Andrew L. Chen

Use of Antibiotic-Impregnated Cement in Total Joint Arthroplasty

&NA; The use of antibiotic‐impregnated cement in revision of total hip arthroplasty procedures is widespread, and a substantial body of evidence demonstrates its efficacy in infection prevention and treatment. However, it is not clear that it is necessary or desirable as a routine means of prophylaxis in primary total joint arthroplasty. In the management of infected implant sites, antibioticimpregnated cement used in one‐stage exchange arthroplasties has lowered reinfection rates. In two‐stage procedures, use of beads and either articulating or nonarticulating antibiotic‐impregnated cement spacers also has lowered reinfection rates. In addition, spacers reduce “dead space,” help stabilize the limb, and facilitate reimplantation. Problems associated with antibiotic‐impregnated cement in total joint arthroplasty include weakening of the cement and the generation of antibiotic‐resistant bacteria in infected implant sites.

Management of Bone Loss Associated With Recurrent Anterior Glenohumeral Instability

The diagnosis and treatment of osseous deficiencies associated with anterior shoulder instability have been a challenge to physicians for centuries. Whereas historical goals centered on the stable reduction and prevention of recurrent dislocation, current standards of success are predicated on the restoration of motion and strength and the return to functional activities, including competitive athletics. Reestablishment of anterior shoulder stability thus requires the recognition of osseous defects of the humeral head and glenoid, as well as a thorough understanding of the available treatment options in the context of a disciplined treatment algorithm. Although many surgical procedures have been described for the management of osseous deficiencies in association with anterior shoulder instability, in the authors’ experience, such procedures are seldom necessary. The purpose of this summary is to review treatment options as well as indications and techniques to address these bony deficiencies.

Osteochondral Lesions of the Talus

Abstract Osteochondral lesions of the talus occur infrequently and usually represent late sequelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral fractures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Nonsurgical management remains the mainstay of treatment of acute, nondisplaced osteochondral lesions. Surgical management is reserved for unstable fragments or failure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and improvement of function.

Granulomatous Inflammation After Hylan G-f 20 Viscosupplementation of the Knee : A Report of Six Cases

Background: Recently, intra-articular viscosupplementation with hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. Mild pain or swelling at the site of injection may occur in up to 20% of patients, although severe local inflammation, warmth, and joint effusion are rare. We present a series of six cases in which granulomatous inflammation of the synovium was observed after hyaluronate viscosupplementation of the knee. Methods: Six knees (five patients) treated with intra-articular Hylan G-F 20 viscosupplementation underwent a surgical procedure because of persistent symptoms. Routine histopathological evaluation, supplemented by alcian-blue staining and hyaluronidase digestion, was performed in each case. Results: Chronically inflamed synovium with areas of histiocytic and foreign-body giant-cell reaction was observed surrounding acellular, amorphous material. The material stained with alcian blue, a stain for hyaluronate, which disappeared after hyaluronidase digestion. Conclusions: We believe that the injected hyaluronate (Hylan G-F 20) may have been responsible for the synovitis in our patients and thus may be a pathological cause of recalcitrant symptoms after such injection. It is not known whether the responsible pathological agent was the hyaluronate derivative, a contaminant of the purification process, or a component of the carrier substance. Importantly, it appears that the findings in these patients most likely represent a previously unreported pathological response to a viscosupplementation product. This report should raise clinical awareness about this potential complication.

Rotator cuff repair in patients with type I diabetes mellitus

Insulin-dependent diabetes mellitus is associated with shoulder stiffness and a propensity toward postoperative wound complications and infection. We compared our results of open repair of full-thickness rotator cuff tears in 30 diabetic patients with those of a matched, nondiabetic population. No differences were observed in preoperative range of motion, although at a mean of 34 months, significant differences in shoulder active range of motion and passive range of motion were found postoperatively at 6 weeks, 6 months, and final follow-up (P <.05). On the basis of American Shoulder and Elbow Surgeons shoulder scoring, there were 27 (90%) and 28 (93%) good or excellent results in the diabetic and comparison groups, respectively. Complications occurred in 5 diabetic patients (17%), with 2 failures (7%) and 3 infections (10%), as compared with 1 failure (3%) and no infections in the comparison group. Repair of the diabetic rotator cuff may be performed with the expectation of improved motion and function, although less than nondiabetic counterparts. The surgeon should remain cognizant that a higher rate of complications, infection in particular, may occur after rotator cuff repair in the diabetic population.

Arthroscopic management of spinoglenoid cysts associated with SLAP lesions and suprascapular neuropathy

Suprascapular neuropathy secondary to cyst compression in the spinoglenoid notch may occur in association with SLAP tears. Arthroscopic techniques may be employed for both cyst excision and repair of labral pathology. We describe 3 cases in which preoperative and postoperative electromyograms and magnetic resonance imaging documented cyst resolution and return of suprascapular nerve function after arthroscopic spinoglenoid cyst excision and labral repair.

Orthopaedic care of the aging athlete.

Abstract Increasing numbers of middle‐aged and older adults participate in sports, and athletes wish to remain active as they age. Understanding the anatomic, physiologic, and psychosocial differences between older and younger athletes can help aging athletes maintain function. Athletic capacity may be sustained well into advanced age, and many of the physiologic consequences of aging may be mitigated or reversed by regular exercise. Most injuries in older athletes are chronic and overuse injuries that result in diminished flexibility and endurance. In addition, many aging athletes have medical and musculoskeletal problems that mandate tailoring athletic activity to the patients general health and functional requirements.

Rheumatoid Arthritis of the Shoulder

&NA; Rheumatoid arthritis affecting the shoulder region is a progressive disorder that results in pain, loss of range of motion, and functional disability. The inflammatory response, which is of unknown etiology, results in synovitis, pannus formation, and articular destruction. Even when patient history and physical examination suggest rheumatoid involvement of the shoulder, laboratory assessment and radiographic evaluation often are necessary to establish the diagnosis. Nonsurgical management is the primary treatment, including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability. Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief. The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues.

The effect of posterior sag on the fixation stability of intertrochanteric hip fractures

BACKGROUND This study evaluates the effects of posterior sag on the fixation stability of intertrochanteric hip fractures. METHODS A simulated, two-part intertrochanteric fracture was created in human cadaveric femurs. One of each pair was stabilized using a sliding hip screw in anatomic reduction and the other in 30 degrees of posterior sag. Measurements for load versus inferior head displacement, gapping, and shearing were made in axial and torsional loading. RESULTS Initial axial and torsional loading showed no significant differences between the two groups. During cyclic loading, the osteotomy gap in the posteriorly angulated specimens decreased by 0.11 cm at 10 cycles (p = 0.006) and by 0.22 cm at 10,000 cycles (p = 0.33), corresponding to a 2-degree and 6-degree reduction in sag angle. Axial stiffness differed between the two groups: 10.3 N/mm for anatomic versus 6.7 N/mm (p = 0.002) for posteriorly angulated specimens. Loading to failure demonstrated no significant differences between the two groups. CONCLUSION This study demonstrated that 30 degrees of posterior sag does not result in a significant difference in construct strength or stability.

Granulomatous Inflammation After Hylan G-F 20 Viscosupplementation of the Knee

Background: Recently, intra-articular viscosupplementation with hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. Mild pain or swelling at the site of injection may occur in up to 20% of patients, although severe local inflammation, warmth, and joint effusion are rare. We present a series of six cases in which granulomatous inflammation of the synovium was observed after hyaluronate viscosupplementation of the knee. Methods: Six knees (five patients) treated with intra-articular Hylan G-F 20 viscosupplementation underwent a surgical procedure because of persistent symptoms. Routine histopathological evaluation, supplemented by alcian-blue staining and hyaluronidase digestion, was performed in each case. Results: Chronically inflamed synovium with areas of histiocytic and foreign-body giant-cell reaction was observed surrounding acellular, amorphous material. The material stained with alcian blue, a stain for hyaluronate, which disappeared after hyaluronidase digestion. Conclusions: We believe that the injected hyaluronate (Hylan G-F 20) may have been responsible for the synovitis in our patients and thus may be a pathological cause of recalcitrant symptoms after such injection. It is not known whether the responsible pathological agent was the hyaluronate derivative, a contaminant of the purification process, or a component of the carrier substance. Importantly, it appears that the findings in these patients most likely represent a previously unreported pathological response to a viscosupplementation product. This report should raise clinical awareness about this potential complication.