Samik Banerjee

Short bone-conserving stems in cementless hip arthroplasty.

➤ Short bone-conserving femoral stems in total hip arthroplasty were designed to preserve proximal bone stock.➤ Given the distinct fixation principles and location of loading among these bone-conserving stems, a classification system is essential to compare clinical outcomes.➤ Due to the low quality of currently available evidence, only a weak recommendation can be provided for clinical usage of certain stem designs, while some other designs cannot be recommended at this time.➤ A high prevalence of stem malalignment, incorrect sizing, subsidence, and intraoperative fractures has been reported in a subset of these short stem designs.➤ Stronger evidence, including prospective multicenter randomized trials comparing standard stems with these newer designs, is necessary before widespread use can be recommended.

Anatomical reconstruction of reverse hill-sachs lesions using the underpinning technique.

Posterior glenohumeral joint dislocation is an uncommon injury and is associated with bony and ligamentous disruption. It requires prompt diagnosis and early treatment to prevent acute or recurrent instability and subsequent dysfunction. Reverse Hill-Sachs lesions associated with this injury are challenging to treat, and optimal treatment is controversial. Treatment methods can be divided into those that achieve stability through muscle transfers, osteotomies, or posterior bone-block procedures (glenoid augmentation) and those that restore the sphericity of the humeral head. Joint replacement is often suggested for large head lesions (>50%) considered beyond reconstruction. Restoration of stability, preservation of the proximal humeral anatomy, and salvage of the humeral head sphericity should be the treatment goals in the younger population.This article describes the surgical technique of elevation of the impressed osteochondral fragment followed by filling the lesion with Allomatrix bone graft putty (Wright Medical Technology, Arlington, Tennessee) in 2 patients. The size of the head lesion was ≤35%. Underpinning raft screws were used to provide subchondral support and prevent the collapse of the elevated fragment. Postoperatively, the sphericity of the humeral head and glenohumeral stability were restored. No evidence of collapse, osteonecrosis, or osteoarthritis progression was seen at latest follow-up. Functional results were excellent, with a minimum follow-up of 2 years.This technique is an alternative method of restoring humeral head sphericity in patients with acute posterior glenohumeral joint dislocations with medium (20%-40%) reverse Hill-Sachs lesions.

Does Co-Existing Lumbar Spinal Canal Stenosis Impair Functional Outcomes and Activity Levels after Primary Total Hip Arthroplasty?

Degenerative lumbar spinal stenosis (LSS) is a cause for substantial morbidity in the elderly population: many often undergo total hip arthroplasty for associated hip arthritis. With a matched cohort we investigated the effect of co-existing LSS on aseptic survivorship, functional outcomes, activity levels, overall subjective physical and mental health status, and satisfaction rates in patients undergoing primary THA. The aseptic-implant survivorship was similar in LSS and non-stenosis cohort. Although both cohorts significantly improved, the LSS cohort achieved lower improvements in HHS, UCLA, SF-36 physical, and satisfaction rates than the matched non-stenotic cohort. Surgeons should consider cautioning patients with LSS that although they can expect relief of their arthritic symptoms following THA, they may continue to expect limitations in function, physical-status, activity-levels, and satisfaction rates.

Composite treatment for primary long-bone hydatidosis.

Hydatid disease is a parasitic tapeworm infection caused by the Echinococcus species. Involvement of the long tubular bones is rare in hydatid bone disease. Patients are initially asymptomatic and usually present at a later stage of the disease when the bony lesions are extensive. Diagnosing bone hydatid disease is challenging, even in endemic regions, and a high index of suspicion is required because the radiologic findings often mimic other bone pathologies. Recurrence following treatment can occur after a long period of quiescence.This article describes a case of hydatid disease in a 62-year-old woman with extensive diaphyseal tibial involvement. She was treated with initial chemotherapy followed by extended curettage, polymethylmethacrylate cementation, and intramedullary fixation. Functional outcome was excellent, with no recurrence at 60-month follow-up. She was fully weight bearing with no pain or discomfort and had full hip, knee, and ankle range of motion.This case was important due to its rarity, the diagnostic challenge it presented, and the composite nature of the treatment used to avoid recurrence. Diaphyseal bone hydatidosis can be initially treated like a low-grade malignant tumor with curettage and high-speed burring, followed by filling the defect with polymethylmethacrylate cement. The composite treatment of chemotherapy with the surgical protocol described offers a reasonable chance of long-term disease suppression. Recurrent disease can be treated with repeat curettage and cementation. Wide excision with reconstruction of the resulting defect should only be considered for recalcitrant diaphyseal hydatid disease.

Nonoperative Treatment of Displaced Type II Odontoid Peg Fractures With a Philadelphia Collar

Although a consensus exists on the nonoperative management of types I and III odontoid peg fractures, treatment of type II fractures remains controversial. An increasing trend exists toward primary fixation of type II peg fractures due to a high rate of nonunion, especially if the displacement is >4 mm. This article reports the results of nonoperative treatment of patients with displaced odontoid peg fractures (>4 mm) using a Philadelphia collar.A retrospective review of clinical and radiological records was performed for nonoperatively treated patients who sustained displaced type II peg fractures between January 2003 and April 2008. The study group comprised 9 patients (2 men and 7 women), and all patients were treated with Philadelphia collars. Patients were followed up for an average of 24.8 months (range, 8-28 months) for clinical and radiological outcomes. Functional outcomes were measured according to the Smiley-Webster scale. Fractures united uneventfully in 6 patients, but nonunion developed in 3 patients. Average time to union was 12.3±2.94 weeks (95% confidence interval, 9.97-14.68 weeks; range, 10-16 weeks). No patient had clinical or radiological signs of instability or delayed onset myelopathy at follow-up. Three patients had excellent, 4 had good, and 2 had fair results as per the Smiley-Webster functional scoring system.Displaced type II peg fractures can be managed nonoperatively in patients who refuse surgery or those with multiple comorbidities. Adequate patient counseling and compliance with close clinicoradiological follow-up is paramount to avoid adverse clinical events and achieve an optimal functional outcome.

Tissue expanders with a focus on extremity reconstruction

ABSTRACT Introduction: Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. Areas covered: In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. Expert commentary: An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

Outpatient Lower Extremity Total Joint Arthroplasty: Where Are We Heading?

By the end of 2050, the incidences of hip and knee arthroplasties performed in the United States are projected to be more than 1.8 million and 4 million, respectively.1 In 2014 alone, more than 1 million elective lower extremity arthroplasties were performed, with collective per procedure expenditures ranging from

Ipsilateral Rupture of Quadriceps Tendon with Distal Tibia Fracture: A Case Report and Review of the Literature

16,500 to

Lateral Subtalar Dislocation with Tarsometatarsal Dislocation: A Case Report of a Rare Injury

75,000. This disbursement covered surgery, hospitalization, and rehabilitative services.2 As the demand for hip and knee arthroplasties continues to escalate, orthopedic surgeons and hospital administrators are striving to provide cost-effective improvements in patient care.3-7 Given the large volume of total joint replacements, even modest reductions in costs will translate into substantial savings in health care expenditures. With the introduction of the Bundled Payments for Care Improvement initiative by the Centers for Medicare & Medicaid Services, providers receive single payments for each procedure covering all costs related to acute hospital stay, the preoperative period, and the period up to 90 days postoperatively. As per this initiative, payments provided to hospitals are based on their previous year’s benchmark. Going forward, hospitals will receive bonuses for reducing average costs by 2% and penalties for failing to meet average costs. Thus, cost reductions are essential in health care organizations.8 Major expenses associated with lower extremity total joint arthroplasties are affected by implant costs, in-hospital length of stay, perioperative complications, readmissions, and discharge to rehabilitative services.9 In an effort to minimize costs and improve efficiency, orthopedic surgeons have focused on reducing length of stay and inpatient rehabilitation services. This has led to the evolution of outpatient surgery. With advancements such as less invasive surgical procedures, strategies to prevent blood loss, improved perioperative pain control, and rapid rehabilitation protocols, outpatient hip and knee arthroplasties have become a reality.10-12 In the past, some authors loosely used the term “outpatient total joint arthroplasty” to encompass discharge within 23 hours of surgery.13 However, we believe that, when patients stay overnight, this should be called short-stay surgery or expedited recovery and that the term outpatient surgery should be reserved for patients discharged home the same day as surgery. Surgeons have used a variety of approaches—strict patient selection, preoperative counseling, preemptive analgesia with antiemetics, multimodal perioperative analgesic protocols that include adductor canal peripheral nerve blocks, wound infiltration with local anesthetics, less invasive surgical techniques, blood management with tranexamic acid, and completion of surgery by mid-morning or early afternoon—to enhance postoperative recovery, permit adjustment of medications, and allow timely discharge.10,11,14,15 Despite the appeal of outpatient arthroplasty, outcomes must be analyzed prior to its universal implementation in this era of cost reduction and savings and delivery of quality health care.

Anomalous biceps origin from the rotator cuff

Traumatic rupture of the quadriceps tendon by itself is not an uncommon clinical condition. However, its association with concurrent ipsilateral closed distal tibia oblique fracture is exceedingly rare with only one previously reported case in English literature. The dual diagnosis of this atypical combination of injury may be masked by pain and immobilization of the more obvious fracture and may be missed, unless the treating physician maintains a high index of suspicion. Suprapatellar knee pain with or without a palpable gap in the quadriceps tendon and inability to straight leg raise in the setting of a distal tibia fracture should raise concern, but if initial treatment employs a long-leg splint the knee symptoms may be muted. In this report, we describe this unusual combination of injury in a 67-year-old male patient who sustained a trivial twisting injury to the leg. The aim of this report is to raise awareness and emphasize the importance of thorough and repeated clinical examinations in the presence of distracting injuries. Despite the complexity of the problem, standard techniques for quadriceps tendon repair using transpatellar bone tunnels following locked intramedullary rodding of the tibia fracture may lead to optimal outcomes.