Steven Velkes

Trends in Femoroacetabular Impingement Research Over 11 Years

Femoroacetabular impingement is the abutment between the proximal femur and the rim of the acetabulum. It is a common cause of labral injury that has been identified as an early cause of hip osteoarthritis. The diagnosis of femoroacetabular impingement of the hip is currently well defined in orthopedic surgery but should attract the attention of physicians in other disciplines. Conversely, much less is known about the etiology and natural history of femoroacetabular impingement.The goal of this study was to assess the number of articles published on femoroacetabular impingement over 11 years in orthopedic vs nonorthopedic medical journals, and to evaluate the quality of available evidence. PubMed and OvidSP databases were searched for articles on femoroacetabular impingement published from 1999 to 2009. Articles were characterized by publication type and journal type per year. Regression analysis was used to determine the effect of publication year on number of publications of each type. The search yielded 206 publications on femoroacetabular impingement during the evaluation period. Seventy-two percent were published in orthopedic journals. Overall, the number of publications increased exponentially with time. There was an increase in clinical trials over the course of the study period. However, studies with high-quality evidence were scarce. The increase in data from orthopedic and nonorthopedic disciplines is welcome. Nevertheless, high-quality evidence on femoroacetabular impingement is lacking. We believe the current trend toward evidence-based orthopedic surgery will impact future research on this relatively new disorder.

Accuracy of non assisted glenohumeral joint injection in the office setting

PURPOSE The diagnostic and therapeutic success of shoulder joint injection depends on its accuracy. Two recent studies reported high success (93-96%) for non-imaging-assisted anterior injection in anesthetized patients. This study examined the accuracy of anterior shoulder injection in awake patients under conditions similar to the office setting. METHODS The study group consisted of 166 consecutive patients with shoulder pain who underwent diagnostic magnetic resonance arthrography at a tertiary medical center in 2011-2012. As part of the examination, contrast material was injected into the glenohumeral joint via an anterior approach by a certified musculoskeletal radiologist without any image assistance. Success was defined as contrast material limited to the intra-articular joint on the scan, without scatter to the periauricular tissue. RESULTS A successful injection was verified by magnetic resonance arthography in 163 patients (98.2%). CONCLUSIONS Non-assisted anterior shoulder injection is highly accurate (98.2%) in the hands of an experienced radiologist, even in awake patients.

Guiding femoral rotational growth in an animal model.

BACKGROUND Guided growth is most commonly utilized about the knee and ankle for the correction of coronal-plane deformities by the use of plates positioned perpendicular to the physis. Sagittal-plane deformity correction has been described as well. The purpose of our study was to examine the ability to affect axial-rotational growth. Our hypothesis was that placement of plates in an oblique orientation relative to the physis can induce rotational growth deformity. METHODS Our hypothesis was tested with use of a mathematical model and a bone model and subsequently in a rabbit model. Thirteen six-week-old rabbits underwent a rotational guided growth procedure involving the distal aspect of the right femur, with a sham procedure performed on the left side. Two plates were positioned in an oblique orientation relative to the physis, medially and laterally, to guide either internal or external rotational growth. After the rabbits were killed six weeks after the surgery, the femoral rotational profile was assessed by computed tomography scans of the dissected femora and the growth plates were examined histologically. RESULTS A significant effect on the rotational profile was found in the treated femora. When the plates were positioned to guide external rotation, the rotational profile was significantly greater in the treated femora (29.0° compared with 11.3° in the sham femora; p = 0.008). There was a positive linear correlation between the right-left difference in rotational profile and the change in inter-plate angle (R2 = 0.72, p = 0.001). Every 1° of inter-plate angle change induced 0.367° of rotational profile difference (p = 0.001). Histologically, a swirling effect of the physeal cell columns was seen in the treated femora. CONCLUSIONS Guided growth using plates was demonstrated to alter axial-rotational growth in a predictable fashion in a rabbit model. CLINICAL RELEVANCE Guided growth using plates may be effective for correction of rotational and multiplanar deformities.

Ankle tourniquet pain control in forefoot surgery: a randomized study.

Background: Forefoot surgery is often performed under regional anesthesia in awake patients, using tourniquet or Esmarch bandage to obtain a bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under ankle block anesthesia. Materials and Methods: We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive either subcutaneous local anesthetic mixture under the tourniquet or no additional anesthetic. We checked for local tourniquet pain score (VAS 0 to 100) and skin condition during and after the procedure. Results: The tourniquet was quite tolerable in both groups, with an average VAS score of 7 to 21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patients age or gender was found. Conclusion: An ankle tourniquet was well-tolerated by patients without need for local anesthetic beneath the cuff. Level of Evidence: II, Prospective Comparative Study

Solitary intraosseous myofibroma of the tibia in an adult patient: A case report.

Myofibromas are mesenchymal tumors showing myofibroblastic differentiation and found most frequently in the head and neck region. While several cases of myofibromas have been reported in adults, they have not been described in long bones of the appendicular skeleton. We describe an otherwise healthy young woman who presented with a progressive incapacitating pain in her right shin. Imaging studies revealed a well-circumscribed osteolytic lesion with slight marginal sclerosis confined to the proximal tibia metaphysis, without a soft tissue component. Surgical intervention was performed and histological examination identified a myofibroma. This case represents an extremely rare occurrence of an intraosseous myofibroma involving a long bone in an adult patient. Although solitary myofibroma is a rare lesion in the skeletal bones of adults we believe it should be included in the differential diagnosis of a solitary lytic mass in bone, especially if it is associated with pain.

Chondrolysis of the Hip following Septic Arthritis: A Rare Complication of Magnetic Resonance Arthrography

Magnetic resonance arthrography (MRA) is commonly used to detect labral tears of the hip. Complications of MRA are unusual and include minor reactions such as chemical synovitis and urticaria. This paper presents a rapidly progressive chondrolysis of the hip in a young patient after arthrography. The patient had suffered from acute septic arthritis and was treated by emergent arthroscopic surgery followed by appropriate antibiotics. At 18 months of followup, there were no signs of active infection but evidence of joint chondrolysis. Magnetic resonance arthrography (MRA) of the hip is an invasive procedure and should therefore be recommended judiciously. Post-MRA pain is common but often mild and temporary, while post-MRA joint infection is rare; nevertheless, severe joint pain and limitation should raise suspicion for septic hip.

A Novel Non-Invasive Adjuvant Biomechanical Treatment for Patients with Altered Rehabilitation after Total Knee Arthroplasty: Results of a Pilot Investigation.

Background Many factors contribute to suboptimal results after total knee arthroplasty (TKA) but little is known regarding the value of postsurgical rehabilitation after TKA. We examined the effects of an enhanced closed kinematic chain exercises program (AposTherapy) on gait patterns and clinical outcomes among patients with a lack of progress in their postsurgical rehabilitation. Methods Twenty-two patients were prospectively followed during the study. Gait spatiotemporal parameters were measured at the initial evaluation, after 15 minutes of therapy, and after 3 months of therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the short form (SF) 36 health survey were completed by patients before treatment and after 3 months of treatment. Results The WOMAC and SF-36 scores improved significantly after 3 months of treatment. Gait velocity, single limb support, and step length of the operated leg improved significantly even after a single 15 minutes treatment. Normal gait velocity was observed in 36% of patients after 3 months of treatment. Conclusions A physiotherapy program that included enhanced closed kinematic chain biomechanical therapy was beneficial for patients who experienced a suboptimal rehabilitation course after TKA.

New approach for the rehabilitation of patients following total knee arthroplasty.

PURPOSE To investigate the effect of a biomechanical therapy on gait, function and clinical condition in patients following total knee arthroplasty (TKA). METHODS Seventeen TKA patients participated in the study. Patients received a biomechanical therapy AposTherapy). Patients underwent a gait test, clinical examination and an assessment of pain, function and quality of life (QOL). Patients were examined again at one, three and six month follow-ups. RESULTS A significant improvement over time was found in most gait measurements. Significant improvements were also found in pain, function and QOL. CONCLUSIONS The examined biomechanical therapy may help in the rehabilitation process following TKA.

Corrective lower limb osteotomies in children using temporary external fixation and percutaneous locking plates

Abstract Background We describe a new method for corrective osteotomy and the fixation of lower limb deformities in children. Methods Following osteotomy, the desired position is obtained and temporarily stabilized using an external fixator. Definitive fixation is performed with a plate and locking screws inserted percutaneously under fluoroscopic guidance. The procedure was performed in 18 segments in 11 patients. Corrections were performed in all planes. Results The mean follow up was 18 months (range 6–36 months). All patients were corrected to within 2° of that which was planned. Union was obtained in 16 segments in ten patients within 6–16 weeks. Conclusions The method was found to be effective for the correction of deformity in the pediatric population. Advantages compared to conventional methods include minimal soft tissue dissection and the ability to adjust the position before definitive fixation.

A non-invasive biomechanical device and treatment for patients following total hip arthroplasty: results of a 6-month pilot investigation.

BackgroundThe purpose of the study was to examine the effect of a foot-worn biomechanical device on the clinical measurements and gait patterns of patients with total hip arthroplasty (THA).MethodsNineteen patients, up to 3 months post-THA, were enrolled to the study. Patients underwent a computerized gait analysis to calculate spatiotemporal parameters and completed the Western Ontario and McMaster Universities osteoarthritis index and the SF-36 health survey. Patients then began therapy with a non-invasive foot-worn biomechanical device coupled with a treatment methodology (AposTherapy). Patients received exercise guidelines and used the device daily during their regular activities at their own environment. Follow-up examinations were conducted after 4, 12, and 26 weeks of therapy. Repeated measures ANOVA was used to evaluate changes over time. The clinical significance of the treatment effect was evaluated by computing the Cohens effect sizes (ES statistic).ResultsAfter 26 weeks of therapy, a significant improvement was seen in gait velocity (50.3%), involved step length (22.9%), and involved single limb support (16.5%). Additionally, a significant reduction in pain (85.4%) and improvement in function (81.1%) and quality of life (52.1%) were noted.ConclusionsPatients following THA demonstrated a significant improvement in gait parameters and in self-assessment evaluations of pain, function, and quality of life. We recommend further RCTs to examine the effect of this therapy compared to other rehabilitation modalities following THA and compared to healthy matched controls.Trial registrationClinical trial registration number NCT01266382