Femoral Head Autograft Can Reliably Reconstruct Dysplastic Acetabula Through the Direct Anterior Approach for Total Hip Arthroplasty.

Background: Bone deficiencies in dysplastic acetabula create technical difficulties during total hip arthroplasty (THA). Bulk femoral head autograft (FHA) is one method to increase cup coverage and bone stock of the true acetabulum; however, only limited data exist on its efficacy through a direct anterior approach (DAA). This study aimed to evaluate the outcomes of FHA during THA via a DAA in dysplastic hips. Methods: Retrospective review of 34 patients (41 hips) with hip dysplasia (Crowe I-III) who underwent primary THA via a DAA with FHA at a single institution was performed. Surgical procedures were performed on a traction table with intraoperative fluoroscopy and highly porous-coated cup placement in the true acetabulum. Patients were assessed clinically and radiographically at a minimum of 2 years postoperatively (range, 2 to 7). Results: The average modified Harris Hip Score improved from 31.9 ± 10.8 to 94.1 ± 5.8, Merle d'Aubigné Hip Score from 7.5 ± 2.8 to 16.6 ± 1.1, and visual analog pain score from 7.9 ± 2.7 to 1.4 ± 1.4 (all P < .001). All hips had an "anatomic" inferomedial cup position postoperatively, with an average increase in horizontal coverage of 43.4%. Mean postoperative limb-length discrepancy improved from 21.8 ± 16.1 mm to 1.6 ± 5.7 mm (P < .001). There were no cases of revision THA, nor complications such as dislocation, infection, or osteolysis. Conclusion: Reconstructing dysplastic acetabula (Crowe I-III) with FHA during THA can be successfully accomplished via the DAA with increased acetabular bone stock and accurate correction of limb-length discrepancy.

Implementation of an enhanced recovery protocol at a safety net hospital : a silver lining to COVID-19?

AIMS: This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. METHODS: A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. RESULTS: The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. CONCLUSION: Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a 'silver lining' to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871-878.

Anterior Total Hip Arthroplasty With Bulk Femoral Head Autograft in a Patient With Camurati-Engelmann Disease.

Camurati-Engelmann disease (CED) is an extremely rare, sclerosing bone disorder of intramedullary ossification with only 300 reported cases worldwide. The pathogenesis is related to activating mutations in transforming growth factor beta 1, which results in bilateral, symmetric hyperostosis affecting primarily the diaphysis of long bones. Despite effective pharmacological treatment options, the diagnosis of CED is problematic owning to its rarity and variability of clinical presentation. We present a patient with known CED with advanced early hip osteoarthritis, secondary to underlying hip dysplasia, for which she underwent a successful total hip arthroplasty via a direct anterior approach with the use of bulk femoral head autograft to reconstruct her native acetabulum.

Application of an antibiotic intramedullary nail in the management of a large metacarpal bone defect.

Contaminated wounds and infected nonunions of the hand are not amenable to primary internal fixation and grafting. Antibiotic-impregnated cement intramedullary nails have been used in the lower extremity in the treatment of these fractures but have not been described in the hand. This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. We describe an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand using readily available operating room equipment. The antibiotic-impregnated cement intramedullary nail can be placed temporarily until definitive internal fixation and grafting occur.

Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures.

BACKGROUND: The aims of the study were (1) to determine the cumulative two to twenty-year survivorship of the hip after open reduction and internal fixation of displaced acetabular fractures, (2) to identify factors predicting conversion to total hip arthroplasty or hip arthrodesis, and (3) to create a predictive model that calculates an individual's probability of early need for total hip arthroplasty or hip arthrodesis. METHODS: Eight hundred and sixteen acetabular fractures treated with open reduction and internal fixation by one surgeon over a twenty-six-year period were analyzed. Cumulative two to twenty-year Kaplan-Meier survivorship analyses of the hip, including best and worst-case scenarios, were performed with total hip arthroplasty or hip arthrodesis as the end point. Univariate and multivariate Cox regression analyses were performed to identify negative predictors, which were then used to construct a nomogram for predicting an individual's probability of needing an early total hip arthroplasty. RESULTS: The cumulative twenty-year survivorship of the 816 hips available for follow-up was 79% at twenty years. The best and worst-case scenarios corresponded to cumulative twenty-year survivorship of 86% and 52%, respectively. Significant independent negative predictors were nonanatomical fracture reduction, an age of more than forty years, anterior hip dislocation, postoperative incongruence of the acetabular roof, involvement of the posterior acetabular wall, acetabular impaction, a femoral head cartilage lesion, initial displacement of the articular surface of ≥ 20 mm, and utilization of the extended iliofemoral approach. CONCLUSIONS: Open reduction and internal fixation of displaced acetabular fractures was able to successfully prevent the need for subsequent total hip arthroplasty within twenty years in 79% of the patients. The results represent benchmark comparative data for any future and past studies on the outcome of surgical fixation of acetabular fractures.

Failed distal biceps tendon repair using a single-incision EndoButton technique and its successful treatment: case report.

Surgical repair has become a mainstay in the treatment of ruptures of the distal biceps tendon and multiple surgical techniques have been described advocating anatomic or near-anatomic repair. Fixation with an EndoButton technique has been shown to have superior fixation strength and durable clinical outcomes. Here, we describe a case of failed EndoButton fixation of the distal biceps tendon, and its successful treatment.

Internal fixation of symphyseal disruption resulting from childbirth.

OBJECTIVES: To investigate the clinical and radiographic results after operative treatment of complete symphyseal disruption resulting from childbirth and to evaluate residual pain and implant failure in relation to the timing of surgery. DESIGN: Retrospective study. SETTING: Tertiary pelvis and acetabulum care unit at a general hospital. PATIENTS: Ten consecutive women with complete symphysis disruption associated with childbirth were included from a database of 603 patients with pelvic fracture. No patients with this diagnosis were excluded. All patients were followed until clinical healing of the symphysis or union of the fusion. INTERVENTION: Open reduction and internal fixation in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients). Fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment in chronic cases (greater than 6 months, three patients). MAIN OUTCOME MEASUREMENT: Analyzed variables included the Lindahl score, maintenance of postoperative reduction, implant failure, malunion, and necessity of reoperation. RESULTS: Mean age of the patients was 32 years (range, 24-37 years). Mean follow up was 29 months (range, 5-139 months). The mean postoperative Lindahl score was 68 ± 14.6 points (range, 38-80 points). There were three excellent, four good, two fair, and one poor result. Fair or poor results occurred in one subacute and two chronic cases. There were two revision surgeries. One patient underwent implant removal resulting from dyspareunia 3.1 years postoperatively. One subacute patient had conversion to symphyseal fusion after implant failure as a result of a fall 11 years after index surgery. Major complications occurred in two and minor complications in three patients. Radiographic loosening of implants was observed in all subacute cases. All fusions healed and symptoms improved at last follow up. CONCLUSIONS: Operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor-induced complete symphysis pubis disruption.

Mechanical failure of the long gamma nail in two proximal femur fractures.

Mechanical failure of the long gamma nail was encountered in two elderly patients with proximal femur fractures over a 6-month period. One of the patients had a known history of lymphoma. The other patient had a history of rheumatoid arthritis but no history of cancer or other metabolic bone disease. Both nails failed at the junction of the compression screw and the nail. The angle of failure of the nail was the same in both cases. The index of suspicion for imminent mechanical failure of the gamma nail should be higher in pathologic fractures and fractures which are malreduced during nailing.

Do scores of the USMLE Step 1 and OITE correlate with the ABOS Part I certifying examination?: a multicenter study.

BACKGROUND: The US Medical Licensing Examination (USMLE) and Orthopaedic In-Training Examination (OITE) are commonly used to select medical students or residents, respectively. Knowing how well these examinations predict performance on the American Board of Orthopaedic Surgery (ABOS) Part I certifying examination is important to provide evaluations for medical students and residents. Previous studies comparing the OITE scores with the ABOS Part 1 scores have been limited to one program. QUESTIONS/PURPOSES: Therefore, we compared the scores on the USMLE Step 1 and OITE examinations with those on the ABOS Part I certifying examination using data from four ACGME approved residency programs. METHODS: We reviewed 202 resident files from 1996 to 2008 from four programs in the same geographic region. Of those, 181 (90%) had complete records. De-identified data were used to compare USMLE Step 1 scores, OITE percentile rank scores, and ABOS Part I percentile rank scores. Pearson coefficients and receiver operator curves were calculated to assess the relationships between tests. RESULTS: We found a correlation of 0.53 between the USMLE Step 1 and ABOS Part I, and an average correlation of 0.50 for postgraduate years (PGY) 2 through 5 OITE scores and ABOS Part I. There was a stepwise increase in correlation from PGY 2 through PGY 5 between the OITE scores and ABOS scores. Those who averaged in the 27th percentile or lower on the OITE had a 57% chance of failing the ABOS Part I examination. CONCLUSION: USMLE Step 1 scores correlated with ABOS Part I certifying examination scores, and we therefore believe it may be used as one factor in resident selection. Use of the OITE scores in guiding education and feedback appears to be justified.

Predictors of reoperation following operative management of fractures of the tibial shaft.

BACKGROUND: Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors. OBJECTIVE: We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures. DESIGN: Retrospective observational study. SETTING: Level 1 trauma center. METHODS: We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure