Advances in Orthopedic Surgery http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Analysis of the Results of Use of Bone Graft and Reconstruction Cages in a Group of Patients with Severe Acetabular Bone Defects Tue, 30 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/aos/2014/376963/ Introduction. Rings and cages are indicated for use in revision total hip with severe bone loss. Material and Methods. A retrospective study was performed on 37 acetabular revision cases with an average age at revision of 67.8 years. According to Paprosky classification, 54% grade II and 46% grade III. We used two types of cages, Protrusio and Contour cage. We used 23 standard liners and 14 dual mobility cups. Results. The average follow-up was 5.4 years. The mean Merlé-d’Aubigné score improved from 5.48 to 10.5 points (). There were 10 nerve palsies, 6 rings that lost fixation, 10 dislocations, and 4 infections. The need for reoperation for any reason rose to 32% (12/37). Success, defined as a stable reconstruction, was 73%. We found that, using a dual mobility cup cemented into the cage, the dislocation rate and revision rate came down (). Conclusions. The treatment of severe acetabular defects using bone graft and reconstruction cages is a viable option. The use of a dual mobility cup cemented into the cage could avoid dislocations and the insertion of the ischial flap inside the ischial portion of the acetabulum for further ring stability and protection of the sciatic nerve. Ainhoa Toro-Ibarguen, Ismael Auñón-Martín, Emilio Delgado-Díaz, Jose Alberto Moreno-Beamud, Miguel Ángel Martínez-Leocadio, Andrés Díaz-Martín, and Luciano Candel-García Copyright © 2014 Ainhoa Toro-Ibarguen et al. All rights reserved. Is There a Gender Difference in Fat Distribution around the Hamstring Tendon Insertion? A Prospective MRI Evaluation of 40 Cases Mon, 11 Aug 2014 12:14:39 +0000 http://www.hindawi.com/journals/aos/2014/606527/ Introduction. Knee ligament reconstructions are commonly performed using hamstring tendon grafts. We observed anecdotally that there was a difference in the fat distribution superficial to the pes anserinus between men and women and proposed that this effect was independent of BMI, being significantly greater in women. Methods. We performed a prospective study to evaluate 40 MRI scans performed in 20 women and 20 men. The scans allowed visualisation of the insertion of the hamstring tendons at the pes anserinus. Results. The mean BMI of the male patients was 25.6 (19.8–37.2) and of the female patients was 24.7 (17.9–34.5). The mean fat distribution superficial to the pes anserinus in men was 16.2 mm (4.1–29.4) and in women was 29.7 mm (19.6–47.5). There was a significant increase in fat superficial to the hamstring tendons in women compared with men (), despite no significant difference in BMI (). Conclusions. Our evaluation of a prospective series of MRI scans has shown that there is significantly more fat superficial to the insertion of the hamstring tendons in women than in men. This effect is independent of BMI and may influence exposure during hamstring tendon graft harvesting. Nathanael Ahearn, Nick R. Howells, and James L. Williams Copyright © 2014 Nathanael Ahearn et al. All rights reserved. A Comparison of Mortality following Distal Femoral Fractures and Hip Fractures in an Elderly Population Thu, 07 Aug 2014 00:00:00 +0000 http://www.hindawi.com/journals/aos/2014/873785/ Introduction. Patients suffering a distal femoral fracture are at a high risk of morbidity and mortality. Currently this cohort is not afforded the same resources as those with hip fractures. This study aims to compare their mortality rates and assess whether surgical intervention improves either outcome or mortality following distal femoral fractures. Methods. Patients over sixty-five admitted with a distal femoral fracture between June 2007 and 2012 were retrospectively identified. Patients mobility was categorised as unaided, walking aid, zimmer frame, or immobile. The 30-day, six-month, and one-year mortality rates were recorded for this group as well as for hip fractures during the same period. Results. 68 patients were included in the study. The mortality rate for all patients with distal femoral fractures was 7% at 30 days, 26% at six months, and 38% at one year, higher than hip fractures during the same period by 8%, 13%, and 18%, respectively. Patients managed surgically had lower mortality rates and higher mobility levels. Conclusion. Patients suffering a distal femoral fracture have a high mortality rate and surgical intervention seems to improve both mobility and mortality. R. W. Jordan, G. S. Chahal, M. Davies, and K. Srinivas Copyright © 2014 R. W. Jordan et al. All rights reserved. Achieving Construct Stability in Periprosthetic Femur Fracture Treatment Sun, 03 Aug 2014 07:49:36 +0000 http://www.hindawi.com/journals/aos/2014/943512/ One of the greatest challenges in treating patients with periprosthetic femoral fractures is achieving bone fixation in the presence of a well-fixed stem. Three techniques are described, which allow for improved fixation. A clinical series of fourteen patients with periprosthetic femur fractures that underwent open reduction internal fixation utilizing these techniques were reviewed. Thirteen patients had clinical and radiographic union. One patient required conversion to a revision total hip arthroplasty when it was noted that he had a loose prosthesis. Average time to radiographic union was 122 days. The described techniques allow surgeons to obtain multiple points of fixation around the prosthesis in an effective manner. Reza Firoozabadi, Matthew L. Graves, James C. Krieg, Jonathan Eastman, and Sean E. Nork Copyright © 2014 Reza Firoozabadi et al. All rights reserved. Incidence of Heterotopic Ossification in Patients Receiving Radiation Therapy following Total Hip Arthroplasty Sun, 27 Apr 2014 12:44:36 +0000 http://www.hindawi.com/journals/aos/2014/495426/ Heterotopic ossification (HO) is a frequent complication of hip surgery. In this study the incidence of HO is analyzed in high risk patients who received radiation therapy (RT) after total hip replacement (THA) with regular and miniposterolateral hip approach. Two hundred and thirty five high risk patients received a single dose of 700 rad after THA. The incidence of HO was 15.7%. The incidence of HO in the high risk subgroup with the miniincision was lower (5.7%) but not significantly different (). Hypertrophic osteoarthritis was demonstrated to be the consistent predisposing factor for HO formation (). Panagiotis Koulouvaris, David Sherr, and Thomas Sculco Copyright © 2014 Panagiotis Koulouvaris et al. All rights reserved. A Brief History of Anterior Cruciate Ligament Reconstruction Thu, 17 Apr 2014 10:09:45 +0000 http://www.hindawi.com/journals/aos/2014/706042/ Reconstructions of the anterior cruciate ligament (ACL) are among the most frequently performed procedures in knee surgery nowadays. The history of ACL surgery can be traced as far back as the Egyptian times. The early years reflect the efforts to establish a viable, consistently successful reconstruction technique while, during the early 20th century, we witness an increasing awareness of, and interest in, the ligament and its lesions. Finally, we highlight the most important steps in the evolution of the ACL reconstruction surgery by discussing the various techniques spanning the years using not only autologous grafts (fascia lata, meniscal, hamstring, patella tendon, bone-patella tendon-bone, and double bundle grafts) but also synthetic ones and allografts. Nikolaos Davarinos, Barry James O'Neill, and William Curtin Copyright © 2014 Nikolaos Davarinos et al. All rights reserved. Evaluation of Amniotic-Derived Membrane Biomaterial as an Adjunct for Repair of Critical Sized Bone Defects Wed, 02 Apr 2014 08:53:25 +0000 http://www.hindawi.com/journals/aos/2014/572586/ Introduction. Autogenous bone graft is the gold standard in reconstruction of bone defects. The use of autogenous bone graft is problematic because of limited bone as well as donor site morbidity. This study evaluates a novel biomaterial as an alternative to autogenous bone graft. The biomaterial is amniotic membrane, rich in growth factors. Methods. Twenty-one adult male Sprague-Dawley rats were implanted with biomaterial using the rat critical size femoral gap model. After creation of the critical size femoral gap animals were randomized to one of the following groups: Group 1 (control): gap left empty and received no treatment; Group 2 (experimental): the gap was filled with commercially available bone graft; Group 3 (experimental): the gap was filled with bone graft plus NuCel amniotic tissue preparation. Results. The experimental groups demonstrated new bone formation compared to controls. The results were evident on radiographs and histology. Histology showed Group 1 controls to have 11.1% new bone formation, 37.8% for Group 2, and 49.2% for Group 3. These results were statistically significant. Conclusions. The study demonstrates that amniotic membrane products have potential to provide bridging of bone defects. Filling bone defects without harvesting autogenous bone would provide a significant improvement in patient care. Mikael Starecki, John A. Schwartz, and Daniel A. Grande Copyright © 2014 Mikael Starecki et al. All rights reserved. Ultrastructure of Intervertebral Disc and Vertebra-Disc Junctions Zones as a Link in Etiopathogenesis of Idiopathic Scoliosis Sun, 23 Mar 2014 08:58:38 +0000 http://www.hindawi.com/journals/aos/2014/850594/ Background Context. There is no general accepted theory on the etiology of idiopathic scoliosis (IS). An important role of the vertebrae endplate physes (VEPh) and intervertebral discs (IVD) in spinal curve progression is acknowledged, but ultrastructural mechanisms are not well understood. Purpose. To analyze the current literature on ultrastructural characteristics of VEPh and IVD in the context of IS etiology. Study Design/Setting. A literature review. Results. There is strong evidence for multifactorial etiology of IS. Early wedging of vertebra bodies is likely due to laterally directed appositional bone growth at the concave side, caused by a combination of increased cell proliferation at the vertebrae endplate and altered mechanical properties of the outer annulus fibrosus of the adjacent IVD. Genetic defects in bending proteins necessary for IVD lamellar organization underlie altered mechanical properties. Asymmetrical ligaments, muscular stretch, and spine instability may also play roles in curve formation. Conclusions. Development of a reliable, cost effective method for identifying patients at high risk for curve progression is needed and could lead to a paradigm shift in treatment options. Unnecessary anxiety, bracing, and radiation could potentially be minimized and high risk patient could receive surgery earlier, rendering better outcomes with fewer fused segments needed to mitigate curve progression. Evalina L. Burger, Andriy Noshchenko, Vikas V. Patel, Emily M. Lindley, and Andrew P. Bradford Copyright © 2014 Evalina L. Burger et al. All rights reserved. Evaluation of the Cementation Index as a Predictor of Failure in Coonrad-Morrey Total Elbow Arthroplasty Mon, 17 Mar 2014 16:34:04 +0000 http://www.hindawi.com/journals/aos/2014/243823/ Background. The aim of this study is to objectively evaluate the quality of cementation by a novel method called the cementation index and assess its utility as a predictor of failure. Materials and Methods. Fifty elbows with primary Coonrad-Morrey total elbow replacement were included. The quality of cementing was assessed by novel methods, the vertical and horizontal cementation index, which were statistically evaluated as predictors of failure. The mean period of followup was years (range: from 5.08 to 10.25 years). Results. The mean vertical cementation index of the humerus (vCIH) was 1.22 ± 0.28 and that of the ulna (vCIU) was . Radiolucent zones were noted in two cases in the humerus with a horizontal cementation index of 0.21 and 0.14, respectively. Both of the cementation indices were not found to be statistically significant predictors of failure (). The five-year survival rate was 94%. Discussion and Conclusion. The cementation index, being a ratio, reduces the confounding effect of taking radiographs in different positions of the limb with different magnification in followup radiographs. It is an easy and objective method of assessment of cementation, the results of which need to be validated by a larger study. Manish Kiran, Arpit Jariwala, and Carlos A. Wigderowitz Copyright © 2014 Manish Kiran et al. All rights reserved. Analysis of Contoured Anatomic Plate Fixation versus Intramedullary Rod Fixation for Acute Midshaft Clavicle Fractures Sun, 02 Mar 2014 00:00:00 +0000 http://www.hindawi.com/journals/aos/2014/518310/ The recent trend has been toward surgical fixation of displaced clavicle fractures. Several fixation techniques have been reported yet it is unclear which is preferable. We retrospectively reviewed one hundred one consecutive patients with acute midshaft clavicle fractures treated operatively at a level-1 trauma center. Thirty-four patients underwent intramedullary pin fixation and 67 had anatomic plate fixation. The outcomes we assessed were operative time, complications, infection, implant failure, fracture union, range of motion, and reoperation rate. There were 92 males and 9 females with an average age of 30 years (range: 14–68 years). All patients were followed to healing with an average followup of 20 months (range: 15–32 months). While fracture union by six months and range of motion at three months were similar, the overall healing time for pin fixation was shorter . The pin group had more infections and implant failures than the plate group. Intramedullary pin fixation may have improved early results, but there was no long term difference in overall rate of union and achievement of full shoulder motion. The higher rate of implant failure with pin fixation may indicate that not all fracture patterns are amenable to fixation using this device. Juliann Kwak-Lee, Elke R. Ahlmann, Lingjun Wang, and John M. Itamura Copyright © 2014 Juliann Kwak-Lee et al. All rights reserved. Clinical and Radiographic Outcomes with a Hydroxyapatite and Porous Coated Cup Design Thu, 27 Feb 2014 09:31:11 +0000 http://www.hindawi.com/journals/aos/2014/302969/ Press-fit, hydroxyapatite-coated acetabular cup designs may offer a lower incidence of loosening and migration than older designs. Our study evaluated the initial clinical and radiographic success of a cementless acetabular shell in a large cohort of primary total hip arthroplasty (THA) patients. We queried our institution’s prospectively collected registry for a series of 771 primary THAs (695 patients) implanted with this cup by 4 high-volume arthroplasty surgeons. Of the 613 hips with minimum 2-year followup, average HHS (Harris Hip Score) was 93.6, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was 87.6, and VAS (Visual Analog Scale) pain score was 1.2. While there was a 2% reoperation rate (12 hips), none of the cups were revised for aseptic loosening. No radiolucencies were found and there was no evidence of acetabular loosening. At early followup, this newer cementless acetabular cup implant design exhibits high survivorship and clinical success. John Wang, James DiPietro, Mathias Bostrom, Bryan Nestor, Douglas Padgett, and Geoffrey Westrich Copyright © 2014 John Wang et al. All rights reserved. The Biological Effects of Combining Metals in a Posterior Spinal Implant: In Vivo Model Development Report of the First Two Cases Wed, 26 Feb 2014 06:39:53 +0000 http://www.hindawi.com/journals/aos/2014/761967/ Study Design. Combinations of metal implants (stainless steel (SS), titanium (Ti), and cobalt chrome (CC)) were placed in porcine spines. After 12 months, tissue response and implant corrosion were compared between mixed and single metal junctions. Objective. Model development and an attempt to determine any detriment of combining different metals in posterior spinal instrumentation. Methods. Yucatan mini-pigs underwent instrumentation over five unfused lumbar levels. A SS rod and a Ti rod were secured with Ti and SS pedicle screws, SS and Ti crosslinks, SS and CC sublaminar wires, and Ti sublaminar cable. The resulting 4 SS/SS, 3 Ti/Ti, and 11 connections between dissimilar metals per animal were studied after 12 months using radiographs, gross observation, and histology (foreign body reaction (FBR), metal particle count, and inflammation analyzed). Results. Two animals had constructs in place for 12 months with no complications. Histology of tissue over SS/SS connections demonstrated 11.1 ± 7.6 FBR cells, 2.1 ± 1.7 metal particles, and moderate to extensive inflammation. Ti/Ti tissue showed 6.3 ± 3.8 FBR cells, 5.2 ± 6.7 particles, and no to extensive inflammation (83% extensive). Tissue over mixed components had 14.1 ± 12.6 FBR cells and 13.4 ± 27.8 particles. Samples surrounding wires/cables versus other combinations demonstrated FBR (12.4 ± 13.5 versus 12.0 ± 9.6 cells, P = 0.96), particles (19.8 ± 32.6 versus 4.3 ± 12.7, P = 0.24), and inflammation (50% versus 75% extensive, P = 0.12). Conclusions. A nonfusion model was developed to study corrosion and analyze biological responses. Although no statistical differences were found in overlying tissue response to single versus mixed metal combinations, galvanic corrosion between differing metals is not ruled out. This pilot study supports further investigation to answer concerns when mixing metals in spinal constructs. Christine L. Farnsworth, Peter O. Newton, Eric Breisch, Michael T. Rohmiller, Jung Ryul Kim, and Behrooz A. Akbarnia Copyright © 2014 Christine L. Farnsworth et al. All rights reserved. A Novel Technique for Proximal Hamstring Tendon Repair: High Reoperation Rate in a Series of 56 Patients Mon, 17 Feb 2014 11:52:53 +0000 http://www.hindawi.com/journals/aos/2014/891875/ This investigation looked at functional outcomes, following a novel technique of surgical repair using table staples. Patients underwent surgery for proximal hamstring rupture with table staples used to hold the tendon reapproximated to the ischial tuberosity. Functional outcomes following surgery were assessed. We also used a combined outcome assessment measure: the Perth Hamstring Assessment Tool (PHAT). A total of 56 patients with a mean age of 51 (range 15–71) underwent surgery. The mean follow-up duration was 26 months (range 8–59 months). A large proportion of patients (21/56, 37.5%) required reoperation for removal of the staple. Patients that did not require removal of the table staple did well postoperatively, with low pain scores (0.8–2 out of 10) and good levels of return to sport or running (75.8%). Those that required removal of the staple had a significantly lower PHAT score prior to removal, 47.8, but this improved markedly once the staple was removed, with a mean of 77.2 (). Although our patients achieved similar outcomes in terms of pain and function, we thought the reoperation rate was unacceptably high. We would not recommend proximal hamstring tendon repair using this technique. William Blakeney, Simon Zilko, Wael Chiri, and Peter Annear Copyright © 2014 William Blakeney et al. All rights reserved. Clinical and Radiological Outcome of the Newest Generation of Ceramic-on-Ceramic Hip Arthroplasty in Young Patients Wed, 12 Feb 2014 07:13:35 +0000 http://www.hindawi.com/journals/aos/2014/863748/ Ceramic-on-ceramic articulations have become an attractive option for total hip arthroplasty in young patients. In this study, we retrospectively evaluated the short- to midterm clinical and radiographic results in 51 consecutive patients (61 hips) using the newest generation of ceramic implants. Results obtained in our study showed positive clinical and radiological outcomes. Both HHS and UCLA activity scores doubled after surgery and tended to increase over time. There was one infection requiring a two-stage revision and a case of squeaking that began 2 years postoperatively after a mechanical fall. The overall survival rate of the implants was 98.4% at six years with revision for any reason as the end point. Based on these results, fourth generation ceramics offer a viable option for young and active patients. Avishai Reuven, Grigorios N. Manoudis, Ahmed Aoude, Olga L. Huk, David Zukor, and John Antoniou Copyright © 2014 Avishai Reuven et al. All rights reserved. Management of Neglected Achilles Tendon Division: Assessment of Two Novel and Innovative Techniques Wed, 12 Feb 2014 00:00:00 +0000 http://www.hindawi.com/journals/aos/2014/729397/ Objective. Repair of injured Achilles tendon in neglected cases is one of the difficult and challenging procedures for surgeon. Here, we share our experience with the use of two innovative techniques for repair of chronic rupture of Achilles tendon. Design. Prospective Study. Setting. Tertiary care hospital. Patients. Twelve patients with chronic Tendo Achilles rupture were followed up over a period of three to five years. Intervention. Patients were divided in two groups, A and B. In Group A, the repair was done with Gastroc-soleus turndown flap and weaving with Plantaris tendon graft and in Group B, with modified Kessler’s technique strengthened with the free plantaris tendon graft. Outcome Assessment. Clinically and by Modified Rupp Scoring system. Results. At an average follow-up of 4 years (Group A, 3.7 and Group B, 4.4 years), the majority of the patients had excellent to good results as assessed with Modified Rupp Scoring with few minor complications in both the groups. There was no significant difference in the baseline variables such as age and gender and also in the Rupp’s score between the two groups. Conclusion. The two techniques are novel and simple and have been found to be useful for repair of chronically ruptured Achilles tendon. Pradeep Jain, Parthapratim Dutta, Prabal Goswami, Amol Patel, Shammi Purwar, and Vaibhav Jain Copyright © 2014 Pradeep Jain et al. All rights reserved. Biomechanical Comparison of Different External Fixation Configurations for Posttraumatic Pelvic Ring Instability Sun, 02 Feb 2014 07:04:19 +0000 http://www.hindawi.com/journals/aos/2014/360165/ Background. External fixation is useful in the primary treatment of pelvic ring injuries. The present study compared the biomechanical stability of five different configurations of an external pelvic ring fixation system. Methods. Five configurations of an anterior external pelvic ring fixation system were tested using a universal testing machine. One single connecting rod was used in group “SINGLE,” two parallel connecting rods in group “DOUBLE,” two and four rods, respectively, in a tent-like configuration in groups “SINGLE TENT” and “DOUBLE TENT,” and a rhomboid-like configuration in group “RHOMBOID.” Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz lateral compression/distraction (±50 N) and torque (±0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700, and 900 cycles. Results. The “SINGLE TENT” and “RHOMBOID” configurations already failed with a preloading of 50 N compression force. The “DOUBLE” configuration had around twice the translational stability compared with the “SINGLE” and “DOUBLE TENT” configurations. Rotational stiffness observed for the “DOUBLE” and “DOUBLE TENT” configurations was about 50% higher compared to the SINGLE configuration. Conclusion. Using two parallel connecting rods provides the highest translational and rotational stability. Simon Tiziani, Georg Osterhoff, Stephen J. Ferguson, Gregor Spreiter, Max J. Scheyerer, Gian-Leza Spinas, Guido A. Wanner, Hans-Peter Simmen, and Clément M. L. Werner Copyright © 2014 Simon Tiziani et al. All rights reserved. McHale Operation in Patients with Neglected Hip Dislocations: The Importance of Locking Plates Wed, 29 Jan 2014 07:34:53 +0000 http://www.hindawi.com/journals/aos/2014/813719/ Neglected hip dislocation in patients with cerebral palsy is a challenge for the pediatric orthopedic surgeon. Many patients experience pain, limitation of hip motion, and sitting and hygiene problems. Arthrodesis, proximal femoral head resection, and subtrochanteric valgus osteotomy are effective salvage procedures for patients with painful hip dislocation and restricted hip motion when reconstruction of the hip is not possible. Osteopenia is one of the problems that can complicate the postoperative course in these patients. Postoperative cast immobilization may further worsen the osteopenia and can predispose to fractures of the femur after cast removal. Standard plating of the proximal osteotomy may not always provide adequate stability of the fixation. In order to prevent postoperative osteoporotic fractures we use locking plates, without casting. Since 2003 until 2011, we operated on 9 patients (14 hips) with painful neglected hip dislocations. The first three patients (five hips) were operated on using standard nonlocking plates. All other patients (nine hips) were operated on using locking plates. During the followup, the hardware failed in one of these cases. All patients treated with locking plates had not been casted postoperatively, and none had loss of fixation or fractures during the followup. Mark Eidelman, Alexander Katzman, Michael Zaidman, and Yaniv Keren Copyright © 2014 Mark Eidelman et al. All rights reserved. Clinical and Radiographic Evaluation of a Commercially Pure Cancellous-Structured Titanium Press Fit Total Hip Prosthetic Stem: Ten-Year Followup of the “Natural Hip” Femoral Stem Mon, 27 Jan 2014 14:04:50 +0000 http://www.hindawi.com/journals/aos/2014/814156/ This study evaluates the outcomes of 92 hip arthroplasties using a press fit, tapered, split tip, proximally porous ingrowth (CSTi) femoral stem (Zimmer Natural Hip) in consecutive hip arthroplasty patients followed for an average of ten years postoperatively (range 5–16 years). Patients were functionally and radiographically evaluated using Harris Hip Scores and plain radiographs assessing postarthroplasty groin or thigh pain and radiographic signs of stem subsidence, proximal femoral fixation, stress shielding, and related calcar resorption. At followup of 5–10 years, the incidence of groin pain and thigh pain was 9.1% and 3.6%, respectively. This incidence improved over time. Beyond 10 years of followup, groin pain was 2.7% and thigh pain zero. In 89% of cases, there was solid contact between the calcar and the undersurface of the stem collar. Five cases were revised for instability (5.4%). The Harris Hip Scores and the incidence of thigh or groin pain were very favorable compared to other reported press fit total hip arthroplasty stems and not significantly different across a broad age range. There were no cases of stem loosening of failure of bony ingrowth into the stem. Thomas B. Pace, James C. Karegeannes, M. Jason Palmer, Stephanie L. Tanner, and Rebecca G. Snider Copyright © 2014 Thomas B. Pace et al. All rights reserved.