Steven F. Schutzer

Posttraumatic piriformis syndrome: diagnosis and results of operative treatment.

BACKGROUND Posttraumatic piriformis syndrome is a rare disorder that is not clearly defined in the orthopaedic literature. We report on the specific diagnosis, operative treatment, and outcome of treatment of fifteen cases of piriformis syndrome (in fourteen patients), treated by one surgeon, in which the common etiology was blunt trauma to the buttock. We are unaware of any previously published report of this kind. METHODS Fourteen patients (fifteen cases of piriformis syndrome), with an average age of thirty-eight years (range, twenty-four to fifty-six years), were managed with an operative release of the piriformis tendon and sciatic neurolysis. All fourteen patients had a history of a blow to the buttock, and all had pain in the buttock, intolerance to sitting, tenderness to palpation of the greater sciatic notch, and pain with flexion, adduction, and internal rotation of the hip. Eleven patients (twelve cases) had severe radicular pain in the affected lower limb. All fourteen patients failed to improve after a prolonged period of conservative treatment with nonsteroidal medication or physical therapy, or both. On the average, the patients had been evaluated by three physicians who were not orthopaedic surgeons and by two orthopaedic surgeons before they were referred to the senior one of us. They had had an average of 4.5 diagnostic tests and an average delay of thirty-two months (range, four to seventy-one months) between the time of the injury and the operation. Preoperative electromyograms revealed extrapelvic compression of the sciatic nerve in six of the eight patients who had this study. Intraoperative findings revealed adhesions between the piriformis muscle, the sciatic nerve, and the roof of the greater sciatic notch. RESULTS Clinical examination at a minimum of twenty-four months (average, thirty-eight months) postoperatively revealed eleven excellent and four good results according our symptom-rating scale. All of the patients returned to work or to their usual daily activities at an average of 2.3 months postoperatively, and the time to maximum subjective improvement averaged 2.1 months. Complications included a seroma and an infected hematoma. CONCLUSIONS Patients who have blunt trauma to the buttock and then have signs and symptoms that are suggestive of lumbar nerve-root compression may have posttraumatic piriformis syndrome. In our group of carefully selected patients, release of the piriformis tendon and sciatic neurolysis led to encouraging results with few complications.

Computerized tomography of the patellofemoral joint before and after lateral release or realignment

Computerized tomography (CT) provides an accurate diagnostic tool for evaluating tilt and subluxation of the patella. Using a previously described technique, this study reviews 62 computerized tomograms, including those of 21 patients before and after lateral release or anteromedial tibial tubercle transfer. One patient was evaluated before and after soft-tissue realignment of the patella. Additional CT studies were evaluated to establish the most appropriate reference line for determining patellar tilt. Results show that lateral retinacular release effectively reduces abnormal patellar tilting as determined by CT. Anteromedial tibial tubercle transfer similarly reduces abnormal tilt. Patellar subluxation may improve substantially following either lateral release or anteromedial tibial tubercle transfer, but this study suggests that correction of subluxation is less consistent than reduction of abnormal tilt with tibial tubercle transfer or lateral release alone. Once articular degeneration has progressed to the point of facet collapse, lateral release fails to restore normal tilt.

High placement of porous-coated acetabular components in complex total hip arthroplasty

The authors retrospectively evaluated the results of 56 hips in 51 patients with an acetabular deficiency who had a total hip arthroplasty with a porous-coated, cementless acetabular component implanted at a high hip center. Forty-nine cases were revisions and seven were primary operations. The mean height of the hip center was 43 mm above the interteardrop line compared to 14 mm for the anatomic center, threefold higher than normal. In contrast, the mean horizontal locus was reduced compared to normal (33 vs 37 mm for the anatomic center). Sixteen acetabular components were small (46-48 mm o.d.) and eight were miniature (40-44 mm o.d.). Despite superior placement of the acetabular component, 32 limbs were lengthened by the procedure. The mean preoperative Harris hip score was 51 (range, 28-93). At a mean follow-up period of 40 months (range, 24-64 months), the mean Harris hip score was 86 (range, 36-100). In 23 hips no radiolucent lines were present at the interface of the bone to the porous mesh, and 33 hips had a thin (0.5 mm), nonprogressive radiolucent line in one or more zones. No acetabular component had migrated and no problems occurred with the screws. Four hips (3 revisions and 1 primary operation) had a complete radiolucent line on one oblique view of the acetabulum. No acetabular component has been revised for loosening.(ABSTRACT TRUNCATED AT 250 WORDS)

Deep-wound infection after total hip replacement under contemporary aseptic conditions.

The role of the combination of perioperative antibiotics, laminar air-flow operating rooms, and body-exhaust systems in reducing the incidence of deep-wound sepsis after total hip replacement remains controversial. We evaluated the incidence of deep-wound infection as associated with the magnitude of the operation in 575 patients (659 procedures) who had all three methods of prophylaxis. The same surgeon performed all of the operations. The procedures were divided into five groups, according to the complexity of the operation and the need for major bone-grafting. Only one patient (who had previously had an infection) had early sepsis. After the 376 standard primary operations, the over-all incidence of sepsis (early and late) was 0.38 per cent. No infection occurred after fifty-four complex primary operations without femoral-head autografting. After fifty-nine complex primary operations with femoral-head autografting, three patients had a late deep infection. No infection occurred within two years after the 170 revision operations. There was no late infection after the 104 revisions without major bone-grafting, but late sepsis developed in two patients after the sixty-six revisions with major bone-grafting. Of the total of six cases of late infection in five patients, five had an identifiable source of infection that was extrinsic to the wound. The incidence of early postoperative sepsis after total hip replacement, even complex primary total hip replacement and revision, was extremely low when using the three contemporary methods of prophylaxis for infection.(ABSTRACT TRUNCATED AT 250 WORDS)

The evaluation of patellofemoral pain using computerized tomography. A preliminary study.

There are well-recognized limitations of conventional axial radiographs of the patellofemoral joint in assessing patients with peripatellar pain, particularly in the first 20 degrees of knee flexion. Computerized tomography (CT) was used, therefore, to evaluate 20 patients with persistent patellofemoral pain and ten asymptomatic volunteers. Multiple midpatellar images were obtained between zero degrees and 30 degrees -40 degrees (sometimes 40 degrees) of flexion, with and without maximal quadriceps contraction. Three distinct patterns of malalignment were identified. When compared to controls, 11 patients had lateralized patellae based on high-congruence angles in extension. With progressive flexion to 30 degrees, all but one reduced into the trochlea. This group was subdivided into those lateralized with or without associated patellar tilting. There were seven patients whose patellae progressively tilted between zero degrees and 30 degrees of flexion while remaining centered in the trochlea. Anatomic differences demonstrated by CT appear to be a factor in distinguishing these groups. Computerized tomography may be the optimal method of radiographically evaluating the patellofemoral joint. Patients have been identified with lateralized patellae in extension that subsequently become congruent by 30 degrees of flexion and therefore may not be appreciated on traditional radiographs. An awareness of different patterns of malalignment is a significant advantage of computerized tomography when planning selective surgical realignment for these patients.

Trochanteric osteotomy for revision total hip arthroplasty. 97% union rate using a comprehensive approach.

In current practice most primary total hip arthroplasties (THAs) are performed without trochanteric osteotomy. The superior exposure afforded by trochanteric osteotomy, however, can be valuable in revision total hip surgery. Between 1969 and 1983, 188 revisions in 177 patients were carried out with osteotomy of the greater trochanter. Ninety-one percent were reattached with a three- or four-wire method. Sixty-one percent of the trochanters (N = 114) were advanced to the lateral cortex. Supplemental trochanteric mesh was used in 75% of the revisions (141 hips). Its use is now routine for all revisions. Most patients (N = 137) were permitted to ambulate within five days, using a walker or two crutches, bearing partial weight on the operative hip. Ninety-seven percent (182 of 188) of the trochanters united. Six failed to unite (3%) and eight others had delayed healing (4%). Two trochanters migrated proximally prior to union (1%). Retrospective evaluation of the initial postoperative radiographs for each patient with nonunion identified one or more technical errors in the reattachment technique. While the overall incidence of wire breakage was 27%, most (42 of 51) of these trochanters healed uneventfully. Five of the six patients with trochanteric nonunion, however, had failure of one or both vertical wires by 12 weeks after surgery. The average hip score for the patients with nonunion was 89 points (versus 57 points before surgery), indicating that the average clinical outcome in this group was not substantially comprised by trochanteric complications. In light of the improvement in surgical exposure, high rate of union of the trochanter, and limited number of complications, trochanteric osteotomy is recommended for most revision THA.

Myositis Ossificans of the Piriformis Muscle: An Unusual Cause of Piriformis Syndrome

Piriformis syndrome is the result of entrapment of the sciatic nerve by the piriformis muscle as it passes through the sciatic notch. Because of its relative rarity, a high index of suspicion is necessary to make the diagnosis4,15,22,24. Etiologies have included hypertrophy of the piriformis muscle3,11,16; trauma17,26; pseudoaneurysm of the inferior gluteal artery17; excessive exercise12; and inflammation and spasm of the piriformis muscle19, often in association with trauma11,20, infection2, and anatomical variations of the muscle1,10,18. The syndrome also has been reported in association with dystonia musculorum deformans8. To our knowledge, traumatic myositis ossificans of the piriformis muscle has not been described previously as a cause of piriformis syndrome. We report the case of a patient in whom the sciatic nerve was compressed between the piriformis muscle and the roof of the sciatic notch; bone-scanning, computerized axial tomography, magnetic resonance imaging, and histopathological testing indicated that the compression was secondary to myositis ossificans of the piriformis muscle. A thirty-two-year-old man who had a history of alcohol abuse fell down a flight of stairs while intoxicated and was not found until the following day. The injuries included a mild closed head injury, several fractures of the ribs, and a contusion of the right thigh and the left buttock. A few days later, he noted increasing pain that radiated from the left gluteal region to the posterior portions of the thigh and calf. Three weeks after the injury, he observed paresthesias and decreased sensation on the lateral border of the left foot as well as weakness in the left ankle. He did not have pain …

Influence of intraoperative femoral fractures and cerclage wiring on bone ingrowth into canine porous-coated femoral components

Intraoperative femoral fractures occur more frequently with cementless than with cemented components. In this study, the influence of controlled femoral fractures fixed with cerclage wires on rotational stability and bone ingrowth into porous-coated canine femoral components was evaluated. These data were compared with results of previous studies on unrecognized femoral fractures (not stabilized) and on the intact canine femur. Micromotion analysis revealed a significant increase in rotational instability in fractures not stabilized with cerclage wires (P < .05) compared with the intact femur. Experimentally created femoral fractures had a significantly deleterious effect on bone ingrowth even after cerclage wiring. This appears to be caused by a lack of bone ingrowth deep to the fracture and an increase in femoral component micromotion. In clinical practice, femoral fractures occurring during cementless total hip arthroplasty are a serious problem, and use of a cemented prosthesis is recommended if rotational stability of the stem cannot be ensured.

Radiation-blocking shields to localize periarticular radiation precisely for prevention of heterotopic bone formation around uncemented total hip arthroplasties

Sixteen patients (18 hips) were treated with localized radiation therapy limited to periarticular regions surrounding the femoral neck by shielding the prosthesis and the adjacent regions to prevent heterotopic bone formation around the uncemented prosthesis. All hips received 1500 rads. Eight of these hips were irradiated after excising severe heterotopic bone, five because they developed extensive heterotopic ossification in the opposite hip, and five others because they were considered to be at high risk for developing heterotopic ossification. Only two of the 18 hips developed a small amount of heterotopic bone after localized periarticular radiation. All wounds healed primarily. No progressive radiolucencies developed at the bone-prosthesis interface. There was only one trochanteric nonunion of six trochanteric osteotomies. Localized periarticular radiation therapy with precision shielding of the prosthetic components and adjacent skeletal structures is an effective means to prevent heterotopic bone formation around cementless total hip arthroplasties. It also has the advantage of not adversely affecting the healing of the trochanteric osteotomy.

Focused Risk Analysis: Regression Model Based on 5,314 Total Hip and Knee Arthroplasty Patients from a Single Institution

We aimed to identify significant demographic, preoperative comorbidity and surgical predictors for major complications for use in the development of a risk prediction tool for a well-defined population as Total Joint Arthroplasty (TJA) patients. Data on 5314 consecutive patients who underwent primary total hip or knee arthroplasty from October 1, 2008 through September 30, 2011 at a single institution were used in a multivariate regression analysis. The overall incidence of a primary endpoint (reoperation during same admission, extended length of stay, and 30-day readmission) was 3.8%. Significant predictors include certain preexisting genitourinary, circulatory and respiratory conditions; ASA>2; advanced age and prolonged operating time. Mental health conditions demonstrate a strong predictive effect for subsequent serious complication(s) in TJA patients and should be included in a risk-adjustment tool.