Anthony J. Scillia

Snapping of the proximal hamstring origin: a rare cause of coxa saltans: a case report.

The term “snapping bottom” was initially used by Rask1 to describe subluxation of the long head of the biceps femoris tendon at the ischial tuberosity, in what we believe to be the only reported case of this phenomenon in the literature. This entity was discovered by reproduction of the snapping during active hip flexion and with direct palpation of the snapping long head of the biceps femoris tendon over the ischial tuberosity. After unsuccessful nonoperative treatment, a tenotomy was performed; all symptoms were alleviated. There are several etiologies of the snapping hip, “coxa saltans,” which include snapping of the iliotibial band or gluteus maximus over the greater trochanter, snapping of the the iliopsoas over the iliopectineal eminence, and intra-articular lesions2. However, subluxation of the proximal hamstring origin is rarely considered in the differential diagnosis. We present the case of a woman with coxa saltans caused by subluxation of the proximal hamstring origin over the ischial tuberosity. Institutional review board approval and the patients informed consent for publication of this information were obtained. A fifty-five-year-old female recreational tennis player presented to us with a one-year history of left buttock pain as well as audible snapping of the buttock when she bent at the hips. The symptoms began approximately one month after she sustained a hamstring strain while playing tennis. Because of the pain, she had been unable to return to athletic activities. Physical examination revealed tenderness at the hamstring origin. Full motion of the hips, knees, and back was present with no contractures. The patient reproduced the snapping with hip flexion of approximately 90° while she was in the standing position. The snapping was palpable at the ischial tuberosity and was audible. Pelvic radiographs showed no abnormalities. Magnetic resonance imaging (MRI) demonstrated a partial tear of the proximal …

Pediatric Anterior Cruciate Ligament Reconstruction A Systematic Review of Transphyseal Versus Physeal-Sparing Techniques

Background: Anterior cruciate ligament reconstruction is becoming more common in skeletally immature individuals, and it may be performed with transphyseal or physeal-sparing techniques. A number of studies have assessed the outcomes of these techniques, but there is a need to systematically evaluate the pooled data from these studies. Purpose: To compare the differences in demographics and outcomes of transphyseal and physeal-sparing techniques by assessing (1) demographics, (2) incidence of growth disturbances, and (3) graft survivorship in the pediatric population. Study Design: Systematic review. Methods: A thorough review of 3 databases was performed to identify all studies that evaluated outcomes after pediatric reconstruction based on transphyseal or physeal-sparing techniques. After completing our search and cross-referencing for additional sources, 43 reports were identified for this review. Reports were analyzed for differences in demographics as well as incidence of leg-length discrepancies, angular deformities, and graft survivorship. After review of manuscripts, 27 studies were included for review (21 transphyseal and 6 physeal-sparing studies). Results: Those who had transphyseal reconstruction were more likely to be female (39% vs 20%; P = .0001), while those with the physeal-sparing surgery were younger (12 vs 13.5 years of age; P = .0001). The transphyseal and physeal-sparing cohorts demonstrated similar incidence rates of leg-length discrepancies (0.81% vs 1.2%, respectively; P = .64) and angular deformities (0.61% vs 0%, respectively; P = .36). The transphyseal and physeal-sparing cohorts also showed similar rates of rerupture (6.2% vs 3.1%, respectively; P = .11). Conclusion: Although the study groups were not well matched with regard to age and sex, our results show that these surgical techniques have no differences in incidence of growth disturbances or graft survivorship. Younger males tend to undergo physeal-sparing reconstruction. Future research should focus on long-term outcome metrics with the physeal-sparing techniques, as there remains a paucity of studies regarding them.

Primary osteomyelitis of the acetabulum resulting in septic arthritis of the hip and obturator internus abscess diagnosed as acute appendicitis

The misdiagnosis of acute appendicitis is not uncommon. Rarely does infection of the triradiate cartilage imitate this entity. This case highlights an uncommon presentation of acetabular osteomyelitis as acute appendicitis and the severity of its sequelae. Like septic arthritis of the hip, acute appendicitis overtreatment is acceptable in part because of the complications resulting from delayed diagnosis and treatment. However, this case demonstrates the need to consider pelvic osteomyelitis and peripelvic infection in the differential diagnosis of appendicitis.

Acromioclavicular Joint Reconstruction

Our technique for acromioclavicular joint reconstruction provides a variation on coracoclavicular ligament reconstruction to also include acromioclavicular ligament reconstruction. An oblique acromial tunnel is drilled, and the medial limb of the gracilis graft, after being crossed and passed beneath the coracoid and through the clavicle, is passed through this acromial tunnel and sutured to the trapezoid graft limb after appropriate tensioning. Tenodesis screws are not placed in the bone tunnels to avoid graft fraying, and initial forces on the graft are offloaded with braided absorbable sutures passed around the clavicle.

Sexual Activity After Total Hip Arthroplasty: A Systematic Review of the Outcomes

BACKGROUND Total hip arthroplasty (THA) may have a marked positive impact on sexual activity. However, it is unclear how important regaining sexual activity is for patients undergoing THA or whether surgeons are aware of such concerns. The purpose of this systematic review was to evaluate the literature on the effect of THA on sexual activity before and after the procedure and to assess patient and surgeon perspectives. METHODS A search of 4 electronic databases yielded 10 reports between 1970 and 2015. Nine evaluated the effects of THA on sexual activity in 1694 patients who had a mean age of 57 years (range 17-98 years). Two studies evaluated the perspective of 337 surgeons. Metrics evaluated included differences in patient and surgeon perspectives, improvements in sexual activity, and differences in outcomes between men and women. RESULTS Seventy-six percent of patients identified hip arthritis as the primary cause of sexual problems with pain and stiffness being the most common complaints. Post THA, 44% of patients reported improvements in sexual satisfaction while 27% reported increased intercourse frequency. Patients returned to sexual activity at a mean 4-month post-THA. Eighty-six percent of surgeons rarely or never discuss sexual activity with their patients, and 61% believed that patients can resume sexual activity 1-month post-THA with many agreeing that certain positions were safer. CONCLUSION The outcomes of this systematic review suggest that THA is associated with improved sexual activities and is an important topic for patients. However, surgeons may spend less time than is desired by the patients on this subject pre- and post-THA.

Midterm Outcomes Following Total Knee Arthroplasty in Lupus Patients

BACKGROUND An increasing number of patients with systemic lupus erythematosus (SLE) are undergoing total knee arthroplasty (TKA), but there are few studies detailing their outcomes. The purpose of this study was to evaluate TKA cohort of patients who had SLE compared with a matched cohort who did not have this disease by analyzing (1) implant survivorship, (2) functional outcomes, (3) complication rates, (4) health-related quality of life, and (5) patient-perceived activity level. METHODS A retrospective review of all patients who underwent TKA and had an International Classification of Diseases, Ninth Revision, code diagnosis for SLE was performed at 3 high-volume institutions. A total of 31 patients (34 arthroplasties) were identified, and they were compared with a matched cohort (1:3) who did not have SLE and had undergone a primary TKA during this same time period. RESULTS After a mean 6-year follow-up (range, 2-10 years), both cohorts had similar implant survivorship (91% vs 99%). In addition, each cohort had similar complication rates (odds ratio = 1.9, 0.99-13). Functional outcomes were similar as measured by Knee Society Scores objective (90 vs 91 points) and functional (89 vs 90 points). There were no differences in Short Form-36 physical (47 vs 49 points) or mental components (51 vs 53 points). University of California Los Angeles activity scores were similar as well (5.1 vs 5.9 points). CONCLUSIONS Our study demonstrated comparable excellent clinical and patient-reported outcomes of TKA in patients with or without SLE. Prospective studies are necessary to evaluate these outcomes at longer follow-up.

Inpatient Cruciate Ligament Reconstruction in the United States: A Nationwide Database Study From 1998 to 2010

This study evaluated inpatient cruciate ligament reconstruction in the United States during a 13-year period. The Nationwide Inpatient Sample database was used to identify inpatient cruciate ligament reconstructions performed from 1998 to 2010. National trends in incidence, patient demographics, perioperative complications, length of stay, and total admission costs were evaluated. The impact of various contributing factors on these outcomes was further evaluated using multivariable regression analyses. The rate of inpatient cruciate ligament reconstruction has decreased significantly in the United States during the past decade. The outcome data from this study can be used as a comparison cohort for future outpatient analyses of anterior cruciate ligament reconstruction in the United States.

Symptomatic Heterotopic Ossification After Ulnar Collateral Ligament Reconstruction: Clinical Significance and Treatment Outcome.

Background: Ulnar collateral ligament (UCL) reconstruction is an increasingly common procedure being performed in overhead throwing athletes. Recently, postoperative imaging has revealed the presence of heterotopic ossification (HO) in symptomatic patients. Purpose: To determine the incidence of symptomatic HO after UCL reconstruction as well as the clinical outcomes after nonoperative or operative treatment of HO. Study Design: Case series, Level of evidence, 4. Methods: A search was performed of diagnostic codes for all UCL reconstructions at a single institution between 2002 and 2012, and the charts were then reviewed of patients who returned to clinic for symptomatic HO after UCL reconstruction. All relevant clinical information, imaging findings, and return-to-play data were obtained. Results: Eight patients were found to have developed symptomatic HO after UCL reconstruction. Of the 8 patients, 6 had gracilis tendon autograft at their primary surgery. All 8 patients had HO on the proximal end of their graft. Two patients were treated nonoperatively, and the remainder had excision of HO performed either arthroscopically or open. Six patients were able to return to the same or higher level of competition after treatment of HO. Conclusion: Symptomatic HO after UCL reconstruction is very uncommon but may prove to be a significant complication among athletes. With appropriate treatment, the majority of patients were able to return to the same level of play. Early identification of this complication is important, as revision surgery with excision of osteophytes resulted in a return to a similar level of play in most patients.

Does Manipulation under Anesthesia Increase the Risk of Revision Total Knee Arthroplasty? A Matched Case Control Study

Abstract Manipulation under anesthesia (MUA) can help patients regain an adequate range of motion (ROM) following total knee arthroplasty (TKA). Although there are studies reporting that MUA can assist in improving ROM, there is a paucity of studies regarding whether requiring an MUA is associated with an increased risk of revision. The purpose of this study was to assess the: (1) incidence of revision TKA and (2) outcomes of those undergoing MUA and compare it with a matched cohort who did not require MUA. A prospectively collected database of two high‐volume institutions was assessed for patients who required a single MUA following TKA between 2005 and 2011. We found a total of 138 knees with a mean 8.5‐year follow‐up post‐MUA. We compared this with a matched cohort (1:1) who underwent TKA during this same time period but did not require an MUA. Incidence of revision surgery and clinical outcomes were compared between the two cohorts. Within the MUA cohort, nine knees underwent revision, which was similar to the matched cohort that had seven revisions (93 vs. 95%; p = 0.6). The mean KSS‐functional (88 vs. 90 points; p = 0.15) and clinical scores (87 vs. 89 points; p = 0.1) were similar between the two cohorts. Undergoing an MUA was not associated with an increased risk of revision TKA. If patients require MUA, they may still achieve satisfactory outcomes. This information can be used in educating patients so they may be able to formulate their expectations following their MUA.

No Decrease in Knee Survivorship or Outcomes Scores for Patients With HIV Infection Who Undergo TKA

BackgroundHIV is prevalent worldwide and numerous patients with this diagnosis ultimately may become candidates for TKA. Although some studies have suggested that complications are more common in patients with HIV who undergo TKA, these studies largely were done before the contemporary era of HIV management; moreover, it is unclear whether patients with HIV achieve lower patient-reported outcome scores or inferior implant survivorship.Questions/purposesWe asked whether there were any differences in the outcomes of patients with HIV without hemophilia who undergo TKA compared with a matched control cohort in terms of: (1) patient-reported outcomes; (2) implant survivorship; and (3) complication rates.MethodsForty-five patients with HIV who had undergone 50 TKAs at three institutions with a minimum followup of 4 years between 2005 and 2011 were identified. An additional three patients were lost to followup before the fourth-year annual visit. All patients with HIV underwent thorough preoperative optimization with their primary care physician and infectious disease specialist. There were 31 men and 14 women with a mean age of 57 years and mean followup of 6 years (range, 4–10 years). These patients were compared with a matched cohort of 135 patients (one-to-three ratio) who did not have HIV and who had undergone a primary TKA by the same surgeons during this same period using the same implant. Matching criteria included patient age (within 2 years), BMI (within 2 kg/m2), surgeon performing TKA, followup (within 6 months), minimum followup of 4 years, sex ratio, and primary diagnosis (degenerative joint disease versus osteonecrosis). Approximately 10% of patients in the matching group had not returned for followup after their sixth annual visit. Outcomes evaluated included The Knee Society objective and function scores, University of California, Los Angeles (UCLA) activity scores, overall implant survivorship (free of revision) using Kaplan-Meier analysis, and complications. With the numbers available, there were no differences in preoperative Knee Society score or UCLA activity scores among the cohorts.ResultsWith the numbers available, there were no differences in the mean Knee Society objective scores between patients with HIV (89 ± 11 points) and the matching cohort (91 ± 14 points) (95% CI, −7 to 3; p = 0.38). There were no differences among the Knee Society functional component as well (88 ± 12 points versus 90 ± 13 points; 95% CI, −6 to 2; p = 0.36) at latest followup. Similarly, there were no differences with the numbers available in the UCLA activity scores (6 ± 5 points [range, 4–7] versus 6 ± 7 points [range, 4–8]; p = 0.87) between the cohorts. With the numbers available, Kaplan-Meier analysis showed no significant difference in the overall implant survivorships between patients with HIV (98%; 95% CI, 94%–99%) compared with the matching group (99%; 95% CI, 98%–100%; p = 0.89). Postoperative complications were also comparable between the two groups.ConclusionsWith the numbers available, we found that patients with HIV had no differences in clinical scores and implant survivorship compared with patients without the disease at mid-term followup. We believe practitioners should not be reluctant to perform TKA on this patient population. However, we believe the preoperative optimization process is crucial to achieving good outcomes and minimizing the risk of complications. Future comparative studies should have longer followup and a larger sample size with greater power to determine if there are differences in complications and implant survivorship.Level of EvidenceLevel III, therapeutic study.