Advances in Orthopedics The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Hip Resurfacing Arthroplasty and Perioperative Blood Testing Wed, 01 Oct 2014 09:12:11 +0000 It is standard practice in many institutions to routinely perform preoperative and postoperative haemoglobin level testing in association with hip joint arthroplasty procedures. It is our observation, however, that blood transfusion after uncomplicated primary hip arthroplasty in healthy patients is uncommon and that the decision to proceed with blood transfusion is typically made on clinical grounds. We therefore question the necessity and clinical value of routine perioperative blood testing about the time of hip resurfacing arthroplasty. We present analysis of perioperative blood tests and transfusion rates in 107 patients undertaking unilateral hybrid hip resurfacing arthroplasty by the senior author at a single institution over a three-year period. We conclude that routine perioperative testing of haemoglobin levels for hip resurfacing arthroplasty procedures does not assist in clinical management. We recommend that postoperative blood testing only be considered should the patient demonstrate clinical signs of symptomatic anaemia or if particular clinical circumstances necessitate. Andrew Cook, Steven Cook, Ian Smith, and Patrick Weinrauch Copyright © 2014 Andrew Cook et al. All rights reserved. Prevalence of Hyponatremia in Femur Neck Fractures: A One-Year Survey in an Urban Emergency Department Mon, 15 Sep 2014 05:30:54 +0000 This study was aimed at investigating the prevalence of hyponatremia in patients with intracapsular femoral neck fracture. All records containing clinical and laboratory information of patients admitted with femoral neck fractures to the Academic Hospital of Parma (Italy) during the year 2013 were retrieved from the hospital database. The control population consisted of subjects admitted to the outpatient phlebotomy center during the same period. The final population consisted of 543 patients with femoral neck fractures and 700 outpatients. The category of elderly subjects (i.e., ≥65 years) included 491 patients and 380 controls. In both the entire population and elderly subjects, serum sodium was lower in patients than in controls (138 versus 139 mmol/L, ). The prevalence of hyponatremia was also higher in cases than in controls, both in the entire population (19.5 versus 10.4%, ) and in elderly subjects (20.8 versus 11.8%, ). The odds ratio of hyponatremia for femoral neck fracture was 2.08 in the entire study population and 1.95 in those aged 65 years and older. In conclusion, we found that hyponatremia is significantly associated with femoral neck fracture. Serum sodium should hence be regularly assessed and hyponatremia eventually corrected. Gianfranco Cervellin, Michele Mitaritonno, Mario Pedrazzoni, Alessandra Picanza, and Giuseppe Lippi Copyright © 2014 Gianfranco Cervellin et al. All rights reserved. Is End-Stage Ankle Arthrosis Best Managed with Total Ankle Replacement or Arthrodesis? A Systematic Review Thu, 21 Aug 2014 12:52:37 +0000 Introduction. End-stage ankle osteoarthritis is a debilitating condition. Traditionally, ankle arthrodesis (AA) has been the surgical intervention of choice but the emergence of total ankle replacement (TAR) has challenged this concept. This systematic review aims to address whether TAR or AA is optimal in terms of functional outcomes. Methods. We conducted a systematic review according to PRISMA checklist using the online databases Medline and EMBASE after January 1, 2005. Participants must be skeletally mature and suffering from ankle arthrosis of any cause. The intervention had to be an uncemented TAR comprising two or three modular components. The comparative group could include any type of ankle arthrodesis, either open or arthroscopic, using any implant for fixation. The study must have reported at least one functional outcome measure. Results. Of the four studies included, two reported some significant improvement in functional outcome in favour of TAR. The complication rate was higher in the TAR group. However, the quality of studies reviewed was poor and the methodological weaknesses limited any definitive conclusions being drawn. Conclusion. The available literature is insufficient to conclude which treatment is superior. Further research is indicated and should be in the form of an adequately powered randomised controlled trial. Robert W. Jordan, Gurdip S. Chahal, and Anna Chapman Copyright © 2014 Robert W. Jordan et al. All rights reserved. Primary TKA Patients with Quantifiably Balanced Soft-Tissue Achieve Significant Clinical Gains Sooner than Unbalanced Patients Mon, 18 Aug 2014 07:16:49 +0000 Although total knee arthroplasty has a high success rate, poor outcomes and early revision are associated with ligament imbalance. This multicenter evaluation was performed in order to provide 1-year followup of a previously reported group of patients who had sensor-assisted TKA, comparing the clinical outcomes of quantitatively balanced versus unbalanced patients. At 1 year, the balanced cohort scored 179.3 and 10.4 in KSS and WOMAC, respectively; the unbalanced cohort scored 156.1 and 17.9 in KSS and WOMAC (; ). The average activity level scores of quantitatively balanced patients were 68.6 (corresponding to tennis, light jogging, and heavy yard work), while the average activity level of unbalanced patients was 46.7 (corresponding to light housework, and limited walking distances) (). Out of all confounding variables, a balanced articulation was the most significant contributing factor to improved postoperative outcomes (). Kenneth A. Gustke, Gregory J. Golladay, Martin W. Roche, Leah C. Elson, and Christopher R. Anderson Copyright © 2014 Kenneth A. Gustke et al. All rights reserved. Management of Humeral and Glenoid Bone Loss in Recurrent Glenohumeral Instability Thu, 17 Jul 2014 09:59:45 +0000 Recurrent shoulder instability and resultant glenoid and humeral head bone loss are not infrequently encountered in the population today, specifically in young, athletic patients. This review on the management of bone loss in recurrent glenohumeral instability discusses the relevant shoulder anatomy that provides stability to the shoulder joint, relevant history and physical examination findings pertinent to recurrent shoulder instability, and the proper radiological imaging choices in its workup. Operative treatments that can be used to treat both glenoid and humeral head bone loss are outlined. These include coracoid transfer procedures and allograft/autograft reconstruction at the glenoid, as well as humeral head disimpaction/humeroplasty, remplissage, humeral osseous allograft reconstruction, rotational osteotomy, partial humeral head arthroplasty, and hemiarthroplasty on the humeral side. Clinical outcomes studies reporting general results of these techniques are highlighted. Randy Mascarenhas, Jamie Rusen, Bryan M. Saltzman, Jeff Leiter, Jaskarndip Chahal, Anthony A. Romeo, and Peter MacDonald Copyright © 2014 Randy Mascarenhas et al. All rights reserved. Partial Facetectomy for Lumbar Foraminal Stenosis Tue, 08 Jul 2014 12:10:08 +0000 Background. Several different techniques exist to address the pain and disability caused by isolated nerve root impingement. Failure to adequately decompress the lumbar foramen may lead to failed back surgery syndrome. However, aggressive treatment often causes spinal instability or may require fusion for satisfactory results. We describe a novel technique for decompression of the lumbar nerve root and demonstrate its effectiveness in relief of radicular symptoms. Methods. Partial facetectomy was performed by removal of the medial portion of the superior facet in patients with lumbar foraminal stenosis. 47 patients underwent the procedure from 2001 to 2010. Those who demonstrated neurogenic claudication without spinal instability or central canal stenosis and failed conservative management were eligible for the procedure. Functional level was recorded for each patient. These patients were followed for an average of 3.9 years to evaluate outcomes. Results. 27 of 47 patients (57%) reported no back pain and no functional limitations. Eight of 47 patients (17%) reported moderate pain, but had no limitations. Six of 47 patients (13%) continued to experience degenerative symptoms. Five of 47 patients (11%) required additional surgery. Conclusions. Partial facetectomy is an effective means to decompress the lumbar nerve root foramen without causing spinal instability. Kevin Kang, Juan Carlos Rodriguez-Olaverri, Frank Schwab, Jenifer Hashem, Afshin Razi, and Jean Pierre Farcy Copyright © 2014 Kevin Kang et al. All rights reserved. External Rotator Sparing with Posterior Acetabular Fracture Surgery: Does It Change Outcome? Sun, 06 Jul 2014 10:04:14 +0000 This study analyses the results of the treatment with external rotator sparing approach in acetabular fractures to determine whether muscle sparing has a positive impact on functional outcome. 20 patients with a mean age of 45.9 years (range: 26–64) that had been treated for displaced acetabular fractures were included in this series. Short Musculoskeletal Function Assessment (SMFA) questionnaire and hip muscle strength measurement were done at the 24-month of follow-up period. The radiographic results at the final followup were excellent in 9 hips (45%), good in 6 hips (30%), fair in 4 hips (20%), and poor in one hip (5%) according to the criteria developed by Matta. The average SMFA score for all of the patients was 18.3 (range: 0–55.4). The mean dysfunctional and bother indexes were 17.2 and 20.6, respectively. The overall muscle strength deficit was 11.8%. The greatest loss of strength was in internal rotation. In patients with better postoperative reduction quality of acetabular fracture, peak torque, and maximum work of hip flexion, extension and also internal rotation maximum work deficit were significantly lower . Accurate initial reduction and longer postoperative muscle strengthening exercise programs seem critical to decrease postoperative hip muscle weakness after acetabular fractures. Halil Ceylan, Ozgur Selek, Murat Inanir, Omer Yonga, Bahar Odabas Ozgur, and Ahmet Y. Sarlak Copyright © 2014 Halil Ceylan et al. All rights reserved. Hip Joint Osteochondroma: Systematic Review of the Literature and Report of Three Further Cases Tue, 20 May 2014 11:41:18 +0000 The aim of this study is to systematically review the literature with regards to surgical treatment of patients with hip joint osteochondromas, and to report our surgical management of three paediatric patients who had femoral neck or acetabular osteochondromas in association with acetabular dysplasia. We performed a systematic review using PubMed and Embase databases for all studies that reported surgical treatments for patients with peritrochanteric or acetabular osteochondroma with or without acetabular dysplasia. We also retrospectively reviewed three patients who were diagnosed with a hip osteochondroma in association with actetabular dysplasia. These patients were known to have hereditary multiple exostoses (HME). The systematic review revealed 21 studies that met our inclusion criteria. All studies were case reports and retrospective in nature and failed to conclude a uniform treatment plan. The three reported cases illustrate successful excision of hip osteochondromas and treatment of acetabular dysplasia. Early excision of hip osteochondromas might prevent acetabular dysplasia in HME patients. Routine radiographic pelvic survey at the time of diagnosis of HME is recommended for early detection of hip osteochondromas and acetabular dysplasia in these children. Asim M. Makhdom, Fan Jiang, Reggie C. Hamdy, Thierry E. Benaroch, Martin Lavigne, and Neil Saran Copyright © 2014 Asim M. Makhdom et al. All rights reserved. Radiographic Markers of Femoroacetabular Impingement: Correlation of Herniation Pit and Femoral Bump with a Positive Cross-Over Ratio Sun, 27 Apr 2014 13:23:48 +0000 Introduction. The goal of this study was to research the association of femoral bumps and herniation pits with the overlap-ratio of the cross-over sign. Methods. Pelvic X-rays and CT-scans of 2925 patients with good assessment of the anterior and the posterior acetabular wall and absence of neutral pelvic tilt were enrolled in the investigation. Finally pelvic X-rays were assessed for the presence of a positive cross-over sign, and CT-scans for a femoral bump or a herniation pit. Additionally, if a positive cross-over sign was discovered, the overlap-ratio was calculated. Results. A femoral bump was found in 53.3% (), and a herniation pit in 27.2% () of all hips. The overlap-ratio correlated positively with the presence of a femoral bump, while a negative correlation between the overlap-ratio and the presence of a herniation pit was found. The latter was significantly more often combined with a femoral bump than without. Conclusions. We detected an increased prevalence of femoral bump with increasing overlap-ratios of the cross-over sign indicating a relation to biomechanical stress. The observed decreased prevalence of herniation pits with increasing overlap-ratios could be explained by reduced mechanical stress due to nontightened iliofemoral ligament in the presence of retroversion of the acetabulum. Max J. Scheyerer, Carol E. Copeland, Jeffrey Stromberg, Thomas Ruckstuhl, and Clément M. L. Werner Copyright © 2014 Max J. Scheyerer et al. All rights reserved. Early Clinical and Radiographic Results of Minimally Invasive Anterior Approach Hip Arthroplasty Sun, 02 Mar 2014 00:00:00 +0000 We present a retrospective review of the early results and complications in a series of 35 consecutive patients with 43 total hip arthroplasties performed through an anterior muscle sparing minimally invasive approach. We found the early complication rates and radiographic outcomes comparable to those reported from arthroplasties performed via traditional approaches. Complications included dislocation (2%), femur fracture (2%), greater trochanteric fracture (12%), postoperative periprosthetic intertrochanteric fracture (2%), femoral nerve palsy (5%), hematoma (2%), and postoperative iliopsoas avulsion (2%). Radiographic analysis revealed average cup anteversion of , average cup abduction angle of , stem varus of , and a mean leg length discrepancy of 0.7 mm. The anterior approach to the hip is an attractive alternative to the more traditional approaches. Acceptable component placement with comparable complication rates is possible using a muscle sparing technique which may lead to faster overall recovery. Tamara Alexandrov, Elke R. Ahlmann, and Lawrence R. Menendez Copyright © 2014 Tamara Alexandrov et al. All rights reserved. Clinical Outcomes of Tibial Components with Modular Stems Used in Primary TKA Wed, 05 Feb 2014 10:03:46 +0000 Due to the known potential for fretting and corrosion at modular junctions in orthopaedic implants, this retrospective study evaluated radiographic and clinical outcomes of 85 primary TKA patients implanted with modular stemmed tibial components and followed up for an average of 82 months. There was low incidence of tibial radiolucent lines, excellent functional outcomes, and no complications associated with stem modularity. The findings were comparable to the historical control study involving 107 TKA with a nonmodular tibial stem design. When using surface cemented tibial components combined with a constrained polyethylene bearing, modular stems appear to be a viable option for primary TKA when adequate fixation and rotational stability are maintained. Nicole Durig, Thomas Pace, Brandon Broome, Obi Osuji, and Melinda K. Harman Copyright © 2014 Nicole Durig et al. All rights reserved. Changes in Joint Gap Balances between Intra- and Postoperation in Total Knee Arthroplasty Thu, 02 Jan 2014 13:30:43 +0000 Achieving correct soft tissue balance and preparing equal and rectangular extension and flexion joint gaps are crucial goals of TKA. Intraoperative gap balances would change postoperatively; however, changes in joint gap balances between pre- and postoperation remain unclear. To explore these changes associated with TKA, we prospectively investigated 21 posterior cruciate ligament retaining TKAs for varus knees. Intraoperative extension gap balance (iEGB) was 2.6 ± 2.0° varus versus postoperative extension gap balance (pEGB) of 0.77 ± 1.8° valgus (), while no significant difference between intraoperative flexion gap balance (iFGB) and postoperative flexion gap balance (pFGB) was observed. We also explored correlations between intraoperative and postoperative gap balances but found no significant correlations. These observations indicate that (i) surgeons should avoid excessive release of the medial soft tissue during TKA for varus knees and (ii) intraoperative gap balance may not be necessarily reflected on postoperative gap balance. Arata Nakajima, Yasuchika Aoki, Masazumi Murakami, and Koichi Nakagawa Copyright © 2014 Arata Nakajima et al. All rights reserved. Current Concepts in Robotics for the Treatment of Joint Disease Mon, 23 Dec 2013 09:43:52 +0000 Michael A. Conditt, William L. Bargar, Justin P. Cobb, Lawrence D. Dorr, and Jess H. Lonner Copyright © 2013 Michael A. Conditt et al. All rights reserved. Cemented versus Uncemented Oxford Unicompartmental Knee Arthroplasty: Is There a Difference? Mon, 09 Dec 2013 09:31:20 +0000 Purpose. The use of uncemented unicompartmental knee prostheses has recently increased. However, few studies on the outcomes of uncemented unicompartmental knee prostheses have been performed. The purpose of this study was to compare the outcomes of cemented and uncemented Oxford unicompartmental knee arthroplasty. Materials and Methods. This retrospective observational study evaluated the clinical and radiological outcomes of 263 medial Oxford unicompartmental prostheses (141 cemented, 122 uncemented) implanted in 235 patients. The mean follow-up was 42 months in the cemented group and 30 months in the uncemented group. Results. At the last follow-up, there were no significant differences in the clinical results or survival rates between the two groups. However, the operation time in the uncemented unicompartmental knee arthroplasty group was shorter than that in the cemented unicompartmental knee arthroplasty group. In addition, the cost of uncemented arthroplasty was greater. Conclusion. Despite the successful midterm results in the uncemented unicompartmental knee arthroplasty group, a longer follow-up period is required to determine the best fixation mode. Burak Akan, Dogac Karaguven, Berk Guclu, Tugrul Yildirim, Alper Kaya, Mehmet Armangil, and Ilker Cetin Copyright © 2013 Burak Akan et al. All rights reserved. Monoaxial Pedicle Screws Are Superior to Polyaxial Pedicle Screws and the Two Pin External Fixator for Subcutaneous Anterior Pelvic Fixation in a Biomechanical Analysis Tue, 03 Dec 2013 16:03:58 +0000 Purpose. Comparison of monoaxial and polyaxial screws with the use of subcutaneous anterior pelvic fixation. Methods. Four different groups each having 5 constructs were tested in distraction within the elastic range. Once that was completed, 3 components were tested in torsion within the elastic range, 2 to torsional failure and 3 in distraction until failure. Results. The pedicle screw systems showed higher stiffness (4.008 ± 0.113 Nmm monoaxial, 3.638 ± 0.108 Nmm Click-x; 3.634 ± 0.147 Nmm Pangea) than the exfix system (2.882 ± 0.054 Nmm) in distraction. In failure testing, monoaxial pedicle screw system was stronger (360 N) than exfixes (160 N) and polyaxial devices which failed if distracted greater than 4 cm (157 N Click-x or 138 N Pangea). The exfix had higher peak torque and torsional stiffness than all pedicle systems. In torsion, the yield strengths were the same for all constructs. Conclusion. The infix device constructed with polyaxial or monoaxial pedicle screws is stiffer than the 2 pin external fixator in distraction testing. In extreme cases, the use of reinforcement or monoaxial systems which do not fail even at 360 N is a better option. In torsional testing, the 2 pin external fixator is stiffer than the pedicle screw systems. Rahul Vaidya, Ndidi Onwudiwe, Matthew Roth, and Anil Sethi Copyright © 2013 Rahul Vaidya et al. All rights reserved. Union Rate on Hinge Side after Open-Door Laminoplasty Using Maxillofacial Titanium Miniplate Tue, 26 Nov 2013 10:23:44 +0000 Background. One of the important complications of open-door laminoplasty is a premature laminoplasty closure. In order to prevent premature laminoplasty closure many techniques have been described and a titanium miniplate is one of the instruments to maintain cervical canal expansion. This study was performed to evaluate the effectiveness of titanium miniplates on the union rate for open-door laminoplasty. Materials and Methods. We performed open-door laminoplasty in 68 levels of fourteen patients using maxillofacial titanium miniplates. Axial computed tomography scans were obtained at 6 months postoperatively to evaluate the union rates of the hinge side. The Japanese Orthopedic Association (JOA) score was used to compare the clinical outcomes before and after surgery. Results. Computed tomography scan data was available on 68 levels in 14 patients. There were no premature closures of the hinge or miniplate dislodgements. The union rate on the hinge side was 70.5% (48/68). The mean JOA score increased significantly from 7.0 before surgery to 10.2, 12.2, and 13.0 after surgery at 1, 3, and 6 months, respectively. Conclusion. Open-door laminoplasty using maxillofacial titanium miniplates can provide union rates comparable to other techniques. It can maintain canal expansion without failures, dislodgements, and premature closures. Koopong Siribumrungwong, Theerasan Kiriratnikom, and Boonsin Tangtrakulwanich Copyright © 2013 Koopong Siribumrungwong et al. All rights reserved. Distal Femur Allograft Prosthetic Composite Reconstruction for Short Proximal Femur Segments following Tumor Resection Sun, 17 Nov 2013 15:12:31 +0000 Short metaphyseal segments remaining after distal femoral tumor resection pose a unique challenge. Limb sparing options include a short stemmed modular prosthesis, total endoprosthetic replacement, cross-pin fixation to a custom implant, and allograft prosthetic composite reconstruction (APC). A series of patients with APC reconstruction were evaluated to determine functional and radiologic outcome and complication rates. Twelve patients were retrospectively identified who had a distal femoral APC reconstruction between 1994 and 2007 to salvage an extremity with a segment of remaining bone that was less than 20 centimeters in length. Seventeen APC reconstructions were performed in twelve patients. Eight were primary procedures and nine were revision procedures. Average f/u was 89 months. Twelve APC reconstructions (71%) united and five (29%) were persistent nonunions. At most recent followup 10 patients (83%) had a healed APC which allowed WBAT. One pt (8%) had an amputation and one pt (8%) died prior to union. Average time to union was 19 months. Four pts (33%) or five APC reconstructions (29%) required further surgery to obtain a united reconstruction. Although Distal Femoral APC reconstruction has a high complication rate, a stable reconstruction was obtained in 83% of patients. Bryan S. Moon, Nathan F. Gilbert, Christopher P. Cannon, Patrick P. Lin, and Valerae O. Lewis Copyright © 2013 Bryan S. Moon et al. All rights reserved.