Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 470 | Issue 3 | Mar, 2012

Does Adjunctive Chemotherapy Reduce Remission Rates Compared to Cortisone Alone in Unifocal or Multifocal Histiocytosis of Bone?

André Mathias Baptista MD, PhD, André Ferrari França Camargo MD, Olavo Pires Camargo MD, PhD, Vicente Odone Filho MD, PhD, Alejandro Enzo Cassone MD, PhD

Langerhans cell histiocytosis (LCH) is a rare disorder that can affect almost any organ, including bone. Treatment options include local corticosteroid infiltration in isolated bone lesions and oral corticosteroids and chemotherapy in multifocal bone lesions. Several studies show local corticosteroid injection in unifocal bone lesions heal in more than 75% of patients with minimal side effects. Therefore, it is unclear whether chemotherapy adds materially to the healing rate.

Sixty Percent 10-year Survival of Patients With Chondrosarcoma After Local Recurrence

Patrick P. Lin MD, Mohammed D. Alfawareh MD, Akihiko Takeuchi MD, PhD, Bryan S. Moon MD, Valerae O. Lewis MD

Chondrosarcoma is treated primarily by surgery. The prognosis of patients after local recurrence is not well defined. Both the survival of patients and the risk of further local relapse after surgical treatment of local recurrence have yet to be established.

Giant Cell Tumor of Bone: Are We Stratifying Results Appropriately?

Thomas J. Kremen MD, Nicholas M. Bernthal MD, Mark A. Eckardt BS, Jeffrey J. Eckardt MD

There is no consensus as to which surgical approach to the treatment of giant cell tumor of bone is most appropriate or which patients are at a higher risk for recurrence or metastasis.

Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases

Norah Harvey MD, Elke R. Ahlmann MD, Daniel C. Allison MD, MBA, Lingjun Wang PA, Lawrence R. Menendez MD, FACS

The proximal femur is the most common site of surgery for bone metastases, and stabilization may be achieved through intramedullary fixation (IMN) or endoprosthetic reconstruction (EPR). Intramedullary devices are less expensive, less invasive, and may yield improved function over endoprostheses. However, it is unclear which, if either, has any advantages.

Extremity Soft Tissue Sarcoma Resections: How Wide Do You Need to Be?

David M. King MD, Donald A. Hackbarth MD, Andrew Kirkpatrick BS

Sarcomas require a wide margin of resection including a cuff of normal tissue to minimize the risk of local recurrence. The amount of tissue that constitutes a wide margin is unclear in the literature.

What Are Risk Factors for Local Recurrence of Deep High-grade Soft-tissue Sarcomas?

Chigusa Sawamura MD, MPH, Seiichi Matsumoto MD, PhD, Takashi Shimoji MD, PhD, Taisuke Tanizawa MD, Keisuke Ae MD, PhD

Patients with local recurrence of soft-tissue sarcomas have a poor overall survival. High-grade, soft-tissue sarcomas in deep locations may have a poorer prognosis regarding local recurrence than low-grade sarcomas or those located superficially. Although previous reports evaluated tumors at various depths, it is unclear what factors influence recurrence of deep, high-grade sarcomas.

Length of Symptoms Before Referral: Prognostic Variable for High-grade Soft Tissue Sarcoma?

Bruce T. Rougraff MD, Jackie Lawrence MA, Kenneth Davis MS

It is commonly assumed patients with high-grade soft tissue sarcomas who are diagnosed and treated quickly after the first onset of symptoms fare better than those with longer symptoms before treatment. The literature contains no substantive data to support this assumption for soft tissue sarcomas, particularly for high-grade lesions.

Survival, Local Recurrence, and Function After Pelvic Limb Salvage at 23 to 38 Years of Followup

Courtney E. Sherman MD, Mary I. O’Connor MD, Franklin H. Sim MD

Malignant pelvic tumors frequently pose challenges to surgeons owing to complex pelvic anatomy and local extension. External hemipelvectomy frequently allows adequate margins but is associated with substantial morbidity and reduced function. Limb salvage is an alternative approach when adequate margins can be achieved, but long-term function and survival are unclear.

Intercalary Femur Allografts Are an Acceptable Alternative After Tumor Resection

Luis Aponte-Tinao MD, Germán L. Farfalli MD, Lucas E. Ritacco MD, Miguel A. Ayerza MD, D. Luis Muscolo MD

With the improved survival for patients with malignant bone tumors, there is a trend to reconstruct defects using biologic techniques. While the use of an intercalary allograft is an option, the procedures are technically demanding and it is unclear whether the complication rates and survival are similar to other approaches.

Aseptic Failure: How Does the Compress® Implant Compare to Cemented Stems?

Andrew C. Pedtke MD, Rosanna L. Wustrack MD, Andrew S. Fang MD, Robert J. Grimer FRCS, Richard J. O’Donnell MD

Failure of endoprosthetic reconstruction with conventional stems due to aseptic loosening remains a challenge for maintenance of limb integrity and function. The Compressimplant (Biomet Inc, Warsaw, IN, USA) attempts to avoid aseptic failure by means of a unique technologic innovation. Though the existing literature suggests survivorship of Compressand stemmed implants is similar in the short term, studies are limited by population size and followup duration.

Aseptic Loosening Rates in Distal Femoral Endoprostheses: Does Stem Size Matter?

Patrick F. Bergin MD, Jenna B. Noveau BS, James S. Jelinek MD, Robert M. Henshaw MD

Long-term survival of distal femoral endoprosthetic replacements is largely affected by aseptic loosening. It is unclear whether and to what degree surgical technique and component selection influence the risk of loosening.

Early Complications of High-dose-rate Brachytherapy in Soft Tissue Sarcoma: A Comparison With Traditional External-beam Radiotherapy

Cynthia L. Emory MD, Corey O. Montgomery MD, Benjamin K. Potter MD, Martin E. Keisch MD, Sheila A. Conway MD

Radiotherapy and surgery are routinely utilized to treat extremity soft tissue sarcoma. Multiple radiation modalities have been described, each with advantages and disadvantages, without one modality demonstrating clear superiority over the others.

Femoral Stress Fractures Associated With Long-term Bisphosphonate Treatment

William G. Ward MD, Christina J. Carter BS, Scott C. Wilson MD, Cynthia L. Emory MD

Recent studies have described unique clinical and radiographic characteristics of femoral stress fractures or low-energy fractures associated with long-term bisphosphonate therapy. However, it is unclear whether these fractures require subsequent surgery after the initial treatment.

Can Stress Radiography of the Knee Help Characterize Posterolateral Corner Injury?

F. Winston Gwathmey MD, Marc A. Tompkins MD, Cree M. Gaskin MD, Mark D. Miller MD

Conventional MRI is limited for characterizing the posterolateral corner of the knee due to the region’s anatomic variability and complexity; further, MRI is a static study and cannot demonstrate pathologic laxity. Stress radiography may provide additional information about instability.

Risk Factors for Peroneal Nerve Injury and Recovery in Knee Dislocation

Christopher J. Peskun MD, Jas Chahal MD, Zvi Y. Steinfeld BSc, Daniel B. Whelan MD

Acute knee dislocation is rare but has a high rate of associated neurovascular injuries and potentially limb-threatening complications. These include the substantial morbidity associated with peroneal nerve injury: neuropathic pain, decreased mobility, and considerably reduced function, which not only impairs patient function but complicates treatment.

Partial Tibial Nerve Transfer to the Tibialis Anterior Motor Branch to Treat Peroneal Nerve Injury After Knee Trauma

Jennifer L. Giuffre MD, Allen T. Bishop MD, Robert J. Spinner MD, Bruce A. Levy MD, Alexander Y. Shin MD

Injuries to the deep peroneal nerve result in tibialis anterior muscle paralysis and associated loss of ankle dorsiflexion. Nerve grafting of peroneal nerve injuries has led to poor function; therefore, tendon transfers and ankle-foot orthotics have been the standard treatment for foot drop.

Surgical Technique: Does Mini-invasive Medial Collateral Ligament and Posterior Oblique Ligament Repair Restore Knee Stability in Combined Chronic Medial and ACL Injuries?

Gian Luigi Canata MD, Alfredo Chiey MD, Tommaso Leoni MD

Residual laxity remains after ACL reconstruction in patients with combined chronic ACL and medial instability. The question arises whether to correct medial capsular and ligament injuries when Grade II and III medial laxity is present.

Surgical Technique: Medial Collateral Ligament Reconstruction Using Achilles Allograft for Combined Knee Ligament Injury

Robert G. Marx MD, MSc, FRCSC, Iftach Hetsroni MD

Previous approaches for medial collateral ligament (MCL) reconstruction have been associated with extensive exposure, risk of donor site morbidity with autografts, loss of motion, nonanatomic graft placement, and technical complexity with double-bundle constructs. Therefore, we implemented a technique that uses Achilles allograft, small incisions, and anatomic insertions to reconstruct the MCL.

Surgical Technique: Development of an Anatomic Medial Knee Reconstruction

Robert F. LaPrade MD, PhD, Coen A. Wijdicks PhD

The main static stabilizers of the medial knee are the superficial medial collateral and posterior oblique ligaments. A number of reconstructive techniques have been advocated including one we describe here. However, whether these reconstructions restore function and stability is unclear.

Posterior Cruciate Ligament and Posterolateral Corner Deficiency Results in a Reverse Pivot Shift

Frank A. Petrigliano MD, Clayton G. Lane MD, Eduardo M. Suero MD, Answorth A. Allen MD, Andrew D. Pearle MD

As measured via static stability tests, the PCL is the dominant restraint to posterior tibial translation while the posterolateral corner is the dominant restraint to external tibial rotation. However, these uniplanar static tests may not predict multiplanar instability. The reverse pivot shift is a dynamic examination maneuver that may identify complex knee instability.

Single- versus Double-bundle ACL Reconstruction: Is There Any Difference in Stability and Function at 3-year Followup?

Alberto Gobbi MD, Vivek Mahajan MD, Georgios Karnatzikos MD, Norimasa Nakamura MD, PhD

Despite a number of studies comparing postoperative stability and function after anatomic double-bundle and single-bundle anterior cruciate ligament reconstruction (ACLR), it remains unclear whether double-bundle reconstruction improves stability or function.

Revision ACL Reconstruction in Skeletally Mature Athletes Younger Than 18 Years

Keith R. Reinhardt MD, Sommer Hammoud MD, Andrea L. Bowers MD, Ben-Paul Umunna BA, Frank A. Cordasco MD

Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction.

Surgical Technique: Revision ACL Reconstruction With a Rectangular Tunnel Technique

Konsei Shino MD, Tatsuo Mae MD, Norimasa Nakamura MD

We developed the rectangular tunnel ACL reconstruction (RT ACLR) using a 10-mm wide bone-patellar tendon-bone (BTB) graft through rectangular tunnels with a rectangular aperture to reduce tunnel size: the cross-sectional area of the tunnels of 50 mm(5 × 10 mm) in RT ACLR is less than that of 79 mmin a conventional 10-mm round tunnel technique presuming the technique would be more suitable in revision ACLR with previous improperly placed tunnels.

Surgical Technique: Aperture Fixation in PCL Reconstruction: Applying Biomechanics to Surgery

Thomas J. Gill MD, Samuel K. Velde MD, Kaitlin M. Carroll BS, William J. Robertson MD, Benton E. Heyworth MD

Biomechanical studies suggest reducing the effective graft length during transtibial posterior cruciate ligament (PCL) reconstruction by augmenting the distal tibial fixation with a proximal screw near the tibial tunnel aperture could increase graft stiffness and provide a more stable reconstruction. However, it remains unknown to what extent this mechanical theory influences in vivo graft performance over time.

Surgical Technique: When to Arthroscopically Repair the Torn Posterior Cruciate Ligament

Gregory S. DiFelice MD, Micah Lissy MD, Paul Haynes MD

Posterior cruciate ligament injuries can occur as isolated ligament ruptures or in association with the multiligament-injured knee. Delayed reconstruction, at 2–3 weeks post-injury, is predominantly recommended for posterior cruciate ligament tears in the multiligament-injured knee. While acute bone and soft tissue avulsion patterns of injury can be amenable to repair, the described techniques have been associated with some difficulties attaching the avulsed ligament.

Surgical Technique: Articulated External Fixator for Treatment of Complex Knee Dislocation

Maurilio Marcacci MD, Stefano Zaffagnini MD, Tommaso Bonanzinga MD, Andrea Pizzoli MD, Mario Manca MD, Enzo Caiaffa MD

Knee dislocation is a severe but relatively uncommon injury caused by violent trauma that can result in long-term complications, such as arthrofibrosis, stiffness, instability, and pain. Perhaps owing in part to its rarity, treatment of this injury is controversial. We therefore describe a treatment approach for these complex cases involving a novel dynamic knee external fixator.

Accumulation of Fatty Marrow in the Osteonecrotic Hip Mimicking Joint Infection

Tae-Young Kim MD, Sun-Joo Kim MD, Young-Kyun Lee MD, Kyung-Hoi Koo MD

Factors such as lipids or cholesterol crystals in body fluids can cause a spurious elevation of leukocytes (WBC) in an automated cell count. This artifact can occur in automated WBC counts of hip fluid from femoral head osteonecrosis (ON), and an erroneous diagnosis of septic arthritis can be made.

Stem and Osteotomy Length are Critical for Success of the Transfemoral Approach and Cementless Stem Revision

Daniel F. A. Menezes MD, Pierre Béguec MD, Hans-Peter Sieber MD, Mathias Goldschild MD

The transfemoral approach is an extensile surgical approach that is performed routinely to facilitate cement and implant removal and improve exposure for revision stem implantation. Previous studies have looked at clinical results of small patient groups. The factors associated with fixation failure of cementless revision stems when using this approach have not been examined.

Are Patient-specific Cutting Blocks Cost-effective for Total Knee Arthroplasty?

Ryan M. Nunley MD, Bradley S. Ellison MD, Erin L. Ruh MS, Brandon M. Williams DC, Keith Foreman RN, BS, CNOR, Adrienne D. Ford MPH, Robert L. Barrack MD

Using patient-specific cutting blocks for TKA increases the cost to the hospital for these procedures, but it has been proposed they may reduce operative times and improve implant alignment, which could reduce the need for revision surgery.

Do Patient-specific Guides Improve Coronal Alignment in Total Knee Arthroplasty?

Ryan M. Nunley MD, Bradley S. Ellison MD, Jinjun Zhu MD, PhD, Erin L. Ruh MS, Stephen M. Howell MD, Robert L. Barrack MD

Coronal alignment may impact clinical outcome and survivorship in TKA. Patient-specific instrumentation has been developed to restore mechanical or kinematic axis and potentially reduce component malpositioning. Although it is clear these instruments add cost, it is unclear whether they improve alignment.

Does Lateral Release Change Patellofemoral Forces and Pressures?: A Pilot Study

Jeffrey I. Peretz MD, Kim R. Driftmier MD, Douglas L. Cerynik MD, MBA, Neil S. Kumar MD, MBA, Norman A. Johanson MD

One complication of TKA is postoperative anterior knee pain. Balancing retinacular tissue tension to improve patellar tracking is essential in preventing pain. Lateral release might help balance tension although the quantitative changes in patellofemoral force and pressure differentials after lateral release are unknown.

A Cell-free Scaffold-based Cartilage Repair Provides Improved Function Hyaline-like Repair at One year

Alberto Siclari MD, Gennaro Mascaro MD, Chiara Gentili MD, Ranieri Cancedda PhD, Eugenio Boux MD

Bone marrow stimulation techniques in cartilage repair such as drilling are limited by the formation of fibrous to hyaline-like repair tissue. It has been suggested such techniques can be enhanced by covering the defect with scaffolds. We present an innovative approach using a polyglycolic acid (PGA)-hyaluronan scaffold with platelet-rich-plasma (PRP) in drilling.

Endoprosthetic Treatment is More Durable for Pathologic Proximal Femur Fractures

Matthew Steensma MD, Patrick J. Boland MD, Carol D. Morris MD, Edward Athanasian MD, John H. Healey MD

Pathologic proximal femur fractures result in substantial morbidity for patients with skeletal metastases. Surgical treatment is widely regarded as effective; however, failure rates associated with the most commonly used operative treatments are not well defined.

A Fracture Does Not Adversely Affect Bone Mineral Density Responses after Teriparatide Treatment

Aasis Unnanuntana MD, Quang V. Ton MD, John P. Kleimeyer BA, Joseph T. Nguyen MPH, Joseph M. Lane MD

Fracture leads to local and systemic catabolic physiologic changes. As teriparatide is an agent used to treat osteoporosis in patients with fragility fractures, it is unclear whether teriparatide treatment alters bone mineral density (BMD) and bone markers when given to patients with fractures.

Repeated Freeze-thaw Cycles Do Not Alter the Biomechanical Properties of Fibular Allograft Bone

Joshua M. Shaw MS, Shawn A. Hunter PhD, J. Christopher Gayton MD, Gregory P. Boivin DVM, Michael J. Prayson MD

Allograft tissues can undergo several freeze-thaw cycles between donor tissue recovery and final use by surgeons. However, there are currently no standards indicating the number of reasonable freeze-thaw cycles for allograft bone and it is unclear how much a graft may be degraded with multiple cycles.

Case Report: Multifocal Subchondral Stress Fractures of the Femoral Heads and Tibial Condyles in a Young Military Recruit

Pil Whan Yoon MD, Jeong Joon Yoo MD, Kang Sup Yoon MD, Hee Joong Kim MD

Subchondral stress fractures of the femoral head may be either of the insufficiency-type with poor quality bone or the fatigue-type with normal quality bone but subject to high repetitive stresses. Unlike osteonecrosis, multiple site involvement rarely has been reported for subchondral stress fractures. We describe a case of multifocal subchondral stress fractures involving femoral heads and medial tibial condyles bilaterally within 2 weeks.

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