Rim Fracture of a Tibial Base-Plate Due to Retained Cement as a Cause of Catastrophic Failure of Unicompartmental Knee Arthroplasty: A Case Report.

CASE: We report a case of catastrophic implant failure due to fatigue fracture of a well-functioning unicompartmental knee arthroplasty at 7 years in an active 55-year-old man, who presented with sudden onset of atraumatic knee pain and effusion. The patient underwent revision to total knee arthroplasty. Intraoperative findings included a metallic fragment fractured off the rim of the tibial base-plate and cement retained in the tibial tray. CONCLUSION: Retained cement in the tibial tray resulted in increased tibial tray contact stresses and fatigue fracture of the rim of the tray, creating a free metallic loose body that produced symptoms.

Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures?

BACKGROUND: Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. METHODS: A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. RESULTS: Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). CONCLUSION: The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. LEVEL OF EVIDENCE: Therapeutic level III.

Factors used by program directors to select hand surgery fellows.

PURPOSE: To identify factors and attributes hand surgery fellowship program directors consider important in selecting applicants for interview and ranking. METHODS: A web-based questionnaire was sent to all hand fellowship program directors in the United States. The questionnaire was designed to identify the most important criteria in granting an interview, sources of letters of recommendation, the interview process, and factors used to rank a candidate. Each criterion was ranked in importance on a 1 to 5 Likert scale, with 1 being not important and 5 being critical. All responses were anonymous. The most important criterion for each section of the survey was determined by comparing the average Likert scores. RESULTS: Fifty-two of 76 program directors responded (68%). The criteria with the highest mean Likert scores for offering an applicant an interview were, in order, quality letters of recommendation from hand surgeons, completion of an orthopedic surgery residency, comments regarding the applicant's technical competence, applicant having an MD degree (as opposed to a DO degree), and residency program reputation. The letters of recommendation with the highest value were from the division chief of hand surgery and another hand surgeon in the division/department. The most important features of the interview were maturity of applicant, ability of applicant to articulate thoughts, ability to listen well, self-confidence, and relevant questions asked. The most important factors in ranking a candidate were applicant integrity, commitment to hard work, quality of letters of recommendation, quality of the interview, and ability to work well with other members of the hand surgery team. CONCLUSIONS: There are identifiable factors considered important by hand surgery fellowship directors when selecting and ranking an applicant. This information may be valuable to medical students and residents contemplating careers in hand surgery.

Short, locked humeral nailing via Neviaser portal: an anatomic study.

OBJECTIVE: Supraspinatus tendon trauma may contribute to residual shoulder pain after nail fixation for proximal humeral fractures. Some have proposed a more medial starting point for humeral nail insertion to avoid cuff tendon footprint damage. We hypothesized that percutaneous nail insertion via Neviaser portal would not only be possible, but would avoid tendon trauma, while sacrificing articular cartilage. MATERIALS AND METHODS: Under c-arm guidance and in percutaneous fashion, we nailed 16 consecutive complete (head and neck, etc, intact) specimen right proximal humeri with locked short humeral nails (Aequalis) via Neviaser portal. Each shoulder was dissected to study the damage to the rotator cuff and long head of the biceps tendons as well as to the articular surfaces. We measured the humeral-thoracic abduction arc before the damaged articular surface contacted the superior glenoid. There were 5 male specimens and 11 female specimens with a mean age of 83 years at the time of death. RESULTS: We successfully inserted 15 of 16 humeral nails through this percutaneous approach. No supraspinatus tendon or long head of the biceps tendon was damaged. All nails passed entirely through supraspinatus muscle belly. Thirteen of 15 starting points were entirely on articular surface. Mean arc of abduction before superior glenoid contact was 76 degrees (range, 50 degrees-130 degrees). Mean distance from the edge of the articular surface to the most lateral part of the nail insertion was 11 mm (0-25 mm). CONCLUSIONS: Short, locked humeral nail insertion is possible in percutaneous fashion via Neviaser portal without tendon injury. However, successful insertion comes at the cost of articular cartilage damage.

Osteolytic lesion of the tibial diaphysis after cementless TKA.

Biomaterial wear debris is a known contributing factor in aseptic loosening of total joint prostheses, particularly when cementless tibial trays are used in total knee arthroplasty (TKA). Local inflammatory response can lead to osteolysis and aseptic loosening of implants. The resulting lesions require careful clinical evaluation. This article presents a case of a 76-year old man with a remote history of prostate cancer and cigarette smoking who presented with acute onset left knee and tibia pain 15 years after TKA. Radiographs showed an osteolytic lesion in the distal tibial diaphysis and magnetic resonance imaging revealed a cystic lesion with evidence concerning for pathologic mid-shaft fracture. Biopsy of the lesion confirmed a foreign body reaction and revision TKA was performed. The patient was seen at 3-year follow-up without complication. The existing literature presents cases reporting osteolytic lesions of the distal femur and proximal tibial metaphysis due to polyethylene wear debris and foreign body reaction following TKA. We are unaware of case reports involving osteolysis of this etiology extending into the distal tibial diaphysis. We conclude that polyethylene wear debris with foreign body reaction should be considered in the differential diagnosis of an osteolytic lesion extending into the tibial diaphysis following TKA.