Advances in Orthopedics The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Factors Driving Readmissions in Tibia and Femur Fractures Tue, 10 Mar 2015 14:23:05 +0000 As the American healthcare system shifts towards bundled payments, readmissions will become a measure of healthcare quality. The purpose of this study was to characterize readmission trends and factors influencing readmission in patients with diaphyseal femur and tibia fractures. Through a retrospective chart review, all patients who presented to a level 1 trauma center from 2004 to 2006 were evaluated. By using current procedural terminology codes, 1,040 patients with diaphyseal tibia or femur fractures fixed by IMN were identified. 645 patients were included for analysis. 30-day, 60-day, and 90-day readmission rates were compared with fracture type, reason for readmission, and basic demographic information. The 60-day readmission rate for open tibia fractures (14.8%) was significantly higher than the 60-day readmission rate for closed tibia fractures (8.0%) (). When comparing reasons for 60-day readmissions, 50% of closed fractures were readmitted due to infection, while the other 50% needed additional surgery. 91.7% of open fractures readmitted in 60 days were due to infection. In a bundled payment system, orthopedic trauma must gain insight into drivers of readmission to identify those at risk for readmission and design effective healthcare plans for these patients. Alexander Chern, Sarah E. Greenberg, Rachel V. Thakore, Vasanth Sathiyakumar, William T. Obremskey, and Manish K. Sethi Copyright © 2015 Alexander Chern et al. All rights reserved. Treatment of the Developmental Dysplasia of the Hip with an Abduction Brace in Children up to 6 Months Old Thu, 26 Feb 2015 11:50:30 +0000 Introduction. Use of Pavlik harness for the treatment of DDH can be complicated for parents. Any misuse or failure in the adjustments may lead to significant complications. An abduction brace was introduced in our institution, as it was thought to be easier to use. Aim. We assess the results for the treatment of DDH using our abduction brace in children of 0–6 months old and compare these results with data on treatments using the Pavlik harness. Method. Retrospective analysis of patients with DDH from 0 to 6 months old at diagnosis, performed from 2004 to 2009. Outcomes were rates of reduction of the hip and avascular necrosis of the femoral head (AVN). Follow-up was at one year and up to 4 years old. Results. Hip reduction was successful in 28 of 33 patients (85%), with no AVN. Conclusion. Our results in terms of hip reduction rate and AVN rate are similar to those found in literature assessing Pavlik harness use, with a simpler and comfortable treatment procedure. Raphaël Wahlen and Pierre-Yves Zambelli Copyright © 2015 Raphaël Wahlen and Pierre-Yves Zambelli. All rights reserved. The Surgical Treatment of Pelvic Bone Metastases Tue, 24 Feb 2015 12:16:41 +0000 Pelvic bone metastases are a growing concern in the field of orthopedic surgery. Patients with pelvic metastasis are individually different with different needs of treatment in order to attain the best possible quality of life despite the advanced stage of disease. A holistic collaboration among the oncologist, radiation therapist, and orthopedic surgeon is mandatory. Special attention has to be directed to osteolytic lesions in the periacetabular region as they can provoke pathological fractures and subsequent functional impairment. Different reconstruction techniques for the pelvis are available; the choice depends on the patient’s prognosis, size of the bone defect, and response of the tumor to adjuvant treatment. If all the conservative treatments are exhausted and the patient is not eligible for surgery, one of the various percutaneous ablation procedures can be considered. We propose a pelvic analogue to the treatment algorithm in long bone metastasis and a scoring system in pelvic metastasis. This algorithm aims to simplify the teamwork and to avoid under- or overtreatment of pelvic bone metastases. Daniel A. Müller and Rodolfo Capanna Copyright © 2015 Daniel A. Müller and Rodolfo Capanna. All rights reserved. Hyponatraemia after Fracture Is Often Caused by Hypovolaemia, Not SIADH Tue, 24 Feb 2015 11:50:50 +0000 K. Cumming and R. L. Soiza Copyright © 2015 K. Cumming and R. L. Soiza. All rights reserved. Immediate Weight-Bearing after Ankle Fracture Fixation Mon, 16 Feb 2015 11:20:02 +0000 We believe that a certain subset of surgical ankle fracture patients can be made weight-bearing as tolerated immediately following surgery. Immediate weight-bearing as tolerated (IWBAT) allows patients to return to ambulation and activities of daily living faster and may facilitate rehabilitation. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had ORIF after unstable ankle injuries treated by the senior author. Patients were excluded if they were not IWBAT based on specific criteria or if they did meet followup requirement. Only 1/26 patients was noted to have loss of fixation. This was found at the 6-week followup and was attributed to a missed syndesmotic injury. At 2-week followup, 2 patients had peri-incisional erythema that resolved with a short course of oral antibiotics. At 6-week followup, 20 patients were wearing normal shoes and 6 patients continued to wear the CAM Boot for comfort. To conclude, IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture could potentially be a safe alternative to a period of protected weight-bearing. Reza Firoozabadi, Emily Harnden, and James C. Krieg Copyright © 2015 Reza Firoozabadi et al. All rights reserved. Ponseti Casting for Severe Club Foot Deformity: Are Clinical Outcomes Promising? Tue, 10 Feb 2015 06:41:40 +0000 Between 2007 and 2010, a prospective study was done on 85 patients with severe idiopathic nonsyndromic clubfeet, in our center. Demographic features, severity of the deformity before and after serial casting according to Diméglio classification, and complications were assessed. The mean age of the patients was 8 days and 69% were male. The mean follow-up period was 26 months. The average number of castings used to correct the deformity was 5.7 times (range: 4 to 8). Tenotomy was performed in 76 (89.4%) of the feet. In all patients, plantigrade foot was achieved. Tenotomy occurred more in patients with higher Diméglio scores. Although patients who underwent Achilles tenotomy began to walk later than those who did not ( versus ), it was not significant (). Relapse rate, at the end of follow-up, was 27.1%. Diméglio score before casting was and at the end of follow-up it was . The patients with bilateral clubfeet had inferior final outcome compared to those with unilateral clubfoot. Eighty percent of parents’ were completely satisfied with their child's gait and foot appearance (94.1%). Ponseti method of manipulation and casting is a valuable technique in severe club foot as well as in common types. Mohammad Hallaj-Moghaddam, Ali Moradi, Mohammad Hosein Ebrahimzadeh, and Seyed Reza Habibzadeh Shojaie Copyright © 2015 Mohammad Hallaj-Moghaddam et al. All rights reserved. Osteoid Osteoma Treated with Radiofrequency Ablation Mon, 02 Feb 2015 13:45:49 +0000 Purpose. Our aim is to evaluate the results of treatment with computed tomography (CT) guided percutaneous radiofrequency ablation for osteoid osteomas which were localized in a difficult area for operation. Materials and Methods. Glenoid, distal tibia, humerus shaft, proximal humerus, and in third finger of the hand proximal phalanx were involved in one patient. Proximal femur was involved in three patients, distal femur was involved in three patients, and proximal tibia was involved in two patients. 9 males and 4 females were aged 4 to 34 years (mean age: 18.5 years). All patients had pain and were evaluated with X-rays, CT, bone scintigraphy, and MRI. In all patients, RF ablation was performed with local anesthesia. The lesion heated to 90°C for 6 minutes. Results. All of the patients achieved complete pain relief after ablation and were fully weight bearing without any support. In all patients, there was soft tissue edema after the procedure. During follow-up, all patients were free from the pain and there was no sign about the tumor. There was no other complication after the process. Conclusion. CT guided RFA is a minimally invasive, safe, and cost-effective treatment for osteoid osteoma placed in difficult area for surgery. Murat Çakar, Cem Zeki Esenyel, Metin Seyran, Ali Çağrı Tekin, Müjdat Adaş, Mehmet Kürşad Bayraktar, and Ünsal Coşkun Copyright © 2015 Murat Çakar et al. All rights reserved. Low Infection Rate after Tumor Hip Arthroplasty for Metastatic Bone Disease in a Cohort Treated with Extended Antibiotic Prophylaxis Sun, 01 Feb 2015 13:11:42 +0000 Background. Compared to conventional hip arthroplasty, endoprosthetic reconstruction after tumor resection is associated with a substantially increased risk of periprosthetic joint infection (PJI), with reported rates of around 10% in a recent systematic review. The optimal duration of antibiotic prophylaxis for this patient population remains unknown. Material and Methods. To establish the infection rate associated with prolonged antibiotic prophylaxis in our department, we performed a retrospective review of all adult patients who underwent endoprosthetic reconstruction of the proximal femur after tumor resection for metastatic bone disease during a 4-year period from 2010 to 2013 patients). Results. Intravenous antibiotic prophylaxis was administrated for an extended duration of a mean of 7.4 days. The overall infection rate was 3.6% (4/111 implants), infection free survival was 96% at 2 years, and the risk of amputation associated with infection was 25% (1/4 patients). Discussion. Preemptive eradication of bacterial contamination may be of value in certain clinical situations, where the risk level and consequences of implant-associated infection are unacceptable. Our findings suggest that extended postoperative antibiotic prophylaxis may reduce the risk of PJI in patients undergoing tumor resection and endoprosthetic replacement for metastatic bone disease associated impending or de facto pathologic fractures of the proximal femur. Werner H. Hettwer, Peter Frederik Horstmann, Thea Bechmann Hovgaard, Tomas Andreas Grum-Scwensen, and Michael M. Petersen Copyright © 2015 Werner H. Hettwer et al. All rights reserved. Long Term Anticoagulation (4–16 Years) Stops Progression of Idiopathic Hip Osteonecrosis Associated with Familial Thrombophilia Thu, 29 Jan 2015 09:18:01 +0000 In 6 patients with familial thrombophilia (5 Factor V (FV) Leiden heterozygotes, 1 with resistance to activated protein C (RAPC)), we prospectively assessed whether continuous longterm (4–16 years) anticoagulation would prevent progression of idiopathic osteonecrosis (ON), ameliorate pain, and facilitate functional recovery. Four men and 2 women (9 hips, 8 Ficat stage II, 1 stage I) were anticoagulated with enoxaparin (60 mg/day) for 3 months and subsequently with Coumadin, Xarelto, or Pradaxa, warranted by 2 prior thrombotic events. Anticoagulation was continued for 4, 4, 9, 13, 13, and 16 years, with serial clinical and X-ray follow-up. On 4–16-years anticoagulation, 9 hips in the 6 patients (8 originally Ficat II, 1 Ficat I) remained unchanged, contrasted to untreated ON Ficat stage II, where 50%–80% of hips progress to collapse (Ficat stages III-IV) within 2 years after diagnosis. Within 3, 3, 3, 9, and 16 months after starting anticoagulation, 5 patients became pain-free and remained asymptomatic throughout follow-up; the 6th patient required Percocet for pain. There were no significant bleeding episodes. Long term (4–16 years) anticoagulation initiated in Ficat stages I-II of idiopathic hip ON in patients with FV-RAPC changes the natural history of ON, stopping progression, resolving pain, and restoring function. Charles J. Glueck, Richard A. Freiberg, Robert Wissman, and Ping Wang Copyright © 2015 Charles J. Glueck et al. All rights reserved. A Feasibility Study into the Use of Three-Dimensional Printer Modelling in Acetabular Fracture Surgery Thu, 29 Jan 2015 09:15:53 +0000 There are a number of challenges associated with the operative treatment of acetabular fractures. The approach used is often extensive, while operative time and perioperative blood loss can also be significant. With the proliferation of 3D printer technology, we present a fast and economical way to aid the operative planning of complex fractures. We used augmented stereoscopic 3D CT reconstructions to allow for an appreciation of the normal 3D anatomy of the pelvis on the fractured side and to use the models for subsequent intraoperative contouring of pelvic reconstruction plates. This leads to a reduction in the associated soft tissue trauma, reduced intraoperative time and blood loss, minimal handling of the plate, and reduced fluoroscopic screening times. We feel that the use of this technology to customize implants, plates, and the operative procedure to a patient’s unique anatomy can only lead to improved outcomes. A. W. Yu, J. M. Duncan, J. S. Daurka, A. Lewis, and J. Cobb Copyright © 2015 A. W. Yu et al. All rights reserved. Percutaneous Vertebral Augmentation with Polyethylene Mesh and Allograft Bone for Traumatic Thoracolumbar Fractures Mon, 26 Jan 2015 14:19:33 +0000 Purpose. In cases of traumatic thoracolumbar fractures, percutaneous vertebral augmentation can be used in addition to posterior stabilisation. The use of an augmentation technique with a bone-filled polyethylene mesh as a stand-alone treatment for traumatic vertebral fractures has not yet been investigated. Methods. In this retrospective study, 17 patients with acute type A3.1 fractures of the thoracic or lumbar spine underwent stand-alone augmentation with mesh and allograft bone and were followed up for one year using pain scales and sagittal endplate angles. Results. From before surgery to 12 months after surgery, pain and physical function improved significantly, as indicated by an improvement in the median VAS score and in the median pain and work scale scores. From before to immediately after surgery, all patients showed a significant improvement in mean mono- and bisegmental kyphoses. During the one-year period, there was a significant loss of correction. Conclusions. Based on this data a stand-alone approach with vertebral augmentation with polyethylene mesh and allograft bone is not a suitable therapy option for incomplete burst fractures for a young patient collective. C. Schulz, U. Kunz, U. M. Mauer, and R. Mathieu Copyright © 2015 C. Schulz et al. All rights reserved. Acute Compartment Syndrome in Orthopedics: Causes, Diagnosis, and Management Mon, 19 Jan 2015 14:10:58 +0000 Almost all orthopaedic surgeons come across acute compartment syndrome (ACS) in their clinical practice. Diagnosis of ACS mostly relies on clinical findings. If the diagnosis is missed and left untreated, it can lead to serious consequences which can endanger limb and life of the patient and also risk the clinician to face lawsuits. This review article highlights the characteristic features of ACS which will help an orthopaedic surgeon to understand the pathophysiology, natural history, high risk patients, diagnosis, and surgical management of the condition. Hasnain Raza and Anant Mahapatra Copyright © 2015 Hasnain Raza and Anant Mahapatra. All rights reserved. The Use of a Dehydrated Amnion/Chorion Membrane Allograft in Patients Who Subsequently Undergo Reexploration after Posterior Lumbar Instrumentation Tue, 13 Jan 2015 06:26:26 +0000 Background Context. Products that can reduce development of epidural fibrosis may reduce risk for ongoing pain associated with development of scar tissue and make subsequent epidural reexploration easier. Purpose. To evaluate the use of dehydrated human amnion/chorion membrane (dHACM) on the formation of soft tissue scarring in the epidural space. Study Design. Case series. Patient Sample. Five patients having transforaminal lumbar interbody lumbar fusion (TLIF) with posterior instrumentation and implantation of dHACM in the epidural space and subsequent epidural reexploration. Outcome Measures. Degree of scar tissue adjacent to the epidural space at reexploration. Intraoperative and postoperative complications related to dHACM and patient reported outcomes. Methods. The degree of scar tissue adjacent to the epidural space was assessed during the reexploration surgery. Patients’ outcomes were collected using standard validated questionnaires. Results. Four of 5 cases had easily detachable tissue during epidural reexploration. Angiolipoma of 10% was noted in 1 case and 5% in 2 cases. Significant improvements in patient reported outcomes were observed. No intraoperative or postoperative complications occurred. Conclusions. Our findings suggest that dHACM implant during TLIF may have favorable effects on epidural fibrosis and is well tolerated. Further studies with larger cohorts are required to prove our results. Brian R. Subach and Anne G. Copay Copyright © 2015 Brian R. Subach and Anne G. Copay. All rights reserved. The Reliability of Classifications of Proximal Femoral Fractures with 3-Dimensional Computed Tomography: The New Concept of Comprehensive Classification Thu, 25 Dec 2014 13:45:58 +0000 The reliability of proximal femoral fracture classifications using 3DCT was evaluated, and a comprehensive “area classification” was developed. Eleven orthopedists (5–26 years from graduation) classified 27 proximal femoral fractures at one hospital from June 2013 to July 2014 based on preoperative images. Various classifications were compared to “area classification.” In “area classification,” the proximal femur is divided into 4 areas with 3 boundary lines: Line-1 is the center of the neck, Line-2 is the border between the neck and the trochanteric zone, and Line-3 links the inferior borders of the greater and lesser trochanters. A fracture only in the first area was classified as a pure first area fracture; one in the first and second area was classified as a 1-2 type fracture. In the same way, fractures were classified as pure 2, 3-4, 1-2-3, and so on. “Area classification” reliability was highest when orthopedists with varying experience classified proximal femoral fractures using 3DCT. Other classifications cannot classify proximal femoral fractures if they exceed each classification’s particular zones. However, fractures that exceed the target zones are “dangerous” fractures. “Area classification” can classify such fractures, and it is therefore useful for selecting osteosynthesis methods. Hiroaki Kijima, Shin Yamada, Natsuo Konishi, Hitoshi Kubota, Hiroshi Tazawa, Takayuki Tani, Norio Suzuki, Keiji Kamo, Yoshihiko Okudera, Ken Sasaki, Tetsuya Kawano, and Yoichi Shimada Copyright © 2014 Hiroaki Kijima et al. All rights reserved. Determination of the Maximal Corrective Ability and Optimal Placement of the Ortho-SUV Frame for Femoral Deformity with respect to the Soft Tissue Envelope, a Biomechanical Modelling Study Thu, 25 Dec 2014 08:48:40 +0000 Circular fixation according to the Ilizarov method is a well-recognised modality of treatment for trauma and deformity. One shortcoming of the traditional fixator is its limited ability to correct more than one plane of deformity simultaneously, leading to lengthy frame-time indices. Hexapod circular fixation utilising computer guidance is commonplace for complex multidimensional deformity but difficulties often arise with correction of femoral deformity due to bulkiness of the frame construct, particularly in proximal deformity and in patients of increased size. The Ortho-SUV frame is an innovative hexapod which permits unique customisation to individual patient anatomy to maximise tolerance and optimal range of deformity correction. We hypothesised that the optimal configuration and maximal degree of correction achievable by the Ortho-SUV frame can be biomechanically modelled and applied clinically. A study was constructed using Ortho-SUV and femoral limb models to measure deformity correction via differing frame constructs and determine optimal frame configuration to achieve correction in proximal, middle, and distal third deformities with respect to the soft tissue envelope. The ideal frame configuration is determined for correction of deformity in all locations of the femur with the maximal parameters of correction calculated whilst avoiding and mitigating soft tissue irritation from bulky frame construction. Petr V. Skomoroshko, Victor A. Vilensky, Ahmed I. Hammouda, Matt D. A. Fletcher, and Leonid N. Solomin Copyright © 2014 Petr V. Skomoroshko et al. All rights reserved. Two-Stage Revision TKA Is Associated with High Complication and Failure Rates Wed, 24 Dec 2014 10:26:17 +0000 Despite two-stage revision remaining the gold standard in treating periprosthetic infection of total knee arthroplasty (TKA), there remains uncertainty regarding the actual success rate and the risk factors for failure. We retrospectively reviewed 58 knees with mean follow-up of 38 months who underwent two-stage revision TKAs from 1998 to 2012 by a single surgeon. Failure was defined as persistent infection or reoperation after two-stage revision TKA surgery. Failure occurred in 36%. The overall mortality was 22%. The mean time to reinfection was 26 months. Polymicrobial infection was associated with a higher risk of failure (RR 3.31, ). Knees requiring soft tissue coverage were also at a greater risk of failure (RR 2.67, ), as were knees that underwent four or more additional surgeries after the primary TKA and prior to stage-one explantation (RR 2.25, ). Thus, opportunities exist for improvement in management of infected TKA. Christopher E. Pelt, Ray Grijalva, Lucas Anderson, Mike B. Anderson, Jill Erickson, and Christopher L. Peters Copyright © 2014 Christopher E. Pelt et al. All rights reserved. Outcomes and Complications of the Midline Anterior Approach 3 Years after Lumbar Spine Surgery Mon, 22 Dec 2014 08:53:46 +0000 Objective. The purpose of this study was to evaluate a new questionnaire to assess outcomes related to the midline anterior lumbar approach and to identify risk factors for negative patient responses. Methods. A retrospective review of 58 patients who underwent anterior lumbar surgery at a single institution for either degenerative disc disease or spondylolisthesis in 2009 was performed. The outcome measures included our newly developed Anterior Lumbar Surgery Questionnaire (ALSQ), ODI, and EQ-5D. Results. There were 58 patients available for followup, 27 women and 31 men. The average age at surgery was 50.8 years, with an average followup of 2.92 years. The average change in ODI was 34.94 (22.7) and EQ-5D was 0.28 (0.29). The rate of complications with the anterior approach was 10.3% and there was one male patient (3.2%) with retrograde ejaculation. Determination of the effectiveness of the new ALSQ revealed that it significantly correlated to the EQ-5D and ODI . Smoking was associated with a negative response on thirteen questions. BMP use was not associated with a negative response on any sexual function questions. Conclusions. Our new Anterior Lumbar Surgery Questionnaire determines patient perceived complications related to the midline anterior lumbar surgical approach. Charla R. Fischer, Brian Braaksma, Austin Peters, Jeffrey H. Weinreb, Matthew Nalbandian, Jeffrey M. Spivak, and Anthony Petrizzo Copyright © 2014 Charla R. Fischer et al. All rights reserved. Cartilage Degeneration at Symptomatic Persistent Olecranon Physis in Adolescent Baseball Players Thu, 18 Dec 2014 10:16:28 +0000 Background. Elbow overuse injuries are common in adolescent baseball players, but symptomatic persistent olecranon physis is rare, and its pathogenesis remains unclear. Purpose. To examine the histopathological and imaging findings of advanced persistent olecranon physis. Methods. The olecranon physes of 2 baseball pitchers, aged 14 and 15 years, were examined by preoperative magnetic resonance imaging (MRI), and surgical specimens were examined histologically. Results. T2-weighted MRI revealed alterations in the intrachondral signal intensity possibly related to collagen degeneration and increased free water content. Histological findings of specimens stained with hematoxylin-eosin showed complete disorganization of the cartilage structure, hypocellularity, chondrocyte cluster formation, and moderately reduced staining. All these findings are hallmarks of osteoarthritis and are suggestive of cartilage degeneration. Conclusion. Growth plate degeneration was evident in advanced cases of symptomatic persistent olecranon physis. These findings contribute to understanding the pathogenesis of this disease. Tetsuya Enishi, Tetsuya Matsuura, Naoto Suzue, Yoshinori Takahashi, and Koichi Sairyo Copyright © 2014 Tetsuya Enishi et al. All rights reserved. Outcomes of Geriatric Hip Fractures Treated with AFFIXUS Hip Fracture Nail Thu, 18 Dec 2014 00:10:25 +0000 Geriatric hip fractures are one of the commonest fractures worldwide. The purpose of this study was to report the outcomes of a series of unstable geriatric hip fractures treated with AFFIXUS hip fracture nail. A retrospective study of 100 unstable geriatric hip fractures treated with AFFIXUS hip fracture nail is presented. The mean follow-up duration was 8 months (range 3–32). Of the patients 83% were female. The average age was 85 years. The fracture was treated by closed reduction and intramedullary fixation. The mean acute hospital stay was 17.6 days. Systemic complications occurred in 29 patients (29%) and local complications in 3 patients (3%) including lag screw cutout in one patient (1%), lag screw backout in one patient (1%), and deep infection in one patient (1%). Mechanical failures and periprosthetic fractures were not observed in our series. Fractures united in all patients. Preinjury activity level was recovered in 78% of the patients. The results of AFFIXUS hip fracture nail were satisfactory in most elderly patients. The unique design of the lag screw and its thread spacing had effectively reduced cut-out rate. Ahmed Mabrouk, Mysore Madhusudan, Mohammed Waseem, Steven Kershaw, and Jochen Fischer Copyright © 2014 Ahmed Mabrouk et al. All rights reserved. Management of Late Onset Perthes: Evaluation of Distraction by External Fixator—5-Year Follow-Up Sun, 14 Dec 2014 06:36:33 +0000 Background. Hip distraction in Perthes’ disease unloads the joint, which negates the harmful effect of the stresses on the articular surfaces, which may promote the sound healing of the area of necrosis. We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes’ disease. Methods and Materials. Twelve children with age more than 8 years with Perthes’ disease of less than one year were treated with hip distraction by a hinged monolateral external fixator. Observation and Results. Mean duration of distraction was 13.9 days. These children were evaluated by clinicoradiological parameters for a mean period of 32.4 months. There was a significant improvement in the range of movements and mean epiphyseal index, but the change in the percentage of uncovered head femur was insignificant. There was significant improvement in Harris Hip score. Conclusions. Hip distraction by hinged monolateral external fixator seems to be a valid treatment option in cases with Perthes’ disease in the selected group of patients, where poor results are expected from conventional treatment. Ajai Singh, Rajeshwar N. Srivastava, Prashant Shukla, Amit Pushkar, and Sabir Ali Copyright © 2014 Ajai Singh et al. All rights reserved. Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected? Sun, 07 Dec 2014 00:10:16 +0000 Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening. Metin Uzun, Adnan Kara, Müjdat Adaş, Bülent Karslioğlu, Murat Bülbül, and Burak Beksaç Copyright © 2014 Metin Uzun et al. All rights reserved. Utility of Intraoperative Neuromonitoring during Minimally Invasive Fusion of the Sacroiliac Joint Thu, 04 Dec 2014 12:02:46 +0000 Study Design. Retrospective case series. Objective. To document the clinical utility of intraoperative neuromonitoring during minimally invasive surgical sacroiliac joint fusion for patients diagnosed with sacroiliac joint dysfunction (as a direct result of sacroiliac joint disruptions or degenerative sacroiliitis) and determine stimulated electromyography thresholds reflective of favorable implant position. Summary of Background Data. Intraoperative neuromonitoring is a well-accepted adjunct to minimally invasive pedicle screw placement. The utility of intraoperative neuromonitoring during minimally invasive surgical sacroiliac joint fusion using a series of triangular, titanium porous plasma coated implants has not been evaluated. Methods. A medical chart review of consecutive patients treated with minimally invasive surgical sacroiliac joint fusion was undertaken at a single center. Baseline patient demographics and medical history, intraoperative electromyography thresholds, and perioperative adverse events were collected after obtaining IRB approval. Results. 111 implants were placed in 37 patients. Sensitivity of EMG was 80% and specificity was 97%. Intraoperative neuromonitoring potentially avoided neurologic sequelae as a result of improper positioning in 7% of implants. Conclusions. The results of this study suggest that intraoperative neuromonitoring may be a useful adjunct to minimally invasive surgical sacroiliac joint fusion in avoiding nerve injury during implant placement. Michael Woods, Denise Birkholz, Regina MacBarb, Robyn Capobianco, and Adam Woods Copyright © 2014 Michael Woods et al. All rights reserved. The Costs of Operative Complications for Ankle Fractures: A Case Control Study Thu, 27 Nov 2014 06:23:15 +0000 As our healthcare system moves towards bundling payments, it is vital to understand the potential financial implications associated with treatment of surgical complications. Considering that surgical treatment of ankle fractures is common, there remains minimal data relating costs to postsurgical intervention. We aimed to identify costs associated with ankle fracture complications through case-control analysis. Using retrospective analysis at a level I trauma center, 28 patients with isolated ankle fractures who developed complications (cases) were matched with 28 isolated ankle fracture patients without complications (controls) based on ASA score, age, surgery type, and fracture type. Patient charts were reviewed for demographics and complications leading to readmission/reoperation and costs were obtained from the financial department. Wilcoxon tests measured differences in the costs between the cases and controls. 28 out of 439 patients (6.4%) developed complications. Length of stay and median costs were significantly higher for cases than controls. Specifically, differences in total costs existed for infection and hardware-related pain. This is the first study to highlight the considerable costs associated with the treatment of complications due to isolated ankle fractures. Physicians must therefore emphasize methods to control surgical and nonsurgical factors that may impact postoperative complications, especially under a global payment system. Frank R. Avilucea, Sarah E. Greenberg, W. Jeffrey Grantham, Vasanth Sathiyakumar, Rachel V. Thakore, Samuel K. Nwosu, Kristin R. Archer, William T. Obremskey, Hassan R. Mir, and Manish K. Sethi Copyright © 2014 Frank R. Avilucea et al. All rights reserved. Early Postoperative Results after Removal of Cranially Migrated Lumbar Disc Prolapse: Retrospective Comparison of Three Different Surgical Strategies Thu, 13 Nov 2014 09:13:04 +0000 Background. To compare the early postoperative results of three surgical approaches to lumbar disc herniations that migrated cranially. Minimally invasive techniques such as the translaminar and endoscopic transforaminal approaches are utilized in patients with lumbar disc herniations to gain access to cranially located disc material and to avoid the potentially destabilizing resection of ligament and bone tissue, which is associated with an extended interlaminar approach. Methods. This retrospective study compares the postoperative pain and functional capacity levels of 69 patients who underwent an interlaminar (Group A, ), a translaminar (Group B, ), or an endoscopic transforaminal procedure (Group C, ). Results. Median VAS scores for leg pain decreased significantly from before to after surgery in all groups. Surgical revisions were required in thirteen cases (five in Group A, one in Group B, and seven in Group C; ). After six weeks, there were significant differences in back pain and functional outcome scores and in the results for the MacNab criteria but not in leg pain scores. Conclusions. The interlaminar and translaminar techniques were the safest and fastest ways of gaining access to cranially migrated disc material and the most effective approaches over a period of six weeks. C. Schulz, U. Kunz, U. M. Mauer, and R. Mathieu Copyright © 2014 C. Schulz et al. All rights reserved. Assessment of Patients with a DePuy ASR Metal-on-Metal Hip Replacement: Results of Applying the Guidelines of the Spanish Society of Hip Surgery in a Tertiary Referral Hospital Sun, 09 Nov 2014 06:51:10 +0000 The prognosis associated with the DePuy ASR hip cup is poor and varies according to the series. This implant was withdrawn from use in 2010 and all patients needed to be assessed. We present the results of the assessment of our patients treated with this device, according to the Spanish Society of Hip Surgery (SECCA) algorithm published in 2011. This retrospective study evaluates 83 consecutive ASR cups, followed up at a mean of 2.9 years. Serum levels of chromium and cobalt, as well as the acetabular abduction angle, were determined in order to assess their possible correlation with failure, defined as the need for revision surgery. The mean Harris Hip Score was 83.2 (range 42–97). Eight arthroplasties (13.3%) required revision due to persistent pain and/or elevated serum levels of chromium/cobalt. All the cups had a correct abduction angle, and there was no correlation between elevated serum levels of metal ions and implant failure. Since two previous ASR implants were exchanged previously to the recall, the revision rate for ASR cups in our centre is 18.2% at 2.9 years. Jenaro Fernández-Valencia, Xavier Gallart, Guillem Bori, Sebastián Garcia Ramiro, Andrés Combalía, and Josep Riba Copyright © 2014 Jenaro Fernández-Valencia et al. All rights reserved. A Longitudinal Low Dose μCT Analysis of Bone Healing in Mice: A Pilot Study Thu, 06 Nov 2014 13:16:38 +0000 Low dose microcomputed tomography (μCT) is a recently matured technique that enables the study of longitudinal bone healing and the testing of experimental treatments for bone repair. This imaging technique has been used for studying craniofacial repair in mice but not in an orthopedic context. This is mainly due to the size of the defects (approximately 1.0 mm) in long bone, which heal rapidly and may thus negatively impact the assessment of the effectiveness of experimental treatments. We developed a longitudinal low dose μCT scan analysis method combined with a new image segmentation and extraction software using Hounsfield unit (HU) scores to quantitatively monitor bone healing in small femoral cortical defects in live mice. We were able to reproducibly quantify bone healing longitudinally over time with three observers. We used high speed intramedullary reaming to prolong healing in order to circumvent the rapid healing typical of small defects. Bone healing prolongation combined with μCT imaging to study small bone defects in live mice thus shows potential as a promising tool for future preclinical research on bone healing. Lu-Zhao Di, Vanessa Couture, Élisabeth Leblanc, Yasaman Alinejad, Jean-François Beaudoin, Roger Lecomte, François Berthod, Nathalie Faucheux, Frédéric Balg, and Guillaume Grenier Copyright © 2014 Lu-Zhao Di et al. All rights reserved. The Mechanisms of Medial Pedicle Wall Violation: Insertion Method Is as Important as Correct Cannulation of the Pedicle Tue, 21 Oct 2014 12:16:29 +0000 A cadaver study aims to determine the mechanisms of medial pedicle wall violation after a correct cannulation of the pedicle. The study presents finding out the effect of insertion angle and insertion force on medial wall violation. We used 100 lumbar pedicles of cadavers. Special wooden blocks were produced to simulate a fixed angle fault after a correct pedicle cannulation. Pedicles were divided into 4 groups: 10-degree free drive (group 10), 15-degree free drive (group 15), 10-degree push drive (group 10P), and 15-degree push drive (group 15P). After insertion of pedicle screws, laminectomies were done and the pedicles were evaluated from the inside. Pedicle complications were more in group 10P than group 10 (). Medial wall fracture () and canal penetration were more in group 15P than group 15 (). Groups 10P and 15P were similar regarding medial wall fractures but canal penetration was significantly higher in group 15P (). Medial wall breaches can happen after correct cannulation of pedicles. Change in insertion angle is one factor but the most important factor is the use of a pushing force while inserting a screw. The pedicle seems to be extremely tolerant to insertion angulation mistakes up to 10 degrees and tends to lead the screw into the correct path spontaneously. Cengiz Isik, Kamil Cagri Kose, Mustafa Erkan Inanmaz, Suleyman Murat Tagil, and Hakan Sarman Copyright © 2014 Cengiz Isik et al. All rights reserved. Increasing Resistance of Coagulase-Negative Staphylococci in Total Hip Arthroplasty Infections: 278 THA-Revisions due to Infection Reported to the Norwegian Arthroplasty Register from 1993 to 2007 Thu, 09 Oct 2014 08:32:43 +0000 We investigated bacterial findings from intraoperative tissue samples taken during revision due to infection after total hip arthroplasty (THA). The aim was to investigate whether the susceptibility patterns changed during the period from 1993 through 2007. Reported revisions due to infection in the Norwegian Arthroplasty Register (NAR) were identified, and 10 representative hospitals in Norway were visited. All relevant information on patients reported to the NAR for a revision due to infection, including bacteriological findings, was collected from the medical records. A total of 278 revision surgeries with bacterial growth in more than 2 samples were identified and included. Differences between three 5-year time periods were tested by the chi-square test for linear trend. The most frequent isolates were coagulase-negative staphylococci (CoNS) (41%, 113/278) and Staphylococcus aureus (19%, 53/278). The proportion of CoNS resistant to the methicillin-group increased from 57% (16/28) in the first period, 1993–1997, to 84% (52/62) in the last period, 2003–2007 (P = 0.003). There was also significant increase in resistance for CoNS to cotrimoxazole, quinolones, clindamycin, and macrolides. All S. aureus isolates were sensitive to both the methicillin-group and the aminoglycosides. For the other bacteria identified no changes in susceptibility patterns were found. Olav Lutro, Håkon Langvatn, Håvard Dale, Johannes Cornelis Schrama, Geir Hallan, Birgitte Espehaug, Haakon Sjursen, and Lars B. Engesæter Copyright © 2014 Olav Lutro et al. All rights reserved. Manipulation of Displaced Distal Radial Fractures in the Superelderly: Prediction of Malunion and the Degree of Radiographic Improvement Wed, 08 Oct 2014 08:35:47 +0000 Superelderly patients (≥80 years old) account for 20% of all distal radial fractures and are at an increased risk of malunion. The primary aim of this study was to identify predictors of malunion and the degree of improvement in the fracture position offered by closed manipulation of displaced distal radial fractures in the superelderly. We retrospectively identified 228 displaced distal radial fractures in superelderly patients from a prospective database of 4024 distal radial fractures. The inclusion criterion was a patient that underwent closed manipulation as their primary intervention. The majority of patients (, 86%) were defined as having a malunion. A premanipulation dorsal angulation of greater than 25 degrees () and an ulnar variance of 6 mm or more () significantly increased the risk of malunion. The premanipulation dorsal angulation was a significant independent predictor of the degree of improvement in the final dorsal angulation () and ulnar variance (). Patients with a high risk of malunion or poor improvement in the fracture position can be identified before manipulation and these patients may benefit from primary surgical intervention. N. D. Clement, A. D. Duckworth, C. M. Court-Brown, and M. M. McQueen Copyright © 2014 N. D. Clement et al. All rights reserved. Total Knee Arthroplasty Designed to Accommodate the Presence or Absence of the Posterior Cruciate Ligament Wed, 08 Oct 2014 07:59:17 +0000 Evidence for selecting the same total knee arthroplasty prosthesis whether the posterior cruciate ligament (PCL) is retained or resected is rarely documented. This study reports prospective midterm clinical, radiographic, and functional outcomes of a fixed-bearing design implanted using two different surgical techniques. The PCL was completely retained in 116 knees and completely resected in 43 knees. For the entire cohort, clinical knee and function scores and radiographic outcomes were good to excellent for 84% of patients after 5–10 years in vivo. Range of motion averaged , with 126 knees exhibiting flexion. Small differences in average knee flexion and function scores were noted, with the PCL-resected group exhibiting an average of 5° more flexion but an average function score that was 7 points lower compared to the PCL-retained group. Fluoroscopic analysis of 33 knees revealed stable tibiofemoral translations. This study demonstrates that a TKA articular design with progressive congruency in the lateral compartment can provide for femoral condyle rollback in maximal flexion activities and achieve good clinical and functional performance in patients with PCL-retained and PCL-resected TKA. This TKA design proved suitable for use with either surgical technique, providing surgeons with the choice of maintaining or sacrificing the PCL. Melinda K. Harman, Stephanie J. Bonin, Chris J. Leslie, Scott A. Banks, and W. Andrew Hodge Copyright © 2014 Melinda K. Harman et al. All rights reserved.