With the PROSTALAC Spacer in Two-stage Revision for Infected Knee Arthroplasty

Christopher R. Gooding BSc, MD, FRCS (Tr & Orth), Bassam A. Masri MD, FRCSC, Clive P. Duncan MD, MSc, FRCSC, Nelson V. Greidanus MD, MPH, FRCSC, Donald S. Garbuz MD, MHSc, FRCSC

A two-stage revision total knee arthroplasty is recognized as the gold standard in the treatment of infection. However, traditional spacers limit function in the interval between the two stages and may cause instability, scarring, and bone erosion. The PROSTALAC knee spacer is an antibiotic-loaded cement articulating spacer that allows some movement of the knee between stages. Whether motion enhances long-term function is unknown.

Intraoperative Molds to Create an Articulating Spacer for the Infected Knee Arthroplasty

Geoffrey S. Thiel MD, MBA, Keith R. Berend MD, Gregg R. Klein MD, Alexander C. Gordon MD, Adolph V. Lombardi MD, Craig J. Della Valle MD

Chronic infections in TKA have been traditionally treated with a two-stage protocol incorporating a temporary antibiotic-loaded cement spacer. The use of a static as opposed to an articulating spacer is controversial. Some surgeons believe a static spacer results in a higher rate of infection eradication, whereas others believe an articulating spacer provides equivalent rates of infection control with improved function between stages and the potential for better eventual range of motion.

What is the Role of Serological Testing Between Stages of Two-stage Reconstruction of the Infected Prosthetic Knee?

Sharat K. Kusuma MD, MBA, Joseph Ward BA, Marc Jacofsky PhD, Scott M. Sporer MD, Craig J. Della Valle MD

Two-stage exchange arthroplasty is the gold standard for treatment of infected TKA. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial fluid white blood cell (WBC) count with differential are often used to determine treatment response; however, it is unclear whether these tests can answer the critical question of whether joint sepsis has been controlled between stages and if reimplantation is indicated.

Two-stage Total Hip Arthroplasty: How Often Does It Control Methicillin-resistant Infection?

Fay Leung MD, FRCSC, Corey J. Richards MD, MASc, FRCSC, Donald S. Garbuz MD, MHSc, FRCSC, Bassam A. Masri MD, FRCSC, Clive P. Duncan MB, MSc, FRCSC

Methicillin-resistant hip infections are increasingly common. Reports of the surgical management of these patients using two-stage THA show variable control of infection, but all reports used static spacers.

Structural Allograft as an Option for Treating Infected Hip Arthroplasty with Massive Bone Loss

Paul T. H. Lee MB BCh, MA, FRCS (Eng), FRCS (Tr & Orth), Robert A. Clayton MBBS, FRCS (Edin), FRCS (Tr & Orth), Oleg A. Safir MD, FRCSC, MEd, David J. Backstein MD, FRCSC, MEd, Allan E. Gross MD, FRCSC, OOnt

Revision of the infected hip arthroplasty with major bone loss is difficult. Attempts to restore bone stock with structural allograft are controversial.

Functional Ability After Above-the-knee Amputation for Infected Total Knee Arthroplasty

Catherine J. Fedorka MD, Antonia F. Chen MD, William M. McGarry BS, Javad Parvizi MD, FRCS, Brian A. Klatt MD

Prosthetic joint infection is an uncommon but serious complication of total knee arthroplasty (TKA). Control of infection after TKA is not always possible, and the resolution of infection may require an above-knee amputation (AKA).

Is Intraoperative CT of Posterior Cervical Spine Instrumentation Cost-effective and Does It Reduce Complications?

Andrew C. Hecht MD, Steven M. Koehler BA, Janelle C. Laudone BS, Arthur Jenkins MD, Sheeraz Qureshi MD, MBA

Symptomatic multilevel cervical myelopathy is often addressed using posterior decompression using two-dimensional fluoroscopy. Intraoperative three-dimensional fluoroscopy provides more accurate information on the position of instrumentation to prevent screw-related complications.

Total Shoulder Arthroplasty in Older Patients: Increased Perioperative Morbidity?

Eric T. Ricchetti MD, Joseph A. Abboud MD, Andrew F. Kuntz MD, Matthew L. Ramsey MD, David L. Glaser MD, Gerald R. Williams MD

More elderly patients are becoming candidates for total shoulder arthroplasty with an increase in frequency of the procedure paralleling the rise in other total joint arthroplasties. Controversy still exists, however, regarding the perioperative morbidity of total joint arthroplasty in elderly patients, particularly those 80 years of age and older.

Where to Tenodese the Biceps: Proximal or Distal?

David M. Lutton MD, Konrad I. Gruson MD, Alicia K. Harrison MD, James N. Gladstone MD, Evan L. Flatow MD

The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove.

Greater Strength Increase with Cyst Decompression and SLAP Repair than SLAP Repair Alone

Gita Pillai MD, Jason R. Baynes MD, James Gladstone MD, Evan L. Flatow MD

Treatment of symptomatic spinoglenoid cysts has been controversial with options ranging from observation, to open excision, to arthroscopic decompression with or without labral repair. It has recently been suggested that isolated repair of SLAP lesions without cyst decompression can restore function in patients with spinoglenoid cysts and SLAP lesions.

Is a Silastic Radial Head Still a Reasonable Option?

Yariv Maghen MD, Andrew J. Leo MD, Jennifer W. Hsu MD, Michael R. Hausman MD

The importance of the radial head to elbow function and stability is increasingly apparent. Although preservation of the native radial head is preferred, severely comminuted fractures may necessitate resection or arthroplasty. Silastic radial head arthroplasty has been condemned on the basis of several sporadic reports of silicone synovitis. However, problems of “overstuffing,” cartilage wear, and motion loss are becoming apparent with metal prostheses, indicating this also is not an ideal solution. Thus, the choices remain controversial.

Can the Change in Center-edge Angle During Pincer Trimming Be Reliably Predicted?

Alexis C. Colvin MD, Steven M. Koehler BA, Justin Bird MD

Femoroacetabular impingement is recognized as a cause of hip pain in young adults and as a precursor to osteoarthritis although many questions persist regarding its management. One in particular is when to resect a pincer lesion and how much to resect. Instability can result from overresection and persistent impingement can result from underresection.

What Is the Best Femoral Fixation of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction?: A Meta-analysis

Alexis Colvin MD, Charu Sharma MD, Michael Parides PhD, Jonathan Glashow MD

Several methods are available for fixing the femoral side of a hamstring autograft in ACL reconstruction and the best method is unclear. Biomechanical studies have shown varying results with regard to fixation failure.

Is the Etiology of Pretibial Cyst Formation After Absorbable Interference Screw Use Related to a Foreign Body Reaction?

Guillem Gonzalez-Lomas MD, Ryan T. Cassilly BS, Fabrizio Remotti MD, William N. Levine MD

Arthroscopically assisted anterior cruciate ligament reconstruction using a bioabsorbable tibial fixation screw is occasionally complicated by pretibial cyst formation. The few case reports describing pretibial cyst formation noted several graft types and fixation techniques, making it difficult to establish one etiology. Some literature suggests cysts form from communication between the joint and pretibial area leading to extravasation of joint fluid, maturing into a cyst. We propose the development of cysts after PLLA screw use may be related to a foreign body reaction.

The Sensitivity and Specificity of Ultrasound for the Diagnosis of Carpal Tunnel Syndrome: A Meta-analysis

John R. Fowler MD, John P. Gaughan PhD, Asif M. Ilyas MD

Carpal tunnel syndrome (CTS) is the most commonly diagnosed compression neuropathy of the upper extremity. Current AAOS recommendations are to obtain a confirmatory electrodiagnostic test in patients for whom surgery is being considered. Ultrasound has emerged as an alternative confirmatory test for CTS; however, its potential role is limited by lack of adequate data for sensitivity and specificity relative to electrodiagnostic testing.

Articulating Spacers Used in Two-stage Revision of Infected Hip and Knee Prostheses Abrade with Time

Bernd Fink MD, Annett Rechtenbach PhD, Hubert Büchner PhD, Sebastian Vogt PhD, Michael Hahn PhD

Articulating spacers used in two-stage revision surgery of infected prostheses have the potential to abrade and subsequently induce third-body wear of the new prosthesis.

Acetabular Anteversion with CT in Supine, Simulated Standing, and Sitting Positions in a THA Patient Population

Jean-Yves Lazennec MD, PhD, Patrick Boyer MD, PhD, Michel Gorin MD, Yves Catonné MD, Marc Antoine Rousseau MD, PhD

Appraisal of the orientation of implants in THA dislocations currently is based on imaging done with the patient in the supine position. However, dislocation occurs in standing or sitting positions. Whether measured anteversion differs in images projected in the position of dislocation is unclear.

No Strength or Gait Benefit of Two-incision THA: A Brief Followup at 1 Year

Aaron J. Krych MD, Mark W. Pagnano MD, Krista Coleman Wood PhD, PT, R. Michael Meneghini MD, Kenton Kaufman PhD, PE

Using comprehensive gait analysis and strength testing, we previously investigated the early (2-month) functional outcome after THA using two-incision and mini-posterior surgical approaches and found an advantage for the mini-posterior approach. Benefits included improved muscle strength, a less antalgic gait, and better hip function as reflected by changes in hip moments during level walking and stair climbing. We questioned how these differences in function would fare with longer followup.

The Surgical Apgar Score in Hip and Knee Arthroplasty

Thomas H. Wuerz MD, MSc, Scott E. Regenbogen MD, MPH, Jesse M. Ehrenfeld MD, Henrik Malchau MD, PhD, Harry E. Rubash MD, Atul A. Gawande MD, MPH, David M. Kent MD, MS

A 10-point Surgical Apgar Score, based on patients’ estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery, was developed to rate patients’ outcomes in general and vascular surgery but has not been tested for patients having orthopaedic surgery.

Perivascular and Diffuse Lymphocytic Inflammation are not Specific for Failed Metal-on-metal Hip Implants

Takaaki Fujishiro MD, PhD, Dirk Jan F. Moojen MD, PhD, Naomi Kobayashi MD, PhD, Wouter J. A. Dhert MD, PhD, FBSE, Thomas W. Bauer MD, PhD

Several studies suggest that histologic findings from tissues obtained at revision arthroplasty for failed metal-on-metal (MOM) total hip implants may reflect an immune reaction to particles or ions in some patients. However, only a limited number of cases without MOM implants were reported as controls in those studies.

The Need for Total Hip Arthroplasty in Perthes Disease: A Long-term Study

Lonnie Froberg MD, Finn Christensen MD, Niels Wisbech Pedersen MD, Søren Overgaard MD

Legg-Calvé-Perthes disease (LCPD) was described a century ago. In previous long-term reports of patients with LCPD, nonoperative treatment varied considerably. The likelihood of hip osteoarthritis (OA) developing in patients with LCPD and possible need for THA are not well defined.

Risk Factors for Revision of Hip Arthroplasties in Patients Younger Than 30 Years

Julien Girard MD, MSc, Christophe Glorion MD, François Bonnomet MD, Damien Fron MD, Henri Migaud MD

Numerous reports of THAs in patients younger than 30 years indicate a high risk of revision. Although risk factors for revision have been reported for older patients, it is unclear whether these risk factors are the same as those for patients younger than 30 years.

Factors Influencing Health-related Quality of Life after TKA in Patients who are Obese

Montserrat Nuñez PhD, Lluis Lozano PhD, Esther Nuñez PhD, Josep-Maria Segur PhD, Sergi Sastre PhD

Although the health-related quality of life (HRQL) for patients who are obese seems to improve after TKA, the magnitude of improvement and the associated factors remain controversial. We previously found body mass index was not associated with changes in HRQL after TKA.

Persistent Hindfoot Valgus Causes Lateral Deviation of Weightbearing Axis after Total Knee Arthroplasty

Arun Mullaji FRCS Ed, MCh Orth, MS Orth, Gautam M. Shetty MS Orth

The weightbearing axis of the limb goes from the pelvis to the ground and includes the hindfoot. However, the influence of hindfoot alignment on mechanical axis and overall limb alignment after TKA is unclear.

Metatarsal Length does not Correlate with Maximal Peak Pressure and Maximal Force

Martin Kaipel MD, Daniel Krapf MD, Christian Wyss MD

Primary metatarsalgia of the lesser metatarsals is common and caused by mechanical overload of the affected metatarsal heads. Increased metatarsal length generally is believed to be a factor in the development of primary metatarsalgia. However, there is no clear biomechanical evidence supporting this theory.

Skeletal Muscle Abnormalities and Genetic Factors Related to Vertical Talus

Laura J. Merrill BS, Christina A. Gurnett MD, PhD, Anne M. Connolly MD, Alan Pestronk MD, Matthew B. Dobbs MD

Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint and fixed equinus contracture of the hindfoot, causing a rigid deformity recognizable at birth. The etiology and epidemiology of this condition are largely unknown, but some evidence suggests it relates to aberrations of skeletal muscle. Identifying the tissue abnormalities and genetic causes responsible for vertical talus has the potential to lead to improved treatment and preventive strategies.

Limb Lengthening and Deformity Correction by the Ilizarov Technique in Type III Fibular Hemimelia: An Alternative to Amputation

Maurizio A. Catagni MD, Makram Radwan MD, Luigi Lovisetti MD, Francesco Guerreschi MD, Nabil A. Elmoghazy MD

Fibular hemimelia is partial or total aplasia of the fibula; it represents the most frequent congenital defect of the long bones. It usually is associated with other anomalies of the tibia, femur, and foot.

Recurrent Giant Cell Tumor of Long Bones: Analysis of Surgical Management

Frank M. Klenke MD, PhD, Doris E. Wenger MD, Carrie Y. Inwards MD, Peter S. Rose MD, Franklin H. Sim MD

Treatment of giant cell tumor of bone (GCT) often is complicated by local recurrence. Intralesional curettage is the standard of care for primary GCTs. However, there is controversy whether intralesional curettage should be preferred over wide resection in recurrent GCTs.

Mortality After Distal Femur Fractures in Elderly Patients

Philipp N. Streubel MD, William M. Ricci MD, Ambrose Wong BS, Michael J. Gardner MD

Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.

Management of Proximal Humeral Fractures in the Nineteenth Century: An Historical Review of Preradiographic Sources

Stig Brorson MD, PhD

The diagnosis and treatment of fractures of the proximal humerus have troubled patients and medical practitioners since antiquity. Preradiographic diagnosis relied on surface anatomy, pain localization, crepitus, and impaired function. During the nineteenth century, a more thorough understanding of the pathoanatomy and pathophysiology of proximal humeral fractures was obtained, and new methods of reduction and bandaging were developed.

In Brief: Patellar Fractures

John Scolaro MD, Joseph Bernstein MD, Jaimo Ahn MD, PhD
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