Michael S. Kain

Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia.

BACKGROUND Chronic mechanical overload of the acetabular rim may lead to acetabular labral disease in patients with hip dysplasia. Although arthroscopic debridement of the labrum may provide symptomatic relief, the underlying mechanical abnormality remains. There is little information regarding how the results of periacetabular osteotomy are affected by a prior primary treatment for labral disease in the presence of acetabular dysplasia. METHODS In a retrospective matched-cohort study, seventeen patients who had arthroscopic labral debridement prior to periacetabular osteotomy (the arthroscopy group) were compared with a control group of thirty-four patients who did not undergo arthroscopic labral debridement prior to periacetabular osteotomy (the non-arthroscopy group). Two control patients were randomly matched to each experimental patient from a pool of controls. Functional outcomes were assessed with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Failure of periacetabular osteotomy was defined as conversion to a total hip replacement. RESULTS Changes in the preoperative and postoperative WOMAC scores of arthroscopy and non-arthroscopy patients were comparable, and the differences between the two treatment groups were not significant. We were unable to show a significant difference between the seventeen arthroscopy and thirty-four non-arthroscopy patients with regard to the risk of having to undergo a total hip replacement. CONCLUSIONS When arthroscopic labral debridement fails to improve symptoms in patients with labral disease secondary to acetabular dysplasia, periacetabular osteotomy may still be considered as a joint-preserving procedure that can achieve good functional results.

Spatiotemporal Parameters of Gait After Total Hip Replacement: Anterior versus Posterior Approach

The objective of this preliminary study was to examine possible differences in gait characteristics between subjects operated by way of a direct anterior approach and a posterior approach for primary total-hip arthroplasty, and age-matched healthy controls. Fifty-one subjects walked over an instrumented mat at two different speeds (self-selected comfortable and faster than normal) and spatiotemporal gait parameters were calculated using a validated methodology. Despite excellent clinical and radiographic scores, and irrespective of surgical approach, patients demonstrated an impaired walking performance (lower velocity and shorter step lengths) during fast walking, but not at the self-selected comfortable speed compared with healthy controls. Subjects operated with the posterior approach reported significantly higher stiffness than anterior subjects, but similar pain and function. Six months after total arthroplasty for primary osteoarthritis of the hip, gait characteristics were comparable between subjects having received the direct anterior approach and the posterior approach.

Healing Time and Complications in Operatively Treated Atypical Femur Fractures Associated With Bisphosphonate Use: A Multicenter Retrospective Cohort

Objectives: The purpose of this study was to characterize demographics, healing time, and complications of a large series of operatively treated atypical femur fractures. Design: Retrospective multicenter review. Setting: Seventeen academic medical centers. Patients: Bisphosphonate-related fractures as defined by American Society of Bone and Mineral Research. Fractures had to be followed for at least 6 months or to union or revision. Intervention: Operative treatment of bisphosphonate-related fracture. Main Outcome Measurements: Union time and complications of treatment, as well as information about the contralateral limb. Results: There were 179 patients, average age 72, average body mass index 27.2. Average follow-up was 17 months. Twenty-one percent had a previous history of fragility fracture; 34% had prodromal pain. Most (88%) lived independently before injury. Thirty-one percent had radiographic changes suggesting stress reaction. Surgical fixation was with cephalomedullary nail (51%), IM nail (48%), or plate (1%). Complications included death (4), PE (3), and wound infection (6). Twenty (12%) patients underwent revision at an average of 11 months. Excluding revisions, average union time was 5.2 months. For revisions, union occurred at an average of 10.2 months after intervention. No association was identified between discontinuation of bisphosphonates and union time (P = 0.5) or need for revision (P = 0.7). Twenty-one percent sustained contralateral femur fractures; 32% of these had pain and 59% had stress reaction before contralateral fracture. Conclusions: In this series, surgery had a 12% failure rate and delayed average time to union. Twenty-one percent developed contralateral femur fractures within 2 years, underscoring the need to evaluate the contralateral extremity. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes after plating of olecranon fractures: A multicenter evaluation

INTRODUCTION The aim of this study was to report the physical and functional outcomes after open reduction internal fixation of the olecranon in a large series of patients with region specific plating across multiple centres. PATIENTS/METHODS Between January 2007 and January 2014, 182 consecutive patients with a displaced olecranon fracture treated with open reduction internal fixation were included in this study. Retrospective review across four trauma centres collected elbow range of motion, DASH scores, hardware complications, and hardware removal. Postoperative visits in the outpatient clinic were at two, six, and twenty-four weeks. After 24 weeks, patients were eligible for hardware removal if symptomatic. All patients were contacted, at least 1 year following surgery, to determine if hardware was removed. RESULTS 182 patients (75 women, 105 men) average age 50 (16-89) with 162 closed and 19 open displaced olecranon fractures were treated with one region specific plate. Nineteen were lost to followup leaving 163 for analysis with all patients united. The most common deficiency was a lack of full extension with 39% lacking at least 10° of extension. Hardware was asymptomatic in 67%, painful upon leaning in 20%, and restricted activities in 11% resulting in a 15% rate of hardware removal. Hardware complaints were more common if a screw was placed in the corner of the plate (P=0.004). When symptomatic, the area of the plate that was bothersome encompassed the whole plate in 39%, was at the edge of the plate in 33%, and was a screw head in 28%. The DASH scores, collected at final follow-up of 24 weeks, was 10.1±16, indicating moderate disability was still present. Patients who lacked 10° of extension had a DASH of 12.3 as compared with 10.5 for those with near full extension, but this was not significant (P=0.5). CONCLUSION Plating of the olecranon leads to predictable union. The most common complication was lack of full extension with 39% lacking more than 10°, although this did not have any effect on DASH scores. Overall results indicate that disability still exists after 6 months with an average DASH score of 10. LEVEL OF EVIDENCE Therapeutic level III.

Long Term Treatment Results for Deep Infections of Total Knee Arthroplasty

This study aims to identify the long-term outcomes of total knee arthroplasty (TKA) treated for deep infection. 3270 consecutive primary and 175 revision TKAs were followed prospectively. There were 39 deep infections (1.16%): 29 primary (0.9%) and 10 revision (5.7%) cases. Two-stage resection and re-implantation procedure was performed in 13 primary cases with 10/13 (77%) successfully resolved. Early (<1 month) Irrigation and Debridement (I&D) was performed in 16 primary cases with 100% success. Late (>4 months) I&D was performed in 6 cases with 5/6 (83.3%) successful. Infection following revision TKA resulted in poor outcomes with both two-stage (2/4 successful) and I&D (2/6 successful). Deep infection after primary TKA can be successfully resolved with I&D and appropriate antibiotic treatment in the early postoperative course.

Do osteotomies of the proximal femur still have a role

Trochanteric valgus and varus correction osteotomies have been described with or without associated rotational correction. In the last decade, new techniques have been described, including femoral neck osteotomy, femoral head reorientation, relative neck lengthening, greater or lesser trochanter distalization, and femoral head reduction osteotomy. While the overall number of femoral osteotomies in the young patients has decreased because of the efficacy of primary total hip arthroplasties, those osteotomy techniques may expand the indications for femoral osteotomies in select patients who meet the indications.

Anterior Approach for Total Hip Arthroplasty: Technique Without Fracture Table

Objective. To describe the minimally invasive anterior approach for total hip arthroplasty using a standard operating room table and report the short-term outcomes in a series of 128 patients. Indications. So-called primary osteoarthritis, rheumatoid arthritis, and degenerative arthritis of the hip. Contraindications. Complex primary hips might be avoided, such as hips after prior hip surgery, revision total hip arthroplasty, posterior acetabular deficiency, proximal femoral deformities, or difficult dysplastic cases as a Crowe type 4 deformity. Surgical Technique. Through a straight 8–10 cm incision starting 2 cm lateral and distal to the ASIS the fascia of the TFL is opened anteriorly. After obtaining hemostasis, the rectus femoris is identified and retracted medially with or without transecting the indirect head. The gluteus medius and minimus and TFL are retracted laterally to expose the hip capsule. After capsulectomy and femoral neck osteotomy, the acetabulum is exposed. The patients’ legs are placed in the figure-of-four position, with the operative hip extended and the femur externally rotated to expose the femoral canal. A press fit or cemented femoral component can be used with this approach. Postoperative Management. Postoperatively, hip flexion is limited to 90° for 4 weeks. Patients are encouraged to ambulate on postoperative day 1 and are usually ready for discharge to home by postoperative day 4. Results. One hundred and 141 hips were operated on in 128 patients during a 1-year period (2007). There were 26 cemented femoral stems implanted, and 115 were press fit. All acetabular components were press fit. The mean patient age was 68 years, of which 84 were females and 57 were males. The average operative time ranged from 60 to 75 min. There were three complications: one dislocation (0.7 %) which did not require treatment and two revisions (1.4 %) for a socket fracture after a low velocity trauma and a cup revision for persistent iliopsoas pain. Radiographic evaluation of acetabular cup position demonstrated the median abduction angle of 44° and anteversion of 23°.