Mark P. Figgie

The results of treatment of supracondylar fracture above total knee arthroplasty

This study analyzes the results of treatment of 22 patients with 24 supracondylar femur fractures above a total knee arthroplasty. Ten knees were treated by closed methods utilizing traction and then a cast, 10 knees with immediate open reduction and internal fixation, 2 knees with a custom total knee integrated with a distal femoral allograft, 1 knee with external fixation, and 1 knee with primary arthrodesis. Nine fractures treated by closed means and 5 fractures treated by open reduction and internal fixation healed primarily. Two of the 5 surgical failures healed after replating and bone graft. The 3 failures of surgical therapy were salvaged utilizing custom total knee arthroplasty, 2 of which required integration with a distal femoral allograft. One knee treated with external fixation developed a deep infection necessitating implant removal and arthrodesis. Twelve of the 14 femoral fractures that united primarily healed with the femoral component in varus with respect to the long axis of the anatomic femur. Nine of these 12 implants developed progressive radiolucent lines at the tibial component. Three of these knees have required implant revision due to progressive loosening of the tibial and/or femoral components. The results of this evaluation indicate that fractures above a well-fixed total knee arthroplasty are difficult to manage. If anatomical alignment cannot be achieved by simple closed techniques, then primary open reduction and internal fixation should be considered. However, because of the complexity of the problem, the surgeon should be prepared to perform a primary arthrodesis or revision using custom components with or without a distal femoral allograft.

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

To provide evidence‐based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).

Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty.

Fourteen patients in whom open reduction and internal fixation could not be achieved satisfactorily had a total elbow arthroplasty for non-union of a supracondylar humeral fracture. All patients had an established non-union, and ten had had from one to four previous attempts at internal fixation. The average age at the time of operation was sixty-five years. The average duration of follow-up was five years, with a minimum of two years. The average preoperative elbow score was 17 points, with both pain and functional disability present. The average postoperative score was 84 points; there were eight good or excellent results and three failures. The latter three patients had an additional operation: one each for dislocation, loosening of the humeral component, and deep infection. Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure. Strict indications for selection of patients must be followed. A semiconstrained implant is recommended, with preservation of the epicondyles and their muscular attachments in order to achieve balance of the soft tissues.

Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis.

Distal femoral replacement with allograft/prosthetic reconstruction for treatment of supracondylar fractures in patients with total knee arthroplasty.

Large-segment distal femoral allografts were used in conjunction with non-linked total knee prostheses to reconstruct bone deficits following supracondylar fracture of the femur in seven patients with previous total knee arthroplasties. Three patients with multiple medical problems died of unrelated causes prior to a minimum 2 year follow-up. Indications for surgery were previously failed attempts at osteosynthesis and significant fracture comminution, osteopenia, and intercondylar extension or femoral component loosening. Specifics of the surgical technique included subperiosteal excision of the involved distal femur with retention of a soft tissue sleeve containing the collateral ligaments and reconstruction with a large-segment allograft and a stemmed, semiconstrained total knee prosthesis. Cement fixation using pressurized technique with intramedullary plugging of the tibial and femoral canal was routinely used to secure the prosthesis/allograft construct to the host bone. Postoperative complications included one dislocation, which was successfully treated closed, and one popliteal artery injury, which was successfully repaired. There were no postoperative infections. Two patients, however, had some degree of persistent instability, warranting bracing at the time of last follow-up. Using the Knee Society rating system, the average knee score for these patients was 71, and the average pain score and function score were 33 and 49, respectively. Range of motion averaged 96 degrees. All of the femoral components were well fixed at last follow-up. Results of this study indicate that large-segment distal femoral allografts used in conjunction with nonlinked knee prostheses can be an acceptable method of treatment of these difficult reconstructive problems.

Total elbow arthroplasty for complete ankylosis of the elbow.

Sixteen patients who received nineteen semiconstrained total elbow replacements for complete ankylosis of the elbow were followed for an average of five and three-quarters years (range, two to twelve years). The average preoperative elbow score was 23 points and the average postoperative score was 84 points. Postoperatively, the average flexion was 115 degrees; extension, 35 degrees; and pronation and supination, 95 degrees. There were fifteen excellent or good results. There was one failure due to a deep infection, but after removal of the prosthesis a satisfactory fascial arthroplasty was achieved in this elbow. Function was improved in all patients, and all patients had relief of the preoperative pain. For the arthroplasty to succeed, the patient must have a good understanding of the procedure and must be willing and able to comply with the postoperative rehabilitation program. The use of a semiconstrained, often custom-fit, implant is necessary. The Bryan-Morrey posteromedial approach to the elbow is recommended for the procedure, since this approach allows early institution of range-of-motion exercises.

Management of infection about total elbow prostheses

Deep infection was a complication after twelve (7.3 per cent) of 164 primary total elbow replacements. Two additional patients who had an infection about an elbow prosthesis were referred for treatment after total elbow replacement elsewhere. A statistical analysis of all of these primary total elbow arthroplasties, including the two in patients who were referred from outside institutions, identified preoperative factors that placed a patient at significant risk for subsequent infection. The risk factors included a previous operation on the elbow, a previous infection in the region of the elbow, psychiatric illness, class-IV rheumatoid arthritis, drainage from the wound after operation, spontaneous drainage after ten days, and reoperation for any reason. Three modes of treatment were used for patients who had an established infection: débridement and salvage of the implant, resection arthroplasty, and arthrodesis. After early operative débridement and suppression of the infection with long-term antibiotic therapy, three patients were able to retain the prosthesis, with restoration of range of motion and function of the upper extremity. One prosthesis was reimplanted after a six-week course of intravenous administration of antibiotics.

Total knee arthroplasty for the treatment of chronic hemophilic arthropathy

Total knee arthroplasty (TKA) for hemophilic (factor VIII deficiency) arthropathy is a complex and demanding procedure with a high complication rate. However, the long-term benefits have not previously been reported. This study reviews 19 TKAs performed for hemophilic arthropathy that were followed for a minimum of 5.5 years and an average of 9.5 years. At present, 13 knees have good or excellent results, and six knees rate as poor or failures. Those patients with excellent results have maintained good pain relief and function. Four of the six failures were among the first seven arthroplasties performed, when only 80% factor VIII coverage was used during the perioperative period. Since the use of 100% factor VIII coverage was instituted, the failure rate has declined. Ten of the 19 knees suffered complications, including one deep infection, six superficial skin necroses, three nerve palsies, seven postoperative bleedings, and one transfusion reaction. Six of the seven knees operated on under 80% factor VIII coverage had complications. Once 100% factor VIII coverage was instituted, the only complications included one skin necrosis and three postoperative bleedings. The roentgenographic failure rate has remained high with progressive roentgenographic lucencies in 13 of 19 tibial components, associated with component shift in three knees. While these roentgenographic findings have not necessarily correlated with clinical results, they are disturbing and may portend future failures. However, pain relief and improved function are maintained at longer follow-up times. The best results were obtained under 100% factor VIII coverage using a posterior stabilized prosthesis and patellar resurfacing.

Perioperative Management of Medications Used in the Treatment of Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.

Failed Total Wrist Arthroplasty; Analysis of Failures and Results of Operative Management

Nine metal on polyethylene total wrist arthroplasties were revised for failure, including eight trispherical devices and one Volz implant. Causes of failure include sepsis in one patient, progressive wrist flexion contracture in two patients, and mechanical failure in six patients. The most common mode of mechanical failure was metacarpal loosening with dorsal perforation of the stem. This was associated with an intact articulation between the third metacarpal and the capitate, with a proximal position of the metacarpal component in the shaft, and with poor cement fill of the metacarpal shaft. The one infected wrist was managed with resection arthroplasty. Five patients had conversion to a wrist arthrodesis and three patients underwent revision total wrist arthroplasty with custom trispherical components. Followup averaged 3.3 years. All patients undergoing arthrodesis attained a solid painless fusion after a single operation at an average of 4.8 months. The three patients treated with revision arthroplasty had wrists that were pain free, functional, and had no evidence of loosening at latest followup. Failed total wrist arthroplasties can be salvaged successfully to either a fusion or a revision arthroplasty in most patients.