John M. Wright

High tibial osteotomy.

Abstract High tibial osteotomy is effective for managing a variety of knee conditions, including gonarthrosis with varus or valgus malalignment, osteochondritis dissecans, osteonecrosis, posterolateral instability, and chondral resurfacing. The fundamental goals of the procedure are to unload diseased articular surfaces and to correct angular deformity at the tibiofemoral articulation. Although the clinical success of total knee arthroplasty has resulted in fewer high tibial osteotomies being done during the past decade, the procedure remains useful in appropriately selected patients with unicompartmental knee disease. Renewed interest in high tibial osteotomy has occurred for a number of reasons. These include the prevalence of physiologically young active patients presenting with medial compartment osteoarthritis; the advent of new techniques for performing the procedure (ie, improved instrumentation and fixation plates for medial opening wedge osteotomy, dynamic external fixation for medial opening wedge osteotomy, and improved instrumentation for lateral closing wedge osteotomy); and the need to concomitantly correct malalignment when performing chondral resurfacing procedures (ie, autologous chondrocyte transplantation, mosaicplasty, and microfracture).

Bone density adjacent to press-fit acetabular components. A prospective analysis with quantitative computed tomography.

Background: The status of periprosthetic bone stock is an important concern when revision total hip arthroplasty is undertaken. Remodeling of periprosthetic femoral bone after total hip arthroplasty has been studied extensively, and the phenomenon of femoral stress-shielding has been well characterized. Finite element analysis and computer-simulated remodeling theory have predicted that retroacetabular bone-mineral density decreases after total hip arthroplasty; however, remodeling of periprosthetic pelvic bone in this setting has yet to be well defined. This study was conducted to evaluate the short-term natural history of periacetabular bone-mineral density following primary total hip arthroplasty. Methods: Periacetabular bone-mineral density was studied prospectively in a group of twenty-six patients who underwent primary hybrid total hip arthroplasty for the treatment of advanced osteoarthritis. Density within the central part of the ilium (directly cephalad to a press-fit acetabular component) was assessed with serial quantitative computed tomography. Baseline density was measured within the first five days following the total hip arthroplasty. Ipsilateral density measurements were repeated at an average of 1.28 years postoperatively. Density values at corresponding levels of the contralateral ilium were obtained at both time-points in all patients to serve as internal controls. Results: Bone-mineral density decreased significantly (p £ 0.001) between the two time-points on the side of the operation. The mean absolute magnitude of the interval density reduction (75 mg/cc) was greatest immediately adjacent to the implant (p < 0.001), but it was also significantly reduced (by 35 mg/cc) at a distance of 10 mm cephalad to the implant (p = 0.001). Relative declines in mean density ranged from 33% to 20% of the baseline values. No focal bone resorption (osteolysis) was detected at the time of this short-term follow-up study. With the numbers available, no significant interval alteration in bone-mineral density was found on the untreated (internal control) side (p 0.07). Conclusions: We suggest that the observed decline in bone-mineral density represents a remodeling response to an altered stress pattern within the pelvis that was induced by the presence of the acetabular implant. This finding corroborates the predictions of finite element analysis and computer-simulated remodeling theory. It remains to be seen whether this trend of atrophy of retroacetabular bone stock will continue with longer follow-up or will ultimately affect the long-term stability of press-fit acetabular components.

Sacral Stress Fracture in an Elite College Basketball Player After the Use of a Jumping Machine

With the competitive nature of college athletics and the lure of lucrative professional careers, athletes are pushing their training regimens to the limit. They lift more weight, run further, and train with greater intensity and duration to excel. While all this effort, for the most part, is commendable, it is important to be aware of possible dangerous training principles and practices. Some strength-enhancing machines provide great benefit to athletes and are dangerous only when overused or operated improperly. Other machines may be inherently dangerous, even when used in the prescribed manner. We report a case of a sacral stress fracture after the “proper” use of a commercial jumping machine in a 20-year-old college athlete. To our knowledge, this injury has not previously been described in this age group or in connection with this type of machine.

Bursal Osteochondromatosis Overlying an Osteochondroma of a Rib. A Case Report

Synovial chondromatosis is a rare, benign, pathological condition characterized by the production and intra-articular extrusion of cartilaginous nodules by metaplastic synovial tissue. These bodies often undergo endochondral ossification—hence the term synovial osteochondromatosis. The disease is idiopathic and appears as a monoarticular arthropathy of a diarthrodial joint, particularly the knee8. Extra-articular lesions have been reported, but they are even rarer than their intra-articular counterparts. In these instances, the chondrometaplasia occurs in tenosynovial or bursal tissue and almost exclusively in the hands and feet9,11,14,16,20,22,26,27. This report describes a case of bursal osteochondromatosis arising within an adventitious bursa over an osteochondroma of a rib. This phenomenon can mimic a malignant tumor and cause clinical confusion. A twenty-eight-year-old, right-hand-dominant male construction worker had a mass on the posterior portion of the right shoulder. The mass was painless and had gradually increased in size over a two-year period. The medical history was unremarkable with the exception of a remote right clavicular fracture. Physical examination revealed a non-tender fourteen-centimeter-diameter mass in the scapulothoracic region that extended cephalad into the caudad posterior cervical region (Fig. 1). There was no atrophy or neurovascular compromise of the right upper extremity. The range of motion of the glenohumeral joint was normal. Scapular retraction was 25 per cent of normal, and upward scapular rotation lacked the terminal 30 degrees. Fig. 1 Posterior photograph of the right scapulothoracic mass, which was firm, fixed, and non-tender to palpation. Plain radiographs showed diffuse mottled mineral deposition within the lesion (Fig. 2). Computed tomography showed an area of dense calcification at the core of the mass that abutted a cephalad rib and was surrounded by numerous uniformly distributed discrete opacities (Fig. 3). The lesion was not directly …

Repair of SLAP Lesions Associated With a Buford Complex: A Novel Surgical Technique

PURPOSE The purpose of this study was to analyze outcomes of a novel arthroscopic repair technique for type II SLAP lesions associated with a Buford complex. METHODS Patients selected for study enrollment had a symptomatic, isolated type II SLAP lesion and the Buford complex anatomic variant. Excluded were patients undergoing any concomitant shoulder procedure (e.g., subacromial decompression) or with any history of shoulder surgery. In addition to standard type II SLAP repair using suture anchors, the described technique also transects the cordlike middle glenohumeral ligament (MGHL) at the equator of the glenoid. This decreases postoperative stress on the repair and allows incorporation of the proximal MGHL segment for repair augmentation. The stout proximal MGHL segment is fixed to the anterosuperior glenoid rim, which is devoid of labral tissue, to enhance fixation of the SLAP repair anterior to the biceps anchor. The distal MGHL segment is left free so as to not impair external rotation. A single surgeon performed all procedures using the same surgical technique. Outcomes were assessed by University of California, Los Angeles (UCLA) and Constant shoulder scoring indexes. RESULTS Twenty-one patients were evaluated. Both UCLA and Constant shoulder scores showed a statistically significant improvement after surgery. The mean UCLA score increased from 14.3 preoperatively to 32.1 postoperatively (P < .0001). The mean Constant score improved from 39.7 to 85.0 (P < .0001). Follow-up examination was performed at a mean of 44 months after surgery (range, 23 to 75 months). No patients had evidence of postoperative instability. CONCLUSIONS For patients with a symptomatic type II SLAP tear and an associated Buford complex, using the proximal Buford MGHL to enhance repair and releasing the distal Buford MGHL segment resulted in significant improvement in outcomes at intermediate follow-up. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Ulnar collateral ligament tear with concommitant extensor pollicis brevis and extensor pollicis longus disruptions: A case report

A patient with a tear of the thumb ulnar collateral ligament and simultaneous extensor pollicis brevis and extensor pollicis longus disruptions is reported. No report of a similar constellation of injuries was found in the literature.

The Effect of In-Stem versus Around-Stem Centralizers on Cement Mantle Thickness and Stem Alignment in Total Hip Arthroplasty

The long term success of cemented total hip arthroplasty has been attributed to the presence of a well pressurized, thick cement mantle around a properly designed stem that has been placed in neutral alignment. Femoral centralizers were developed to achieve this goal more consistently. While some centralizers fit into the distal tip, others fit around the tip of the prosthesis. We undertook a study to compare the effect of an into-distal-tip (IDT) centralizer versus around-distal-tip (ADT) one. A retrospective review of three groups of primary total hip arthroplasty (THA) patients was performed. Group I consisted of a control population of the last 100 consecutive cases performed with no distal centralizer. Group II consisted of the first 100 consecutive cases performed with the IDT design. Group III consisted of 51 consecutive patients performed using an ADT centralizer. All cases were performed with similar cementing technique by the same senior surgeon (E.S.). Our results show that, while adequate mantles can be obtained, either with or without the use of a centralizer, an around-stem centralizer on a tapered distal stem consistently gave a more neutral stem alignment and a thicker, concentric cement mantle.

Depth of Insertion and Radiographic Fate of Non-Holed Cementless Metal Backed Acetabular Components

A retrospective radiographic review of 48 non-holed, factory assembled, cementless metal backed acetabular components, implanted in 45 patients, was performed. Post operative anteroposterior radiographs of the hips were compared to the radiographs at one year follow-up. In addition, measurements were made on 100 post-operative radiographs from patients implanted during the same time period with multiple holed acetabular components whose polyethylene liner was assembled after final impaction of the metal shell. The non-holed cups were implanted at a greater distance from Kohlers line than the multiple holed acetabular components (1.45 ± 1.83 mm [range 0 - 7.89 mm] vs. 0.69 ± 1.70 mm [range 0 -15.26 mm], p = 0.018). A larger percentage of non-holed cups had gaps between the metal shell and the bone bed (67% vs. 17.5%). Impaction through the polyethylene liner of the non-holed acetabular components leads to a higher incidence of radiographic gaps between the metal shell and the bone bed as well as lateralization of the component, since there were no holes to assess the proper seating at surgery. These radiographic findings did not appear to be detrimental, however, as the cups remained radiographically stable at one year follow-up.