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 12 | Dec, 2014

The 2014 ABJS Nicolas Andry Award: The Puzzle of the Thumb: Mobility, Stability, and Demands in Opposition

Amy L. Ladd MD, Joseph J. Crisco PhD, Elisabet Hagert MD, PhD, Jessica Rose PhD, Arnold-Peter C. Weiss MD

The paradoxical demands of stability and mobility reflect the purpose and function of the human thumb. Its functional importance is underscored when a thumb is congenitally absent, injured, or afflicted with degenerative arthritis. Prevailing literature and teaching implicate the unique shape of the thumb carpometacarpal (CMC) joint, as well as its ligament support, applied forces, and repetitive motion, as culprits causing osteoarthritis (OA). Sex, ethnicity, and occupation may predispose individuals to OA.

What is the Trouble With Trunnions?

Christina I. Esposito PhD, Timothy M. Wright PhD, Stuart B. Goodman MD, PhD, Daniel J. Berry MD

Recent studies have attributed adverse local tissue reactions (ALTRs) in patients with total hip arthroplasties (THAs) to tribocorrosion debris generated by modular femoral stems. The presentations of ALTR are diverse, as are the causes of it, and the biological responses can be important reasons for failure after THA.

What Are the Current Clinical Issues in Wear and Tribocorrosion?

Daniel J. Berry MD, Matthew P. Abdel MD, John J. Callaghan MD

Wear and corrosion in joint arthroplasty are important causes of failure. From the standpoint of current clinical importance, there are four main categories of wear and tribocorrosion: polyethylene wear, ceramic-on-ceramic (CoC) bearing wear, metal-on-metal (MoM) bearing wear, and taper tribocorrosion. Recently, problems with wear in the knee have become less prominent as have many issues with hip polyethylene (PE) bearings resulting from the success of crosslinked PE. However, MoM articulations and taper tribocorrosion have been associated with soft tissue inflammatory responses, and as a result, they have become prominent clinical concerns.

What Are the Advantages and Disadvantages of Imaging Modalities to Diagnose Wear-related Corrosion Problems?

Denis Nam MD, Robert L. Barrack MD, Hollis G. Potter MD

Adverse tissue reactions are known to occur after total hip arthroplasty using both conventional and metal-on-metal (MoM) bearings and after MoM hip resurfacing arthroplasty (SRA). A variety of imaging tools, including ultrasound (US), CT, and MRI, have been used to diagnose problems associated with wear after MoM hip arthroplasty and corrosion at the head-trunnion junction; however, the relative advantages and disadvantages of each remain a source of controversy.

The Surgical Options and Clinical Evidence for Treatment of Wear or Corrosion Occurring With THA or TKA

Charles A. Engh MD, Henry Ho MSc, Douglas E. Padgett MD

Wear and corrosion occurring in patients with hip and knee arthroplasty are common causes of failure leading to revision surgery. A variety of surgical approaches to these problems have been described, with varying efficacy. Polyethylene wear, metal-on-metal (MoM) hip bearing wear, and problems associated with modular taper corrosion are the areas of greatest clinical impact; results of revisions for these problems are likely to dictate a large portion of revision resources for the foreseeable future, and so they call for specific study.

How Have New Bearing Surfaces Altered the Local Biological Reactions to Byproducts of Wear and Modularity?

Thomas W. Bauer MD, PhD, Patricia A. Campbell PhD, Gretchen Hallerberg MS, MSLS, AHIP

The biologic reactions to byproducts of wear or corrosion can involve innate and adaptive processes and are dependent on many factors, including the composition, size, surface properties, shape, and concentration of debris.

How Has the Introduction of New Bearing Surfaces Altered the Biological Reactions to Byproducts of Wear and Modularity?

Paul H. Wooley PhD

Biological responses to wear debris were largely elucidated in studies focused on conventional ultrahigh-molecular-weight polyethylene (UHMWPE) and some investigations of polymethymethacrylate cement and orthopaedic metals. However, newer bearing couples, in particular metal-on-metal but also ceramic-on-ceramic bearings, may induce different biological reactions.

Do Genetic Susceptibility, Toll-like Receptors, and Pathogen-associated Molecular Patterns Modulate the Effects of Wear?

Edward M. Greenfield PhD

Overwhelming evidence supports the concept that wear particles are the primary initiator of aseptic loosening of orthopaedic implants. It is likely, however, that other factors modulate the biologic response to wear particles. This review focuses on three potential other factors: genetic susceptibility, Toll-like receptors (TLRs), and bacterial pathogen-associated molecular patterns (PAMPs).

Do Retrieval Analysis and Blood Metal Measurements Contribute to Our Understanding of Adverse Local Tissue Reactions?

Patricia A. Campbell PhD, Michael S. Kung BA, Andrew R. Hsu MD, Joshua J. Jacobs MD

Metal-on-metal (MoM) total hip arthroplasties (THAs) and the head-neck and neck-body junctions in modular THA are associated with a variety of local and systemic reactions to their related wear and corrosion products. Although laboratory testing is available, the relationship between laboratory values—including serum metal ion levels—and adverse local tissue reactions (ALTRs) remains controversial and incompletely characterized.

Are There Biological Markers for Wear or Corrosion? A Systematic Review

D. Rick Sumner PhD, Ryan Ross PhD, Ed Purdue PhD

Identification of biomarkers associated with wear and tribocorrosion in joint arthroplasty would be helpful to enhance early detection of aseptic loosening and/or osteolysis and to improve understanding of disease progression. There have been several new reports since the last systematic review (which covered research through mid-2008) justifying a new assessment.

Are Biologic Treatments a Potential Approach to Wear- and Corrosion-related Problems?

R. Lane Smith PhD, Edward M. Schwarz PhD

Biological treatments, defined as any nonsurgical intervention whose primary mechanism of action is reducing the host response to wear and/or corrosion products, have long been postulated as solutions for osteolysis and aseptic loosening of total joint arthroplasties. Despite extensive research on drugs that target the inflammatory, osteoclastic, and osteogenic responses to wear debris, no biological treatment has emerged as an approved therapy. We review the extensive preclinical research and modest clinical research to date, which has led to the central conclusion that the osteoclast is the primary target. We also allude to the significant changes in health care, unabated safety concerns about chronic immunosuppressive/antiinflammatory therapies, industry’s complete lack of interest in developing an intervention for this condition, and the practical issues that have narrowly focused the possibilities for a biologic treatment for wear debris-induced osteolysis.

How Have Alternative Bearings and Modularity Affected Revision Rates in Total Hip Arthroplasty?

William M. Mihalko MD, PhD, Markus A. Wimmer PhD, Carol A. Pacione BS, Michel P. Laurent PhD, Robert F. Murphy MD, Carson Rider BS

Total hip arthroplasty (THA) continues to be one of the most successful surgical procedures in the medical field. However, over the last two decades, the use of modularity and alternative bearings in THA has become routine. Given the known problems associated with hard-on-hard bearing couples, including taper failures with more modular stem designs, local and systemic effects from metal-on-metal bearings, and fractures with ceramic-on-ceramic bearings, it is not known whether in aggregate the survivorship of these implants is better or worse than the metal-on-polyethylene bearings that they sought to replace.

Which Design and Biomaterial Factors Affect Clinical Wear Performance of Total Disc Replacements? A Systematic Review

Sai Y. Veruva BS, Marla J. Steinbeck MT(ASCP), PhD, Jeffrey Toth PhD, Dominik D. Alexander PhD, MSPH, Steven M. Kurtz PhD

Total disc replacement was clinically introduced to reduce pain and preserve segmental motion of the lumbar and cervical spine. Previous case studies have reported on the wear and adverse local tissue reactions around artificial prostheses, but it is unclear how design and biomaterials affect clinical outcomes.

What Design and Material Factors Impact the Wear and Corrosion Performance in Total Elbow Arthroplasties?

Mark P. Figgie MD, Timothy M. Wright PhD, Denise Drinkwater BA

The survivorship of total elbow arthroplasties is lower than surgeons and patients would like it to be, especially in patients with posttraumatic arthritis of the elbow. To improve durability, it is important to understand the failure modes of existing implants. Total elbow arthroplasties were designed primarily for low-demand rheumatoid patients. As surgical indications have extended to more active patient populations, the mechanical performance of current designs must meet an increased mechanical burden. Evaluating the degree to which they do this will guide conclusions about which contemporary devices might still meet the need and, as importantly, what design and material changes might be needed to improve performance.

Safe Zone for Superolateral Entry Pin Into the Distal Humerus in Children: An MRI Analysis

Tamir Bloom MD, Caixia Zhao MD, Alpesh Mehta MD, Uma Thakur MD, John Koerner MD, Sanjeev Sabharwal MD, MPH

The radial nerve is at risk for iatrogenic injury during placement of pins, screws, or wires around the distal humerus. Unlike adults, detailed anatomic information about the relationship of the nerve to the distal humerus is lacking in children.

Bone Marrow Aspirate Concentrate and Platelet-rich Plasma Enhanced Bone Healing in Distraction Osteogenesis of the Tibia

Dong Hoon Lee MD, PhD, Keun Jung Ryu MD, Jin Woo Kim MD, Kyung Chung Kang MD, PhD, Young Rak Choi MD

During lower limb lengthening, poor bone regeneration is a devastating complication. Several local or systemic applications have been used to promote osteogenesis, and biologic stimulations are gaining attention, but their utility has not been proven in this setting.

Uncultured Autogenous Adipose-derived Regenerative Cells Promote Bone Formation During Distraction Osteogenesis in Rats

Issei Nomura MD, Koji Watanabe MD, PhD, Hidenori Matsubara MD, PhD, Katsuhiro Hayashi MD, PhD, Naotoshi Sugimoto MD, PhD, Hiroyuki Tsuchiya MD, PhD

Adipose-derived stem cells have recently shown differentiation potential in multiple mesenchymal lineages in vitro and in vivo. These cells can be easily isolated in large amounts from autologous adipose tissue and used without culturing or differentiation induction, which may make them relatively easy to use for clinical purposes; however, their use has not been tested in a distraction osteogenesis model.

Is There a Difference in Sagittal Alignment of Blount’s Disease Between Radiographic and Clinical Evaluation?

Seung-Ju Kim MD, PhD, Sanjeev Sabharwal MD, MPH

A procurvatum deformity of the proximal tibia often is seen in patients with Blount’s disease. If left untreated, it can lead to progressive angulation in the sagittal plane and altered contact stresses across the knee.

External Fixation for Closed Pediatric Femoral Shaft Fractures: Where Are We Now?

Heather Kong MD, Sanjeev Sabharwal MD, MPH

Recent advances in external fixation technique and pin design have sought to minimize complications such as pin site infection and premature removal of the external fixator. Although newer forms of internal fixation have gained popularity, external fixation may still have a role in managing pediatric femoral shaft fractures.

Fracture Reduction and Primary Ankle Arthrodesis: A Reliable Approach for Severely Comminuted Tibial Pilon Fracture

Douglas N. Beaman MD, Richard Gellman MD

Posttraumatic arthritis and prolonged recovery are typical after a severely comminuted tibial pilon fracture, and ankle arthrodesis is a common salvage procedure. However, few reports discuss the option of immediate arthrodesis, which may be a potentially viable approach to accelerate overall recovery in patients with severe fracture patterns.

Botulinum Toxin A Does Not Decrease Calf Pain or Improve ROM During Limb Lengthening: A Randomized Trial

Dong Hoon Lee MD, PhD, Keun Jung Ryu MD, Dong Eun Shin MD, PhD, Hyun Woo Kim MD, PhD

During lower limb lengthening, distraction-induced muscle pain and surrounding joint contractures are frustrating complications for which few effective treatments are available.

What Risk Factors Predict Usage of Gastrocsoleus Recession During Tibial Lengthening?

S. Robert Rozbruch MD, Samuel Zonshayn BA, Saravanaraja Muthusamy MBBS, MS, Ortho, Eugene W. Borst BA, Austin T. Fragomen MD, Joseph T. Nguyen MPH

Tibial lengthening is frequently associated with gastrocsoleus contracture and some patients are treated surgically. However, the risk factors associated with gastrocsoleus contracture severe enough to warrant surgery during tibial lengthening and the consistency with which gastrocsoleus recession (GSR) results in a plantigrade foot in this setting have not been well defined.

Complications of the Intramedullary Skeletal Kinetic Distractor (ISKD) in Distraction Osteogenesis

Dong Hoon Lee MD, PhD, Keun Jung Ryu MD, Hae Ryong Song MD, PhD, Soo-Hong Han MD, PhD

The Intramedullary Skeletal Kinetic Distractor (ISKD) (Orthofix Inc, Lewisville, TX, USA) is an intramedullary device designed for more comfortable limb lengthening than that with external fixators; lengthening is achieved with this nail using rotational oscillation between two telescoping sections. However, the degree to which this device achieves this goal and its complication rate have not been fully documented.

Internal Lengthening Device for Congenital Femoral Deficiency and Fibular Hemimelia

Lior Shabtai MD, Stacy C. Specht MPA, Shawn C. Standard MD, John E. Herzenberg MD

Patients with congenital limb shortening can present with joint instability, soft tissue contractures, and significant leg length discrepancy. Classically, lengthening is done with external fixation, which can result in scarring, pin site infection, loss of motion, and pain. We therefore developed an alternative to this approach, a new, controllable, internal lengthening device for patients with congenital limb shortening.

Precision of the PRECICE® Internal Bone Lengthening Nail

Yatin M. Kirane MBBS, DOrtho, PhD, Austin T. Fragomen MD, S. Robert Rozbruch MD

Previous designs of internal bone lengthening devices have been fraught with imprecise distraction, resulting in nerve injuries, joint contractures, nonunions, and other complications. Recently, a magnet-operated PRECICEnail (Ellipse Technologies, Inc, Irvine, CA, USA) was approved by the FDA; however, its clinical efficacy is unknown.

Time-dependent Changes After Latissimus Dorsi Transfer: Tenodesis or Tendon Transfer?

Ali Erşen MD, Hakan Ozben MD, Mehmet Demirhan MD, Ata Can Atalar MD, Mehmet Kapıcıoğlu MD

Transfer of the latissimus dorsi tendon to the posterosuperior part of the rotator cuff is an option in active patients with massive rotator cuff tears to restore shoulder elevation and external rotation. However, it is unknown whether this treatment prevents progression of cuff tear arthropathy.

Ilizarov Fixator Combined With an Intramedullary Nail for Tibial Nonunions With Bone Loss: Is It Effective?

Deniz Gulabi MD, Mehmet Erdem MD, Gultekin Sıtkı Cecen MD, Cem Coskun Avci MD, Necdet Saglam MD, Fevzi Saglam MD

Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment.

Apical and Intermediate Anchors Without Fusion Improve Cobb Angle and Thoracic Kyphosis in Early-onset Scoliosis

Meric Enercan MD, Sinan Kahraman MD, Erden Erturer MD, Cagatay Ozturk MD, Azmi Hamzaoglu MD

The main goal of treatment in early-onset scoliosis is to obtain and maintain curve correction while simultaneously preserving spinal, trunk, and lung growth. This study introduces a new surgical strategy, called the modified growing rod technique, which allows spinal growth and lung development while controlling the main deformity with apical and intermediate anchors without fusion. The use of intraoperative traction at the initial procedure enables spontaneous correction of the deformity and decreases the need for forceful correction maneuvers on the immature spine and prevents possible implant failures. This study seeks to evaluate (1) curve correction; (2) spinal length; (3) number of procedures performed; and (4) complications with the new approach.

Subject-specific Patterns of Femur-labrum Contact are Complex and Vary in Asymptomatic Hips and Hips With Femoroacetabular Impingement

Ashley L. Kapron PhD, Stephen K. Aoki MD, Christopher L. Peters MD, Andrew E. Anderson PhD

Femoroacetabular impingement (FAI) may constrain hip articulation and cause chondrolabral damage, but to our knowledge, in vivo articulation and femur-labrum contact patterns have not been quantified.

Psychological Distress Negatively Affects Self-assessment of Shoulder Function in Patients With Rotator Cuff Tears

Michael Q. Potter MD, James D. Wylie MD, Patrick E. Greis MD, Robert T. Burks MD, Robert Z. Tashjian MD

In many areas of orthopaedics, patients with greater levels of psychological distress report inferior self-assessments of pain and function. This effect can lead to lower-than-expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychological component.

Patient Activity After TKA Depends on Patient-specific Parameters

Cornelia Lützner Dipl-Päd, Stephan Kirschner Dr med, PD, Jörg Lützner Dr med, PD

Most patients expect an improvement of walking ability and an increase in activity levels after TKA. Unfortunately, few studies report qualitative and quantitative activity improvements after TKA.

Comorbidities in Patients Undergoing Total Knee Arthroplasty: Do They Influence Hospital Costs and Length of Stay?

Andrew J. Pugely MD, Christopher T. Martin MD, Yubo Gao PhD, Daniel A. Belatti BS, John J. Callaghan MD

Increasing national expenditures and use associated with TKA have resulted in pressure to reduce costs through various reimbursement cuts. However, within the arthroplasty literature, few studies have examined the association of medical comorbidities on resource use and length of stay after joint arthroplasty.

Does Fluoroscopy Improve Acetabular Component Placement in Total Hip Arthroplasty?

Brandon S. Beamer MD, Jordan H. Morgan BS, Christopher Barr BS, Michael J. Weaver MD, Mark S. Vrahas MD

The success of THA largely depends on correct placement of the individual components. Traditionally, these have been placed freehand using anatomic landmarks, but studies have shown poor accuracy with this method.

Modern Trunnions Are More Flexible: A Mechanical Analysis of THA Taper Designs

David A. Porter MD, Robert M. Urban PhD, Joshua J. Jacobs MD, Jeremy L. Gilbert PhD, José A. Rodriguez MD, H. John Cooper MD

There is renewed concern surrounding the potential for corrosion at the modular head-neck junction to cause early failure in contemporary THAs. Although taper corrosion involves a complex interplay of many factors, a previous study suggested that a decrease in flexural rigidity of the femoral trunnion may be associated with an increased likelihood of corrosion at retrieval.

What Is the Effect of Advanced Age and Comorbidity on Postoperative Morbidity and Mortality After Musculoskeletal Tumor Surgery?

Koichi Ogura MD, Hideo Yasunaga MD, PhD, Hiromasa Horiguchi PhD, Kiyohide Fushimi MD, PhD, Hirotaka Kawano MD, PhD

Although the elderly population is increasing rapidly, little information is available regarding how the risk of postoperative mortality and morbidity increases when combined with age and comorbidity burden in patients undergoing musculoskeletal tumor surgery.

Antirotation Pins Improve Stability of the Compress Limb Salvage Implant: A Biomechanical Study

Raffi S. Avedian MD, Timothy Chen MD, Derek Lindsey MS, Ariel Palanca MD, David Mohler MD

Limb salvage implants that rely on compliant compression osseointegration to achieve bone fixation may achieve longer survivorship rates compared with traditional cemented or press-fit stemmed implants; however, failures resulting from rotational instability have been reported. The effect of using antirotation pins on the rotational stability of the fixation has not been well studied.

Prevalence of Triangular Fibrocartilage Complex Abnormalities Regardless of Symptoms Rise With Age: Systematic Review and Pooled Analysis

Jimmy J. Chan BSc, Teun Teunis MD, David Ring MD, PhD

Triangular fibrocartilage complex abnormalities seem to be more common with age, but the degree to which this is so, and the degree to which the presence of an abnormality is associated with symptoms, are topics of controversy.

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Matthew W. Tetreault MD, Nathan G. Wetters MD, Mario Moric MS, Christopher E. Gross MD, Craig J. Della Valle MD

Serum C-reactive protein (CRP) is a general marker of inflammation, and recent studies suggest that measurement of CRP in synovial fluid may be a more accurate method for diagnosing periprosthetic joint infection (PJI).

The Alpha Defensin-1 Biomarker Assay can be Used to Evaluate the Potentially Infected Total Joint Arthroplasty

Joshua Bingham MD, Henry Clarke MD, Mark Spangehl MD, Adam Schwartz MD, Christopher Beauchamp MD, Brynn Goldberg RN

Diagnosing a periprosthetic joint infection (PJI) requires a complex approach using various laboratory and clinical criteria. A novel approach to diagnosing these infections uses synovial fluid biomarkers. Alpha defensin-1 (AD-1) is one such synovial-fluid biomarker. However little is known about the performance of the AD-1 assay in the diagnosis of PJI.

Revision Surgery Occurs Frequently After Percutaneous Fixation of Stable Femoral Neck Fractures in Elderly Patients

Michael S. Kain MD, Andrew J. Marcantonio DO, Richard Iorio MD

Femoral neck fractures are a major public health problem. Multiple-screw fixation is the most commonly used surgical technique for the treatment of stable femoral neck fractures.

Vancomycin-bearing Synthetic Bone Graft Delivers rhBMP-2 and Promotes Healing of Critical Rat Femoral Segmental Defects

Jordan D. Skelly ME, Jeffrey Lange MD, Tera M. Filion PhD, Xinning Li MD, David C. Ayers MD, Jie Song PhD

Bone grafts simultaneously delivering therapeutic proteins and antibiotics may be valuable in orthopaedic trauma care. Previously, we developed a poly(2-hydroxyethyl methacrylate)-nanocrystalline hydroxyapatite (pHEMA-nHA) synthetic bone graft that, when preabsorbed with 400-ng rhBMP-2/7, facilitated the functional repair of critical-size rat femoral defects. Recently, we showed that pHEMA-nHA effectively retains/releases vancomycin and rhBMP-2 in vitro. The success of such a strategy requires that the incorporation of vancomycin does not compromise the structural integrity of the graft nor its ability to promote bone healing.

An Analysis of References Used for the Orthopaedic In-Training Examination: What are Their Levels of Evidence and Journal Impact Factors?

Bryan D. Haughom MD, Zach Goldstein BS, Michael D. Hellman MD, Paul H. Yi MD, Rachel M. Frank MD, Brett R. Levine MD, MS

Although the references recommended for the Orthopaedic In-Training Examination (OITE) have been evaluated in certain subspecialty domains, suggested reference level of evidence (LOE), impact factor, and citation age have not been evaluated comprehensively to our knowledge.

Erratum to: Patient-Specific Anatomical and Functional Parameters Provide New Insights Into the Pathomechanism of Cam FAI

K. C. Geoffrey Ng MASc, Mario Lamontagne PhD, Andrew P. Adamczyk MSc, Kawan S. Rakhra MD, Paul E. Beaulé MD

Thigh Pain in an 18-year-old Man

Frank Traub MD, PhD, Marilyn Heng MD, Brendan C. Dickson MD, MSc, Peter C. Ferguson MD, MSc
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