Chao-Ching Chiang

Distal linear osteotomy compared to oblique diaphyseal osteotomy in moderate to severe hallux valgus.

Background: There are no comparative studies of proximal and distal osteotomy for treatment of moderate to severe hallux valgus. Our purpose was to compare the surgical outcomes of modified proximal Ludloff (oblique diaphyseal) osteotomy with modified distal Bösch (distal linear) osteotomy by a single surgeon in moderate to severe hallux valgus. Methods: This retrospective study included feet with a hallux valgus angle greater than 30 degrees. A total of 30 feet (average age, 64.5 years) underwent Ludloff and 32 feet (average age, 61.1 years) underwent Bösch osteotomy. Both osteotomies were combined with distal soft tissue procedure. Clinical outcomes including AOFAS score and satisfaction rate were compared and radiographic parameters analyzed at 2 years of followup. Results: AOFAS scores were equivalent (p = 0.483), with comparable satisfaction rates in both groups (p = 0.418). The radiographic results including hallux valgus angle (p = 0.026), intermetatarsal angle 1-2 (p < 0.001), sesamoid position (p = 0.008), correction of intermetatarsal angle 1-2 (p < 0.001), and change of sesamoid position (p < 0.001) were significantly better in the Bösch group. Correction of hallux valgus angle (p = 0.308) and shortening of the first metatarsal (p = 0.086) were insignificant with the numbers available. Recurrence developed in eight feet of the Ludloff group and two of the Bösch group (p = 0.040). Dorsiflexion malunion occurred in four feet in the Bösch group, as compared with one in the Ludloff group. Conclusion: Our study found that distal linear osteotomy was a more reliable reconstruction with equivalent function outcomes than an oblique diaphyseal osteotomy. Additional fixation may be necessary to decrease sagittal malunion in distal Bösch osteotomy. Level of Evidence: III, Retrospective Comparative Study

Effectiveness of plate augmentation for femoral shaft nonunion after nailing.

Background: Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger‐sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods: Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17–77 years). The mean period of nonunion after surgery was 20.0 months (range, 7–63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results: All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back‐out, axial or rotational malalignment, or deep infections. Conclusion: Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.

Cementation of Cross-linked Polyethylene Liner Into Well-Fixed Acetabular Shells Mean 6-Year Follow-Up Study

The purpose of this study was to evaluate retrospectively the outcomes of cementation of cross-linked polyethylene (PE) liner in a well-fixed metal shell in 23 hips with an average follow-up period of 6 years. The mean Harris hip score was 69.6 +/- 12 (range, 46-83) points preoperatively. The average postoperative follow-up was 72.3 months (range, 56-100 months). At the final follow-up, the mean Harris hip score was 95.5 +/- 3 (84-100) points. There was no change in the bone-shell interface. No new osteolytic lesions were identified. The lesions impacted with bone graft had united completely. The remaining osteolytic lesions had decreased in size. There was no recurrent osteolysis, hip dislocation, component migration, and failure at the cement-metal interface. The results of the current study revealed that cementation of cross-linked PE liner into a well-fixed shell provided good midterm durability.

Extracorporeally irradiated autograft-prosthetic composite arthroplasty using AML extensively porous-coated stem for proximal femur reconstruction: a clinical analysis of 14 patients.

Allograft‐prosthetic composite for reconstruction of the proximal femur after tumor excision is widely used as an alternative to megaprosthesis. To achieve greater biological fixation, we employed a long‐stem prosthesis that is cemented proximally into the extracorporeally irradiated autograft and press‐fit distally into the host femur without any supplementary plate fixation of the junction instead of the standard all‐cemented technique.

Shepherd's Crook Deformity of Polyostotic Fibrous Dysplasia Treated with Corrective Osteotomy and Dynamic Hip Screw

Fibrous dysplasia, a condition in which the skeleton fails to develop normally, is characterized by fibroblastic stroma and immature bone. Bowing of the long bones occurs frequently in the polyostotic form, and stress fractures often result. Shepherds crook deformity is a characteristic feature of fibrous dysplasia. The goal of its treatment is to obtain normal walking ability and relieve pain due to pathologic fracture secondary to the deformity; however, correction of the deformity is a surgical challenge. We present 2 cases of shepherds crook deformity treated with corrective osteotomy and a dynamic hip screw. Both cases showed good bone healing and no recurrent deformity. The gross deformities were corrected, and both patients were pain-free after operation.

Joint replacement in human immunodeficiency virus-infected patients.

Background: Human immunodeficiency virus (HIV)‐infected patients are at risk for bacterial and opportunistic infections with worsening immunosuppression. Methods: From June 2000 to January 2009, six patients who were diagnosed with HIV infection underwent 10 joint replacement procedures, including six total hip arthroplasties, two total knee arthroplasties, and one shoulder hemiarthroplasty. An ordinary dose of postsurgical‐empirical antibiotics was prescribed, with an average follow‐up period of 38.6 months. All prostheses of total knee arthroplasty and shoulder hemiarthroplasty were fixed with vancomycin‐impregnated bone cement. Results: The rate of postoperative infection for HIV infected patients is supposed to be higher than for HIV negative patients. However, in our institution, there have been no HIV‐ positive patients who have suffered postoperative infection. Conclusion: HIV‐positive patients can have excellent outcomes after undergoing various arthroplastic surgeries. This revelation, coupled with the advances in antiviral therapy that have helped to lengthen HIV patient lifespans, strongly suggests that these patients should receive arthroplastic surgery.

Comparison of a minimally invasive technique with open tension band wiring for displaced transverse patellar fractures

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure‐eight wiring through two‐paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow‐up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 ± 12.5 minutes for POMC group; greater degrees of flexion, 140.4 ± 6.1 for POMC group; better total range of motion, 139.6 ± 8.2 for POMC group; higher Lysholm scores, 93.6 ± 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures.

Diaphyseal Locking Hip Arthroplasty for Treatment of Failed Fixation of Intertrochanteric Hip Fractures

Between 1997 and 2004, 18 patients (8 men and 10 women, with a mean age of 73.2 years) with failed treatment of intertrochanteric hip fractures underwent hip arthroplasty as salvage procedures at our institution. Cementless, 5/8-porous coated, 6-in. primary diaphyseal locking femoral stems were used. Prospective follow-up ranging from 2 to 5 years (mean, 37.1 months) showed improvement of hip function without prosthesis loosening. Complications included 1 case of postoperative infection, 2 cases of dislocation, and 2 cases of stem subsidence. The clinical results were satisfactory. The 5/8-porous coated, 6-in. cementless femoral stems could be used in the salvage procedures for failed fixation of intertrochanteric hip fractures.

Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures

Background: Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures. Methods: This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications. Results: The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group. Conclusion: Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF. Level of Evidence: Level III, retrospective comparative study.

Cefuroxime-impregnated cement and systemic cefazolin for 1 week in primary total knee arthroplasty: An evaluation of 2700 knees

Background: Infection is one of the most devastating complications after primary total knee arthroplasty (TKA). Antibiotics‐impregnated cement has been used and proven effective in preventing deep infection. This study was to evaluate the long‐term results of using cefuroxime‐impregnated cement and systemic cefazolin for one week to assess their efficacy in preventing infection of primary TKA. Methods: From 1999 to 2007, 2700 cases of primary TKA were performed with cemented fixation of all patellar, tibial, and femoral components. Cefuroxime‐impregnated cement for fixation and systemic cefazolin for one week were selected in all cases. The average follow‐up period was 89 months (range, 40–140). The effects of this selected regime in the periprosthetic infection were evaluated. Results: A total of eight infections occurred after primary TKA, including five deep infections (0.19%) and three superficial infections (0.11%) in the 2700 knees. No loosening or osteolysis was noted. Conclusion: Comparable with other measurements, cefuroxime‐impregnated cement, accompany by systemic cefazolin for 1 week was shown to control postoperative deep infection to 0.19% (after primary TKA was performed in an operative setting without lamina flow and body exhaust suit).