Jess H. Lonner

Simultaneous Femoral Osteotomy and Total Knee Arthroplasty for Treatment of Osteoarthritis Associated with Severe Extra-Articular Deformity*

Background: In the presence of large extra-articular deformity, complex imbalance of the collateral ligaments may result if standard techniques of soft-tissue releases and intra-articular bone resection are used during total knee arthroplasty. The purpose of this paper is to review our experience with simultaneous corrective osteotomy and total knee arthroplasty for the treatment of severe extra-articular femoral deformity associated with ipsilateral osteoarthritis of the knee. Methods: The results of simultaneous corrective osteotomy and total knee arthroplasty in eleven knees with osteoarthritis and associated extra-articular angular deformity of the femur were reviewed retrospectively. The femoral deformity resulted from fracture malunion in ten knees and from hypophosphatemic rickets in one. There were five primarily uniplanar deformities (four varus deformities and one antecurvatum deformity), five biplanar (varus and antecurvatum) deformities, and one triplanar (varus, antecurvatum, and internal rotation) deformity. Four knees were approached through a standard medial parapatellar arthrotomy and seven, through an anterolateral subvastus approach with an osteotomy of the tibial tubercle. The site of the femoral osteotomy was fixed with a blade-plate in seven patients, a press-fit long-stemmed femoral component in two, and a retrograde femoral nail in two. An extramedullary alignment system was utilized in eight patients, and intramedullary alignment was used in three. Results: The duration of follow-up averaged forty-six months (range, twenty-six to eighty-eight months). According to the classification system of the Knee Society, the mean function score increased from 22 points preoperatively to 81 points at the time of follow-up and the mean knee score increased from 10 points preoperatively to 87 points at the time of follow-up. The mean flexion contracture decreased from 19 degrees preoperatively to 2 degrees at the time of follow-up. The arc of motion averaged 56 degrees (range, 30 to 75 degrees) preoperatively and 89 degrees (range, 65 to 115 degrees) at the time of follow-up. The mechanical alignment in the coronal plane was restored to within 2 degrees of normal in each patient. Ten femoral osteotomy sites healed, and one, in a patient treated with a press-fit long-stemmed femoral component, had not healed by the time of follow-up. All seven sites of the tibial tubercle osteotomies healed. There were no complete radiolucent lines at the prosthetic interfaces, and no total knee arthroplasty was revised. One patient had a nonfatal postoperative pulmonary embolism. As determined by clinical examination and the patients assessment of function, no ligament imbalance was noted at the time of the most recent follow-up. Conclusions: Simultaneous femoral osteotomy and total knee arthroplasty is a technically difficult but effective treatment for patients with severe femoral deformity associated with ipsilateral osteoarthritis of the knee. We recommend that the femoral osteotomy site be secured with a plate or a locked intramedullary nail, depending on the location of the deformity and the subsequent osteotomy.

Subchondral Magnetic Resonance Imaging Changes in Early Osteoarthrosis Associated With Tibial Osteonecrosis

SUMMARYnThe authors report on 41 patients with acute or subacute knee pain and early or midstage degenerative arthrosis with osteonecrotic lesions in the subchondral and metaphyseal region of the medial proximal tibia. Each lesion was identified only on magnetic resonance images (MRI). These MRI changes are classified and the clinical course is defined during a follow-up period averaging 4.5 years. Radiographically, 22 patients had minimal degenerative changes; 12 had moderate arthritis; and 7 were normal. With MRI, 3 distinct types of lesions were identified. Type A lesions had localized areas of decreased signal in the subchondral area. Type B lesions had diffuse signal changes with extension into the metaphysis. Type C lesions had metaphyseal involvement as well as a marginated serpentine subchondral rim usually associated with advanced osteonecrosis. There were 9 type A lesions, 23 type B, and 9 type C. At the end of 1 year, 33 patients (80%) had no or mild symptoms, and 8 (20%) had persistent moderate pain. At 4.5-year follow-up, most patients had symptoms consistent with progressive osteoarthrosis, 12 patients had severe symptoms (29%), 17 (41%) had mild or moderate symptoms, and only 12 (29%) were asymptomatic or had minimal symptoms. The type of MRI change seen initially was predictive of prognosis. Only 6 (19%) of the 32 patients with type A or B findings had severe symptoms at last follow-up. Six (66%) of the 9 patients with a type C MRI lesion had severe symptoms or had an operation by last follow-up. Twelve patients had follow-up MRI at a mean 15 months (range, 12 to 18 months) after the initial evaluation. The type A and B changes were either absent or significantly reduced. The type C subchondral marginated rim changes remained but metaphyseal involvement was reduced. There appears to be a spectrum of tibial subchondral MRI changes associated with sudden onset of medial knee pain in patients with early osteoarthritis of the knee. These changes may be indicative of osteonecrosis. The initial MRI classification is useful in predicting prognosis. Recognition of this problem may avoid unnecessary intra-articular surgery.

Chirurgen als Hand-Patienten

ZusammenfassungUm Einblick in die Behandlung von Patienten mit Hand- und Handgelenkverletzungen zu gewinnen, wurden mit einer Reihe klinischer und psychologischer Analysen neun Chirurgen untersucht, die sich alle einer Osteosynthese einer Hand- oder Handgelenkfraktur unterzogen hatten. Die Ergebnisse dieser Untersuchungen legen nahe, dass das funktionale Outcome nach der Handoperation von der Persönlichkeitsstruktur des Patienten, seiner Motivation, seiner Fähigkeit, die Verletzung zu akzeptieren und sich an sie anzupassen, von der Art der Verletzung und vom Stellenwert des Gebrauchs der Hand im beruflichen Kontext abhängt. Chirurgen sind hoch motivierte und pflichtbewusste Individuen, die in ihrer beruflichen Tätigkeit eine wesentliche Quelle ihrer Identität und ihres Selbstwertgefühls sehen. Die meisten Patienten kehrten früher zu ihrer Arbeit zurück, als es ihr behandelnder Handchirurg vorgesehen hatte (im Durchschnitt 25 Tage postoperativ), sahen die Verletzung als positive Herausforderung an und nahmen Lifestyle-Veränderungen zum Schutz ihrer Hände vor. AbstractTo gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons’ personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons’ careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.

[The surgeon as a hand patient: the clinical and psychological impact of hand and wrist fractures].

ZusammenfassungUm Einblick in die Behandlung von Patienten mit Hand- und Handgelenkverletzungen zu gewinnen, wurden mit einer Reihe klinischer und psychologischer Analysen neun Chirurgen untersucht, die sich alle einer Osteosynthese einer Hand- oder Handgelenkfraktur unterzogen hatten. Die Ergebnisse dieser Untersuchungen legen nahe, dass das funktionale Outcome nach der Handoperation von der Persönlichkeitsstruktur des Patienten, seiner Motivation, seiner Fähigkeit, die Verletzung zu akzeptieren und sich an sie anzupassen, von der Art der Verletzung und vom Stellenwert des Gebrauchs der Hand im beruflichen Kontext abhängt. Chirurgen sind hoch motivierte und pflichtbewusste Individuen, die in ihrer beruflichen Tätigkeit eine wesentliche Quelle ihrer Identität und ihres Selbstwertgefühls sehen. Die meisten Patienten kehrten früher zu ihrer Arbeit zurück, als es ihr behandelnder Handchirurg vorgesehen hatte (im Durchschnitt 25 Tage postoperativ), sahen die Verletzung als positive Herausforderung an und nahmen Lifestyle-Veränderungen zum Schutz ihrer Hände vor. AbstractTo gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons’ personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons’ careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.

Chirurgen als Hand-Patienten@@@The surgeon as a hand patient: Klinische und psychologische Auswirkungen von Hand- und Handgelenkfrakturen@@@The clinical and psychological impact of hand and wrist fractures

ZusammenfassungUm Einblick in die Behandlung von Patienten mit Hand- und Handgelenkverletzungen zu gewinnen, wurden mit einer Reihe klinischer und psychologischer Analysen neun Chirurgen untersucht, die sich alle einer Osteosynthese einer Hand- oder Handgelenkfraktur unterzogen hatten. Die Ergebnisse dieser Untersuchungen legen nahe, dass das funktionale Outcome nach der Handoperation von der Persönlichkeitsstruktur des Patienten, seiner Motivation, seiner Fähigkeit, die Verletzung zu akzeptieren und sich an sie anzupassen, von der Art der Verletzung und vom Stellenwert des Gebrauchs der Hand im beruflichen Kontext abhängt. Chirurgen sind hoch motivierte und pflichtbewusste Individuen, die in ihrer beruflichen Tätigkeit eine wesentliche Quelle ihrer Identität und ihres Selbstwertgefühls sehen. Die meisten Patienten kehrten früher zu ihrer Arbeit zurück, als es ihr behandelnder Handchirurg vorgesehen hatte (im Durchschnitt 25 Tage postoperativ), sahen die Verletzung als positive Herausforderung an und nahmen Lifestyle-Veränderungen zum Schutz ihrer Hände vor. AbstractTo gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons’ personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons’ careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons personality, motivation, and ability to accept and adapt to the injury, the nature of the injury, and the importance of the hand to the surgeons careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.