Assessment of static progressive stretch for the treatment of shoulder stiffness: a prospective case series.

INTRODUCTION: The purpose of this study was to evaluate the use of a patient-directed static progressive stretch orthosis for the treatment of shoulder stiffness. METHODS: Twenty-three patients who had limitations in range of motion of the shoulder and who had failed conventional physical therapy methods were studied. This cohort included 15 women and 8 men with a mean age of 53 years. Treatment comprised one to three 30- to 60-minute sessions per day with a patient-controlled orthosis utilizing static progressive stretch. The patients adjusted the degree of stretch at 5-minute intervals as tolerated. Compliance, range of motion, patient satisfaction, and complications were assessed, and a two-way repeated measure ANOVA was performed to assess the effects of age or gender. RESULTS: After a mean treatment duration of 10 weeks (range, 4 to 19 weeks), the patients gained a mean of 22° (range, -47 to 57°) of external rotation, 18° (range, -19 to 55°) of internal rotation, 46° (range, 3 to 97°) of abduction, and 23° (range, 3 to 40°) of forward flexion. In total, 22 of 23 patients (96%) experienced increases in range of motion that were maintained at 1 year following treatment. Statistically significant increases in range of motion and clinical function scores were noted; age and gender did not appear to influence the outcomes. DISCUSSION: This device compared favorably to other treatment methods for shoulder stiffness. An orthosis utilizing static progressive stretch was a useful adjunct for the treatment of shoulder stiffness refractory to conventional therapy.

Peroneal nerve dysfunction after total knee arthroplasty: characterization and treatment.

The purpose of this study was to report on the presentation, evaluation, treatment, and outcome of patients who had a peroneal nerve dysfunction after total knee arthroplasty. Six patients were unable to achieve adequate range of motion after physical therapy, and the remaining 5 patients had sensory symptoms that interfered with daily activities despite adequate range of motion. All 11 patients had abnormal electrodiagnostic testing but had intact motor strength and were treated with surgical decompression of the nerve. The patients with motion problems had a mean increase in range of motion of 40 ° (range, 20 °-70 °) at final follow-up. All patients with dominant sensory symptoms had a resolution of leg and foot pain after treatment. Orthopedic surgeons should be aware of peroneal nerve dysfunction as a possible cause of unsatisfactory rehabilitation and/or persistent atypical lateral leg pain after total knee arthroplasty.

Restoring range of motion via stress relaxation and static progressive stretch in posttraumatic elbow contractures.

HYPOTHESIS: Loss of range of motion after injury or surgery of the elbow is a common complication. We hypothesized that an orthosis that used progressive stretch and stress relaxation principles would improve elbow range of motion. METHODS: This study evaluated the result of a patient-directed, bidirectional orthosis that uses static progressive stretch and stress relaxation principles to improve elbow range of motion in patients who had posttraumatic elbow contractures. Treatment in 37 elbows consisted of a 30-minute stretching protocol performed in 1 to 3 sessions daily for a mean of 10 weeks (range, 2-22 weeks). RESULTS: The mean gain in range of motion was 26 degrees (range, 2 degrees -60 degrees ). Gains of motion were noted in 35 of 37 elbows. Patients lowered their analgesic use and were highly satisfied with the device (mean satisfaction score of 8.5 of 10 points possible). DISCUSSION: This device compared favorably with reports of other devices. Consistent improvements in restoring range of motion can be achieved with short treatment times by using a device based on the principles of static progressive stretch and stress relaxation in patients with posttraumatic elbow contractures.

An arthroscopic technique to enhance visualization during total hip arthroplasty.

This technical note describes the use of an arthroscope or endoscope to enhance visualization during minimally invasive total hip arthroplasty. The arthroscope/endoscope is used to verify seating of the components and to look for potential impingements, loose bodies, or fractures. This technique was successfully used to identify and address 2 bony or soft tissue impingements as well as a calcar fracture that might otherwise have been missed. Although further study is necessary, we believe that this technique might reduce postoperative complications and improve clinical outcomes of total hip arthroplasty.

Incidence and cost of intraoperative waste of hip and knee arthroplasty implants.

Many strategies have been reported for decreasing the cost of orthopedic procedures, but prosthetic waste has not been investigated. The purpose of this study was to characterize the cost of intraoperative waste of hip and knee implants. A regional prospective assessment was performed, evaluating the reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Implant waste occurred in 79 (2%) of 3443 procedures, with the surgeon and operating room staff bearing primary responsibility in 73% of occurrences. The annualized cost was $109 295.35, with 67% absorbed by hospitals. When extrapolated to the whole of the United States, the annual cost to hospitals would be $36,019,000 and is estimated to rise to $112,033,000 by 2030, representing a potential target for educational programs and other cost containment measures.

Strategies to reduce blood loss in lower extremity total joint arthroplasty.

Concerns about blood loss and the safety of allogenic blood transfusion have led to the development of many transfusion options for lower extremity joint arthroplasty. Techniques for dealing with such blood loss include allogenic blood transfusion, autologous donation and transfusion, hemodilution, perioperative blood salvage, intraoperative cell savers, bipolar sealers, and pharmacological agents. A blood management strategy must consider both the patient and the surgical procedure, assess the transfusion risks, and formulate a plan to address them appropriately. This article is an overview of the blood management techniques for lower extremity joint arthroplasty. The purpose of this review is to report our opinion regarding the use of alternative blood management strategies and to discuss the possible advantages and disadvantages of each technique. The results of this review indicate that a patient-focused algorithm using one or more strategies such as preoperative administration of erythropoietin, preoperative autologous blood donation, use of a bipolar sealer, intraoperative blood collection and reinfusion, as well as postoperative reinfusion drains may reduce the need for allogenic blood transfusions in patients undergoing primary and revision lower-extremity joint arthroplasties. The authors believe that a patient-specific algorithm utilizing the aforementioned techniques can lead to a substantial decrease in morbidity and mortality and an overall cost saving for both patients and medical institutions.

Percutaneous drilling for the treatment of atraumatic osteonecrosis of the ankle.

Atraumatic osteonecrosis of the ankle can be severely debilitating and can lead to joint collapse. A relatively new technique of percutaneous drilling has previously been used to relieve the symptoms of osteonecrotic hips and knees. The purpose of the present study was to examine the results of this technique when used to treat osteonecrosis of the ankle. Between September 2002 and June 2005, the senior author (M.A.M.) treated and prospectively followed 44 symptomatic osteonecrotic ankles (31 patients) using this drilling technique. The series included 23 (74.2%) women and 8 (25.8%) men with a mean age of 43 +/- 11 years. Arthrodesis had been recommended for 14 (45.2%) of these patients (20 [45.5%] ankles). At a mean follow-up duration of 45 +/- 12 months, 40 (91%) ankles had achieved a successful clinical outcome. The mean American Orthopaedic Society of Foot and Ankle Society Ankle and Hindfoot score increased from 42 +/- 5 points preoperatively to 88 +/- 10 points postoperatively, and this difference was statistically significant (P < .0001). There were no perioperative complications, although 3 ankles subsequently collapsed and required arthrodesis. The percutaneous drilling technique appears to be a useful method for the relief of symptomatic ankle osteonecrosis.

Resurfacing is comparable to total hip arthroplasty at short-term follow-up.

UNLABELLED: Metal-on-metal total hip resurfacing arthroplasty has had excellent reported results at early to midterm followup, and some studies suggest that outcomes are comparable to conventional THA. We compared the clinical and radiographic outcomes of two closely matched groups of 54 patients who underwent resurfacing and conventional THA, respectively. Each group consisted of 36 men and 18 women who had a mean age of 52 years and a mean body mass index of 29 kg/m(2). At a minimum followup of 24 months (mean, 40 months; range, 24-60 months), the mean Harris hip scores increased similarly in both groups (from 52 to 90 points and from 50 to 91 points for the resurfacing and conventional groups, respectively). Radiographic outcomes, revision rates, complications, pain scores, and satisfaction ratings of the two groups were similar. The patients who underwent resurfacing had higher postoperative weighted activity scores than the patients who underwent conventional THA, although they had higher preoperative weighted activity scores as well. The early outcomes of resurfacing are comparable to those of conventional THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Surface replacement is comparable to primary total hip arthroplasty.

UNLABELLED: Conversion of a failed surface hip replacement to a conventional total hip arthroplasty is reportedly a straightforward procedure with excellent results. We compared perioperative parameters, complications, and clinical as well as radiographic outcomes of 39 hemi and total hip resurfacing conversions with conventional THAs. The hips were matched by diagnosis, gender, age, body mass index, preoperative Harris hip score, and followup time to a cohort of primary conventional THAs performed during the same time period by the same surgeon. The mean operative time was longer (by 19 minutes) for the conversions, but other perioperative parameters were similar. At a mean followup of 45 months (range, 24-63 months), the mean Harris hip scores were similar in the two groups (92 points versus 94 points for the conversion and conventional hips, respectively). Thirty-eight of 39 stems were well-aligned and appeared osseointegrated. When a resurfaced hip fails, conversion to conventional THA has similar early clinical and radiographic outcomes to primary conventional THA. LEVEL OF EVIDENCE: Level III, therapeutic (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Total knee arthroplasty using cementless keels and cemented tibial trays: 10-year results.

The problem of early mechanical stability of cemented and cementless keels of the tibial component in total knee arthroplasty (TKA) is controversial. The purpose of this study was to assess clinical and radiographic outcomes of a cohort of 51 TKAs using a cemented platform with cementless keel fixation. At a mean follow-up of 10.4 years (range, 7 to 14 years), the mean Knee Society Score (KSS) was 93 points (range, 59 to 100 points), and the mean functional score was 73 points (range, 0 to 100 points). Only one patient demonstrated progressive tibial radiolucencies at 13.1 years follow-up, which resolved with a revision with an exchange of components. The results of this study suggest that a proximally cemented tibial tray with a press-fit keel TKA provides excellent mean 10-year outcomes.

Results of total knee replacement for isolated patellofemoral arthritis: when not to perform a patellofemoral arthroplasty.

Many procedures have been used to treat advanced isolated patellofemoral arthritis, with varying results. Patellofemoral arthroplasty (PFA) is a bone-conserving procedure that has shown short-term success but has relatively high revision rates. Total knee arthroplasty (TKA) has been recommended for treatment of this disease in patients who are older than 60 years of age. Recent literature indicates that PFA is most successful in patients who have isolated patellofemoral arthritis secondary to trochlear dysplasia or patellar fracture and in patients who are younger than 60 years; TKA is recommended for older patients who have primary or idiopathic isolated patellofemoral arthritis.

Navigation did not improve the precision of minimally invasive knee arthroplasty.

UNLABELLED: Potential advantages of minimally invasive total knee arthroplasty (TKA) include decreased pain, faster recovery, and increased quadriceps muscle strength. Computer-assisted navigation has been associated with more accurate component alignment. We evaluated two groups of 50 patients who had minimally invasive TKAs performed with and without navigation by two surgeons. A comparison of 50 previous TKAs by each of the two surgeons showed similar results. The mean operative times for the navigation and nonnavigation groups were 112 minutes (range, 63-297 minutes) and 54 minutes (range, 35-86 minutes), respectively. The mean estimated blood losses, mean Knee Society pain as well as functional scores and mean component alignments were similar. The number of knees that deviated by more than 3 degrees from the normal anatomic axis was three and one in the navigated and nonnavigated groups, respectively. Complication rates were 6% and 4% in the navigated and nonnavigated groups, respectively. Our data demonstrate no distinct advantage of navigation when combined with a minimally invasive approach. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Computer navigation-assisted versus minimally invasive TKA: benefits and drawbacks.

UNLABELLED: Computer-navigated and minimally invasive TKAs are emerging technologies that have distinct strengths and weaknesses. We compared duration of surgery, length of hospitalization, Knee Society scores, radiographic alignments, and complications in two unselected groups of 81 consecutive knees that underwent TKA using either a minimally invasive approach or computer navigation. The two groups were operated on by two different surgeons over differing timeframes. The mean surgical time was longer in the navigated group by 63 minutes. The Knee Society scores and lengths of hospitalization of the two groups were similar. The postoperative component alignments of the two groups were similar; the mean femoral valgus and tibial varus angles of the navigation group changed from 96 degrees and 88 degrees preoperatively to 95 degrees and 89 degrees postoperatively, respectively, and in the minimally invasive group, the mean femoral valgus angles and tibial varus angles changed from 97 degrees and 88 degrees preoperatively to 95 degrees and 89 degrees postoperatively, respectively. There were 11 major and three minor complications in the navigation group, including one revision, two femoral shaft fractures, four reoperations for knee stiffness, and four instances of bleeding from tracker sites. We believe the higher incidence of complications in addition to the longer operative time in the navigated group may outweigh any potential radiographic benefits. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evidence supporting the use of bone morphogenetic proteins for spinal fusion surgery.

Bone morphogenetic proteins (BMPs) are capable of promoting bone healing and even induce de novo osteogenesis. Their clinical application in spinal fusion surgery has recently increased in popularity. This is especially true for the use of BMPs in combination with artificial bone substitutes that have the capability to replace autologous bone graft, which can be associated with severe harvesting complications. This review will examine the use of BMP-2 and BMP-7 as commercially available products that have proven their osteoinductive capacity in spinal fusion. We will perform an overview of the literature for scientific evidence supporting the use of these new technologies. Despite their high osteoinductive potency, the use of BMPs does not replace proper surgical stabilization in spinal fusion. Safety issues with BMPs are osteoclast activation, postoperative swelling and hyperostosis. Despite these issues, manufacturers continue to expend more effort concerning proper application, dosage and carriers for these devices for spinal fusion, both presently and in the future.

Reductions in blood loss with a bipolar sealer in total hip arthroplasty.

Altogether, 50 primary total hip arthroplasties were performed in a prospective, blinded, randomized study comparing a bipolar sealer device to standard electrocautery for hemostasis. Cohorts were evaluated for intra- and postoperative blood loss, transfusion rate, hemoglobin levels and modified Harris hip scores. Variables such as age, gender and body mass index were correlated to transfusion requirements. Total blood loss in the bipolar sealer group was decreased by 40% and transfusions were reduced by 73%. There was a significant reduction in the intra- and postoperative blood loss, p = 0.002 and p = 0.001, respectively. There was no difference in clinical hip scores between groups. The bipolar sealer was an effective coagulation alternative for total hip arthroplasties, reducing blood loss and transfusion requirements without affecting outcome. It appears to reduce tissue damage and smoke production in comparison with standard electrocautery. These results were found even in patients with demographic characteristics associated with a higher risk of blood-related complications.

Bone morphogenetic proteins in total hip arthroplasty, osteonecrosis and trauma surgery.

This review provides an overview of the use of bone morphogenetic proteins to enhance bone healing and bone graft incorporation in difficult defects created from failed total hip arthroplasties, osteonecrosis of the femoral head and trauma. Multiple publications have demonstrated that bone morphogenetic proteins are osteoinductive in preclinical trials (i.e., animal models); however, there is controversy and limited understanding of the use of this technology in orthopedic surgical practice. The question remains as to whether they are useful in difficult fractures, nonunions and large defects created from failed total hip arthroplasty or femoral head osteonecrosis. There might be a small risk for infection by the process of introducing foreign materials in a clinical situation, but this has not yet been realized to date. In addition, these materials offer an advantage in large defects where there is not enough transplantable material available from the host. We believe that the use of these materials will become more widespread with newer carriers, minimally invasive applications and diminished commercial costs.

Evaluation of static progressive stretch for the treatment of wrist stiffness.

PURPOSE: Decreased wrist flexion and/or extension after trauma or surgery can be a challenging problem. Physical therapy, orthoses, and additional surgical interventions may not restore the desired range of motion or functionality. The purpose of this study was to assess the total arc of motion and the satisfaction scores of patients who had wrist stiffness and who were treated with a bidirectional, patient-directed orthosis that used the principles of static progressive stretch. METHODS: Forty-seven patients who experienced posttraumatic or postsurgical wrist stiffness were treated with a patient-directed orthosis. Treatment consisted of a 30- to 60-minute stretching protocol performed 1 to 3 times per day. Compliance with the device, treatment duration, mean total arc of motion, patient satisfaction, and complications were evaluated. RESULTS: The total arc of motion increased by a mean of 35 degrees (range, 5 degrees to 100 degrees ) after a mean of 10 weeks of treatment (range, 5 to 26 weeks). The mean flexion and extension increased by 18 degrees (range, 1 degrees to 50 degrees ) and 17 degrees (range, 3 degrees to 50 degrees ), respectively. Assessment of age, gender, and time before commencement of treatment showed that these factors did not significantly affect the magnitude of improvement or the final arc of motion. The mean patient satisfaction score was 8.2 points on a scale of 0 to 10 points. All patients completed the treatment, and there were no complications reported with use of the device. CONCLUSIONS: All of the patients who used this protocol improved their total arc of motion. A splinting device that uses the principles of static progressive stretch is a useful treatment for patients who have posttraumatic or postsurgical wrist stiffness and whose progress has plateaued after a course of conventional physical therapy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Static progressive stretch for the treatment of knee stiffness.

Persistent knee stiffness is common after knee arthroplasties, cruciate ligament repairs, and trauma. Static progressive stretch protocols have shown success in treating contractures of the elbow, ankle, and knee in case reports and small case series. This study evaluated static progressive stretch as a treatment method for patients who had refractory knee stiffness, and compared the outcomes to published results of other therapeutic modalities. Forty-one patients who had knee stiffness and who had not improved with conventional physical therapy modalities were treated with a patient-directed orthosis that utilized the principles of static progressive stretch. After a mean of 9 weeks of use (range, 3 to 27 weeks), the total arc of motion increased by a mean of 33 degrees (range, 0 to 85 degrees ). Forty of 41 patients had increased motion at a mean final follow-up time of 1 year (range, 6 months to 2 years), and 93% were satisfied with the results. The outcomes were comparable to other nonoperative treatments reported in the literature, but the results in the present study occurred in a shorter mean treatment time. An orthosis that utilizes the principles of static progressive stretch may be a successful treatment for improving the range of motion and satisfaction of patients who have knee contractures.

A comparison of the minimally invasive dual-incision versus posterolateral approach in total hip arthroplasty.

This study directly compared a minimally invasive dual-incision muscle-sparing surgical technique with a standard posterolateral approach in total hip arthroplasty to assess for early complications, clinical success, and alignment. Total hip arthroplasties using a minimally invasive, muscle-sparing, dual-incision approach were performed on 21 hips (20 patients). This cohort was compared to a contemporaneously performed group of 21 hips (20 patients) using a standard posterolateral approach. Five complications were reported for the dual-incision group versus one complication for the posterolateral group. Postoperative radiographic alignment of the prosthesis was closer to optimal for the posterolateral group. The dual-incision group had longer operating times and a significant increase in complications. The authors have discontinued the use of this technique based on the results of this study.

Botulinum toxin type A injections for the management of flexion contractures following total knee arthroplasty.

The development of knee flexion contractures following total knee arthroplasty is detrimental to a patient's functional capabilities. Despite using aggressive rehabilitative modalities postoperatively, some knee arthroplasty patients do not respond and continue to experience muscle spasms. Botulinum toxin type A has been used as a temporary neuromuscular transmitter blocker to treat muscle spasms in patients with neurological disorders, and it has been utilized as a treatment method for clubfoot. The purpose of this study was to evaluate botulinum toxin type A as a new treatment modality for patients with flexion contractures following total knee arthroplasty that were recalcitrant to standard treatment methods. By 2 years following injections, 9 out of 11 knees achieved extension within 10; of neutral position, and 8 of the 11 maintained this improved range of motion by a mean follow-up of 36 months. There were two failures in patients who had a revision knee arthroplasty, suggesting that this treatment is more effective in patients following primary cases. Based on these results, botulinum toxin type A should be considered as a potential treatment modality, especially in difficult-to-treat cases of knee flexion contracture that are recalcitrant to standard therapy.