Advances in Orthopedic Surgery The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. The Influence of Psychiatric Comorbidity on Inpatient Outcomes following Distal Humerus Fractures Thu, 14 Apr 2016 07:38:30 +0000 Background. The influence of psychiatric comorbidity on outcomes following inpatient management of upper extremity fractures is poorly understood. Methods. The National Hospital Discharge Survey was queried to identify patients admitted to US hospitals with distal humerus fractures between 1990 and 2007. Patients were subdivided into 5 groups: depression, anxiety, schizophrenia, dementia, and no psychiatric comorbidity. Multivariable logistic regression analysis identified independent risk factors for adverse events, requirement of blood transfusion, and discharge to another inpatient facility. Results. A cohort representative of 526,185 patients was identified as having a distal humerus fracture. Depression, anxiety, and dementia were independently associated with higher odds of in-hospital adverse events (). Depression was associated with higher odds of inpatient blood transfusion (). Depression, schizophrenia, and dementia were associated with higher odds of nonroutine discharge to another inpatient facility (). Patients with a diagnosis of schizophrenia had a mean of 12 () more days of care than patients with no psychiatric comorbidity. Discussion. Patients with comorbid psychiatric illness who are admitted to hospitals with distal humerus fractures are at increased risk of inpatient adverse events and posthospitalization care. Leonard T. Buller, Matthew J. Best, Milad Alam, Karim Sabeh, Charles Lawrie, and Stephen M. Quinnan Copyright © 2016 Leonard T. Buller et al. All rights reserved. Reducing Shoulder by Vertical Traction: A One-Man Method for Shoulder Reduction Thu, 07 Apr 2016 11:49:08 +0000 Fifty percent of joint dislocations reported to the emergency department are of shoulder joint. Various techniques are used to reduce the shoulder and Spaso technique is the least known to the orthopaedic residents which is a simple one-man vertical traction method of shoulder reduction. We evaluated the effectiveness of vertical traction method for anterior shoulder dislocation by orthopaedic residents. Sixty consecutive patients of anterior glenohumeral dislocation attending the emergency department of our hospital were taken up for the study. The reduction was done using Spaso technique. Right shoulder was dislocated in 40 patients and 31 patients had recurrent shoulder dislocation. In 55 patients, shoulder was reduced without the use of any anaesthesia. In patients where no anaesthesia was used, the time of traction ranged from 45 seconds to 5 minutes, while under anaesthesia the time of traction ranged from 1 to 4 minutes. Twenty-one patients had associated greater tuberosity fracture which did not affect the method of reduction and all of them were reducible. No complication was reported, and all the patients were satisfied with the method. In conclusion vertical traction method is a good technique for reducing anterior shoulder dislocation with an easy learning curve among the residents and no complication has been reported so far. Hayat Ahmad Khan, Younis Kamal, Mohammad Ashraf Khan, Munir Farooq, Naseemul Gani, Nazia Hassan, Adil Bashir Shah, and Mohammad Shahid Bhat Copyright © 2016 Hayat Ahmad Khan et al. All rights reserved. Enhanced Recovery Protocol Reduces Transfusion Requirements and Hospital Stay in Patients Undergoing an Elective Arthroplasty Procedure Thu, 31 Mar 2016 09:42:21 +0000 Background. Enhanced recovery (ER) for elective total hip or total knee replacement has become common practice. The aim of this study is to evaluate the impact of ER on transfusion rates and incidence of venous thromboembolism (VTE). Methods. A comprehensive review was undertaken of all patients who underwent primary hip or knee arthroplasty surgery electively between January 2011 and December 2013 at our institution. ER was implemented in August 2012, thus creating two cohorts: the traditional protocol (TP) group and the ER group. Outcome measurements of length of stay, postoperative transfusion, thromboembolic complications, and number of readmissions were assessed. Main Findings. 1262 patients were included. The TP group contained a total of 632 patients and the ER group contained 630 patients. Postoperative transfusion rate in the ER group was reduced with 45% (). There was no statistical difference in postoperative VTE complications. The length of stay was reduced from 5.5 days to 4.8 days (). Conclusions. There was no difference in the number of readmissions. ER has contributed to a significant decrease in transfusions after elective arthroplasty surgery, with no increase in the incidence of thromboembolic events. Furthermore, it has significantly reduced inpatient length of stay. Kirsten Juliette de Burlet, James Widnall, Cefin Barton, Veera Gudimetla, and Stephen Duckett Copyright © 2016 Kirsten Juliette de Burlet et al. All rights reserved. Early Clinical Outcomes Associated with a Novel Osteochondral Allograft Transplantation System in the Knee Thu, 31 Mar 2016 09:12:08 +0000 Background. Osteochondral defects of the knee are a common finding at the time of arthroscopic intervention. Purpose/Hypothesis. To report our outcomes after utilizing a new technique of osteochondral allograft transplantation for focal cartilage defects. Study Design. Case series. Methods. All patients treated with osteochondral allograft transplantation with a Zimmer Chondrofix plug (Zimmer Inc., Warsaw, IN) for focal cartilage defects over a 12-month period were followed up at a minimum of 24 months. Failures were documented and radiographs were evaluated. Results. 61 knees (58 patients) underwent grafting. Three cases were lost to follow-up. In the remaining 58 cases the average age was 40 (range 18–59). At a mean follow-up of 28 months (range 24–36), there were 5 failures requiring further surgery. Mean KOOS scores in the Pain, Symptoms, ADL, Sports, and Quality of Life dimensions were 82, 79, 84, 66, and 58, respectively. Radiographs demonstrated maintenance of the subchondral bone without graft absorption or subsidence. Conclusions. Our observations suggest that osteochondral allograft transplantation leads to a satisfactory activity level and function at early follow-up while avoiding the inherent complexities associated with other cartilage restoration techniques. Longer follow-up is warranted to monitor the subchondral bone, articular surface, and patient outcome measures. William J. Long, Joseph W. Greene, and Fred D. Cushner Copyright © 2016 William J. Long et al. All rights reserved. Open Reduction and Internal Fixation of Displaced Supracondylar Fracture of Late Presentation in Children: A Preliminary Report Wed, 20 Jan 2016 13:21:43 +0000 Background. In late presentation of cases there is dilemma whether to wait for osteotomy later or do open reduction on arrival. The purpose of this prospective multicentric study is to evaluate the functional outcome of open reduction and internal fixation (ORIF) with crossed Kirschner wires fixation and early joint motion in the late presentation of supracondylar fractures in children. Methods. A total of 21 children, with an average delay of 20.3 days, with displaced type III Gartland supracondylar fracture, were treated by ORIF with crossed Kirschner wires fixation and early joint motion. Average follow-up was 12 months. Results. Flynn’s criteria were used to evaluate the outcome. All of them had more functional range of motion of the injured elbow than the published reports. Conclusions. Most of the surgeons in the developing world prefer ORIF for optimal results. Thus it appears to be justifiable to go for ORIF with K-wires even in the late presentation of supracondylar fractures. The overall results are encouraging. However, the small number of cases and lack of control group are the limitations of this study. The study is ongoing and so the full report with more cases will be presented later. Ram K. Shah, Raju Rijal, Rosan P. Shah Kalawar, Sujit R. Shrestha, and Niraj Kumar Shah Copyright © 2016 Ram K. Shah et al. All rights reserved. Experiences of a Peripheral Unit in Using a Tripolar Constrained Acetabular Component for Recurrent Dislocations following Total Hip Joint Replacements Tue, 19 Jan 2016 18:25:09 +0000 Primary total hip arthroplasty is a successful procedure, although complications such as dislocation can occur. In certain patient populations if this is recurrent, it can be difficult to manage effectively. We present a retrospective analysis of our experience of using a capture/captive cup over an 8-year period for frail elderly patients who presented with recurrent hip dislocations. Our findings show no redislocations in our cohort and a survival analysis demonstrates just less than half surviving at 2 years after surgery. Furthermore, Harris Hip Scores were generally calculated to be good. A constrained acetabular component provides durable protection against additional dislocations without substantial deleterious effects on component fixation. Such components should be considered especially in a group of patients with comorbidities or those who are fragile, elderly, and low-demand in nature. Mohammed S. Arshad, Shashi Godey, Arun Kumar, and Martyn Lovell Copyright © 2016 Mohammed S. Arshad et al. All rights reserved. Implementation of an Accelerated Rehabilitation Protocol for Total Joint Arthroplasty in the Managed Care Setting: The Experience of One Institution Wed, 30 Dec 2015 06:04:46 +0000 Accelerated rehabilitation following total joint replacement (TJR) surgery has become more common in contemporary orthopaedic practice. Increased utilization demands improvements in resource allocation with continued improvement in patient outcomes. We describe an accelerated rehab protocol (AR) instituted at a community based hospital. All patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) were included. The AR consisted of preoperative patient education, standardization of perioperative pain management, therapy, and next day in-home services consultation following discharge. Outcomes of interest include average length of stay (ALOS), discharge disposition, 42-day return to Urgent Care (UC), Emergency Department (ED), or readmission. A total of 4 surgeons performed TJR procedures on 1,268 patients in the study period (696 TKA, 572 THA). ALOS was reduced from 3.5 days at the start of the observation period to 2.4 days at the end. Discharge to skilled nursing reduced from 25% to 14%. A multifaceted and evidence based approach to standardization of care delivery has resulted in improved patient outcomes and a reduction in resource utilization. Adoption of an accelerated rehab protocol has proven to be effective as well as safe without increased utilization of UC, ER, or readmissions. Nicholas B. Robertson, Tibor Warganich, John Ghazarossian, and Monti Khatod Copyright © 2015 Nicholas B. Robertson et al. All rights reserved. Variation in Planned Resection of CAM FAI Based on Surgeon Experience Thu, 24 Dec 2015 15:10:45 +0000 Introduction. Currently, there are no definitive guidelines for the resection of a cam lesion. The purpose of this study was to investigate factors indicating the potential differences in low and high volume hip arthroscopists in marking the area of resection in cam lesions using X-rays for preoperative planning. Methods. Thirty-nine surgeons with varying levels of hip arthroscopy experience participated in the study. Surgeons filled out a survey and traced the area of optimal resection on radiographs with varying amounts of cam FAI. Participants were grouped by number of hip arthroscopies performed, years of surgical experience, and number of surgeries performed. Results. Surgeons who perform osteoplasty as a high percentage of their total hip surgeries per year correlate to the total number of hip arthroscopies performed per year (, ) and number of years of experience (, ). Surgeons performing greater than 50 cases per year traced a larger resection area for 3 different patients’ radiographs as compared to those performing less than 50 cases per year (117%, 143%, and 173%, ). Conclusions. This study demonstrates that surgeons with less experience (decreased number of years operating and total number of surgeries) plan for resecting less cam than do experienced surgeons. Derek Ochiai, Skye Donovan, Farshad Adib, and Eric Guidi Copyright © 2015 Derek Ochiai et al. All rights reserved. Treatment of Aseptic Hypertrophic Nonunion of the Lower Extremity with Less Invasive Stabilization System (New Approach to Hypertrophic Nonunion Treatment) Mon, 14 Dec 2015 08:00:05 +0000 Aim. To evaluate whether aseptic hypertrophic nonunion in the long bones of the lower extremity can be treated successfully with LISS applied with closed methods without grafting. Materials and Methods. The study included 7 tibias and 9 femurs of 16 patients. All cases had hypertrophic nonunion. Initial surgical treatment was with intramedullary nailing in 14 cases, 6 of which had required an exchange of intramedullary nail. All the patients were treated with LISS plate with closed methods. Results. Union was obtained at mean 7 months in all patients. No implant loosening or breakage of the implant was observed and there was no requirement for secondary surgery. Conclusion. Cases of hypertrophic nonunion have excellent blood supply and biological potential. Therefore, there is no need for bone grafting and the addition of fracture stability is enough to achieve full union. Using a limited approach and percutaneous screw insertion, LISS provides fracture stabilization with soft tissue protection. Metin Uzun, Murat Çakar, Ahmet Murat Bülbül, and Adnan Kara Copyright © 2015 Metin Uzun et al. All rights reserved. Is Single Use Portable Incisional Negative Pressure Wound Therapy System Suitable for Revision Arthroplasty? Mon, 30 Nov 2015 06:45:02 +0000 Incisional negative pressure wound therapy (INPWT) has been used for high-risk surgery across specialties but has yet to be utilised for revision hip and knee surgery. Between 2013 and 2014, patients who underwent revision arthroplasty by the senior author were identified. 36 (9 hips and 27 knees) operations in 36 patients identified 18 (8 male, median age 77 (61–86)) who received standard dressing and 18 (12 male, median age 67 (58–81)) who received single use portable INPWT dressings (4 hips, 14 knees). Wound complications were seen in 3 (2 knees) from the standard group and 1 (hip) in the INPWT group (). There was no statistical difference in age or gender between groups. Risk factors (BMI > 30, smoking, and diabetes) were identified in 9 patients, median ASA 3, in the standard group and 10 patients, median ASA 2, in the INPWT group. There were no dressing related complications. This is the first study of INPWT with a low pressure single use 80 mmHg dressing with revision arthroplasty. This initial study showed a threefold decrease in wound complication in the INPWT group and that INPWT is a safe alternative to standard dressings. Thomas Hester, Shoib Mahmood, and Farid Moftah Copyright © 2015 Thomas Hester et al. All rights reserved. The Impact of an Intact Infrapatellar Fat Pad on Outcomes after Total Knee Arthroplasty Mon, 16 Nov 2015 09:17:30 +0000 Background. The infrapatellar fat pad (IPFP) is currently resected in approximately 88% of Total Knee Arthroplasties (TKAs). We hypothesised that an intact IPFP would improve outcomes after TKA. Methods. Patients with an intact IPFP participated in this cross-sectional study by completing two surveys, at 6 and 12 months after TKA. Both surveys included questions regarding kneeling, with the Oxford Knee Score also included at 12 months. Results. Sixty patients participated in this study. At 6 and 12 months, a similar number of patients were able to kneel, 40 (66.7%) and 43 (71.7%), respectively. Fifteen (25.0%) patients were unable to kneel due to knee pain at 6 months; of these, nine (15%) were unable to kneel at 12 months. Moreover, at 12 months, 90.0% of the patients reported minimal or no knee pain. There was no correlation between the inability to kneel and knee pain (). There was a significant correlation between the inability to kneel and reduced overall standardised knee function scores (). Conclusions. This was the first study to demonstrate improved kneeling and descending of stairs after TKA with IPFP preservation. These results in the context of current literature show that IPFP preservation reduces the incidence of knee pain 12 months after TKA. Leigh White, Nicholas Hartnell, Melissa Hennessy, and Judy Mullan Copyright © 2015 Leigh White et al. All rights reserved. Elution Characteristics of Vancomycin, Gentamicin, and Vancomycin/Gentamicin Combination from Calcium Phosphate Cement Wed, 20 May 2015 11:38:44 +0000 The antibiotic elution profiles from calcium phosphate cement (CPC) used for treating infection sites after total joint arthroplasty vary depending on the type and number of impregnated antibiotics. The purpose of this study was to develop a method for efficiently eluting vancomycin hydrochloride (VCM) and gentamicin sulfate (GM) from CPC. Examination of the antibiotic elution profiles of CPC impregnated with either VCM (CPC/V) or GM (CPC/G) or both (CPC/VG) revealed that the early elution of VCM from CPC/VG was impaired compared to CPC/V. However, the elution of GM from CPC/VG was similar or higher compared to CPC/G. Scanning electron microscopy showed that the pore structure of CPC markedly differed depending on the type and number of antibiotics present. The pore size of CPC/VG was smaller compared to CPC/V but was larger compared to CPC/G. Thus, the inhibition of the early elution of VCM, which is a larger molecule than GM, was attributed to the decreased pore size of CPC/VG. These findings suggest that when dual treatment with VCM and GM is required for infection following total joint arthroplasty, each antibiotic should be individually impregnated into CPC to maximize the elution efficiency of VCM. Masataka Uchino, Ken Sugo, Kouji Naruse, Kentaro Uchida, Noriko Hirakawa, Masahiro Toyama, Genyou Miyajima, and Ken Urabe Copyright © 2015 Masataka Uchino et al. All rights reserved. Outcome in Patients with High Body Mass Index following Primary Total Hip Arthroplasty Mon, 11 May 2015 13:43:51 +0000 Obesity is becoming a critical problem in the developed world and is associated with an increased incidence of osteoarthritis of the hip. The Oxford Hip Score was used to determine if Body Mass Index (BMI) is an independent factor in determining patient outcome following primary total hip arthroplasty (THA). Using data from 353 operations we found that patients with BMI ≥ 30 had an absolute score that was lower preoperatively and postoperatively compared to those with a BMI < 30. There was no difference in pre- and postoperative point score change within each group; Kendall’s rank correlation was 0.00047 (95% CI, −0.073 to 0.074 ()) and demonstrated no trend. There was no statistically significant difference in change between those with BMI ≥ 30 and < 30 . We suggest that those with a higher BMI be considered for THA as they can expect the same degree of improvement as those with a lower BMI. Given the on-going increase in obesity these findings could be significant for the future of THA. Zuned Hakim, Claire Rutherford, Elizabeth Mckiernan, and Tony Helm Copyright © 2015 Zuned Hakim et al. All rights reserved. A Simplified Approach for Arthroscopic Repair of Rotator Cuff Tear with Dermal Patch Augmentation Mon, 26 Jan 2015 11:32:17 +0000 Here, we describe an arthroscopic method specifically developed to augment rotator cuff repair using a flexible acellular dermal patch (ADP). In this method, an apparently complex technique is simplified by utilizing specific steps to augment a rotator cuff repair. In this method, using a revised arthroscopic technique, rotator cuff repair was performed. This technique allowed easy passage of the graft, excellent visualization, minimal soft tissue trauma, and full four-corner fixation of an ADP. Twelve patients underwent rotator cuff repair with augmentation using the combination of this method and ADP. Due to the technique and biomechanical characteristics of the material, the repairs have been stable and with high patient satisfaction. Anthony C. Levenda and Natalie R. Sanders Copyright © 2015 Anthony C. Levenda and Natalie R. Sanders. All rights reserved. The Effect of a Femoral Fracture Sustained before Skeletal Maturity on Bone Mineral Density: A Long-Term Follow-Up Study Sun, 21 Dec 2014 00:10:08 +0000 Background and Purpose. The possible effect of pediatric femoral fractures on the bone mineral density (BMD) is largely unknown. We conducted a study to investigate BMD in adults who had sustained a femoral shaft fracture in childhood treated with skeletal traction. Materials and Methods. Forty-four adults, who had had a femoral fracture before skeletal maturity, were reexamined on average 21 (range 11.4) years after treatment. Our follow-up study included a questionnaire, a clinical examination, length and angle measurements of the lower extremities from follow-up radiographs, and a DEXA examination with regional BMD values obtained for both legs separately. Results. At follow-up femoral varus-valgus and ante-/recurvatum angles were slightly larger in the injured lower-limb compared to the contralateral limb. The mean BMD of the entire injured lower-limb was lower than that of the noninjured (1.323 g/cm2 versus 1.346 g/cm2, ). Duration of traction was the only factor in multiple linear regression analysis that was positively correlated with the BMD discrepancy between the injured and noninjured lower-limb explaining about 17% of its variation. Conclusion. The effect of a femoral fracture sustained during growth is small even in patients treated with traction. J. A. Kettunen, S. Palmu, K. Tallroth, Y. Nietosvaara, and M. Lohman Copyright © 2014 J. A. Kettunen et al. All rights reserved. Risk Factors for Recurrent Shoulder Dislocation Arthroscopically Managed with Absorbable Knotless Anchors Tue, 25 Nov 2014 12:29:20 +0000 Purpose. To evaluate the clinical outcome and risk factors for recurrent dislocation after arthroscopic stabilization with absorbable knotless anchor. Methods. We treated 197 patients affected by anterior shoulder instability, either traumatic or atraumatic with the same arthroscopic suture technique. We recorded age at surgery and number and type of dislocations (traumatic/atraumatic). Of the 197 patients, 127 (65.4%) were examined with a mean follow-up of 5.6 years (range: 25–108 months). Eighty-one shoulders were evaluated with the Rowe score and 48 with the Simple Shoulder Test (SST). Results. The mean Rowe score was 90.8, while the mean SST score was 10.9. Recurrence occurred in 10 cases (7.7%) but only in 4 cases was atraumatic, which reduces the real recurrence rate to 3.1%. Patients with recurrence were significantly younger at surgery than patients who did not relapse (). Moreover, neither the number () nor the type of shoulder instability (), or the amount of glenoid bone loss () significantly affected the probability of recurrence. Conclusions. In a patient population with involuntary monodirectional anterior shoulder instability, use of absorbable knotless anchor was reliable and resulted in a good outcome. In this series the statistical significant risk factors for recurrent dislocation were age of patient. Raffaele Russo, Fabio Cautiero, and Giuseppe Della Rotonda Copyright © 2014 Raffaele Russo et al. All rights reserved. Arthrodesis of the Trapeziometacarpal Joint Using a Chevron Osteotomy and Plate Fixation Wed, 22 Oct 2014 12:39:27 +0000 Introduction. Trapeziometacarpal (TM) osteoarthritis is common. Despite the availability of numerous surgical options, none has been definitively proven to be superior. This study aims to determine the union rate and key strength following arthrodesis using a chevron osteotomy and plate fixation. Methods. 32 consecutive cases of TM joint arthrodesis performed between 2001 and 2006 were retrospectively identified. A chevron osteotomy was used to resect joint surfaces and fixation obtained using an AO mini T-plate. The patients were followed up for a mean of 65 months. Outcomes included visual analogue pain score, patient satisfaction, pinch strength, radiographic union, radiographic signs of scaphotrapezial arthritis, and complications. Results. The 32 cases included 16 females and 8 males with an average age of 56 years. Overall there was a 90% patient satisfaction rate. Average key pinch strength was 8.4 kg and pain score was 2.5. The union rate was 94%, and the two patients with nonunion underwent successful revision surgery. Only one case of radiographic progression of scaphotrapezoid arthritis was identified during followup. Conclusion. TM joint arthrodesis using a chevron osteotomy and plate fixation has high patient satisfaction and low nonunion rates. The authors endorse this technique in the management of TM joint osteoarthritis. G. Shyamalan, R. W. Jordan, and A. Jarvis Copyright © 2014 G. Shyamalan et al. 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 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 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 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 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 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 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 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 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 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 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 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 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 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.