Arthur L. Malkani

Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma.

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

The Effect of Prehabilitation Exercise on Strength and Functioning After Total Knee Arthroplasty

The purpose of this study was to examine the effect of a preoperative exercise intervention on knee pain, functional ability, and quadriceps strength among patients with knee osteoarthritis before and after total knee arthroplasty (TKA) surgery.

Effect of ketamine on bispectral index and levels of sedation.

To the Editor: An electroencephalographic (EEG) variable, i.e., bispectral index (BIS), a numerical index ranging from 0 to 100, has been shown to correlate with sedation produced by midazolam, thiopental and propofol [1^3]. However, the relationship between levels of sedation produced by low-dose ketamine and BIS is not known.We assessed the relationship between levels of sedation produced by the administration of low-dose ketamine and BIS, as well as other EEG variables, i.e., relative alpha, beta, theta, and delta powers; and percentile frequencies (f95% and f50%), in 24 adult patients, age 19^46, ASA physical status I^II, scheduled for elective operations under general anesthesia. Informed consent was obtained. Patients with a history of substance abuse, patients taking psychotropic and/or opiate drugs, and those with psychiatric diseases or psychological problems were excluded. Premedication was omitted. Patients were randomly assigned to one of three groups: (1) those receiving ketamine 0.5 mg/kg (n = 8); (2) those receiving ketamine 0.25 mg/kg (n = 8); and (3) those receiving ketamine 0.1 mg/kg (n = 8). In the operating room, patients were asked to keep their eyes closed. After 5 min of quiet rest, ketamine was infused over a period of 20 s. The degree of sedation was assessed 2 min after the administration of ketamine using the observers assessment of alertness/ sedation (OAA/S) scale: 5 = responds readily to name spoken in normal tone; 4 = lethargic response to name spoken in normal tone; 3 = responds only after name is called loudly and/or repeatedly; 2 = responds only after mild prodding or shaking; and 1 = does not respond to mild prodding or shaking. The EEG variables were monitored continuously using an A-1000 EEG Monitor (version 3.0 algorithm) and Zipprep selfprepping disposable electrodes (Aspect Medical Systems, Inc., Natick, MA) in the bifrontal montage (FP1^FPZ and FP2^FPZ) with impedance under 5 K . The data were recorded using a Lifebook-635T (Fujitsu, Tokyo, Japan) until shortly after thiopental induction and endotracheal intubation. Data on EEG variables were analyzed using ANOVA for repeated measures and adjusted p-value for multiple tests using the Holms sequential rejection algorithm, and data on OAA/S scores were analyzed using KruskalWallis test. There was a dose-dependent decrease in the OAA/S score. There was no correlation between BIS and levels of sedation or dose of ketamine (Table 1). However, the relative theta power increased signi¢cantly after injection of ketamine (p < 0.05, adjusted p-value), and there were correlations between levels of sedation and the increase in the relative theta power as well as dose of ketamine (r = ÿ0.57, p < 0.005 and r = ÿ0.61, p < 0.002, respectively). There was a signi¢cant reduction in the relative delta power (p < 0.05). The reduction in the relative delta power correlated with the dose of ketamine (r = 0.43, p < 0.05) but not with the levels of sedation. These results suggest that the levels of sedation after the administration of low-dose ketamine alone do not correlate with the BIS. Our results, however, suggest that, as was shown previously [4], the levels of sedation induced by low-dose ketamine may correlate with the changes in theta power.

Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients.

The purpose of the present study is to determine the differences in cost, complications, and mortality between knee arthroplasty (TKA) patients who stay the standard 3-4 nights in a hospital compared to patients who undergo an outpatient procedure, a shortened stay or an extended stay. TKA patients were identified in the Medicare 5% sample (1997-2009) and separated into the following groups: outpatient, 1-2 days, 3-4 days, or 5+ days inpatient. At two years, costs associated with the outpatient and the 1-2 day stay groups were

Comparison of Intravenous versus Topical Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

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Prehabilitation Before Total Knee Arthroplasty Increases Strength and Function in Older Adults With Severe Osteoarthritis

1967 lower than the 3-4 day stay group, respectively. Out to 2 years, the outpatient and 1-2 day stay groups reported less pain and stiffness, respectively, though the 1-2 day group also had a higher risk for revision.

Decreased Dislocation After Revision Total Hip Arthroplasty Using Larger Femoral Head Size and Posterior Capsular Repair

The purpose of this study was to compare the efficacy of topical Tranexamic Acid (TXA) versus Intravenous (IV) Tranexamic Acid for reduction of blood loss following primary total knee arthroplasty (TKA). This prospective randomized study involved 89 patients comparing topical administration of 2.0g TXA, versus IV administration of 10mg/kg. There were no differences between the two groups with regard to patient demographics or perioperative function. The primary outcome measure, perioperative change in hemoglobin level, showed a decrease of 3.06 ± 1.02 in the IV group and 3.42 ± 1.07 in the topical group (P = 0.108). There were no statistical differences between the groups in preoperative hemoglobin level, lowest postoperative hemoglobin level, or total drain output. One patient in the topical group required blood transfusion (P = 0.342). Based on our study, topical Tranexamic Acid has similar efficacy to IV Tranexamic Acid for TKA patients.

Cross-Sectional Geometry of the Sacral Ala for Safe Insertion of Iliosacral Lag Screws : A Computed Tomography Model

Swank, AM, Kachelman, JB, Bibeau, W, Quesada, PM, Nyland, J, Malkani, A, and Topp, RV. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. J Strength Cond Res 25(2): 318-325, 2011-Preparing for the stress of total knee arthroplasty (TKA) surgery by exercise training (prehabilitation) may improve strength and function before surgery and, if effective, has the potential to contribute to postoperative recovery. Subjects with severe osteoarthritis (OA), pain intractable to medicine and scheduled for TKA were randomized into a usual care (UC) group (n = 36) or usual care and exercise (UC + EX) group (n = 35). The UC group maintained normal daily activities before their TKA. The UC + EX group performed a comprehensive prehabilitation program that included resistance training using bands, flexibility, and step training at least 3 times per week for 4-8 weeks before their TKA in addition to UC. Leg strength (isokinetic peak torque for knee extension and flexion) and ability to perform functional tasks (6-minute walk, 30 second sit-to-stand repetitions, and the time to ascend and descend 2 flights of stairs) were assessed before randomization at baseline (T1) and 1 week before the subjects TKA (T2). Repeated-measures analysis of variance indicated a significant group by time interaction (p < 0.05) for the 30-second sit-to-stand repetitions, time to ascend the first flight of stairs, and peak torque for knee extension in the surgical knee. Prehabilitation increased leg strength and the ability to perform functional tasks for UC + EX when compared to UC before TKA. Short term (4-8 weeks) of prehabilitation was effective for increasing strength and function for individuals with severe OA. The program studied is easily transferred to a home environment, and clinicians working with this population should consider prehabilitation before TKA.

Supracondylar distal femoral nonunions treated with a megaprosthesis in elderly patients: A report of two cases

The purpose of this study was to determine if the use of both a larger femoral head size and a posterior capsular repair would lead to a decreased incidence of dislocation following revision total hip arthroplasty (THA). Two hundred forty-two consecutive revision THAs with posterolateral approach were performed between 2000 and 2005. Group 1 had 132 revision THAs with posterolateral approach and 28-mm head size without posterior capsule repair. Group 2 had 100 revision THAs with a 32-mm head size and repair of the remaining hip capsule. There were no statistically significant differences in the two groups. Group 1 had 14 dislocations (10.6%). Group 2 had 3 dislocations (2.7%) (P < .05). Based on the results of this retrospective review, the authors recommend the use of both larger femoral head sizes and repair of any posterior capsular tissue available in patients undergoing revision hip arthroplasty.

Wear Analysis of First-Generation Highly Cross-Linked Polyethylene in Primary Total Hip Arthroplasty An Average 9-Year Follow-Up

OBJECTIVE To measure the dimensions of the narrowest portion of the sacral ala for safe insertion of iliosacral lag screws. DESIGN Computed tomography (CT) model. SETTING Level One trauma center. PATIENTS Thirteen adult patients underwent pelvic CT imaging. MAIN OUTCOME MEASURE Axial CT scans of intact pelves were reformatted in the sagittal plane at three-millimeter intervals from the first sacral body (S1 body) to the sacroiliac (SI) joint. Computer analysis and measurements of sacral geometry were used to determine the narrowest portion of the bony sacral ala. The maximum height, maximum width, and slope of the sacral ala through its geometric center in cross-section were measured. RESULTS The narrowest portion of the sacral ala in all patients was consistently located at the junction between the sacral body and the alar wings, termed the sacral pedicle, directly cephalad to the first sacral foramen. The average slope of the sacral ala at the sacral pedicle was 45.08 degrees (range 25 to 65 degrees). The average maximum height at the geometric center in cross-section was 27.76 millimeters, and the average width was 28.05 millimeters. However, outside the geometric center there was a sharp decrease in height and width of the sacral ala that was in large part determined by its relative slope. CONCLUSION Although the cross-sectional geometry of the sacral ala is highly variable among patients, there is ample space for iliosacral screws. To ensure safe insertion, iliosacral lag screws must be positioned in the geometric center of the sacral ala to avoid extraosseous placement.