Brian P. Gladnick

Reduced cortical bone compositional heterogeneity with bisphosphonate treatment in postmenopausal women with intertrochanteric and subtrochanteric fractures.

Reduction of bone turnover with bisphosphonate treatment alters bone mineral and matrix properties. Our objective was to investigate the effect of bisphosphonate treatment on bone tissue properties near fragility fracture sites in the proximal femur in postmenopausal women with osteoporosis. The mineral and collagen properties of corticocancellous biopsies from the proximal femur were compared in bisphosphonate‐naive (−BIS, n = 20) and bisphosphonate‐treated (+BIS, n = 20, duration 7 ± 5 years) patients with intertrochanteric (IT) and subtrochanteric (ST) fractures using Fourier transform infrared imaging (FTIRI). The mean values of the FTIRI parameter distributions were similar across groups, but the widths of the parameter distributions tended to be reduced in the +BIS group relative to the −BIS group. Specifically, the widths of the cortical collagen maturity and crystallinity were reduced in the +BIS group relative to those of the −BIS group by 28% (+BIS 0.45 ± 0.18 versus −BIS 0.63 ± 0.28, p = 0.03) and 17% (+BIS 0.087 ± 0.012 versus −BIS 0.104 ± 0.036, p = 0.05), respectively. When the tissue properties were examined as a function of fracture morphology within the +BIS group, the FTIR parameters were generally similar regardless of fracture morphology. However, the cortical mineral:matrix ratio was 8% greater in tissue from patients with atypical ST fractures (n = 6) than that of patients with typical (IT or spiral ST) fractures (n = 14) (Atypical 5.6 ± 0.3 versus Typical 5.2 ± 0.5, p = 0.03). Thus, although the mean values of the FTIR properties were similar in both groups, the tissue in bisphosphonate‐treated patients had a more uniform composition than that of bisphosphonate‐naive patients. The observed reductions in mineral and matrix heterogeneity may diminish tissue‐level toughening mechanisms.

Does Vitamin D Status Affect the Attainment of In-Hospital Functional Milestones After Total Hip Arthroplasty?

Our study aims to identify the prevalence of low vitamin D status in patients undergoing total hip arthroplasty (THA) and to evaluate the association between serum vitamin D level and the attainment of in-hospital functional milestones. We collected data from patients who underwent THA and had preoperative serum vitamin D (serum 25-hydroxy vitamin D) levels measured. From 200 patients, 79 (39.5%) had low serum vitamin D (serum 25-hydroxy vitamin D <32 ng/mL). There were no associations between serum vitamin D level and the attainment of in-hospital functional milestones as well as length of hospital stay or perioperative complications after THA. Because low vitamin D status did not compromise the short-term functional outcomes after THA, surgery need not be delayed, but low vitamin D levels should be corrected once identified.

The Increased Total Cost Associated With Post-Operative Drains in Total Hip and Knee Arthroplasty

In a consecutive series of 536 unilateral primary total hip arthroplasties (THAs) and 598 unilateral primary total knee arthroplasties (TKAs), the use of a post-operative drain was associated with

Range of motion and function are not affected by increased post constraint in patients undergoing posterior stabilized total knee arthroplasty

538 additional cost per THA, and

Comparison of unipedicular and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures: A prospective randomised study

455 for TKA. The use of a drain increased hospital length of stay (LOS) for THA, but not for TKA. In both groups, the use of a drain increased estimated blood loss (EBL) and increased the amount of allogeneic blood transfused. Over the 10-week period, drain use was associated with a total cost of

Patellofemoral Crepitation and Clunk Following Modern, Fixed-Bearing Total Knee Arthroplasty

432,972 for our institution. Data from this study would favor a selective approach to the use of drains in primary joint arthroplasties.

Primary and coupled motions of the native knee in response to applied varus and valgus load

BACKGROUND Constrained primary total knee arthroplasty (TKA) can provide stability in the face of incompetent collateral structures or irreconcilable flexion-extension imbalances. However, little is known about its effect on overall knee range of motion (ROM). This study determines whether TKA with increased constraint affects postoperative ROM. METHODS Patients undergoing primary TKA using either posterior stabilized (PS) or constrained condylar knee (CCK) inserts were match-paired based on body mass index, preoperative ROM, and direction and severity of the coronal deformity, yielding 68 pairs. ROM and Knee Society Score (KSS) were obtained preoperatively and at 6 weeks, 4 months, and 1 year. RESULTS When the 68 matched pairs were considered, all outcome variables related to ROM between the PS and CCK groups at each of the postoperative intervals were similar. Additionally, both the individual items and combined scores of the KSS were similar between groups at all time points. CONCLUSIONS We demonstrate that the use of increased constraint does not affect ROM, relief of pain, or function after TKA. LEVEL OF EVIDENCE Level III (retrospective case-controlled study, based on prospectively collected data).

Assessment of Vertebral Curves Using the Manual Post-It® Technique.

This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures.

Comparison of unipedicular and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

Patellar crepitation and clunk (PCC) is an important and modifiable complication of total knee arthroplasty (TKA). We calculated the incidence of PCC using a modern fixed-bearing TKA prosthesis, assessed whether PCC is associated with knee range of motion, and determined if there were any radiographic variables associated with the development of PCC in this prosthetic design. Five hundred seventy primary TKAs were evaluated after a mean follow-up of 24 months (range 12-81). Thirty-four knees developed PCC (6%); 6 required arthroscopic debridement. With each degree increase in the flexion angle, the likelihood of developing PCC increased by 4.2%. The incidence of PCC was low but increased with postoperative flexion ≥ 110°. No radiographic parameters were associated with the development of PCC.

Comparison of unipedicular and bipedicularballoon kyphoplasty for the treatment of osteoporotic vertebralcompression fractures

BACKGROUND Knowledge of the complex kinematics of the native knee is a prerequisite for a successful reconstructive procedure. The aim of this study is to describe the primary and coupled motions of the native knee throughout the range of knee flexion, in response to applied varus and valgus loads. METHODS Twenty fresh-frozen cadaver knees were affixed to a six degree of freedom robotic arm with a universal force-moment sensor, and loaded with a 4Nm moment in varus and valgus at 0, 15, 30, 45, and 90° of knee flexion. The resulting tibiofemoral angulation, displacement, and rotation were recorded. RESULTS For each parameter investigated, the knee joint demonstrated more laxity at higher flexion angles. Varus angulation increased progressively from zero (2.0° varus) to 90 (5.2° varus) degrees of knee flexion (p<0.001). Valgus angulation also increased progressively, from zero (1.5° valgus) to 90 (3.9° valgus) degrees of knee flexion (p<0.001). At all flexion angles, the magnitude of tibiofemoral angle deviation was larger with varus than with valgus loading (p<0.05). CONCLUSIONS We conclude that the native knee exhibits small increases in coronal plane laxity as the flexion angle increases, and that the knee has generally more laxity under varus load than with valgus load throughout the Range of Motion (ROM). Larger differences in laxity of more than 2 to 3°, or peak laxity specifically during the range of mid-flexion, were not found in our cadaver model and are not likely to represent normal coronal plane kinematics. LEVEL OF EVIDENCE Level V, biomechanical cadaveric study.