Ely L. Steinberg

Preoperative planning of total hip replacement using the TraumaCad™ system

IntroductionTemplating is now the standard approach for preoperative planning of total joint replacement and fracture fixation. The aim of this study was to assess the accuracy of new software, TraumaCad™, for preoperative planning for total hip replacement.MethodsThis software enables the import and export of all picture archiving communication system (PACS) files from local working stations. It can integrate with all PACS systems. We retrospectively reviewed TraumaCad™-generated templates of digitalized preoperative radiographs of 73 consecutive patients.ResultsThe acetabular component, measured within ±1 size, was accurate in 65 patients (89%), and the femoral stem design component was accurate in 70 patients (97%). The accuracy of the femoral size was predicted in 57 patients within 1 size (87%) and in 65 patients within 2 sizes (96%) out of 68 patients in the Corail femoral component group. TraumaCad™ successfully predicts the sizes of femoral and acetabular component and easily integrates with all PACS files.

Comparative analysis of the benefits of autotransfusion of blood by a shed blood collector after total knee replacement

IntroductionJoint replacement is associated with massive blood loss. Various techniques have been used to avoid the use of allogeneic blood. One of the techniques used is postoperative salvage and reinfusion of shed blood that was found to reduce the use of banked blood with its potential risk.Materials and methodsWe prospectively studied 365 patients who underwent knee joint replacement (TKR) and were divided in two groups. Group A’s shed blood (SureTrans System) was collected (n=194) and reinfused and group B’s was not (n=171, “controls”). Hemoglobin levels before and after the operation were recorded.ResultsAllogeneic blood requirement for TKR decreased by 65% in group A compared to group B. The packed cell/patient index dropped from 0.91 to 0.29 in group 2A. Statistical analysis yielded the odds ratio for blood replacement, a “predicting formula” for blood replacement depending on hemoglobin levels, and a cutoff point for a patient’s receiving blood replacement.ConclusionWe recommend using this system in TKR for decreasing allogeneic blood replacement and potential associated risks. The predicting formula for blood replacement may be a helpful tool when making a decision of whether or not to use the collector system and for whom.

Clinical and Functional Outcome After Acetabular Labral Repair in Patients Aged Older Than 50 Years

PURPOSEnTo assess the clinical and functional outcome of labral repair in patients aged older than 50 years.nnnMETHODSnWe performed a prospective analysis of 20 patients aged older than 50 years who had undergone arthroscopic repair of a torn acetabular labrum (6 men and 14 women; mean age, 58 years). The indication for surgery was groin pain due to various causes with or without associated mechanical symptoms that did not respond to nonoperative treatment for more than 6 months. Intraoperatively, all patients were diagnosed with labral pathology. The mean duration of symptoms was 3.1 years (range, 0.5 to 15 years). The mean follow-up period was 22 months (range, 12 to 35 months). The outcome was prospectively measured with the modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS).nnnRESULTSnThe indication for surgery was femoroacetabular impingement (FAI) with cam deformity and a labral tear in 4 patients, FAI with pincer deformity and a labral tear in 1 patient, FAI with both deformities in 1 patient, a gluteus medius tear in 2 patients, and an isolated labral tear in 12 patients. Acetabular chondral lesions were present in 11 patients (55%). The mean preoperative and postoperative MHHS was 62.5 and 87.2, respectively (P < .001); the mean preoperative and postoperative HOS was 42.7 and 86.3, respectively (P < .001); and the mean preoperative and postoperative level of function during usual activities of daily living according to the HOS was 46.0% and 73.7%, respectively (P < .001). No significant difference was identified in MHHS and HOS between gender groups.nnnCONCLUSIONSnArthroscopic management of FAI and labral repair in patients aged older than 50 years without significant arthritis (Tönnis grade 1 or better) are associated with significant improvement in outcome. Because of the potential importance of the labrum for long-term hip joint integrity, we advocate repair of the labrum in patients aged older than 50 years when possible.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Predicting the need for blood transfusion in patients with hip fractures.

PurposeThe need for perioperative blood management measures aimed at improving patient outcomes and reducing allogenic blood transfusion (ABT) is increasingly recognised. Our study aim is to create an algorithm to predict and manage the need for blood transfusion in patients with hip fractures.MethodsWe retrospectively assessed 1,484 patients with hip fractures and analysed the probability of receiving an ABT within 72xa0hours of admission. Univariate, multiple logistic regression analysis and a probability algorithm for predicting the need for blood transfusion on the basis of independent multivariate predictors were used.ResultsSignificant predictors for ABT were: older age; lower haemoglobin on admission; female gender; type of surgical implant (cephalomedullary nail and dynamic hip screw more than hemiarthroplasty); and a shorter wait time from admission to surgery. A regression model algorithm correctly predicted the need for an ABT in 73xa0% of the cases.ConclusionAn algorithm and a simple clinical tool were devised to predict and manage the need for a blood transfusion within 72xa0hours of admission in patients with hip fractures.

Predictors for nonunion, reoperation and infection after surgical fixation of patellar fracture

IntroductionThe most common major complications following surgical fixation of patellar fractures are infection, nonunion and reoperation. In this study, we sought to define the predisposing factors to the development of these complications.MethodsOpen reduction and internal fixation surgeries for patellar fractures that were performed in a single institution between 2006 and 2011 were retrospectively reviewed. Patients demographic data (age, gender, comorbidities), injury and fracture data (associated injuries, type of fracture, open or closed fracture), surgical data (type of surgery and interval between fracture occurrence and surgery) and major postoperative complications (infection, nonunion, symptomatic hardware and revision surgery) were collected from the medical records and verified by a telephone survey. Correlation analysis identified the major variables influencing the development of these complications.ResultsThe cohort of 188 patients had an average follow-up of 908xa0days. Thirteen (6.9xa0%) patients developed infection, 3 (1.6xa0%) had fracture nonunion and 42 (22.3xa0%) required a second operation. A history of cerebrovascular accident (CVA) correlated significantly with the development of infection (OR 6.18, CI 1.1–35.6, pxa0=xa00.041) and nonunion (OR 14.9, CI 1.2–188.1; pxa0=xa00.037). A history of diabetes significantly increased the risk of a second operation (OR 8.69, CI 95xa0% 1.8–41.9, pxa0=xa00.007). Open fracture did not increase the risk of any of these complications.ConclusionsA history of CVA and diabetes mellitus significantly increased the risk of complications following patellar fracture fixation. Patients with these comorbidities should be informed of their increased risk of these complications and be followed up more rigorously.

Dynamic locking plate vs. simple cannulated screws for nondisplaced intracapsular hip fracture: A comparative study

INTRODUCTIONnIntracapsular hip fractures (ICHF) are a common cause of morbidity and mortality and pose a great economic burden on the health care systems. Appropriate surgical treatment requires balancing optimal outcomes with the cost of treatment to the health care system. While in elderly patients with displaced ICHF arthroplasty became the standard of care, the internal fixation method for conserving the femoral head in younger patients or in nondisplaced ICHF is still in debate. We compared a dynamic locking plate with the standard cancellous cannulated screws (CCS) for treatment of nondisplaced ICHF.nnnMETHODSnAll patients treated with internal fixation for nondisplaced ICHF between July 2009 and December 2012 at our level one trauma center were included in this study. Patients treated with Targon FN (Aesculap) implants and CCS (Synthes) were compared. Charts were reviewed for demographics, intraoperative data and peri/post operative complications retrospectively. Radiographical analysis, pain (VAS), quality of life (SF12) and function (MHHS) data were prospectively gathered.nnnRESULTSnOne hundred and fifteen non-displaced ICHFs were treated with internal fixation, 81 with CCS and 34 with Targon FN implant; the mean follow-up was 19 and 28 months, respectively. Group fracture characteristics (Garden/Powel classification), and demographics, excluding age, were not significantly different. Post-operative revision rates of the Targon FN and CCS groups, perioperative complications were not statistically different (p>0.05). Quality of life (SF-12), function (Modified Harris Hip Score) and Visual Analogue Scale (VAS) pain scores were not statistical different.nnnCONCLUSIONSnComplication rates and clinical outcomes for the treatment of nondisplaced ICHF with Targon FN and SCC showed no significant differences. Based on this evidence in consideration of the substantial cost differential between the Targon FN and SCC we suggest SCC for treatment of nondisplaced ICHF.nnnLEVEL OF EVIDENCEnIII.

Capsular closure does not affect development of heterotopic ossification after hip arthroscopy.

PURPOSEnThe purpose of this study was to evaluate the role of capsular closure after hip arthroscopy in reduction of the incidence of heterotopic ossification (HO).nnnMETHODSnOne hundred (50 study group, 50 control group) consecutive hip arthroscopy procedures with radiographic follow-up of more than 9 weeks were included in the study. The study group consisted of 50 patients in whom capsular closure with 2 No. 1 polydioxanone (PDS) sutures was performed, and a control group consisted of 50 patients in whom the capsule remained open after capsulotomy. HO was assessed by radiographs using the Brooker classification. Statistical analysis of the data was carried out with the χ-square or Fisher exact test and Student t test, when appropriate, at a significance level of .05.nnnRESULTSnThirty-six (36%) patients had radiographic evidence of postoperative HO (14 patients in the capsular closure group). No significant difference was found regarding sex, side of operation, age, or HO rate between the study and the control groups (P = .778, P = .123, P = .744, and P = .144, respectively). Furthermore, no significant difference was found in the rate of HO with potential clinical significance (Brooker classification > I) between the control and study groups (P = .764).nnnCONCLUSIONSnCapsular closure did not seem to alter the rate of HO when compared with a control group of patients in whom the capsulotomy was not repaired.nnnLEVEL OF EVIDENCEnLevel III, retrospective comparative study.

The impact of serum albumin and serum protein levels on POSSUM score of patients with proximal femur fractures

BACKGROUNDnPOSSUM was developed to predict risk-adjusted mortality and morbidity rates for surgical procedures. We evaluated the impact of serum albumin and serum protein levels on POSSUM scores.nnnMETHODSnMedical files of 2269 patients operated for proximal femur fractures were reviewed. Preoperative serum albumin levels were available for 387 patients (mean 35.1g/l, range 22-49) and serum protein levels for 279 patients (mean 61.6g/l, range 40-86).nnnRESULTSnSerum albumin and protein levels were inversely associated with mortality in multivariate models (albumin, OR=0.89, p=0.009; protein, OR=0.92, p=0.009) and in composite outcome models as well (albumin, OR=0.955, p=0.219, protein, OR=0.94, p=0.014). The area under the curve (AUC) for POSSUM prediction of mortality (n=1770) was 0.632 (95% CI: 0.580-0.684, p<0.001). The AUC for a model including serum protein levels was 0.742 (95% CI: 0.649-0.834, p<0.001). Hospitalisation time was longer for patients with lower serum proteins levels (p=0.045), with an inverse correlation (Pearson correlation -0.164, p=0.011).nnnCONCLUSIONSnLower preoperative serum albumin and serum protein levels were associated with increased risk for mortality, increased hospitalisation time and poorer outcomes in patients operated for proximal femoral fractures. Including those values to POSSUM scores would increase their predictive power.

The femoral head expandable peg: improved periimplant bone properties following expansion in a cadaveric model.

PurposeThe femoral head expandable peg offers a new concept of bone-device purchase treating proximal femur fractures. We describe the expansion influence on both the periimplant bone properties and the intraosseous pressure.MethodsA 10xa0×xa08xa0mm cannulated peg consisting of a stainless steel oval-shaped transversely sectioned rod was tested on 13 femoral heads retrieved from patients with subcapital fracture treated by hemiarthroplasty. Normal saline solution was used to expand the diameter of its membrane from 7.8 to 10.5xa0mm, resulting in abutment of the distal peg to the compacted cancellous bone of the femoral head. The intraosseous pressure was monitored using a 1.4xa0mm drill-hole.ResultsDual-energy X-ray absorptiometry and microradiography demonstrated increased periimplant bone density following peg expansion, without significant increase in the intraosseous pressure.ConclusionThe new implant afforded improved periimplant bone density, less trabecular damage and preservation of bone stock, all contributing to reliable biomechanical support and potentially decreasing the high complication rate following screw fixation in osteoporotic femora. Further studies are needed in order to establish clinical safety and efficacy.

Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy

PurposePartial patellectomy (PP) and reattachment of the patellar ligament with transosseous suturing is the mainstay of surgical treatment for distal pole patellar fractures. An anchor suturing (AS) technique has recently been reported as an alternative to PP in such fractures and allows for bone-to-bone interface and possibly superior fracture healing than bone-to-tendon interface with PP. We present our experience with AS and compare it to PP.MethodsBetween 2006 and 2011, 60 patients with distal pole patellar fracture underwent either AS (nu2009=u200927) or PP (nu2009=u200933). We retrospectively gathered their demographic data and information on fracture type, fixation technique, operation time, postoperative complications and knee range of motion. A telephone survey was performed to grade functional outcomes with standard questionnaires (the SF-12 for quality of life, the Kujala score for patellofemoral function and a visual analog scale [VAS] pain score).ResultsAS was equivalent to PP in terms of residual pain and functional outcomes (VAS: 2.45 vs. 2.26, pu2009=u20090.83 and Kujala score: 74.3 vs. 69, pu2009=u20090.351, respectively) as well as for knee range of motion. Complications included three cases of infection in each group, two cases of early hardware failure and one case of non-union in the AS group. Operation time was significantly shorter for AS compared to PP (68.5 vs. 79.1xa0min, pu2009=u20090.03).ConclusionsAS is non-inferior to PP for function and pain after distal pole patellar fractures and is superior to PP with regard to operative time. Common complications of this technique are hardware failure and infections.Level of evidenceTherapeutic Level III