Comparing internal and external stabilization for traumatic elbow instability: a systematic review.

Background: Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods: A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results: The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion: The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.

Local Soft-Tissue Thickness vs. Body Mass Index as Predictors of Complications After Total Knee or Hip Arthroplasty: A Literature Review.

¼ Body mass index (BMI) is a nonspecific measure of general fat composition that demonstrates little conclusive or definitive association with surgical site complications after total knee and total hip arthroplasty.¼ Quantifying soft-tissue thickness (STT) around the joint of interest has shown positive correlations with complications and is arguably a better predictor than BMI.¼ In this literature review, 14 articles (7 discussing hips and 7 discussing knees) discussing the association of STT, BMI, and surgical site complications after total hip and knee arthroplasty were scrutinized and summarized to present relevant information necessary to compare STT with BMI.¼ Five of the 7 studies involving hips and 4 of the 7 studies involving knees show a positive relationship between STT and outcomes including complications and infection, with some claiming STT as a stronger predictor of surgery site problems than BMI.¼ Since many variables, such as STT measurement technique, surgical outcomes, sample sizes, and surgical approach, varied between the studies, definitive inferences are difficult to make and future studies of bigger sample size and higher power should focus on the described measurement techniques.

Avascular Necrosis as a Sequela of COVID-19: A Case Series.

Avascular necrosis (AVN) is a degenerative bone condition characterized by cellular death and bone collapse from compromised subchondral blood circulation. AVN begins with vascular interruption, hypertension, intravascular occlusion, or extravascular compression which reduces bone circulation. Although corticosteroids are frequently used to treat acute COVID-19 infections, patients are prone to its side effects, particularly AVN. Furthermore, COVID-19 produces coagulopathies, specifically hypercoagulability, that may contribute to venous thrombosis, which may serve as the impetus of AVN. While the literature discussing COVID-19, AVN, and corticosteroid use is not conclusive, patients being treated with corticosteroids for COVID-19 are at an increased risk for AVN possibly due to the combination of COVID-19 infection and corticosteroid use, or the use of high-dose steroids alone. The purpose of this case series is to elucidate AVN as a long-term sequalae of COVID-19, describe our management of COVID-19 and steroid-induced AVN, and discuss the current literature regarding AVN and COVID-19. Three patients hospitalized for COVID-19 infections were treated with corticosteroids and subsequently developed AVN. All patients, but one, had multiple sites of infarction and were treated with core decompression in the hip where there was no collapse of the subchondral bone. One of these patients had multiple infarcts in bilateral femoral heads, femoral shafts, and knees. This patient had a history of end-stage renal disease, and, therefore, total knee replacement was postponed until medical clearance. Core decompression was performed on the femoral head that showed no collapse to delay osteoarthritis of the hip. Multiple articles in the current literature support the idea that the combination of COVID-19 and corticosteroid use increases the risk of AVN and reduces the onset of COVID-19-related respiratory symptoms. The patient cases discussed in this case series suggest a possible association between COVID-19, corticosteroid use, and AVN.

The Treatment of Heterotopic Ossification With a Dual Mobility Total Hip Replacement System: A Case Report.

Heterotopic ossification (HO) is the formation of bone within extraskeletal soft tissue. The development of mature lamellar bone within soft tissues can be acquired in cases like trauma. Clinical manifestations of HO primarily include pain at the site of the extraskeletal ossification and limited range of motion or function when it involves a joint. This case report presents a 56-year-old man with severe HO. His past medical history included a traumatic hip dislocation in 1996. He denied any other past medical, family, or surgical history. This patient had severely limited range of motion and difficulty performing activities of daily living like going up and down the stairs and getting up from a seated position. After failing conservative therapy with non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy, a non-cemented dual mobility hip replacement system was used to treat this patient. A non-cemented dual mobility hip replacement system was chosen because the patient had significant bone loss and was relatively young. The dual mobility system significantly reduces the risk of dislocation and is a good option for younger patients who require more stability in their hips. The patient progressed well with a full range of motion and no pain. There was no evidence of HO recurrence. Treatment of HO with a total hip replacement, let alone a dual mobility system, is not prevalent throughout the literature. Furthermore, cemented total hip arthroplasty has been associated with increased recurrence of HO, which is why we elected to use a non-cemented technique. Osteoplasty is typically the mainstay of treatment for HO. The purpose of this case report is to introduce an incident of HO treated with a non-cemented dual mobility system and emphasize its use in young, middle-aged, or active patients who have bone loss and require increased stability.

Chronic Posterior Tibiofemoral Dislocation of a Cruciate Retaining Total Knee Arthroplasty in the Setting of Wernicke-Korsakoff Syndrome: A Case Report.

Introduction: Knee dislocations are an uncommon complication following total knee arthroplasty (TKA). There are many causes of TKA dislocation; however, Wernicke-Korsakoff syndrome is one uncommon neurologic condition that increases the risk of TKA dislocation. Case Report: A 71-year-old male with presented to a local community hospital with knee pain due to advanced osteoarthritis of the knee and subsequently underwent an uncomplicated TKA with a cruciate retaining prosthesis. He eventually returned to the hospital due to infection, medical instability, chronic knee instability, and posterior tibiofemoral dislocation. A revision process was required. Throughout the course of management, the patient had altered mental status and was admitted to the intensive care unit. The first procedure involved removing the cruciate retaining prosthesis and replacing it with a static cement antibiotic spacer. This prosthesis was eventually dislocated through the tibia and a second procedure requiring the placement of an intercalary fusion was needed. The patient has not followed up after the hospital admission. Conclusion: Wernicke-Korsakoff Syndrome is an uncommon condition that affects alcoholics and complicates treatment with joint replacement surgery. Patients with Wernicke-Korsakoff syndrome provide a unique set of challenges that may require multiple surgeries and varying prostheses. Chronic posterior tibiofemoral dislocation is one specific complication that may affect the management of these patients. As orthopedic surgeons, it is important to consider alcohol use disorder and Wernicke-Korsakoff Syndrome when treating patients with total joint replacement.