Jared R.H. Foran

Characterization of the symptoms associated with dural ectasia in the Marfan patient.

Dural ectasia, an expansion of the dural sac surrounding the spinal cord, is one of the most common orthopedic manifestations of Marfan syndrome. The purpose of the present study was to characterize the clinical symptoms associated with dural ectasia in patients with Marfan syndrome and to understand the effects of symptomatic dural ectasia on the overall health of affected patients. Twenty‐two volunteers aged 9–55 years with Marfan syndrome, and dural ectasia diagnosed by MRI or CT, filled out a “symptoms” questionnaire and completed an SF‐36 health survey. Overall, It appears that the symptoms associated with dural ectasia have a marked impact on the overall health of patients with Marfan syndrome. Based on our findings, a “classic” picture of dural ectasia in the Marfan patient may consist of low back pain, headache, proximal leg pain, weakness and numbness above and below the knee, and genital/rectal pain. Symptoms, when present, are typically moderate to severe, occur several times per week (often daily), are commonly exacerbated by upright posture, and are not always relieved by recumbency.

Protrusio acetabuli in Marfan syndrome: Age-related prevalence and associated hip function

BACKGROUND Protrusio acetabuli is known to occur in patients with Marfan syndrome, but its prevalence, its effects on hip function, and its possible association with the subsequent development of degenerative hip disease have not been studied in a large population. Nevertheless, some clinicians have recommended prophylactic hip surgery for preadolescents with Marfan syndrome and protrusio acetabuli. METHODS We performed a cross-sectional study of 173 patients (346 hips) with Marfan syndrome who were interviewed and examined for calculation of the Iowa hip score. Anteroposterior radiographs of the pelvis were made, and two radiographic indices of acetabular depth were measured: (1) the center-edge angle of Wiberg and (2) the acetabular-ilioischial distance. The presence of protrusio was defined with use of two extant definitions: (1) a center-edge angle of >50 degrees or (2) an acetabular-ilioischial distance of >/=3 mm in male patients or >/=6 mm in female patients. Linear regression analyses were performed between these radiographic indices of acetabular depth and patient age, Iowa hip scores, the magnitude of the radiographic joint space, and range of motion. RESULTS The prevalence of protrusio acetabuli was 27% according to the center-edge angle criterion and 16% according to the acetabular-ilioischial distance criterion. The prevalence of protrusio increased until the age of twenty years and remained stable after the age of twenty years. Slight but significant negative correlations were detected between the two radiographic indices of acetabular depth and both the Iowa hip score and the summed range of motion (p < 0.02 for all). No significant relationship was found between the two radiographic indices and pain scores. In patients with Marfan syndrome who were more than forty years old, the Iowa hip scores for hips with protrusio were not significantly lower than those for hips without protrusio. CONCLUSIONS In patients with Marfan syndrome, the prevalence of protrusio acetabuli increases during the first two decades of life and then plateaus in terms of both population-wide prevalence and radiographic severity. In this population, protrusio generally is not associated with severely problematic hip function but it is associated with slightly decreased range of motion of the hip. We concluded that prophylactic surgical intervention is not indicated for most patients with Marfan syndrome who have a radiographic diagnosis of protrusio.

Arthrofibrosis Associated With Total Knee Arthroplasty

BACKGROUND Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patients ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Early aseptic loosening with a precoated low-profile tibial component: a case series.

Between March 2007 and December 2008, we performed 529 consecutive total knee arthroplasties in 460 patients with the Zimmer (Warsaw, IN) NexGen MIS Tibial Component using a minimally invasive approach. Eight knees in 8 patients (1.5%) were revised for early aseptic loosening of the tibial component despite normal initial postoperative radiographs. Several additional patients have concerning radiographic signs of pending failure. The mean time to revision was 17 months (range, 9-31 months). Intraoperatively, in all cases, more than 50% of the tibial tray was devoid of cement and factory-applied polymethylmethacrylate. Our experience with early aseptic loosening of this tibial component has led us to discontinue its use until the etiology of the high early failure rate is able to be determined.

Patient perception of physician reimbursement in elective shoulder surgery

BACKGROUND A previous study revealed that patients perceived physician reimbursement to be much higher than current Medicare schedules for hip and knee replacement. The purpose of this study was to evaluate patient perception of surgeon reimbursement for total shoulder replacement (TSA) and rotator cuff repair (RCR). METHODS The study surveyed 250 patients. Patients were asked what they believe a surgeon should be reimbursed for performing TSA and RCR. Patients were then asked to estimate what Medicare reimbursed for each of these procedures. We then revealed the Medicare reimbursement rate for TSA and RCR, and patients were asked to comment. Finally, patients were asked whether surgeons with advanced shoulder training should receive additional payments. RESULTS Patients thought that surgeons should receive

Postsurgical bleeding following treatment of a chronic Morel-Lavallée lesion.

13,178 for TSA and

Prevalence, risk factors, and management of proximal femoral remodeling in revision hip arthroplasty.

8459 for RCR. Patients estimated actual Medicare reimbursement was

The Inter-Observer and Intra-Observer Reliability of the Paprosky Femoral Bone Loss Classification System

7177 for TSA and

Hip Resurfacing and Conventional THA: Comparison of Acetabular Bone Stock Removal, Leg Length, and Offset

4692 for RCR. Eighty percent of patients stated that Medicare reimbursement was too low for TSA, 75% thought that payment for RCR was lower than what it should be. Less than 1% of patients felt that it was higher than it should be. A total of 87% of patients thought that surgeons with advanced shoulder training should be reimbursed at a higher rate. CONCLUSION Patients perceived the values of TSA and RCR were much higher than current Medicare schedules. This is in agreement with prior surveys. Continued decreases in Medicare reimbursements may force surgeons to not participate in Medicare and create a potential access issue. Further investigation should focus on identifying how many surgeons may opt out.

Protrusio acetabuli and total hip arthroplasty in patients with Marfan syndrome.

Morel-Lavallée lesions are closed soft-tissue degloving injuries that occur when the skin and subcutaneous tissues are separated from underlying fascia as a result of a sudden shearing force. The space that is created has the potential to be filled with a mixture of blood, lymph fluid, or necrotic fat, which may easily become infected. The optimal treatment of Morel-Lavallée lesions is controversial. We present a case of a 29-year-old man who sustained pelvic fractures in a motorcycle accident and 1 year later presented with a painless, slowly expanding left thigh mass. Treatment, consisting of open debridement and primary closure, was complicated by significant postoperative bleeding requiring reoperation. The patient was followed clinically as an outpatient, and at 6-month follow-up he was doing well and had no evidence of recurrence of the lesion. Morel-Lavallée lesions are rare complications that are often missed or underappreciated at the time of initial injury. In many cases these lesions can persist for months before they are recognized. For long-standing Morel-Lavallée lesions, it is important to determine the nature of the fluid in the cavity before planning treatment. In the current case, it was unclear based on the official radiographic interpretation whether the lesion was filled with frank blood versus serous or serosanguineous fluid.