Alexander J Lampley

The Effect of Obesity on Functional Outcomes and Complications in Total Ankle Arthroplasty

Background: The prevalence of obesity in the United States is staggering. Currently, the effect of obesity on third-generation total ankle replacement (TAR) is unknown. Methods: We prospectively identified a consecutive series of 455 primary TARs operated between May 2007 and September 2013 who had a minimum follow-up of 2 years. We identified 266 patients with a body mass index (BMI) <30 (control), 116 with a BMI between 30 and 35 (Obese I), and 73 with a BMI >35 (Obese II). Clinical outcomes including wound issues, infection rate, complications, and failure rates were compared. Functional outcomes including American Orthopaedic Foot & Ankle Society hindfoot score, Short Form–36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), Foot and Ankle Disability Index (FADI), and Foot and Ankle Outcome Score (FAOS) were compared. Average patient follow-up in the Obese I group was 44.7 ± 17.3 months, Obese II was 42.7 ± 16.4 months, and 45.2 ± 17.4 months in the control group. Results: Age, race, and smoking history in the obese group were not significantly higher than the control group; however, sex was significantly related to BMI. There was no difference in complication, infection, or failure rates between the groups. Preoperatively, the Obese II group had significantly lower SF-36 scores and higher SMFA function, FADI, and FAOS Symptoms scores. For each of the Obese I, Obese II, and control groups, all functional outcome scores 1 year postoperatively and at most recent follow-up were significantly improved. However, at most recent follow-up, Obese II patients had lower FAOS Pain and SF-36 scores and higher FADI and SMFA Functional scores. Conclusion: Total ankle arthroplasty in obese patients was a relatively safe procedure. Although obese patients after TAR had lower functional outcome scores compared to their nonobese counterpart, they did experience significant functional and pain improvements at most recent follow-up. Level of Evidence: Level III, comparative series.

Association of Cigarette Use and Complication Rates and Outcomes Following Total Ankle Arthroplasty

Background: Tobacco use is a known risk factor for increased perioperative complications and having worse functional outcomes in many orthopedic procedures. To date, no study has elucidated the effect of cigarette smoking on complications or functional outcome scores after total ankle replacement (TAR). Methods: We retrospectively reviewed the records of 642 patients who had TAR between June 2007 and February 2014 with a known smoking status. These patients were separated into 3 groups based on their smoking status: 34 current smokers, 249 former smokers, and 359 nonsmokers. Outcome scores and perioperative complications, which included infection, wound complications, revision surgeries, and nonrevision surgeries were compared between the groups. Results: When comparing perioperative complications in the active smokers to the nonsmokers, we found a statistically significant increased risk of wound breakdown (hazard ratio [HR] 3.08, P = .047). Although the active smokers had an increased rate of infection (HR 2.61, P = .392), revision surgery (HR 1.75, P = .470), and nonrevision surgery (HR 1.69, P = .172), these findings were not statistically significant. With regard to outcome scores, all groups demonstrated improvement at 1- and 2-year follow-up compared with their preoperative outcome scores. However, the active smokers had less improvement in their outcome scores than the nonsmokers at 1- and 2-year follow-up. Furthermore, there was no significant difference in the outcome scores when comparing the nonsmokers to the former smokers. Conclusion: Active cigarette smokers undergoing TAR had a significantly higher risk of wound complications and worse outcome scores compared with nonsmokers and former smokers. Furthermore, tobacco cessation appeared to reverse the effects of smoking, which allowed TAR to be an effective and safe procedure for providing pain relief and improving function in former smokers as they had perioperative complication rates and outcomes similar to nonsmokers. Level of Evidence: Level III, retrospective comparative series.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications

Introduction. Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support. Methods. Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications. Results. All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusions. The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing. Levels of Evidence: Level IV: Case series

Intrawound Vancomycin Powder in Primary Total Hip Arthroplasty Increases Rate of Sterile Wound Complications

Purpose Total hip arthroplasty (THA) is a successful surgery for the treatment of hip osteoarthritis; however, the risk of a post-operative prosthetic joint infection (PJI) remains at 1% to 2%. The purpose of this study was to investigate the safety profile of using vancomycin powder (VP) to reduce infection rates by reviewing acute postoperative complications. Materials and Methods A retrospective review of 265 consecutive patients undergoing THA was performed. The first 128 patients, the control group, did not receive VP, and the subsequent 137 patients, the VP group, received VP at the time of wound closure. Patient demographic data, medical comorbidities, and perioperative information were compared. Results The primary outcome was a post-operative surgical complication within 90 days from surgery. The control and VP groups demographic, medical comorbidities and perioperative information data were statistically similar. Deep infection rate in the control group was 5.5%, whereas the deep infection rate in the VP group was 0.7% (P=0.031). Sterile wound complication rate was 4.4% in the VP group, and 0% in the control group (P=0.030). Remaining complications were not statistically different between the groups. Conclusion VP was associated with an increase rate of sterile wound complications compared to the control group. The rate of PJI was decreased with the use of VP. We do not recommend for or against the use of VP at time of wound closure to prevent PJI, and higher powered studies will need to be performed to demonstrate the efficacy of VP.

Open Ankle Fractures with Loss of the Medial Malleolus: A Case Series on a Rare Injury

In patients with particularly high-energy injuries causing open ankle fractures, the medial malleolus can be extruded from the ankle and either lost at the scene of the injury or unable to be fixed at the time of operative intervention. Minimal reporting of this devastating injury exists in the literature. Our study aims to report the outcomes in patients with open ankle fractures and loss of the medial malleolus. We retrospectively reviewed eight patients with this injury pattern over a 14-year span (2000–2014). Two of these patients were treated with below-knee amputation for a mangled extremity. Five of the patients were treated with tibiotalocalcaneal (TTC) arthrodesis. Of the five patients treated with ankle and subtalar arthrodesis, two were treated with open reduction and internal fixation (ORIF) prior to their arthrodesis. The remaining three patients were treated with arthrodesis after their initial surgical treatment with irrigation and debridement (I&D) and external fixation. Four of the six patients required soft tissue coverage with a rotational or free flap. All patients undergoing TTC arthrodesis went on to fusion; at final followup (average 2.7 years; 1.1–8.2 years), they reported minimal pain in the operative extremity and were able to ambulate. We found TTC arthrodesis to be a viable option for patients with this devastating injury. These findings could aid orthopedic surgeons not only in preoperative patient education and prognosis but also in operative planning in patients with this rare injury.

The radiocapitellar synovial fold: a lateral anatomic landmark for sizing radial head arthroplasty

BACKGROUND Successful radial head arthroplasty relies on reproduction of anatomy. We hypothesized that the radiocapitellar synovial fold could serve as a reference point in radial head prosthesis sizing. Our study aimed to define the relationship between the synovial fold and the radial head in elbows with and without lateral ulnar collateral ligament (LUCL) injury. MATERIALS AND METHODS We performed magnetic resonance imaging evaluation of 34 elbows to determine the normal relationship between the radiocapitellar synovial fold and the radial head. Next, we used cadaveric dissections to evaluate the anatomic relationships with the LUCL intact and disrupted, as well as in the setting of sizing with a radial head prosthesis. The fold-to-radial head distance (FRHD) was measured on all images and analyzed to determine the relationship of the synovial fold and radial head. RESULTS The FRHD in cadavers with an intact LUCL and native radial head measured an average of 1.5 mm proximal to the radial head. With the LUCL disrupted and a native radial head, the FRHD measured an average of 1.2 mm proximal to the radial head. The mean difference between the groups was 0.5 mm (P = .031), suggesting that the fold migrated distally in the cadavers with a disrupted LUCL. CONCLUSION The radiocapitellar synovial fold may be a helpful landmark for radial head sizing. The synovial fold is always just proximal to the articular surface of the radial head. Using this information, the surgeon can prevent overlengthening as the implant should not be placed proximal to the fold.

Risks and Benefits of the Different Types of Gloves used in the Perioperative Setting

The role of powder gloves in allergic reactions, infections, wound healing and granuloma formation has been known for many years. Despite a gradual shift away from powder gloves over the last several decades, many healthcare professionals and facilities continue to use powder gloves as the FDA has continued to refrain from issuing a comprehensive formal ban. However, recent advancements in glove technology and position statements by professional societies have continued the push for removal of powder gloves from all clinical and surgical settings and will hopefully entirely eradicate usage in the coming years.

Highlights in Spine Care during the Last One Hundred Years

The article reviews milestones in spine care that have occurred in the past 100 years. The various conditions and diagnoses we commonly treat today were poorly understood and there were few reliable treatments available in the first half of the twentieth century. Various diagnostic and imaging techniques have evolved as well as nonoperative and operative modalities to treat deformity, degenerative, and traumatic spine conditions. The reader should gain an understanding and appreciation of how interrelated the early concepts of management and treatment relate to the procedures and technology we take for granted today.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy: Is there a Difference in Perioperative Complications compared with Periacetabular Osteotomy Alone?

Purpose: To evaluate the safety of hip arthroscopy combined with a periacetabular osteotomy (PAO) compared with PAO alone in treating concomitant intra-articular pathology in hip dysplasia. Materials and methods: Forty-one patients (46 hips) with symptomatic hip dysplasia were retrospectively reviewed. Preand postoperative radiographic data and intraoperative data consisting of estimated blood loss, intraoperative and postoperative blood transfusions, operative time, and length of hospital stay were recorded. The complications occurring within the first 3 months after surgery including lateral femoral cutaneous and pudendal nerve neuropraxia, wound complications, and reoperations were recorded. Additionally, rates of deep venous thrombosis and other major adverse outcomes (myocardial infarction, pulmonary embolism, stroke, death) were examined. Results: Twenty-one patients (24 hips) underwent PAO alone. Twenty patients (22 hips) underwent hip arthroscopy followed immediately by PAO. There were no significant differences in the 90-day complication rates between the two groups, comparing the rate of neuropraxia (p = 0.155) and wound complications (p = 0.6). Operative time for PAO alone was 179 minutes (standard deviation [SD] ± 37) compared with 251 minutes (SD ± 52) for combined hip arthroscopy and PAO (p < 0.001). No incidence of deep vein thrombosis or major adverse events was noted in either group. Preoperative lateral center edge angle (LCEA) and acetabular index (AI) were 14° and 20° respectively, in the PAO-alone group and 19° and 16° respectively, in the combined group. Postoperatively, LCEA was 29° in the PAOalone group and 30° in the combined group. Postoperative AI was 11° in the PAO-alone group and 5° in the combined group. Conclusion: This study demonstrates that hip arthroscopy in combination with PAO to treat intra-articular pathology shows no difference in 90-day complication rates when compared with PAO alone. RETROSPECTIVE COMPARATIVE STUDY 1,2Fellow, 3Resident, 4,5Surgeon, 6Professor 1Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, USA 2Department of Orthopaedic Surgery, Rady Children’s Hospital San Diego, California, USA 3,4,6Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA 5Mount Kisco Medical Group, Fishkill, New York, USA Corresponding Author: Julie A Neumann, Fellow, KerlanJobe Orthopaedic Clinic, Los Angeles, California, USA, Phone: +2253175800, e-mail: Julie.Neumann.MD@gmail.com 10.5005/jp-journ ls-10017-1083 Level of evidence: Level III, retrospective comparative study

Infrared Thermography is not a Valid Method to Track Changes in Core Temperature in Exercising Athletes

Purpose: Field measurement of core temperature typically requires rectal or other invasive, expensive core temperature methods. Infrared (IR) thermography uses a handheld camera to measure surface temperature at discrete locations. We attempted to validate IR thermography against coretemperature capsules for the tracking of core-temperature changes at rest, during exercise, and recovery. Hypothesis: Infrared thermography is a noninvasive method to follow changes in core temperature during exercise. Materials and methods: Twelve athletes swallowed an ingestible core-temperature (CorTemp) capsule 1-hour prior to exercise. Athletes refrained from drinking for 2 hours prior to or during the study. Temperatures were obtained using both the CorTemp capsule and IR thermography at 10-minute intervals for 30 minutes before exercise, during 30 minutes of moderate intensity aerobic exercise, and for 30 minutes of recovery. The temperatures were then averaged for each segment of data collection. Study design: Prospective descriptive study. Results: Infrared thermography results (rest = 34.7°C C 0.49, exercise = 34.1°C ± 0.77, recovery = 34.6°C ± 0.46) were significantly lower than with the CorTemp capsules (rest = 37°C ± 0.55, exercise = 38.6°C ± 0.47, recovery = 37.7°C ± 0.47) throughout the data collection period. There were no significant correlations between the two measurement methods (rest = 0.22, exercise = 0.07, recovery = 0.59; all p > 0.05). Conclusion: Infrared thermography is not a valid method to track core-temperature changes during exercise. In addition to IR thermography readings being consistently lower, temperature changes before, during, and after exercise showed wide and inconsistent variability.