Mark J. Lemos

Athletic Activity after Joint Replacement

The first decade of the 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 states in the United States as of March 2001. It is not surprising that Americans are interested in musculoskeletal disease and the treatment of bone and joint disorders because our population is aging, the prevalence of arthritic joints is increasing, and senior Americans are demonstrating a strong desire to stay active in activities of daily living and athletics. One of the most successful treatments for painful arthritic joints, which limit activity, is total joint replacement, which predictably relieves pain and improves function. Much has been written about the technical aspects of total joint arthroplasty. Less has been written about safe and appropriate activities for patients who have had joint replacement operations. This article evaluates athletic activity after joint replacement by reviewing the orthopaedic literature and surveying members of The Hip Society, The Knee Society, and The American Shoulder and Elbow Surgeons Society. The authors have developed consensus recommendations for appropriate athletic activity for patients who have had joint replacement operations. This article is intended to serve as a guide for orthopaedic surgeons and primary care physicians who give patients recommendations for athletic activity after joint replacement. This article is also intended to stimulate further research in the area of athletic activity after total joint arthroplasty.

The Evaluation and Treatment of the Injured Acromioclavicular Joint in Athletes

Injuries to the acromioclavicular joint are among the most commonly occurring problems in the athletic patient population. However, these injuries are often confused with other problems associated with the shoulder complex. This confusion was noted by Hippocrates (460-377 BC), who realized that acromioclavicular dislocation often was misdiagnosed as a glenohumeral injury. Galen (129-199 AD) experienced an acromioclavicular dislocation and could not tolerate the tight bandaging recommended at the time and thus became one of the earliest noncompliant patients. The understanding of acromioclavicular injuries and their management has evolved rapidly during the last 2 decades. This review will clarify the current concepts in the management and treatment of acromioclavicular injuries in the athlete.

Acromioclavicular Separation: Reconstruction Using Synthetic Loop Augmentation

A total of 110 patients with a diagnosis of acromiocla vicular joint separation were seen at our clinic between 1986 and 1991. Of these, 14 patients (12.7%) with grade III, IV, or V injuries required surgical reconstruc tion and were examined 2 years after surgery. All 14 patients underwent acromioclavicular reconstruction using a synthetic loop passed through drill holes in the base of the coracoid and the anterior third of the clavicle. When the loop is tightened, the clavicle is reduced ana tomically without the anterior subluxation caused by simple clavicular cerclage. At an average followup of 44.2 months, patients were evaluated using the Uni versity of California, Los Angeles, rating scale. Twelve of the 14 had good or excellent results and returned to normal sport and work activities at 6 months. Of the two initial poor results, one required revision 1 month post operatively because the patient was noncompliant, and the other required manipulation under anesthesia 3 months after surgery. The results in these two patients at 2 years were good and excellent, respectively. We concluded that, when medically indicated, fixation of the clavicle to the coracoid using this technique yields sat isfactory results in an athletic population.

Rupture of the Pectoralis Major Muscle: Outcome After Repair of Acute and Chronic Injuries*

We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.

Radiographic analysis of femoral interference screw placement during ACL reconstruction: Endoscopic versus open technique

Fifty patients with anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft performed by two techniques were evaluated roentgenographically to compare the position of the femoral interference screws. Group I consisted of 25 patients in whom the screw was placed using a distal lateral femoral incision (the two-incision technique). Group II patients underwent arthroscopically assisted intraarticular placement of the screw. These patients were then evaluated with anterior-posterior (AP) and lateral roentgenograms. We observed that the AP and lateral screw angles were significantly different with the two techniques. In addition, the endoscopic placement of the femoral screw had an associated divergence of the screw relative to the bone plug in nine of 25 patients compared with zero of 25 in the open group. In conclusion, radiographic differences do exist between femoral interference screws placed for fixation of an ACL graft using the open approach and those placed endoscopically. Although the clinical significance of these differences is not known, we raise the question of greater divergence in femoral interference screw placement with the newer intraarticular femoral interference screw placement techniques.

Salvage of Failed Acromioclavicular Joint Reconstruction Using Autogenous Semitendinosus Tendon from the Knee Surgical Technique and Case Report

The appropriate management of acute type III acromioclavicular dislocations remains controversial. Although the current trend in treatment of these injuries is toward nonoperative therapy, some authors advocate surgical repair of acute injuries in athletes who participate in overhead sports and in heavy laborers. Operative treatment of acute type IV, V, and VI injuries is well accepted. Similarly, surgical reconstruction is required for chronic symptomatic type III acromioclavicular dislocations. Historically, many different surgical techniques have been described to accomplish reconstruction in the acute or chronic condition, with more than 100 different procedures reported in the literature. There has been a trend toward stabilization of the coracoclavicular ligaments for acute injuries. In the symptomatic patient with chronic instability of the acromioclavicular joint, stabilization is mandatory for a successful result. Various procedures are available to achieve this end. Weaver and Dunn transferred the coracoacromial ligament, and Bunnell and Lom used autogenous fascia lata graft. Other authors have used a variety of synthetic materials and implants, such as coracoclavicular screws, cerclage wires, nonabsorbable synthetic sutures, Dacron, and expanded polytetrafluoroethylene (GORE-TEX; W. L. Gore, Flagstaff, Arizona). More recently, absorbable synthetics, such as polydioxanonsulfate bands, have been used. The use of rigid implants, such as coracoclavicular screws, may necessitate a second operation for removal to prevent fatigue failure and possible migration of the hardware. Synthetic materials may produce a foreign body response in the local tissue, as has been described with Dacron. Similarly, particulate polytetrafluoroethylene has been associated with foreign body reaction in regional lymph nodes after its use in the knee. Osteolysis adjacent to a polytetrafluoroethylene implant in the hand has also been described, but this complication has not, to our knowledge, been described in the shoulder. Bony erosion and amputation of the clavicle or coracoid process secondary to clavicular or coracoid cerclage with such material may also result in failure. We present a case of failed acromioclavicular reconstruction in which salvage surgery was performed to reconstruct the coracoclavicular ligaments with a loop of autogenous semitendinosus tendon from the patient’s ipsilateral knee. To our knowledge, no similar reports of coracoclavicular reconstruction using autogenous semitendinosus tendon graft have appeared in the literature.

Current Concepts Review - Blood Transfusion in Orthopaedic Operations*

The use of blood transfusion to treat acute blood loss was first reported in the early nineteenth century when Blundell14, known by some as the father of modern autologous transfusion, described the reinfusion of blood resulting from postpartum hemorrhage. Homologous, now properly called allogenic, blood transfusion began in the twentieth century22,25, after Landsteiner72 described blood groups in 1901. In 1937, Cook County Hospital in Chicago opened the first hospital blood bank in order to deal with the increasing demand for blood transfusion. The success of blood transfusion in resuscitating victims of trauma during World War II popularized transfusion for the treatment of blood loss in elective operative procedures after the war. Blood banks and allogenic blood components have had an important impact on operative treatment and health care worldwide. Resuscitation after trauma, radical operations for the treatment of cancer, coronary artery bypass grafting, and transplantation of major organs became not only possible but routine because of the availability of allogenic blood and blood products. However, blood transfusion has been limited by the availability of donor blood. In the 1950s and 1960s, allogenic blood was usually available to meet the demand for blood transfusion, and its use was considered safe according to medical knowledge at that time. Blood donors were usually laborers and factory workers. During the 1970s, this population decreased, as did the availability of allogenic blood, and the demand for blood increased simultaneously. The blood-donor population decreased further in the 1980s, when a general fear of acquiring transmissible diseases was prevalent and donors began to be tested for such diseases, including hepatitis and acquired immunodeficiency syndrome. From 1981 to 1990, the demand for blood transfusion increased 100 per cent, whereas the collection of blood increased only 30 per cent66. In …

Athletic activity after total knee arthroplasty.

Americans are aging, elderly Americans are more active, and the prevalence of total knee arthroplasty is increasing. Indications for knee replacement include pain, deformity, and a desire to improve function. When patients have knee replacement operations, frequently they increase their activities. It is important for patients with knee replacements to understand the impact of athletic activity on the outcome of knee replacements. Orthopaedic surgeons should educate patients regarding athletic activity after total knee arthroplasty. Considerations and risk factors for athletic activity after knee replacements include athletic activity before surgery, preoperative rehabilitation, surgical reconstruction, implant failure or fracture, implant fixation or loosening, and joint bearing surface wear. Anatomic reconstruction and compulsive postoperative rehabilitation with restoration of muscular control are important for optimum function after total knee arthroplasty. In general, patients with knee replacements are encouraged to participate in low-impact, low-demand sports, and to avoid high-impact, high-demand sports.

Complications of the treatment of the acromioclavicular and sternoclavicular joint injuries, including instability

Treatment of AC joint injuries and SC joint injuries continues to evolve. The risk of complications of both the operative and nonoperative management of these injuries can be minimized by the treating physician if the physician thoroughly evaluates and understands the problem. Making an accurate diagnosis of the underlying pathology and then selecting the appropriate treatment for this will minimize the risk of an associated complication. Paying attention to detail and using the appropriate technique before any operative intervention is chosen will decrease the risk of failure and complication. Close follow-up and early detection of complications will lead to less severe sequelae. AC joint injuries are more common and operative management is accepted for specific indications. Most Orthopaedic Surgeons are comfortable treating these. SC joint injuries are less common and nonoperative treatment is the mainstay. As our approach to these complex problems evolves, we must keep a wary eye towards avoiding and minimizing the complications of the new techniques.

Single Price/Case Price Purchasing in Orthopaedic Surgery: Experience at the Lahey Clinic*

Background: Hospital revenues for orthopaedic operations are not keeping pace with inflation or with rising hospital expenses. In an attempt to reduce the hospital cost of orthopaedic operations by reducing the cost of operating-room supplies, we developed a Single Price/Case Price Purchasing Program for implants used in total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty as well as for arthroscopic shavers and burrs, interference screws, and bone-suture anchors. Methods: The Lahey Clinic asked orthopaedic vendors to supply all instruments, implants, and disposable items related to these selected products for one single price per unit or case. For example, a single price for total hip arthroplasty implants included instruments, acetabular cups, acetabular liners, acetabular screws, femoral stems, femoral heads, and stem centralizers, if required. The hospital implemented the Single Price/Case Price Purchasing Program with a competitive-bid request for proposal. Surgeons evaluated the responses to the bidding process, and they made final decisions on product selection. Results: The Single Price/Case Price Purchasing Program at the Lahey Clinic was successful in reducing the cost of orthopaedic implants and supplies. In the present article, we could not disclose the specific prices that we agreed to pay our vendors. The specific cost reductions were 32 percent for hip implants with a change of vendor, 23 percent for knee implants without a change of vendor, 25 percent for shoulder implants with a change of vendor, 45 percent for arthroscopic shavers and burrs without a change of vendor, 45 percent for interference screws without a change of vendor, and 23 percent for bone-suture anchors without a change of vendor. Conclusions: The Single Price/Case Price Purchasing Program at the Lahey Clinic allowed the hospital to reduce its cost of orthopaedic operations by lowering the cost of operating-room supplies. This cost reduction is important in a health-care economy in which hospital revenues per unit of service or care are decreasing.