Robert J. Feibel

Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution.

One thousand one hundred ninety patients underwent knee arthroplasty between January 2004 and July 1, 2007, and received an indwelling continuous infusion femoral catheter for postoperative ropivicaine pump infusion. Catheters were placed using electrical stimulation guidance. For the initial 469 patients (group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the infusion was discontinued 12 hours after surgery. There were 9 femoral nerve palsies (2 in group 1, 7 in group 2) and 8 major falls (0.7%). The overall complication rate was 1.5%, and the risk of permanent nerve injury was 0.2%. Patients should be made aware of these complications as part of the usual informed consent process before using this technique for postoperative pain control after knee arthroplasty. We did not observe fewer falls when the continuous infusion was stopped 12 hours after surgery.

Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects.

Thirty-six patients were treated by Ilizarov transport in conjunction with muscle and myocutaneous flaps coverage. Thirty-one free flaps and 5 rotation flaps were performed. In 13 patients the procedures were carried out in 1-stage or simultaneous manner. In 23 patients, soft tissue coverage proceeded as the initial step followed by Ilizarov reconstruction as a delayed procedure. All flaps survived the simultaneous and delayed procedures and there were no anastomotic complications, but partial flap necrosis occurred in 1 patient 3 months after the index procedure at the time of flap elevation for docking site bone graft placement. The mean segmental defects were 10 cm and 5.8 cm for the simultaneous and delayed groups, respectively. The followup interval from the time of free flap coverage ranged from 2 to 44 months in the simultaneous group with a mean and median of 22 and 24 months, respectively. Twelve patients completed treatment in the simultaneous group with the followup interval from frame removal ranging from 3 to 36 months with a mean and median of 18 and 14 months, respectively. In the delayed group this interval ranged from 1 to 36 months, with a mean and median of 16 and 12 months, respectively, and a mean and median of 24.5 and 21 months, respectively, from the time of the index procedure. Union and absence of infection were achieved in 35 of 36 patients presenting with an acute open fracture, infected nonunion, or aseptic nonunion without stable soft tissue coverage. The Ilizarov fixators remained in place for a median of 9.5 months for the simultaneous group and 8.5 months for the delayed group. When soft tissue defects accompany an infected nonunion or high grade open fracture, the traditional Ilizarov treatment approach of soft tissue recruitment into the wound from the distant corticotomy site is inconsistent with the proven benefit of early soft tissue coverage. The combined approach provides a more reliable soft tissue bed for early cancellous bone grafting of the docking site and permits the accurate restoration of limb length for these very difficult problems.

Initial experience with the oxford unicompartmental knee arthroplasty.

Our initial experience with mobile bearing medial compartment unicompartmental arthroplasty (UKA) is presented to highlight lessons that have been learned to avoid short-term failures. Consecutive cases of the Oxford medial UKA performed between February 2001 and April 2006 were reviewed to derive those cases that were revised to total knee arthroplasty (TKA). There were 545 patients available with mean age and body mass index of 65.0 and 30.1, respectively. At final follow-up, 32 patients were revised for lateral compartment arthritis, aseptic component loosening, persisting medial or anterior pain and dislocated meniscal bearing. Revisions were performed with primary unconstrained TKA implants with no stems or wedges required. Our results seem to reflect those seen in registries confirming an earlier higher revision rate and highlight the technical issues of overstuffing the compartment, inadequate cementation technique, and strict adherence to patient selection.

3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee.

OBJECTIVE Flexion and erect standing radiographs were evaluated in the current study to compare their sensitivity in detecting articular cartilage wear. DESIGN Prospective cohort study. SETTING A tertiary care hospital outpatient orthopedic clinic. PATIENTS All patients with osteoarthritis of the knee ages 40 to 75 scheduled for arthroscopic debridement between March 1995 and November 1997 were considered for the current study. INTERVENTION Radiographs were obtained 1 week preoperatively in both the 3-foot standing anteroposterior (AP) and a 45 degrees posteroanterior (PA) flexion weight-bearing projection. Joint space height was measured with a ruler in millimeters at the narrowest point of each compartment. All radiographs were assessed by two independent observers who were blinded to the arthroscopic findings and clinical symptoms of the subjects. MAIN OUTCOME MEASURES Prediction accuracy of each radiograph for severe Grade IV articular cartilage wear in tibio-femoral compartments. RESULTS One hundred fifty-two patients with a mean (+/- SD) age of 60.5+/-8.5 years were enrolled in the study. Fifty-one percent were female. Twelve patients were categorized as having severe lateral compartment articular chondropathy (Grade IV) at the time of arthroscopy. The lateral joint space height averaged 1.0+/-1.7 mm SD on the 45 degrees PA radiograph compared with 2.7+/-1.1 mm SD on the 3-foot standing AP view. Using a cutoff of 2 mm or less, the 45 degrees PA view was much more sensitive (83% versus 42%) at correctly detecting the most severe chondropathy. Forty-one patients were classified with severe Grade IV medial compartment chondropathy at arthroscopy. There was little difference in the average joint space height measured by the 45 degrees PA view (1.4+/-1.4 mm SD) or the 3-foot standing AP view (1.9+/-1.6 mm SD). A number of cutoff measures were evaluated, but no significant advantage could be found for either view in evaluating the medial compartment severity. CONCLUSIONS The bilateral 45 degrees PA is superior for detecting lateral compartment wear but offers no advantage on the medial side. This view should be considered as the screening radiograph of choice in evaluating osteoarthritis of the knee.

Primary Ilizarov ankle fusion for nonreconstructable tibial plafond fractures

ZusammenfassungOperationszielArthrodese des oberen Sprunggelenks in plantigrader Stellung. Nach hochenergetischem Trauma mit segmentalem Knochenverlust: Kortikotomie der proximalen Tibia und Segmenttransport mit dem Ilisarov-Fixateur zum Längenausgleich.IndikationenPosttraumatische Zerstörung der distalen Tibiagelenkfläche, häufig nach offener Unterschenkelfraktur vom Typ IIIC.KontraindikationenGleichzeitige und gleichseitige Fußverletzung, die eine Mobilisation des Patienten nach ausgeheilter Arthrodese verhindern würde.Verletzung des Nervus tibialis posterior mit nachfolgender Gefühllosigkeit der Fußsohle.Nicht rekonstruierbare Weichteilschäden am Unterschenkel.Fehlende Mitarbeit des Patienten bei der postoperativen Behandlung.Fortgeschrittenes Alter.Ausgeprägte Osteoporose.Akute Infektion.OperationstechnikStandardtechnik: Ventromedialer Längsschnitt. Entfernung der knorpeligen Gelenkflächen des zerstörten oberen Sprunggelenks. Einbringen von Ilisarov-Drähten durch die distale Fibula, den Talushals und den Taluskörper. Durch Stichinzisionen werden 5 mm dicke „Halbnägel“ senkrecht zur Facies medialis der Tibia platziert. Optional kann ein 1,8-mm-Ilisarov-Draht von lateral nach medial in die proximale Tibiametaphyse gebohrt werden.Kallusdistraktion-/Ilisarov-Segmenttransport: Zugang durch eine ventromediale Inzision oder Erweiterung der Verletzungswunde. Entfernung von residualen Knochenfragmenten der distalen Tibia, die den Segmenttransport blockieren könnten. Vaskularisierte kleinere Knochenfragmente, die den Transport nicht behindern, sollten belassen werden. Anbringen von zwei Ilisarov-Ringen an der proximalen Tibia. Osteoklasiebohrung der proximalen Tibiametaphyse 1 cm distal der Tuberositas tibiae und Vervollständigung der Knochendurchtrennung mit dem Ilisarov-Meißel. Verspannen des Ilisarov-Fixateurs und Mobilisation unter Vollbelastung. Beginn der Distraktion 14 Tage nach der Kortikotomie mit 0,5–1 mm pro Tag, abhängig vom Patientenalter. Nach dem Anschluss an den Talus folgt die Arthrodese.ErgebnisseZwischen Januar 1993 und September 1996 wurden vier Patienten (zwei Frauen, zwei Männer) mit schweren, nicht rekonstruierbaren Frakturen der distalen Tibiagelenkfläche behandelt. Eine Kallusdistraktion mit Segmenttransport war bei drei Patienten notwendig. Das Alter der Patienten lag zwischen 19 und 68 Jahren, im Mittel bei 45,7 Jahren. Die mittlere Nachuntersuchungszeit betrug 6,6 Jahre (4 Jahre und 9 Monate bis 7 Jahre und 4 Monate). Bei drei Patienten mit Segmenttransport betrug die Länge der Behandlung im Mittel 54,4 Tage/cm. Die mittlere Transportstrecke lag bei 6 cm (4,5–8,5 cm).AbstractObjectiveAnkle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy.IndicationsPosttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC.ContraindicationsIpsilateral foot injuries impairing ambulation after fusion.Severe injury to the posterior tibial nerve with absent plantar sensation.Soft-tissue injury not manageable surgically.Inadequate patient compliance.Advanced age.Severe osteoporosis.Acute infection.Surgical TechniqueStandard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional.Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5–1 mm per day depending on patient’s age. After docking: Ilizarov ankle arthrodesis.ResultsBetween January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19–68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external fixation 54.4 days/cm for the three bone distraction patients. Mean transport 6 cm (4.5–8.5 cm). One patient required repeat ankle arthrodesis.

Primäre Arthrodese des oberen Sprunggelenks nach nicht rekonstruierbarer Trümmerfraktur der distalen Tibia (Pilonfraktur)

ZusammenfassungOperationszielArthrodese des oberen Sprunggelenks in plantigrader Stellung. Nach hochenergetischem Trauma mit segmentalem Knochenverlust: Kortikotomie der proximalen Tibia und Segmenttransport mit dem Ilisarov-Fixateur zum Längenausgleich.IndikationenPosttraumatische Zerstörung der distalen Tibiagelenkfläche, häufig nach offener Unterschenkelfraktur vom Typ IIIC.KontraindikationenGleichzeitige und gleichseitige Fußverletzung, die eine Mobilisation des Patienten nach ausgeheilter Arthrodese verhindern würde.Verletzung des Nervus tibialis posterior mit nachfolgender Gefühllosigkeit der Fußsohle.Nicht rekonstruierbare Weichteilschäden am Unterschenkel.Fehlende Mitarbeit des Patienten bei der postoperativen Behandlung.Fortgeschrittenes Alter.Ausgeprägte Osteoporose.Akute Infektion.OperationstechnikStandardtechnik: Ventromedialer Längsschnitt. Entfernung der knorpeligen Gelenkflächen des zerstörten oberen Sprunggelenks. Einbringen von Ilisarov-Drähten durch die distale Fibula, den Talushals und den Taluskörper. Durch Stichinzisionen werden 5 mm dicke „Halbnägel“ senkrecht zur Facies medialis der Tibia platziert. Optional kann ein 1,8-mm-Ilisarov-Draht von lateral nach medial in die proximale Tibiametaphyse gebohrt werden.Kallusdistraktion-/Ilisarov-Segmenttransport: Zugang durch eine ventromediale Inzision oder Erweiterung der Verletzungswunde. Entfernung von residualen Knochenfragmenten der distalen Tibia, die den Segmenttransport blockieren könnten. Vaskularisierte kleinere Knochenfragmente, die den Transport nicht behindern, sollten belassen werden. Anbringen von zwei Ilisarov-Ringen an der proximalen Tibia. Osteoklasiebohrung der proximalen Tibiametaphyse 1 cm distal der Tuberositas tibiae und Vervollständigung der Knochendurchtrennung mit dem Ilisarov-Meißel. Verspannen des Ilisarov-Fixateurs und Mobilisation unter Vollbelastung. Beginn der Distraktion 14 Tage nach der Kortikotomie mit 0,5–1 mm pro Tag, abhängig vom Patientenalter. Nach dem Anschluss an den Talus folgt die Arthrodese.ErgebnisseZwischen Januar 1993 und September 1996 wurden vier Patienten (zwei Frauen, zwei Männer) mit schweren, nicht rekonstruierbaren Frakturen der distalen Tibiagelenkfläche behandelt. Eine Kallusdistraktion mit Segmenttransport war bei drei Patienten notwendig. Das Alter der Patienten lag zwischen 19 und 68 Jahren, im Mittel bei 45,7 Jahren. Die mittlere Nachuntersuchungszeit betrug 6,6 Jahre (4 Jahre und 9 Monate bis 7 Jahre und 4 Monate). Bei drei Patienten mit Segmenttransport betrug die Länge der Behandlung im Mittel 54,4 Tage/cm. Die mittlere Transportstrecke lag bei 6 cm (4,5–8,5 cm).AbstractObjectiveAnkle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy.IndicationsPosttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC.ContraindicationsIpsilateral foot injuries impairing ambulation after fusion.Severe injury to the posterior tibial nerve with absent plantar sensation.Soft-tissue injury not manageable surgically.Inadequate patient compliance.Advanced age.Severe osteoporosis.Acute infection.Surgical TechniqueStandard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional.Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5–1 mm per day depending on patient’s age. After docking: Ilizarov ankle arthrodesis.ResultsBetween January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19–68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external fixation 54.4 days/cm for the three bone distraction patients. Mean transport 6 cm (4.5–8.5 cm). One patient required repeat ankle arthrodesis.

A Single-Center Experience With a Titanium Modular Neck Total Hip Arthroplasty

BACKGROUND Added modular junction has been associated with implant-related failures. We report our experience with a titanium-titanium modular neck-stem interface to assess complications, possible clinical factors influencing use of neck modularity, and whether modularity reduced the incidence of dislocation. METHODS A total of 809 total hip arthroplasties completed between 2005 and 2012 from a prospectively collected database were reviewed. The mean follow-up interval was 5.7 years (3.3-10.3 years). Forty-five percent were male (360 of 809), and 55% were female (449 of 809). All stems were uncemented PROFEMUR TL (titanium, flat-tapered, wedge) or PROFEMUR Z (titanium, rectangular, dual-tapered) with a titanium neck. RESULTS Increased modularity (anteverted/retroverted and anteverted/retroverted varus/valgus (anteverted/retroverted + anteverted/retroverted varus/valgus) was used in 39.4% (135 of 343) of cases using the posterior approach compared with 6.8% (20 of 293) of anterior and 23.7% (41 of 173) of lateral approaches. Four males sustained neck fractures at a mean of 95.5 months (69.3-115.6 months) after primary surgery. Overall dislocation rate was 1.1% (9 of 809). The posterior approach had both the highest utilization of increased modularity and the highest dislocation rate (2.3%), of which the most were recurrent. The anterior (0.3%) and lateral (0%) approaches had lower dislocation rates with no recurrences. CONCLUSION At a mean 5.7 years, our experience demonstrates a low neck fracture (0.5%) and a low dislocation rate (1.1%). Use of increased modularity may not improve dislocation risk for the posterior approach. Continued surveillance of this group will be necessary to determine long term survivorship of this modular titanium implant.

Kniearthrodese nach Ilizarov

ZusammenfassungOperationsziel Kniegelenksarthrodese mit oder ohne gleichzeitige Beinverlängerung. Indikationen Schwere Arthrose bei jüngeren Patienten.Neuropathische Gelenke mit Knochenverlust und/oder Bandinstabilität.Versagen der Knietotalendoprothese. Kontraindikationen Absolut: ausgedehnte Osteomyelitis.Relativ: schlechte Knochenqualität.Bei älteren Patienten stellt die gleichzeitige Beinverlängerung eine relative Kontraindikation dar. Operationstechnik Bei primärer Arthrodese: Resektion des Gelenkknorpels und des subchondralen Knochens.Bei aseptischer Endoprothesenlockerung: Entfernen der Prothesenkomponenten und achsengerechte Einstellung von Femur und Tibia.Bei infizierten Endoprothesen: zweizeitiges Vorgehen.Unter allen Umständen soll die Versteifung in leichter Beugestellung angestrebt werden. Vorübergehende Stabilisierung mit gekreuzten Kirschner-Drähten. Montage des Ilizarov-Rahmens und Kompression. Zur Verlängerung: Distraktionsmethode nach Ilizarov. Ergebnisse Zwischen 1993 und 1996 wurde bei elf Patienten eine Arthrodese nach Ilizarov durchgeführt. Der durchschnittliche Nachuntersuchungszeitraum betrug 35 Monate. Indikationen waren: schwere Arthrose (2), Bandinstabilität bei Patienten mit Spina bifida (1), Versagen der Knietotalendoprothese (8). Drei Patienten entwickelten eine Pseudarthrose. Bei allen drei bestand ein erheblicher Knochendefekt. Zwei dieser Patienten wurden mit einer Orthese versorgt, der dritte wurde erfolgreich durch eine AO-Doppelplattenosteosynthese stabilisiert. Zweimal mußten Kirschner-Drähte wegen Infektionen entfernt werden. Die durchschnittliche Zeit bis zur knöchernen Konsolidierung betrug 4,5 Monate.SummaryObjectives Arthrodesis of the knee without or with simultaneous lengthening. Indications Severe degenerative osteoarthritis in younger patients.Neuropathic joint with bone loss and/or ligamentous instability.Failed total knee arthroplasty. Contraindications Absolute: extensive osteomyelitis.Relative: severe bone deficiency.In elderly patients a simultaneous limb lengthening constitutes a relative contraindication. Surgical Technique For primary arthrodesis: resection of articular cartilage and subchondral bone.For aseptic loosening: removal of components and alignment of bone ends.For infected total joint: 2-stage procedure.In all instances obtain a slight flexion at the arthrodesis. Temporary fixation with crossed Kirschner wires. Application of Ilizarov frame and compression. For lengthening: Ilizarov distraction method. Results Between 1993 and 1996, 11 patients underwent an Ilizarov knee arthrodesis with an average follow-up interval of 35 months. Indications included: severe osteoarthritis: 2; ligament instability in spina bifida patients: 1; and failed total knee arthroplasty: 8. Three patients developed a pseudarthrosis, all were noted to have a severe bone loss. Two of these patients were fitted with an orthosis and the 3rd underwent a successful AO double plate fixation. Removal of wires on account of infection was needed twice. Average time to union was 4,5 months.

Idiopathic simultaneous bilateral Achilles tendon rupture

Cases of simultaneous bilateral rupture of the Achilles tendon are extremely rare and usually associated with other pathology. Our patient was a healthy, previously asymptomatic 33-year-old woman with no obvious predisposing factors other than a remote history of involvement in gymnastics. The patient opted for surgical management which resulted in a favourable outcome.

Major complications after femoral nerve blocks for knee replacement: A cause for concern

Purpose: Multi-modal therapy remains the cornerstone of post-operative pain management following knee replacement surgery. Femoral nerve catheters and blocks have been used with success in the management of post-operative pain yet most practicing arthroplasty surgeons and anaesthesiologists are unaware of the potential complications and risks of the procedure. The purpose of this study is to report on the complications associated with these techniques following knee replacement surgery. Method: One thousand one hundred and ninety patients underwent knee replacement surgery between January 2004 and July 1, 2007 and received an indwelling continuous infusion femoral catheter for post-operative marcaine pump infusion. For the initial 469 patients (Group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the continuous infusion was discontinued 12 hours following surgery (Group 2). Results: There were 15 major complications observed in 1190 patients: 7 femoral nerve palsies (2 in Group 1, 5 in Group 2) and 8 falls (4 in each group). For the patients who had fallen in hospital, the injuries sustained were: traumatic hemarthrosis, hemarthrosis requiring arthrotomy, major wound dehiscence with exposed implants, complete medial collateral ligament rupture requiring repair, quadriceps tendon rupture requiring delayed repair, minor wound dehiscence with suture, and displaced ankle fracture. Conclusion: Femoral nerve catheters and blocks are effective tools for post-operative pain relief following knee arthroplasty surgery. However, it is important for the surgeon and anaesthesiologist to provide information regarding the potential complications of the treatment as part of an informed consent. Although the complication rate is relatively low at 1.3%, the occurrence of femoral nerve palsies as well as re-operations significantly delayed patient recovery. We did not observe a benefit in terms relative risk reduction with discontinuation of the continuous infusion 12 hours following surgery. The femoral palsies reported in our series have led our institution to adopt ultrasound guidance for catheter placement rather than tradition nerve stimulation technique, although the safety of this newer technique is currently under evaluation.