Vastus Lateralis Muscle Flap for High-Risk Patients Undergoing Orthopaedic Hip Surgery.

INTRODUCTION: Chronic infections and soft-tissue defects are serious complications after total hip arthroplasties (THAs) that may require hip disarticulation (HD). HD is a relatively high-risk procedure with poor long-term outcomes and survival. This is the first study to analyze the effect of an ipsilateral, pedicled vastus lateralis (VL) muscle flap in preventing HD in patients with recurrent complications after THA. METHODS: This retrospective case review analyzed the 6-month postoperative outcomes of 14 patients who underwent soft-tissue hip reconstruction with a VL muscle flap by a single surgeon. RESULTS: Most (86%) patients fully recovered after 6 months with preserved hip range of motion, no pain, and no weakness on ambulation. Two (14%) patients ultimately required HD despite introducing a VL flap. DISCUSSION: A VL muscle flap is an effective treatment of nonhealing THA and prophylactic intervention for patients at high risk for HD. The VL muscle is optimal because of its large size allowing reduction of soft-tissue dead space, its local anatomical location to the hip, and its exceptional vascularity. Additional prospective studies are necessary to determine the most appropriate population for this technique.

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

BACKGROUND: Obesity has been associated with complications after a total knee arthroplasty (TKA). Surgical site infection (SSI) after TKA is one of the feared complications as it increases revision rates, costs, and stress to the patient. There is conflicting evidence in the literature regarding body mass index (BMI) and risk of infection after TKA, and some studies have suggested that site-specific fat distribution may be a better metric for determining risk of postoperative infections. Here, we investigate the correlation of soft tissue distribution about the knee to SSI after TKA. METHODS: We retrospectively review 572 patients who underwent primary TKA at a single institution from 2006 to 2010. We introduce the prepatellar fat thickness ratio (PFTR) as a radiographic means to quantitatively assess fat distribution about the knee and evaluate this measurement's ability to assess the risk of developing an SSI after TKA. RESULTS: The PFTR was shown to be a better predictor of SSI than BMI in both the univariate (P = .05) and multivariate (P = .01) analyses. CONCLUSION: Although BMI cannot fully account for variations in adipose distribution, the PFTR may account for this variability and may be a helpful tool for assessing a patient's preoperative risk of SSI after TKA.

Reliability of the classification of proximal femur fractures: Does clinical experience matter?

BACKGROUND: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. QUESTIONS/PURPOSES: We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup. METHODS: This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons. RESULTS: There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001). CONCLUSIONS: This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Longer Length of Stay Increases 1-year Readmission Rate in Patients Undergoing Hip Fracture Surgery.

BACKGROUND: Proximal femur fractures are prevalent among the elderly and associated with substantial morbidity, mortality, and early readmission. Early readmission is gaining popularity as a measure of quality of hospital care and can lower reimbursement. A better understanding of the patient and treatment characteristics associated with readmission may help inform program improvement initiatives. This study tested the primary null hypothesis that length of stay is not associated with higher rates of readmission within 30 days and 1 year in patients having operative treatment of a proximal femur fracture, accounting for discharge destination and other factors. METHODS: We performed a secondary analysis on a database of 1,061 adult patients, age 55 years or older, admitted for treatment of a proximal femoral fracture in an urban level 2 trauma center. Multivariable logistic and linear regression models were created to account for the influence of age, sex, race, BMI, American Society of Anesthesiologists score (ASA), fracture type (AO/OTA), fixation type, operating surgeon, operative duration, and discharge destination. RESULTS: In multivariable logistic regression analysis, treatment by surgeon 4 was independently associated with a lower 30-day readmission rate. Higher one-year readmission rate was associated with a longer length of stay, ASA class 3, 4 and 5. CONCLUSION: The observation that patients cared for by specific surgeons are more likely to experience readmission within one year of surgery for a fracture of the proximal femur, suggests that program improvements to identify and disseminate best practices might reduce readmission rates. LEVEL OF EVIDENCE: III.

Lower Bone Mineral Density is Associated with Intertrochanteric Hip Fracture.

BACKGROUND: A better understanding of how bone mineral density and vitamin D levels are associated with femoral neck and intertrochanteric hip fractures may help inform healthcare providers. We asked: 1) In patients age ≥ 55 years, is there a difference in quantitative ultrasound of the heel (QUS) t-score between patients with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors 2) In patients age ≥ 55 years, is there a difference in vitamin D level between those with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors? 3) Is there an association between vitamin D level and QUS t-score? METHODS: In this retrospective cohort study, 1,030 patients were identified using CPT codes for fixation of hip fractures between December 2010 and September 2013. Patients ≥ 55 years of age who underwent operative management for a hip fracture following a fall from standing height were included. Three orthopaedic surgeons categorized fracture type using patient radiographs. Upon hospital admission, QUS t-scores and vitamin D levels were determined. Descriptive statistics, bivariate analyses and multivariable regression were performed. RESULTS: Accounting for potential confounders, patients with lower QUS t-scores were more likely to have intertrochanteric femur fractures than femoral neck fractures. In a bivariate analysis, there was no association between vitamin D level and either fracture type. There was no association between vitamin D level and bone mineral density. CONCLUSION: Patients with lower bone density that fracture their hips are more likely to fracture in the intertrochanteric region than the femoral neck, but vitamin D levels are unrelated. Awareness of this association emphasizes the importance of bone mineral density screening to assist with intertrochanteric hip fracture prevention. LEVEL OF EVIDENCE: III.

Protecting the PCL During Total Knee Arthroplasty Using a Bone Island Technique.

BACKGROUND: Prior studies have shown that the posterior cruciate ligament (PCL) may be partially resected during cruciate retaining (CR) total knee arthroplasty (TKA) using highly experienced hands and standard surgical technique; therefore, proper surgical technique is aimed at preservation and balance of the PCL during CR TKA. The central objective of this study is to evaluate the effectiveness of a simple surgical technique to prevent PCL damage during performance of a CR TKA. METHODS: Sixty embalmed cadaver specimens were randomized into 2 groups, experimental and control. The control group consisted of standard tibial resection without the use of an osteotome. The experimental group utilized an osteotome in addition to standard technique to preserve a bone island anterior to the tibial attachment of the PCL. RESULTS: In the control group, PCL damage was noted in 73% (22/30) of specimens. In the experimental group, where an osteotome was used, PCL damage was found in 23% (7/30) of specimens. The use of an osteotome was found to have an absolute risk reduction of 50% when compared to the control group which did not use an osteotome to protect the PCL. CONCLUSION: In the setting of minimal surgical experience, the use of an osteotome to preserve the PCL during CR TKA by forming a bone island was found to be an effective means of protecting the PCL over standard technique. In addition, standard technique with the use of a Y-shaped PCL retractor was found to provide questionable protection to the PCL.

Effect of Posterior Tibial Slope on Flexion and Anterior-Posterior Tibial Translation in Posterior Cruciate-Retaining Total Knee Arthroplasty.

Reduced posterior tibial slope (PTS) and posterior tibiofemoral translation (PTFT) in posterior cruciate-retaining (PCR) total knee arthroplasty (TKA) may result in suboptimal flexion. We evaluated the relationship between PTS, PTFT, and total knee flexion after PCR TKA in a cadaveric model. We performed a balanced PCR TKA using 9 transfemoral cadaver specimens and changed postoperative PTS in 1° increments. We measured maximal flexion and relative PTFT at maximal flexion. We determined significant changes in flexion and PTFT as a function of PTS. Findings showed an average increase in flexion of 2.3° and average PTFT increase of 1mm per degree of PTS increase when increasing PTS from 1° to 4° (P<.05). Small initial increases in PTS appear to significantly increase knee flexion and PTFT.

Shortening femoral osteotomy with stemmed resurfacing total knee arthroplasty for severe flexion contracture in Juvenile Rheumatoid Arthritis.

Juvenile Rheumatoid Arthritis (JRA) is a progressive disease characterized by pain, swelling, and loss of motion in the joints of adolescents. Total knee arthroplasty (TKA) can be indicated, during the adolescent years, in patients with advanced JRA to alleviate pain and improve function. Because of the relative infrequency of TKA in patients with JRA, evaluation of the type of TKA performed and the results merit review. This case report present two distinct operations performed to obtain full extension. 1. Distal femoral resection with conversion to hinged arthroplasty. 2. Femoral shortening osteotomy with resurfacing TKA.

Metastatic endometrial carcinoma invading bilateral total knee arthroplasties.

We present a case of a 64-year old female with bilateral knee pain several months after undergoing staged bilateral TKA. Radiolucencies surrounding the keels of bilateral tibial components were found to represent metastatic poorly differentiated endometrial carcinoma. PET scan showed adrenal, pulmonary and tibial foci consistent with metastatic disease. No other cases of bilateral periprosthetic metastasis of endometrial carcinoma have been described in the literature. Metastases around orthopedic implants are a rare occurrence. The possibility of periprosthetic metastasis should remain in the differential diagnosis for any patient with a painful total joint arthroplasty, especially in the setting of a patient with a known diagnosis of cancer elsewhere in their body.

Efficacy of skin preparation in eradicating organisms before total knee arthroplasty.

The solution of 2% chlorhexidine gluconate and 70% isopropyl alcohol (Chloraprep) is commonly used for antiseptic skin preparation before surgery. We conducted a study to evaluate the efficacy of this solution in eradicating organisms during skin preparation for total knee arthroplasty (TKA), to isolate the organism type, and to evaluate possible contributing factors leading to infection. Ninety-nine patients who were undergoing TKA were swabbed for cultures in the popliteal fossa before and after solution application. Swabs were collected, cultured, and read. Culture isolates grew in 20 (20%) of the 99 patients before solution application and in 5 (5%) of the 99 after application. Mean presolution body mass index (BMI) was 38 for patients with bacterial isolates and 34 for patients without isolates (P<.03). Mean postsolution BMI was 40 for patients with bacterial isolates and 35 for patients without isolates. BMI was a statistically significant factor in predicting presence of isolates after solution application. In addition, presence of bacteria in presolution cultures was predictive of isolation in postsolution cultures. Diabetic patients were 3.6 times more likely than nondiabetic patients to have a bacterial isolate. Other factors did not predict organism isolation. No patient developed a postoperative infection.

Quadriceps and patellar tendon pie-crusting as a treatment for limited flexion in total knee arthroplasty.

The pie-crusting method of ligament and tendon lengthening has been used successfully in various tissues but is not reported in the literature as an option for patellar or quadriceps tendons to address flexion limitation. Our case report discusses a patient with longstanding flexion limitation who underwent primary total knee arthroplasty. The report reviews the literature on intraoperative treatments, which primarily pertains to the condition of patella baja, and demonstrates that the pie-crusting technique should be included as a treatment option for a tight extensor mechanism while having some advantages over tibial tubercle osteotomy or Z-plasty.

Fixed versus rotating platform total knee arthroplasty: a prospective, randomized, single-blind study.

The purpose of this randomized, single-blind clinical trial was to compare a rotating platform (RP) total knee arthroplasty to a fixed-bearing (FB) total knee arthroplasty. Ninety-five knees in 69 patients were implanted by 2 surgeons. There were no significant differences in the preoperative demographics. At a minimum of 2-year follow-up, clinical outcomes and complication rates were similar, with the exception that the RP group had significantly better stair-climbing scores (P = .04). Postoperative range of motion was equally good in both groups (FB knees, 1°-125°; RP knees, 1-126°). There were no bearing dislocations in the RP group. In conclusion, this RP design performs at least as well as the FB version, and the RP patients reported better stair-climbing ability. Enthusiasm for this finding should be tempered by the relatively small sample size.

Pneumothorax following infraclavicular brachial plexus block for hand surgery.

The infraclavicular brachial plexus block is a routinely used anesthesia technique for orthopedic hand, wrist, and arm surgeries. Although the pulmonary anatomy surrounding the brachial plexus would suggest a theoretical potential for pneumothorax development during infraclavicular brachial plexus blockade, this complication is rarely reported in the literature. We report two occurrences of pneumothorax development following routine infraclavicular brachial plexus blockade performed by physicians at an academic training institution with technical experience. Both patients were healthy adult males with a normal body habitus undergoing elective upper extremity surgical intervention. They presented to the emergency department on postoperative days 1 and 2 with shortness of breath and chest pain. Despite different clinical management strategies for each patient, including conservative physical activity with inspirational spirometry compared to thoracic decompression, both patients' pneumothoraces resolved with no apparent sequelae. This article describes the clinical benefits of infraclavicular brachial plexus blockade versus general anesthesia during elective outpatient surgeries. The development of symptomatic pneumothoraces in 2 healthy adult patients stresses the importance of careful patient assessment pre- and postoperatively. Possible preventative strategies to avoid pneumothorax complications during infraclavicular brachial plexus blockade are discussed. This case report indicates there is a risk of iatrogenic injury during infraclavicular brachial plexus blockade. This information could be valuable in determining anesthesia modalities used for orthopedic upper extremity surgeries in patient populations with problematic follow-up or limited access to health care.