Relatively High Complication and Revision Rates of the Mayo® Metaphysical Conservative Femoral Stem in Young Patients.

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18-64 years), and the mean follow-up was 97 months (range, 26.9-166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [Orthopedics. 2018; 41(4):e516-e522.].

New approach for the rehabilitation of patients following total knee arthroplasty.

PURPOSE: To investigate the effect of a biomechanical therapy on gait, function and clinical condition in patients following total knee arthroplasty (TKA). METHODS: Seventeen TKA patients participated in the study. Patients received a biomechanical therapy AposTherapy). Patients underwent a gait test, clinical examination and an assessment of pain, function and quality of life (QOL). Patients were examined again at one, three and six month follow-ups. RESULTS: A significant improvement over time was found in most gait measurements. Significant improvements were also found in pain, function and QOL. CONCLUSIONS: The examined biomechanical therapy may help in the rehabilitation process following TKA.

Clinical and radiographic outcomes of 139 hips with articular surface replacement total hip arthroplasty*.

BACKGROUND: The articular surface replacement (ASR) total hip arthroplasty (THA) was recently recalled from the market due to high failure rates. This modality was used frequently by surgeons at our medical center. OBJECTIVES: To assess the clinical and radiographic outcomes in patients following the surgery and determine the revision rate in our cohort. METHODS: Between 2007 and 2010 139 hips were operated on and evaluated in our clinic. All patients underwent a clinical interview, function and pain evaluation, as well as physical examination and radiographic evaluation. When necessary, patients were sent for further tests, such as measuring cobalt-chromium levels and magnetic resonance hip imaging. RESULTS: With an average follow-up of 42 months the revision rate was 2% (3/139). Patients reported alleviation of pain (from 8.8 to 1.7 on the Visual Analog Scale, P < 0.001), good functional outcomes on the Harris Hip Score, and improved quality of life. Overall satisfaction was 7.86 on the reversed VAS. For patients who required further tests, clinical and radiographic outcomes were significantly poorer than for the rest of the cohort. Average blood ion levels were high above the normal (cobalt 31.39 ppb, chromium 13.32 ppb), and the rate of inflammatory collection compatible with pseudotumors on MRI was 57%. DISCUSSION: While our study favors the use of the ASR implant both clinically and radiographically, some patients with abnormal ion levels and inflammatory collections on MRI might require revision in the future.

Early results of retrograde expandable nail fixation of 29 distal femoral fractures.

The authors retrospectively reviewed 27 consecutive patients with 29 fractures of the distal femur treated with the new retrograde expandable nail. One 10-mm diameter nail that expands to 16 mm was used with the possibility of locking in the condylar area only. Retrieved data included single versus multiple injuries, fracture type, operation time, reaming or nonreaming, hospitalization and healing times, and intra- and postoperative complications. The overall average operation time was 96 (range 40-320) minutes, but only 65 (range 40-120) minutes for isolated fractures. The overall mean hospitalization time was 16 (range 3-40) days, but only 7 (range 4-10) days for isolated fractures. Follow-up continued until fracture healing or for a minimum of 1 year (average 14 months, range 12-24 months). The average clinical union time was 83 (range 43-179) days, and the mean radiographic healing was 87 (range 43-179) days. One patient developed a nonunion that required exchange of the nail to the same device. Another patient underwent hardware removal during a procedure for a torn meniscus. These preliminary results demonstrate satisfactory healing and alignment for the treatment of distal femoral shaft fractures by means of this new device without jeopardizing the knee joint by nail protrusion.

Preoperative planning of total hip replacement using the TraumaCad™ system.

INTRODUCTION: Templating is now the standard approach for preoperative planning of total joint replacement and fracture fixation. The aim of this study was to assess the accuracy of new software, TraumaCad™, for preoperative planning for total hip replacement. METHODS: This software enables the import and export of all picture archiving communication system (PACS) files from local working stations. It can integrate with all PACS systems. We retrospectively reviewed TraumaCad™-generated templates of digitalized preoperative radiographs of 73 consecutive patients. RESULTS: The acetabular component, measured within ± 1 size, was accurate in 65 patients (89%), and the femoral stem design component was accurate in 70 patients (97%). The accuracy of the femoral size was predicted in 57 patients within 1 size (87%) and in 65 patients within 2 sizes (96%) out of 68 patients in the Corail femoral component group. TraumaCad™ successfully predicts the sizes of femoral and acetabular component and easily integrates with all PACS files.

Digital versus conventional templating techniques in preoperative planning for total hip arthroplasty.

BACKGROUND: The purpose of our investigation was to compare a digital templating system to conventional templating techniques when preoperatively planning for total hip arthroplasty. METHODS: We included 18 consecutive patients with primary osteoarthritis undergoing uncemented total hip arthroplasty in our study. At separate sittings, we independently conducted preoperative templating. They performed the templating using hard-copy radiographic films and traditional hard-copy prosthetic overlays on a radiograph view box. They then repeated templating using a digital technique at a computer workstation with specially developed software. We used kappa statistical analysis to evaluate intra-and interobserver variability of both techniques. We also examined correlation of template measurements with final component selection. RESULTS: Intra-and interobserver variability was satisfactory for both templating techniques. There was no significant difference in the performance of the 2 techniques in predicting final component selection during surgery. CONCLUSION: Digital preoperative templating is as reliable as conventional templating techniques.

Tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes.

The purpose of this study was to describe the surgical technique, and evaluate and analyze the clinical outcomes of patients who underwent tibial tubercle realignment in our institution. Reported results of tibial tubercle transfer for patellofemoral malalignment vary considerably. Most authors rely mainly on the passive intraoperative patellar tracking test in determining the new location of the tibial tubercle. Conversely, the senior author relocates the tibial tubercle based on the intraoperative active and passive patellar tracking tests and the condition of the patellar articular surface. The medical records of 66 consecutive patients who underwent 80 tibial tubercle relocation procedures due to patellar instability or patellofemoral pain and maltracking were reviewed. Fifty-five patients with 69 operated knees participated in designated follow-ups which were conducted according to a predesigned protocol. The median follow-up was 6.2 years (range 2-13 years). Clinical outcomes significantly improved compared to the preoperative state; 72.5% of operated knees demonstrated good-to-excellent results according to the Lysholm and Karlsson scores, and physical findings supported the positive effect of the procedure. A statistically significant positive correlation was found between clinical outcomes and male gender, the absence of moderate to severe patellar chondral damage, and instability as the dominant preoperative symptom. Postoperative complication rate was low and patients with longer postoperative follow-ups demonstrated better clinical outcomes. The presented method of tibial tubercle transfer provided a good long-lasting surgical solution for patients with patellar instability and patients with patellar maltracking and anterior knee pain. Good prognostic factors included male gender, clinical patellar instability as the dominant preoperative symptom and intact patellar articular cartilage.

The femoral head expandable peg: improved periimplant bone properties following expansion in a cadaveric model.

PURPOSE: The femoral head expandable peg offers a new concept of bone-device purchase treating proximal femur fractures. We describe the expansion influence on both the periimplant bone properties and the intraosseous pressure. METHODS: A 10 x 8 mm cannulated peg consisting of a stainless steel oval-shaped transversely sectioned rod was tested on 13 femoral heads retrieved from patients with subcapital fracture treated by hemiarthroplasty. Normal saline solution was used to expand the diameter of its membrane from 7.8 to 10.5 mm, resulting in abutment of the distal peg to the compacted cancellous bone of the femoral head. The intraosseous pressure was monitored using a 1.4 mm drill-hole. RESULTS: Dual-energy X-ray absorptiometry and microradiography demonstrated increased periimplant bone density following peg expansion, without significant increase in the intraosseous pressure. CONCLUSION: The new implant afforded improved periimplant bone density, less trabecular damage and preservation of bone stock, all contributing to reliable biomechanical support and potentially decreasing the high complication rate following screw fixation in osteoporotic femora. Further studies are needed in order to establish clinical safety and efficacy.

Intramedullary fixation of tibial shaft fractures using an expandable nail: early results of 54 acute tibial shaft fractures.

OBJECTIVE: To evaluate and present our experience using the expandable nail system for the treatment of acute tibial shaft fractures. DESIGN: Retrospective study. SETTING: Two level-1 trauma centers-University teaching hospitals. METHODS: Fifty-four consecutive patients were treated by this nail system for acute tibial shaft fracture. Two nail diameters were used, 8.5 mm and 10 mm. Operation, hospitalization and healing times, reaming versus nonreaming, isolated versus multiple injuries, and reoperations were recorded and analyzed statistically. RESULTS: Follow-up was obtained either until fracture healing or for a minimum of 1 year with an average of 14 months (12 to 24). All fractures healed in an average time of 72 days (21 to 204). The average healing times for patients treated with 8.5-mm and 10-mm nails were 77.2 days (27 to 204) and 63.4 days (21 to 121), respectively. Average operative time was 103 minutes (40 to 185) if reamed and 56 minutes (30 to 80) if unreamed. Average healing times were 65.4 days (21 to 190) if reamed and 79.5 days (42 to 204) if unreamed. There were 11 complications (20.4%) related to the nailing: 3 deep infections, 2 superficial infections, 2 bone shortenings of 1 cm secondary to nail protrusion in the knee, 1 compartment syndrome, 1 fracture propagation, 1 distal malalignment, and 1 delayed union. Hardware was removed in 6 patients (3 infections, 2 patients' request and 1 protrusion into the knee), and 1 additional patient underwent exchange nailing due to a delayed union. CONCLUSIONS: The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. This study demonstrates satisfactory healing and alignment for the treatment of tibial shaft fractures using this device. However, caution must be exercised when using this nail in cases of significant comminution and in cases where the fracture pattern involves the more proximal or distal aspect of the tibial shaft.

Total knee replacement in previous recipients of fresh osteochondral allograft transplants.

BACKGROUND: Fresh osteochondral allograft transplantation is a treatment option for young patients with osteochondral lesions of the knee. The present study evaluated the surgical complexity of, and the prevalence of complications related to, total knee arthroplasty in patients who had had a previous osteochondral graft transplantation. METHODS: A retrospective analysis was performed on thirty-three consecutive patients (thirty-five knees) who underwent total knee arthroplasty from 1974 to 2000 after having had a previous transplantation of a fresh osteochondral allograft into the same knee. The mean duration of follow-up was ninety-two months. Perioperative data were analyzed with regard to etiology, preoperative impairment, intraoperative technical complications, early and late postoperative complications, and postoperative functional and subjective outcomes. The Knee Society clinical rating system was used for clinical evaluation beginning in 1990. RESULTS: Four knees required additional techniques for exposure. Three knees required stemmed components, one knee required a tibial augment, and two knees required morselized grafts. The mean Knee Society objective score (available for eighteen knees) improved from 34.7 preoperatively to 87.9 at the time of the latest follow-up, and the mean Knee Society function score improved from 45 to 82. The mean range of motion of all knees improved from 85 degrees to 105 degrees . Six of the thirty-five knees underwent revision total knee arthroplasty because of aseptic loosening, with two knees being revised within two years after the index total knee arthroplasty. CONCLUSIONS: Total knee arthroplasty after previous fresh osteochondral allograft transplantation provides improvements in knee function and range of motion, with manageable technical difficulties. Compared with routine total knee arthroplasty, an increased rate of early revision can be expected.

Long-term followup of the use of fresh osteochondral allografts for posttraumatic knee defects.

UNLABELLED: Posttraumatic osteochondral defects of the distal femur or proximal tibia pose a reconstructive challenge for the young active patient. Fresh osteochondral allografts have been used to reconstruct these defects and this report deals with the long-term clinical and radiographic follow-up in this patient population. This is a prospective nonrandomized study. Sixty patients with an average followup of 10 years received femoral condylar grafts. Twelve grafts failed, requiring removing of the graft in three patients and conversion to total knee replacement in nine patients. Kaplan-Meier survivorship showed 95% graft survival at 5 years and 85% at 10 years. Sixty-five patients received fresh osteochondral allografts to reconstruct the tibial plateau with an average followup of 11.8 years. In this group of patients, conversion to total knee arthroplasty was done in 21 patients at a mean interval of 9.7 years. Survival analysis revealed 95% survival at 5 years, 80% at 10 years, and 65% at 15 years. Through our long-term prospective study, we confirm the value of fresh osteochondral allografts to reconstruct articular defects of the knee in the young active patient. LEVEL OF EVIDENCE: Therapeutic study, Level II-1 (prospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Complications of ilioischial reconstruction rings in revision total hip arthroplasty.

The complications, management, and outcome of a consecutive series of 61 ilioischial reconstruction rings performed by 1 surgeon over a 15-year period are reported. Structural corticocancellous allografts were used in 48 cases. Twenty-seven cases had no complications, 9 had medical complications, and 5 had complications related to femoral revision. Other complications included 4 sciatic and 2 peroneal nerve palsies, 4 rings that lost fixation, 1 possibly loose ring, 3 fractured flanges, 3 loose cups, 7 dislocations, and 3 deep infections. Success, defined as a stable reconstruction with no further acetabular revision and bone graft incorporation, was 76%. We recommend a constrained acetabular liner to avoid dislocation in selected cases, slotting the ischial flange into bone for further ring stability and protection of the sciatic nerve.

Long-term follow-up of fresh tibial osteochondral allografts for failed tibial plateau fractures.

BACKGROUND: The management of large posttraumatic full-thickness osteochondral defects in the proximal part of the tibia remains a challenge. The goal of treatment is a pain-free range of motion of the knee that provides enduring function and enables a young patient to participate in a wide range of activities. The use of fresh osteochondral allograft transplantation for tibial plateau lesions has been well documented. The purpose of the present study was to assess the survivorship and the long-term functional outcome following fresh osteochondral transplantation for unipolar posttraumatic tibial plateau defects in young, high-demand patients. METHODS: A cohort study was carried out to assess outcome in patients who had undergone fresh tibial osteochondral grafting for the treatment of a posttraumatic defect that measured at least 3 cm in diameter and 1 cm in depth. Sixty-five (97%) of sixty-seven patients were identified and were evaluated clinically and radiographically. A modified Hospital for Special Surgery (HSS) score was calculated for each patient. Radiographic examination was directed toward the identification of graft union, resorption, or collapse. Degeneration of the joint and alignment of the limb (on standing radiographs) was assessed. The end points that defined survivorship were an HSS score of <70 points, a patient's decision to undergo knee arthroplasty, or revision of the graft for any reason. RESULTS: At a mean of twelve years, forty-four patients had an intact graft and twenty-one had had conversion to a total knee arthroplasty. The mean modified HSS Score for the patients with an intact graft was 85 points. Radiographs, reviewed for thirty-five of the forty-four patients with an intact graft, revealed union of the graft to host bone in all cases and an 8.6% prevalence of graft collapse in excess of 3 mm. Forty percent of these thirty-five patients demonstrated moderate to severe degenerative changes. Kaplan-Meier survivorship analysis showed that the survival rate was 95% at five years, 80% at ten years, 65% at fifteen years, and 46% at twenty years. A trend toward increased survivorship (p = 0.08) was seen among patients who had undergone meniscal transplantation in conjunction with osteochondral grafting. CONCLUSIONS: Fresh osteochondral allografts for large traumatic defects of the tibial plateau have provided a long-lasting and reliable reconstructive solution for a high-demand population. Meniscal allografts should be used when clinically warranted. In the present study, all grafts were protected with a coincident realignment osteotomy when preoperative radiographs suggested that the allograft would be placed under increased load. Conversion to knee arthroplasty was required for approximately one-third of the patients at an average of ten years.

Long-term clinical experience with fresh osteochondral allografts for articular knee defects in high demand patients.

Fresh osteochondral allografts are used to repair osteoarticular defects of the knee. For post-traumatic defects recent advances in other techniques for cartilage repair and resurfacing have reduced the role of allograft tissue transplantation to defects larger than 3 cm in diameter and 1 cm in depth.A fresh osteochondral allograft that has been harvested from a donor within 24 h from death and preserved in 4 degrees C for up to 4 days shows 100% viability of the cartilage. The avascular bone remains structurally intact and mechanically strong until it is replaced by host bone or until it is weakened or absorbed. The indications for fresh osteochondral allografts for reconstructive surgery of the articular surface of the knee do not justify the use of immunosuppressive drugs and we therefore believe that surgical vascularization of the grafts should not be carried out.This clinical approach can provide a reconstructive solution for younger higher demand patients where implants are not desirable and arthrodesis is not acceptable. A clinical follow-up study as early as 1975 showed successful early outcomes. More recently, survival analysis found 95% survival at 5 years, 71% at 10 years, and 66% at 20 years. It was learned that older patients, bipolar transplants, improper loading of the graft, and grafts for osteoarthritis and steroid-induced avascular necrosis do not lead to good long-term outcomes.We would like to describe here some of our long-term clinical experience concerning this surgery.