Ayesha Abdeen

Allograft-Prosthesis Composite Reconstruction of the Proximal Part of the Humerus Functional Outcome and Survivorship

BACKGROUND Limb salvage following resection of a tumor in the proximal part of the humerus poses many challenges. Reconstructive options are limited because of the loss of periarticular soft-tissue stabilizers of the glenohumeral joint in addition to the loss of bone and articular cartilage. The purpose of this study was to evaluate the functional outcome and survival of the reconstruction following use of a humeral allograft-prosthesis composite for limb salvage. METHODS An allograft-prosthesis composite was used to reconstruct a proximal humeral defect following tumor resection in thirty-six consecutive patients at one institution over a sixteen-year period. The reconstruction was performed at the time of a primary tumor resection in thirty cases, after a failure of a reconstruction following a previous tumor resection in five patients, and following excision of a local recurrence in one patient. The mean duration of follow-up of the living patients was five years. Glenohumeral stability, function, implant survival, fracture rate, and union rate following the reconstructions were measured. Functional outcome and implant survival were analyzed on the basis of the amount of deltoid resection, whether the glenohumeral resection had been extra-articular or intra-articular, and the length of the humerus that had been resected. RESULTS One patient sustained a glenohumeral dislocation. Deltoid resection (partial or complete) resulted in a reduced postoperative range of motion in flexion and abduction but had no effect on the mean Musculoskeletal Tumor Society score. Extra-articular resections were associated with lower Musculoskeletal Tumor Society scores. All patients had either mild or no pain and normal hand function at the time of final follow-up. The overall estimated rate of survival of the construct, with revision as the end point, was 88% at ten years. There were three failures due to progressive prosthetic loosening that necessitated removal of the construct. Four patients required an additional bone-grafting procedure to treat a delayed union of the osteosynthesis site. CONCLUSIONS An allograft-prosthesis composite used for limb salvage following tumor resection in the proximal part of the humerus is a durable construct associated with an acceptable complication rate. Deltoid preservation and intra-articular resection are associated with a greater range of shoulder motion and a superior functional outcome, respectively.

Correlation between clinical outcome and growth factor pathway expression in osteogenic sarcoma

Multiple cell‐signaling ligands and receptors—including vascular endothelial growth factor (VEGF), insulin‐like growth factor (IGF), endothelial growth factor (EGF), v‐akt murine thymoma viral oncogene homolog (AKT), platelet‐derived growth factor (PDGF), mitogen‐activated protein kinase (MAPK), and 70‐kilodalton (kD) protein S6 kinase (p70S6 kinase)—reportedly are variably expressed in osteogenic sarcoma. Expression of these proteins may have future implications for prognostication and targeted therapy. The objective of the current study was to determine the relation between clinical outcome and the expression of these proteins.

Fifteen-Year to 19-Year Follow-Up of the Insall-Burstein-1 Total Knee Arthroplasty

This represents a 15-year to 19-year follow-up of 100 Insall-Burstein-I posterior-stabilized knee prostheses implanted in 86 patients from 1986 to 1989 and originally reported at 10 to 12 years (Thadani et al, 2000). In the original cohort, 6 failures occurred by 10 years. At 15 to 19 years, 55 patients (66 knees) had died; 18 patients were followed with clinical examination and radiographs, and 11 by telephone; 3 knees in 2 patients were lost. There were no new failures or additional surgeries from 10 to 19 years. Three knees exhibited osteolytic lesions. No case required revision due to symptomatic osteolysis or polyethylene wear. Using revision as end point, survival was 92.4% at 19 years. In summary, the prosthesis is likely to outlive the patients when classic indications for age and activity are respected.

Allograft-prosthesis composite reconstruction of the proximal part of the humerus: surgical technique.

BACKGROUND Limb salvage following resection of a tumor in the proximal part of the humerus poses many challenges. Reconstructive options are limited because of the loss of periarticular soft-tissue stabilizers of the glenohumeral joint in addition to the loss of bone and articular cartilage. The purpose of this study was to evaluate the functional outcome and survival of the reconstruction following use of a humeral allograft-prosthesis composite for limb salvage. METHODS An allograft-prosthesis composite was used to reconstruct a proximal humeral defect following tumor resection in thirty-six consecutive patients at one institution over a sixteen-year period. The reconstruction was performed at the time of a primary tumor resection in thirty cases, after a failure of a reconstruction following a previous tumor resection in five patients, and following excision of a local recurrence in one patient. The mean duration of follow-up of the living patients was five years. Glenohumeral stability, function, implant survival, fracture rate, and union rate following the reconstructions were measured. Functional outcome and implant survival were analyzed on the basis of the amount of deltoid resection, whether the glenohumeral resection had been extra-articular or intra-articular, and the length of the humerus that had been resected. RESULTS One patient sustained a glenohumeral dislocation. Deltoid resection (partial or complete) resulted in a reduced postoperative range of motion in flexion and abduction but had no effect on the mean Musculoskeletal Tumor Society score. Extra-articular resections were associated with lower Musculoskeletal Tumor Society scores. All patients had either mild or no pain and normal hand function at the time of final follow-up. The overall estimated rate of survival of the construct, with revision as the end point, was 88% at ten years. There were three failures due to progressive prosthetic loosening that necessitated removal of the construct. Four patients required an additional bone-grafting procedure to treat a delayed union of the osteosynthesis site. CONCLUSIONS An allograft-prosthesis composite used for limb salvage following tumor resection in the proximal part of the humerus is a durable construct associated with an acceptable complication rate. Deltoid preservation and intra-articular resection are associated with a greater range of shoulder motion and a superior functional outcome, respectively.

Telescope Allograft Method to Reconstitute the Diaphysis in Limb Salvage Surgery

AbstractWe propose a surgical technique for structural allograft reconstitution of the diaphysis of long bones, maximizing surface contact between host and allograft bone. This method, analogous to a telescope, overlaps the graft and host bone, theoretically increasing bone surface contact substantially. We report the outcome of 22 telescoped allograft junction sites in 19 patients who lacked sufficient host bone to accommodate a regular-length stemmed implant. This joint-sparing reconstruction preserved 15 of 16 adjacent joints at risk for replacement. Five patients needed additional surgery, but none for nonunion. The diaphyseal length could be reconstructed enough so that a short prosthesis (less than the critical 40% of total bone length) could be used. This biologic method to reconstruct major segments of the diaphysis is best suited for patients with quantitatively or qualitatively deficient residual bone stock after tumor resection or prosthetic revision. We believe it is an excellent technique for revision knee megaprostheses when there is a short remnant of proximal femur. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Component Alignment in Revision Total Knee Arthroplasty Using Diaphyseal Engaging Modular Offset Press-Fit Stems

We performed a retrospective study of the radiographic position of femoral and tibial components in a series of revision total knee arthroplasties using diaphyseal-engaging, press fit, modular stems. Fifty-two consecutive revision cases were performed. Femoral and tibial component alignment was measured preoperatively and postoperatively. The canal-filling ratio was measured and correlated with anatomic alignment. There was a trend toward improved alignment with increasing canal fill, suggesting that uncemented diaphyseal engaging press-fit modular stems facilitate accurate alignment for both femoral and tibial components in revision surgery.

An unusual pathogen for prosthetic joint infection

In 2012, an 84-year-old Chinese man presented with progressive, chronic left atraumatic knee pain and swelling. His medical history was notable for pulmonary tuberculosis treated in China in 1951 and rheumatoid arthritis diagnosed in 2006. His joint pain progressed despite use of disease modifying drugs and steroid injections. Antitumor necrosis factor inhibitors were not used because of concerns of tuberculosis reactivation. Clinical examination showed he had antalgic gait, knee eff usion, stiff ness, and joint-line tenderness. Laboratory results included erythrocyte sedimentation rate of 88 mm/h and C-reactive protein of 205 mg/L. Radiographs showed severe tri-compartmental degenerative arthritis (fi gure A). The patient underwent total knee arthroplasty in August, 2012 (fi gure B). Extensive synovitis was noted and pathological examination showed granulomatous infl ammation (fi gure C). Staining of synovial tissue for acid-fast bacilli and tuberculosis PCR were negative. The patient’s knee symptoms initially improved, but 5 months after total knee arthroplasty he developed a draining sinus from the knee incision. He underwent irrigation and debridement of the knee with exchange of the polyethylene tibial insert. Initial synovial tissue fl uid cultures were negative, but subsequent acid-fast bacilli cultures from synovial tissue and joint fl uid grew Mycobacterium tuberculosis. Sputum cultures were negative for pulmonary tuberculosis. He started a course of antituberculosis therapy including rifampicin, isoniazid, pyrazinamide, and ethambutol for treatment of tuberculosis prosthetic joint infection in February, 2013. He was advised to undergo a two-stage resection-revision arthroplasty but declined further surgery and thus an implant retention strategy was pursued. The patient completed 12 months of antituberculosis therapy in February, 2014. He has since continued rifampicin and isoniazid treatment with a plan for long-term suppressive therapy in the setting of retained prosthesis. At his latest follow-up, 2 years after initial diagnosis of tuberculous prosthetic joint infection, the incision had healed without clinical sign of infection and his knee has a pain-free range of motion from 0–95°. Tuberculous arthritis accounts for 1–5% of people with tuberculosis. Scarce data are available for optimum management of tuberculous prosthetic joint infection. This case illustrates an unusual reactivation of tuberculosis in an isolated extra-pulmonary site after joint replacement surgery. Prompt initiation of antituberculosis therapy might enable implant retention, although continuation of suppressive therapy might be needed. In the setting of globalisation and the increasing use of immunomodulatory therapies and joint replacement surgeries, this case illustrates the need for tuberculosis to be thought about early in the diff erential diagnosis for culture-negative prosthetic joint infection in patients with previous exposures or epidemiological risk factors.

Fracture of a Tapered Femoral Neck After Total Hip Arthroplasty

Fracture of the femoral component after total hip arthroplasty is an uncommon event according to Swedish registry data1 and retrospective data in the United States2. Early monoblock components demonstrated fatigue fracturing through the implant stem3-5. Fracture through the tapered femoral neck is extremely rare, although it has been reported6-10. We describe a case of fracture through the tapered neck of a cementless femoral component that had been coupled with a skirted femoral head with a high neck length. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A sixty-one-year-old woman had undergone primary total hip arthroplasty with an uncemented prosthesis for osteoarthritis of the left hip in February 2004. The procedure had been performed at an outside institution. A modified Hardinge approach had been used. The components included a Meridian (Howmedica) uncemented size-4 femoral stem, a 32-mm femoral head with a +16-mm skirted neck length, a Trident (Howmedica) 54-mm hemispherical acetabular shell, and a 54/32-mm 10° liner. The femoral stem and head were both composed of forged Vitallium, an alloy consisting of 60% cobalt, 20% chromium, and 5% molybdenum, among other substances. This stem was only available in a standard offset and had a 30-mm neck length and a neck-shaft angle of 132°. The tapered neck was a V40 taper. As was routine for the surgeon who had performed the index procedure, the anterior third of the abductor was elevated off of the greater trochanter for exposure, and then repaired with two screw anchors. The index operative report stated that a skirted head with a +16-mm neck length was required to provide appropriate soft-tissue tension and stability of the construct. Documentation from the outside hospital did not mention a preoperative …

Coloarticular fistula: A rare complication of revision total hip arthroplasty.

Fistula formation between bowel and total hip arthroplasty or revision arthroplasty hardware is rare. We present a case of a 78-year-old woman with protrusio of left hip arthroplasty and acetabular reconstruction hardware that caused direct perforation of the sigmoid colon and fistula formation between the sigmoid colon and the left hip joint. The patient underwent several joint debridements, sigmoid colectomy, and removal of all orthopedic hardware; she ultimately died after two prolonged hospitalizations.

Improving communication between medical and surgical specialists using interspecialty education strategies: A mixed-methods study -

Objective: Poor communication between medical and surgical specialists negatively impacts patient care and represents a serious challenge for medical educators. The objective of this study was to measure the effect of a brief interspecialty education program on perceived communication between medical and surgical specialists at a US medical center. Methods: In 2011, an interspecialty education program (“Diagnosing Prosthetic Joint Infections”) was developed and administered by orthopaedic surgery (OS) and infectious diseases (ID) faculty to members of both divisions. The 60-minute program included a review of diagnostics followed by small mixed-group discussions about optimal diagnostic approaches. Surveys (immediately pre- and post-intervention) and a focus group (3 months post-intervention) assessed the impact of the program on interspecialty communication and collaboration. Results: Seventeen OS (41% of whom were trainees) and 13 ID (46% trainee) providers participated. Twenty-nine percent of OS and 62% of ID providers were female. Postintervention, the proportion of participants perceiving that “other” specialty providers were often “effective communicators” (p=0.014) and “effective collaborators” (p=0.025) increased. All participants believed interspecialty education would improve communication. Focus group participants perceived that the program improved interspecialty communication, organizational practice, and patient care. Conclusions: These findings demonstrate that brief interspecialty education programs can improve communication between medical and surgical specialists and could enhance patient care.