Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 472 | Issue 10 | Oct, 2014

Small Improvements in Mechanical Axis Alignment Achieved With MRI versus CT-based Patient-specific Instruments in TKA: A Randomized Clinical Trial

Tilman Pfitzner MD, Matthew P. Abdel MD, Philipp Roth MD, Carsten Perka MD, Hagen Hommel MD

Patient-specific instrumentation in TKA has the proposed benefits of improving coronal and sagittal alignment and rotation of the components. In contrast, the literature is inconsistent if the use of patient-specific instrumentation improves alignment in comparison to conventional instrumentation. Depending on the manufacturer, patient-specific instrumentation is based on either MRI or CT scans. However, it is unknown whether one patient-specific instrumentation approach is more accurate than the other and if there is a potential benefit in terms of reduction of duration of surgery.

Implant Survival, Adverse Events, and Bone Remodeling of Osseointegrated Percutaneous Implants for Transhumeral Amputees

Georgios Tsikandylakis MD, Örjan Berlin MD, PhD, Rickard Brånemark MD, PhD

Osseointegrated percutaneous implants provide direct anchorage of the limb prosthesis to the residual limb. These implants have been used for the rehabilitation of transhumeral amputees in Sweden since 1995 using a two-stage surgical approach with a 6-month interval between the stages, but results on implant survival, adverse events, and radiologic signs of osseointegration and adaptive bone remodeling in transhumeral amputees treated with this method are still lacking.

Progression of Bone Ingrowth and Attachment Strength for Stability of Percutaneous Osseointegrated Prostheses

Sujee Jeyapalina PhD, J. Peter Beck MD, Roy D. Bloebaum PhD, Kent N. Bachus PhD

Percutaneous osseointegrated prosthetic (POP) devices have been used clinically in Europe for decades. Unfortunately, their introduction into the United States has been delayed, in part due to the lack of data documenting the progression of osseointegration and mechanical stability.

Radiographic Evaluation of Bone Adaptation Adjacent to Percutaneous Osseointegrated Prostheses in a Sheep Model

Sujee Jeyapalina PhD, James Peter Beck MD, Kent N. Bachus PhD, Ornusa Chalayon MD, Roy D. Bloebaum PhD

Percutaneous osseointegrated prostheses (POPs) are being investigated as an alternative to conventional socket suspension and require a radiographic followup in translational studies to confirm that design objectives are being met.

Fluid Collections in Amputations Are Not Indicative or Predictive of Infection

Elizabeth M. Polfer MD, Benjamin W. Hoyt BS, Lien T. Senchak MD, Mark D. Murphey MD, Jonathan A. Forsberg MD, Benjamin K. Potter MD

In the acute postoperative period, fluid collections are common in lower extremity amputations. Whether these fluid collections increase the risk of infection is unknown.

Targeted Muscle Reinnervation: A Novel Approach to Postamputation Neuroma Pain

Jason M. Souza MD, Jennifer E. Cheesborough MD, Jason H. Ko MD, Mickey S. Cho MD, Todd A. Kuiken MD, PhD, Gregory A. Dumanian MD

Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied.

Does Targeted Nerve Implantation Reduce Neuroma Pain in Amputees?

Mitchell A. Pet MD, Jason H. Ko MD, Janna L. Friedly MD, Pierre D. Mourad PhD, Douglas G. Smith MD

Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.

A Model to Predict Limb Salvage in Severe Combat-related Open Calcaneus Fractures

Adam J. Bevevino MD, Jonathan F. Dickens MD, Benjamin K. Potter MD, Theodora Dworak MD, Wade Gordon MD, Jonathan A. Forsberg MD

Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern.

Bilateral Transfemoral/Transtibial Amputations Due to Battle Injuries: A Comparison of Vietnam Veterans with Iraq and Afghanistan Servicemembers

Paul J. Dougherty MD, Lynne V. McFarland PhD, Douglas G. Smith MD, Gayle E. Reiber PhD

Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War.

Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma?

Katherine M. Bedigrew MD, Jeanne C. Patzkowski MD, Jason M. Wilken PhD, MPT, Johnny G. Owens MPT, Ryan V. Blanck LCPO, Daniel J. Stinner MD, Kevin L. Kirk DO, Joseph R. Hsu MD

Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.

How Does Ankle-foot Orthosis Stiffness Affect Gait in Patients With Lower Limb Salvage?

Elizabeth Russell Esposito PhD, Ryan V. Blanck CPO, Nicole G. Harper MS, Joseph R. Hsu MD, Jason M. Wilken PT, PhD

Ankle-foot orthoses (AFOs) are commonly prescribed during rehabilitation after limb salvage. AFO stiffness is selected to help mitigate gait deficiencies. A new custom dynamic AFO, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), is available to injured service members but prescription guidelines are limited.

Do Patients With Bone Bridge Amputations Have Improved Gait Compared With Patients With Traditional Amputations?

Trevor Kingsbury MA, Nancy Thesing MS, John David Collins MA, ATC, Joseph Carney MD, Marilynn Wyatt MA, PT

Two surgical techniques for performing a transtibial amputation include a traditional approach and a bone bridge approach. To date, there is no conclusive evidence of superiority of either technique in terms of temporal-spatial, kinetic, and mechanical work parameters.

Does Use of a Powered Ankle-foot Prosthesis Restore Whole-body Angular Momentum During Walking at Different Speeds?

Susan D’Andrea PhD, Natalie Wilhelm BA, Anne K. Silverman PhD, Alena M. Grabowski PhD

Whole-body angular momentum (H) influences fall risk, is tightly regulated during walking, and is primarily controlled by muscle force generation. People with transtibial amputations using passive-elastic prostheses typically have greater H compared with nonamputees.

Transfemoral Amputations: Is There an Effect of Residual Limb Length and Orientation on Energy Expenditure?

Johanna C. Bell MSE, Erik J. Wolf PhD, Barri L. Schnall MPT, John E. Tis MD, Benjamin K. Potter MD

Energy cost of ambulation has been evaluated using a variety of measures. With aberrant motions resulting from compensatory strategies, persons with transfemoral amputations generally exhibit a larger center of mass excursion and an increased energy cost. However, few studies have analyzed the effect of residual femur length and orientation or energy cost of ambulation.

Does Activity Affect Residual Limb Skin Temperatures?

Glenn K. Klute PhD, Elizabeth Huff MS, William R. Ledoux PhD

Many lower limb amputees experience thermal discomfort as a result of wearing a prosthesis. The development of new prosthetic technology to address thermal discomfort requires an understanding of how activity (or inactivity) affects residual limb skin temperatures and how skin temperatures are mapped across the skin-prosthesis interface.

Does Intact Limb Loading Differ in Servicemembers With Traumatic Lower Limb Loss?

Alison L. Pruziner DPT, Kathryn M. Werner BS, Timothy J. Copple MS, Brad D. Hendershot PhD, Erik J. Wolf PhD

The initiation and progression of knee and hip arthritis have been related to limb loading during ambulation. Although altered gait mechanics with unilateral lower limb loss often result in larger and more prolonged forces through the intact limb, how these forces differ with traumatic limb loss and duration of ambulation have not been well described.

Task-specific Fall Prevention Training Is Effective for Warfighters With Transtibial Amputations

Kenton R. Kaufman PhD, PE, Marilynn P. Wyatt MA, PT, Pinata H. Sessoms PhD, Mark D. Grabiner PhD

Key factors limiting patients with lower extremity amputations to achieve maximal functional capabilities are falls and fear of falling. A task-specific fall prevention training program has successfully reduced prospectively recorded trip-related falls that occur in the community by the elderly. However, this program has not been tested in amputees.

Does a Torsion Adapter Improve Functional Mobility, Pain, and Fatigue in Patients with Transtibial Amputation?

Ava D. Segal MS, Rose Kracht BS, Glenn K. Klute PhD

Turning gait is an integral part of daily ambulation and likely poses a greater challenge for patients with transtibial amputation compared with walking a straight pathway. A torsion adapter is a prosthetic component that can increase transverse plane compliance of the prosthesis and decrease the torque applied to the residual limb, but whether this will improve patients’ mobility, pain, and fatigue remains unknown.

Does a Microprocessor-controlled Prosthetic Knee Affect Stair Ascent Strategies in Persons With Transfemoral Amputation?

Jennifer M. Aldridge Whitehead MS, Erik J. Wolf PhD, Charles R. Scoville PT, DPT, Jason M. Wilken MPT, PhD

Stair ascent can be difficult for individuals with transfemoral amputation because of the loss of knee function. Most individuals with transfemoral amputation use either a step-to-step (nonreciprocal, advancing one stair at a time) or skip-step strategy (nonreciprocal, advancing two stairs at a time), rather than a step-over-step (reciprocal) strategy, because step-to-step and skip-step allow the leading intact limb to do the majority of work. A new microprocessor-controlled knee (Ottobock X2) uses flexion/extension resistance to allow step-over-step stair ascent.

Punitive Limb Amputation

Anna Mavroforou MSc, LLM-LAMB, MBA, Konstantinos Malizos MD, Theofilos Karachalios MD, Konstantinos Chatzitheofilou MD, Athanasios D. Giannoukas MSc, MD, PhD, FEBVS

Limb amputation has been carried out through the ages as a punitive method in various parts of the world. This article highlights the historical and societal background associated with the use of punitive limb amputation.

Knee Muscle Strength After Recent Partial Meniscectomy Does Not Relate to 2-year Change in Knee Adduction Moment

Michelle Hall MSc, Tim V. Wrigley MSc, Ben R. Metcalf BSc, Rana S. Hinman PhD, Alasdair R. Dempsey PhD, Peter M. Mills PhD, Flavia M. Cicuttini PhD, David G. Lloyd PhD, Kim L. Bennell PhD

Knee muscle weakness and a greater external knee adduction moment are suggested risk factors for medial tibiofemoral knee osteoarthritis. Knee muscle weakness and a greater knee adduction moment may be related to each other, are potentially modifiable, and have been observed after arthroscopic partial meniscectomy.

Does Imageless Computer-assisted TKA Lead to Improved Rotational Alignment or Fewer Outliers? A Systematic Review

Marrigje F. Meijer BSc (Med), Inge H. F. Reininga PhD, Alexander L. Boerboom MD, Sjoerd K. Bulstra MD, PhD, Martin Stevens PhD

Computer-assisted surgery (CAS) has been developed to enhance prosthetic alignment during primary TKAs. Imageless CAS improves coronal and sagittal alignment compared with conventional TKA. However, the effect of imageless CAS on rotational alignment remains unclear.

What Are the Economic Consequences of Unplanned Readmissions After TKA?

R. Carter Clement MD, MBA, Michael M. Kheir BS, Peter B. Derman MD, MBA, David N. Flynn MD, MBA, Rebecca M. Speck PhD, L. Scott Levin MD, FACS, Lee A. Fleisher MD

In 2009, the Center for Medicare & Medicaid Services (CMS) began penalizing hospitals with high rates of 30-day readmissions after hospitalizations for certain conditions. This policy will expand to include TKA in 2015.

The Bernese Periacetabular Osteotomy: Is Transection of the Rectus Femoris Tendon Essential?

Eduardo N. Novais MD, Young-Jo Kim MD, PhD, Patrick M. Carry BA, Michael B. Millis MD

The Bernese periacetabular osteotomy (PAO) traditionally is performed using the iliofemoral or the ilioinguinal approach with transection of the rectus femoris tendon attachments. Although a rectus-preserving approach has been developed, there is limited direct comparison data regarding the surgical safety, radiographic correction, and improvement in hip pain and function between the rectus-preserving and the classic approaches.

Fluoroscopy and Imageless Navigation Enable an Equivalent Reconstruction of Leg Length and Global and Femoral Offset in THA

Markus Weber MD, Michael Woerner MD, Robert Springorum MD, Ernst Sendtner MD, Alexander Hapfelmeier PhD, Joachim Grifka MD, Tobias Renkawitz MD

Restoration of biomechanics is a major goal in THA. Imageless navigation enables intraoperative control of leg length equalization and offset reconstruction. However, the effect of navigation compared with intraoperative fluoroscopy is unclear.

Benefit of Cup Medialization in Total Hip Arthroplasty is Associated With Femoral Anatomy

Alexandre Terrier PhD, Francesc Levrero Florencio MSc, Hannes A. Rüdiger MD

Medialization of the cup with a respective increase in femoral offset has been proposed in THA to increase abductor moment arms. Insofar as there are potential disadvantages to cup medialization, it is important to ascertain whether the purported biomechanical benefits of cup medialization are large enough to warrant the downsides; to date, studies regarding this question have disagreed.

Does Fracture Affect the Healing Time or Frequency of Recurrence in a Simple Bone Cyst of the Proximal Femur?

Soo Min Cha MD, Hyun Dae Shin MD, PhD, Kyung Cheon Kim MD, PhD, Jung Woo Park MD

Studies have focused on intramedullary nailing of femoral simple bone cysts but have not clarified the recurrence frequency or management of recurrent cysts. In particular, the affect of pathologic fractures on cyst healing, recurrence, and complications of treatment have not been reported.

Embolization of Hypervascular Bone Metastases Reduces Intraoperative Blood Loss: A Case-control Study

Theresa J. C. Pazionis MD, MA, Ioannis D. Papanastassiou MD, PhD, Majid Maybody MD, John H. Healey MD

Small case series suggest that preoperative transcatheter arterial embolization minimizes bleeding and facilitates surgery for hypervascular metastatic bone tumors. However, control groups would make our confidence in clinical recommendations stronger, but small patient numbers make prospective trials difficult to conduct on this topic.

What Are the Factors That Affect Survival and Relapse After Local Recurrence of Osteosarcoma?

Akihiko Takeuchi MD, PhD, Valerae O. Lewis MD, Robert L. Satcher MD, Bryan S. Moon MD, Patrick P. Lin MD

Despite improvements in treatment of primary osteosarcoma, treatment of patients who have local recurrence is not well defined.

Operative Management of Metastatic Melanoma in Bone May Require En Bloc Resection of Disease

Jeffrey E. Krygier MD, Valerae O. Lewis MD, Christopher P. Cannon MD, Robert L. Satcher MD, Bryan S. Moon MD, Patrick P. Lin MD

Bone metastasis is a poor prognostic indicator in melanoma. Some authors have advocated only palliative treatment for patients with osseous disease.

What are the Patterns of Prophylactic Postoperative Oral Antibiotic Use After Foot and Ankle Surgery?

David J. Ruta MD, Anish R. Kadakia MD, Todd A. Irwin MD

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons’ use of prophylactic postoperative oral antibiotics is less defined.

Are Copy Number Variants Associated With Adolescent Idiopathic Scoliosis?

Jillian G. Buchan MS, David M. Alvarado PhD, Gabe Haller PhD, Hyuliya Aferol BS, Nancy H. Miller MD, Matthew B. Dobbs MD, Christina A. Gurnett MD, PhD

Adolescent idiopathic scoliosis (AIS) is a complex genetic disorder that causes spinal deformity in approximately 3% of the population. Candidate gene, linkage, and genome-wide association studies have sought to identify genetic variation that predisposes individuals to AIS, but the genetic basis remains unclear. Copy number variants are associated with several isolated skeletal phenotypes, but their role in AIS, to our knowledge, has not been assessed.

How is Forearm Compliance Affected by Various Circumferential Dressings?

John T. Capo MD, Regis L. Renard MD, MS, Mark J. R. Moulton MD, David J. Schneider MD, Natalie R. Danna MD, Bryan G. Beutel MD, Vincent D. Pellegrini MD

The forearm is the second most common location for extremity compartment syndrome. Compliance is a physical property that describes a material’s ability to expand with an increasing internal volume. The effect of circumferential dressings on extremity pressures has been investigated in various animal models and in some nonphysiologic mechanical models, but the importance of this effect has not been fully investigated in the human upper extremity. In addition, the physical property of compliance has not been reported in the analysis of compartment volume-pressure relationships.

Letter to the Editor: Orthopaedic Education in the United Kingdom

James Tomlinson MA (Cantab), MB, BChir, FRCS (Tr & Orth), Almas Khan MB, BS, FRCS (Tr & Orth)

Erratum to: Surgical Resection of Relapse May Improve Postrelapse Survival of Patients with Localized Osteosarcoma

Kwok Chuen Wong FHKAM (Orth), Vincent Lee FHKAM (Paed), MRCP, Matthew M. K. Shing FHKAM (Paed), MRCPCH, Shekhar Kumta PhD
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