Treatment of an Ulnar Fracture Bone Defect Using Heterotopic Bone Autograft: A Case Report.

CASE: Autologous bone grafting has wide applications for the treatment of bony defects. Generally, cancellous or corticocancellous bone grafts are used depending on the characteristics and size of the bony defect and wound bed. The use of heterotopic bone as a potential source of bone graft has not been widely reported. We present a 56-year-old right-hand-dominant male victim of dog mauling who sustained a right ulnar fracture with a 5-cm bony defect, treated with the use of heterotopic bone autograft. CONCLUSION: Heterotopic bone can be successfully used as an autograft in the treatment of bony defects.

Comparison of complication rates between hemiarthroplasty and total hip arthroplasty for intracapsular hip fractures.

Hip fractures are common and have come to represent an increasing burden of disease. As a result, it is critical that cost-effective and evidence-based treatments be used to treat hip fractures. However, with regard to hemiarthroplasty vs total hip arthroplasty (THA), the optimal treatment of displaced femoral neck fractures in elderly patients remains controversial. The purpose of this study was to compare complication rates after hemiarthroplasty and THA for intracapsular hip fractures.Data on hospitalizations from 1995 through 2005 were obtained from California's Office of Statewide Health Planning and Development. Regression analyses were used to compare rates of short-term complications and mid-term revision surgeries following hemiarthroplasty and THA. The data identified 2437 patients undergoing THA and 38,328 undergoing hemiarthroplasty. At 90 days postoperatively, patients undergoing THA had no statistically significant increase in short-term complication risk compared with patients undergoing hemiarthroplasty (odds ratio, 0.89; P=.06). Cox regression analysis demonstrated no statistically significant difference in risk of revision surgery during the 11-year observation period.This study demonstrates similar short-term complication and mid-term revision risks following hemiarthroplasty and THA. This suggests that both procedures are safe alternatives, but further study is needed to clarify differences in functional outcomes and long-term revision rates for patients undergoing these procedures following a hip fracture.

Complication rates following operative treatment of calcaneus fractures.

BACKGROUND: The purpose of this study is to report the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures. METHODS: This is a retrospective study of Californians undergoing operative treatment of a calaneus fracture from 1995 to 2005. The main outcomes reported are readmission for a short-term complication within 90 days of surgery and reoperation for subtalar fusion during the observation period. RESULTS: We identified 4481 patients who underwent open reduction and internal fixation of their fracture as inpatients within 30 days of the index admission. The short-term rate of complications included a 90-day rate of readmission of 1.03% for wound infection, 0.25% for thromboembolic disease, and 0.22% for mortality. The mid-term rate of subtalar fusion was 3.49% at 5 years post-operatively. CONCLUSIONS: This study reports the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures using population-based data.

Disparities in the utilization of high-volume hospitals for total hip replacement.

OBJECTIVE: Higher hospital surgical volumes have been associated with lower complication rates following total-hip replacement. The objective of this study was to identify the characteristics of patients who undergo total-hip replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals. METHODS: Discharge data from patients undergoing total hip replacement in California from 1995 to 2005 were analyzed. Hospitals were classified into 3 tiers of low, intermediate, or high surgical volume. The relationships between race/ethnicity and income to utilization of low-volume and high-volume hospitals were examined by creating logistic regression models that include patient covariates such as age, gender, and comorbidity. RESULTS: This study analyzed 138399 cases of primary total-hip replacements during the study period. Patients of Hispanic ethnicity, or black or Asian race had higher relative risk ratios for being treated at a low-volume center compared to white patients. CONCLUSIONS: There are disparities in the characteristics of patients receiving care at hospitals performing a high volume or low volume of total-hip replacements. Hispanic ethnicity, and black and Asian race were statistically significant predictors of utilization of a low-volume hospital.

Factors predicting complication rates after primary shoulder arthroplasty.

HYPOTHESIS: Shoulder arthroplasty is an effective treatment for arthritic conditions and intraarticular fractures of the proximal humerus. Treatment options include total and hemiarthroplasty of the shoulder. They hypothesis of this study was that a mandatory statewide discharge database could identify the epidemiology of primary shoulder arthroplasty, 90 day complication rates, implant survival rates, and patient and hospital characteristics associated with complications. MATERIALS AND METHODS: We identified patients undergoing primary total shoulder replacement and hemiarthroplasty between 1995 and 2005. We report rates of complications within 90 days of surgery and performed survival analysis using revision surgery as the endpoint. Logistic and proportional hazard regression models were used to estimate the effect of patient and provider factors in predicting the rates of adverse outcomes. RESULTS: During the study period, 15,288 patients underwent shoulder arthroplasty. Patients undergoing total shoulder arthroplasty and hemiarthroplasty had no statistically significant difference in the aggregate risk of 90-day complications or the risk of implant failure within the study period. Fracture patients were shown to have a higher risk of short-term complications (odds ratio, 3.2; P < .001). Implant failure rates were lower in patients with fracture, rheumatoid arthritis, increased comorbidity, and advanced age. CONCLUSION: This study reports similar rates of short-term complications and implant failure in patients undergoing total or hemiarthroplasty, an overall mortality rate of 1.3%, and a pulmonary embolism rate of 0.6%. The findings of our study indicate that the risk of short-term complications is highest in patients undergoing total or hemiarthroplasty for a fracture compared with nonfracture indications. Our results also indicate that longer-term, implant survival is largely driven by factors associated with increased activity, such as age. In patients undergoing surgery for arthritis of the shoulder, we found no difference in implant survival rates between total and hemiarthroplasty of the shoulder.

Complication and revision rates following total elbow arthroplasty.

PURPOSE: To determine the complication rates after total elbow arthroplasty (TEA) in a large and diverse patient population. METHODS: We identified patients undergoing TEA as inpatients in the years 1995 to 2005 using California's Discharge Database. Short-term outcomes of interest included rates of infection or wound complications, revision, reoperation, and pulmonary embolism that were diagnosed during an inpatient hospital admission and mortality within 90 days of index surgery. Longer-term outcomes analyzed included rates of revision, amputation, and conversion to fusion. We used regression models to estimate the role of patient and provider characteristics in predicting the rates of adverse outcomes. RESULTS: We identified 1,625 patients undergoing TEA. Early complications, defined as those requiring inpatient re-admission within the first 90 days after index surgery, were identified in 170 patients, and 132 patients required reoperation. Eighty one patients required revision in 90 days, and 48 underwent revision within one year. Early infections and wound complications requiring readmission occurred in 88 patients. In the 90 days after surgery, 4 patients had a pulmonary embolism and 10 patients died. One-hundred and twenty-one patients required revision, amputation, or fusion during the observation period, with a mean follow-up of 4 years. Hospital volume was not associated with increased risk of adverse outcomes. CONCLUSIONS: We analyzed a large and diverse patient population undergoing TEA. The overall rate of short-term complications requiring inpatient treatment was high, at over 10% (170 patients), with almost 8% (132 patients) requiring reoperation within the first 90 days. Although population-based studies have shortcomings, they can add to the body of knowledge of less frequent procedures such as TEA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Incidence of pulmonary embolism following surgical treatment of metatarsal fractures.

BACKGROUND: The purpose of this study was to identify the rates of readmission to the hospital for pulmonary embolism following open reduction and internal fixation of metatarsal fractures using observational, population-based data from all inpatient admissions in California over an 11-year period. MATERIALS AND METHODS: We identified patients undergoing open reduction and internal fixation of a metatarsal fracture in the years 1995 to 2005 as inpatients using California's discharge database. The outcomes analyzed included readmission within 90 days of surgery for pulmonary embolism. Logistic regression models were used to estimate the impact of patient factors such as age, race/ethnicity and gender in predicting the rates of thromboembolic disease. RESULTS: A total of 1,477 metatarsal ORIF procedures were performed as inpatients during the study period. We identified four patients (0.27%) readmitted with pulmonary embolism within 90 days of their initial ORIF procedure. There were three (0.20%) cases of mortality, none of which occurred in the four patients readmitted with pulmonary embolism. Given the low incidence, we did not identify age, gender, or race/ethnicity as statistically significant predictors of a higher risk of thromboembolic disease. CONCLUSION: The rate of readmission for pulmonary embolism was low. This suggests that the routine use of thromboprophylaxis may not be necessary for isolated metatarsal fractures to prevent pulmonary embolism.

Factors that predict short-term complication rates after total hip arthroplasty.

BACKGROUND: There remains uncertainty regarding the relative importance of patient factors such as comorbidity and provider factors such as hospital volume in predicting complication rates after total hip arthroplasty (THA). PURPOSE: We therefore identified patient and provider factors predicting complications after THA. METHODS: We reviewed discharge data from 138,399 patients undergoing primary THA in California from 1995 to 2005. The rate of complications during the first 90 days postoperatively (mortality, infection, dislocation, revision, perioperative fracture, neurologic injury, and thromboembolic disease) was regressed against a variety of independent variables, including patient factors (age, gender, race/ethnicity, income, Charlson comorbidity score) and provider variables (hospital volume, teaching status, rural location). RESULTS: Compared with patients treated at high-volume hospitals (above the 20th percentile), patients treated at low-volume hospitals (below the 60th percentile) had a higher aggregate risk of having short-term complications (odds ratio, 2.00). A variety of patient factors also had associations with an increased risk of complications: increased Charlson comorbidity score, diabetes, rheumatoid arthritis, advanced age, male gender, and black race. Hispanic and Asian patients had lower risks of complications. CONCLUSIONS: Patient and provider characteristics affected the risk of a short-term complication after THA. These results may be useful for educating patients and anticipating perioperative risks of THA in different patient populations. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures.

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children's elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann's angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann's angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

Perioperative quality-of-care measures for patients undergoing total hip or total knee replacement.

Recent years have seen the proliferation of numerous standards of quality for the process of providing health care, including total joint replacement. These attempts include the implementation of pay-for-reporting and pay-for-performance programs based on quality measures. These programs have often been implemented with few studies of the validity of the quality measures used and with limited input from the orthopedic community. Our project addresses this relative lack of evidence-based measures by developing a set of quality measures that address the perioperative care of patients undergoing total joint replacement. Our goal is to create a model for improving the quality of care and outcomes of total joint replacement in the United States by facilitating physicians in their efforts to apply the best scientific evidence to their daily practice.

The effects of GDF-5 and uniaxial strain on mesenchymal stem cells in 3-D culture.

Recent endeavors in tissue engineering have attempted to identify the optimal parameters to create an artificial ligament. Both mechanical and biochemical stimulation have been used by others to independently modulate growth and differentiation, although few studies have explored their interactions. We applied previously described fabrication techniques to create a highly porous (90%-95% porosity, 212-300 microm), 3-D, bioabsorbable polymer scaffold (polycaprolactone). Scaffolds were coated with bovine collagen, and growth and differentiation factor 5 (GDF-5) was added to half of the scaffolds. Scaffolds were seeded with mesenchymal stem cells and cultured in a custom bioreactor under static or cyclic strain (10% strain, 0.33 Hz) conditions. After 48 hours, both mechanical stimulation and GDF-5 increased mRNA production of collagen I, II, and scleraxis compared to control; tenascin C production was not increased. Combining stimuli did not change gene expression; however, cellular metabolism was 1.7 times higher in scaffolds treated with both stimuli. We successfully grew a line of mesenchymal stem cells in 3-D culture, and our initial data indicate mechanical stimulation and GDF-5 influenced cellular activity and mRNA production; we did not, however, observe additive synergism with the mechanical and biological stimuli.

Body mass index and Blount disease.

As the increasing prevalence of overweight and obese children is approaching epidemic proportions in North America, this study was designed to investigate whether Body Mass Index (BMI) and age- and gender-specific percentile Body Mass Index (BMI %) are associated with the likelihood of being listed for surgery for Blount disease after initial presentation to a tertiary referral centre. In a restrospective consecutive sample of 102 children with an average age of 5.9 +/- 4.3 years, it was determined that there was a significant association between BMI and BMI% and being listed for surgery, after adjusting for the effects of the child's age and gender, with mean odds ratios of 1.30 (95% confidence interval 1.02-1.60) and 1.05 (95% confidence interval 1.01-1.09) respectively. When the sample was subgrouped into infantile (less than 3 years of age) and late-onset (greater than 3 years of age), BMI and BMI% were still significantly associated with the children being listed for surgery in the late-onset group with mean odds ratios 2.75 (95% confidence interval 1.03-7.33) and 1.09 (95% confidence interval 1.01-1.18) respectively. However, of the two measures only the BMI was significant in the infantile group with an odds ratio of 1.27 (95% confidence interval 1.01-1.60). Should these associations be real then measures aimed at decreasing weight in children may have some effect on the number of children undergoing surgery for the treatment of Blount disease.

Anterior cruciate ligament radiofrequency thermal shrinkage: a short-term follow-up.

PURPOSE: To review the results of 34 patients who underwent radiofrequency thermal shrinkage (RFTS) for treatment of anterior cruciate ligament (ACL) laxity in the attenuated and partially torn ACL. TYPE OF STUDY: Retrospective cross-sectional survey performed at least 6 months after treatment. METHODS: Patients with recurrent instability after attenuation of ACL autografts and partially torn ACLs were treated with RFTS. Follow-up included subjective questionnaires (International Knee Documentation Committee [IKDC], Tegner, and Lysholm) and objective clinical tests (IKDC, KT-1000, pivot-shift, Lachman, single-leg hop). RESULTS: Mean follow-up was 21.4 months. Based on IKDC and subjective evaluation, 18 of 20 (90%) partially torn ACLs and 10 of 14 reconstructed ACLs (71%) treated with RTFS were judged to have good or excellent knee function (overall 82%). ACL laxity based on KT-1000 was less successful, with 15 of 20 (75%) partially torn ACLs and 8 of 12 (66%) reconstructed ACLs considered successful. CONCLUSIONS: With no major complications in this study, we conclude that RFTS for treatment of ACL laxity is a well-tolerated procedure with success rates around 71% to 90% in selected patients. RFTS may be offered as a less-extensive alternative to patients being considered for ACL reconstruction who have either attenuated or partially torn ligaments, especially in the athletically low-demand population. LEVEL OF EVIDENCE: Level IV, case series.

Meniscal repair devices: a clinical and biomechanical literature review.

PURPOSE: The development of new approaches to arthroscopic meniscal repair has spurred the concomitant publication of studies reviewing their use and biomechanical properties. The purpose of this article is to review both the devices and the literature surrounding their clinical and biomechanical properties. TYPE OF STUDY: Literature review. METHODS: Studies were initially gathered using a MEDLINE search, and additional information was found through cross references. We evaluate a series of studies comparing sutures, suture anchors, screws, staples, and a variety of other devices in terms of initial fixation strength, degradation profile, performance under cyclical loading, and clinical success. RESULTS: In the traditional suture studies, vertical sutures are clearly superior to both horizontal sutures and knot-end techniques in terms of initial fixation strength and performance under cyclical loading. Unfortunately, multidevice studies have been less consistent and less conclusive. the Linvatec Biostinger, Smith & Nephew T-fix, and Bionx Meniscus Arrow have separately been shown to have superior initial fixation strength on par with suture techniques. After cyclical loading, horizontal sutures, vertical sutures, 16-mm Arrows, 13-mm Arrows, and the Smith & Nephew T-fix generally show higher fixation strengths. Only the Bionx Arrow, Linvatec Biostinger, and Clearfix Screw have been shown to retain their initial fixation strengths through four months of hydrolysis time. CONCLUSIONS: Data suggest that the biomechanical performance of some devices is nearly equivalent to current suture techniques. Ultimately, the combination of a simplified surgical technique, high clinical healing rates (75%-92%), and relatively minor complications makes these devices attractive for properly indicated meniscal tears.