Incidence of Anterior Knee Pain and Functional Difficulty in a Prospectively Recruited Cohort Following Total Knee Arthroplasty With Selective Patellar Resurfacing.

BACKGROUND: The influence of patellar resurfacing on anterior knee pain, stair climbing, and functional activity outcomes following total knee arthroplasty (TKA) are incompletely understood. This study examined the influence of patellar resurfacing on patient-reported outcome measures (PROMs) relating to anterior knee pain and function. METHODS: The Knee Injury and Osteoarthritis Outcome Score of Joint Replacement (KOOS, JR.) patient PROMs were collected preoperatively and at 12 months follow-up for 950 TKAs performed over 5 years. Indications for patellar resurfacing included Grade IV patello-femoral (PFJ) changes or mechanical PFJ findings during patellar trialing. Patellar resurfacing was performed on 393 (41%) of the 950 TKAs performed. Multivariable binomial logistic regressions were performed, using KOOS, JR. questions assessing pain during stair climbing, standing upright, and function during rising from sitting as surrogates for anterior knee pain. Independent regression models were performed for each of the targeted KOOS, JR. questions, with adjustment for age at surgery, sex, and baseline pain and function. RESULTS: No association was observed between 12-month postoperative anterior knee pain or function with patellar resurfacing (P = .17, .97). Patients who had moderate or greater preoperative pain on stairs had an increased likelihood of postoperative pain and functional difficulty (odds ratio 2.3, P = .013), while males were 42% less likely to report postoperative anterior knee pain (odds ratio 0.58, P = .002). CONCLUSION: Selective patellar resurfacing based on PFJ degeneration and mechanical PFJ symptoms produces similar improvement in PROMs for resurfaced and unresurfaced knees.

What Role Does Patello-Femoral Joint Degeneration Have on Pain and Function After Unicompartmental Knee Arthroplasty? A Prospective Observational Cohort Study.

BACKGROUND: Influences on anterior knee pain, stair climbing limitations, and function such as rising from sitting are poorly understood in unicompartmental knee arthroplasty (UKA). Original indications for UKA excluded patients who had patello-femoral disease, while more recent studies have expanded the indications to include these patients. This study examined the influence of the patello-femoral joint degeneration on patient-reported outcome measures relating to anterior knee pain and function after UKA. METHODS: Between October 2017 and August 2021, Knee Injury and Osteoarthritis Outcome Score of Joint Replacement (KOOS, JR) patient-reported outcome measures were collected preoperatively and at 12 months of follow-up for 678 medial UKAs. Patello-femoral joint status was visually graded intraoperatively. Radiographic or intraoperative medial patellar facet and trochlear patello-femoral arthritis and preoperative anterior knee pain were not considered contraindications for UKA, while grade IV lateral patello-femoral arthritis was considered a contraindication for UKA. Multivariable ordinal logistic regressions were performed, using the KOOS, JR questionnaire assessing pain during stair climbing, standing upright, and function during rising from sitting. Independent regressions were performed for each targeted KOOS, JR question, with adjustments for age at surgery, sex, and baseline pain and function scores. RESULTS: No association was observed between 12-month postoperative anterior knee pain (P = .575) and function (P = .854) with patellar osteoarthritis grading after UKA. When comparing fixed and mobile-bearing UKA designs, no association was observed between bearing type and pain (P = .663) or functional outcomes (P = .758). CONCLUSION: Pain and function improved significantly following medial UKA and was independent of medial patellar and trochlear degenerative status.

Periprosthetic Supracondylar Femoral Fractures Above a Total Knee Replacement: An Updated Compatibility and Technique Guide for Fixation With a Retrograde Intramedullary Nail.

BACKGROUND: Multiple studies have described retrograde nailing as a treatment of periprosthetic supracondylar femoral fractures (OTA/AO type 33A-C) above total knee replacements (TKRs). It is often difficult to discern which TKRs will be compatible with intramedullary nailing because the femoral component design and intercondylar distance is highly variable among total knee designs. The goal of our study is 3-fold: (1) Review and update previous work of intercondylar distances of all currently available prostheses in the United States. (2) Review retrograde nails currently on the market and associated driving end to nail shaft diameter mismatch and opening reamer sizing. (3) Review technical tricks for executing a retrograde femoral nail for the treatment of periprosthetic supracondylar femur fractures. METHODS: Data for the intercondylar distance of the femoral components, diameter of retrograde nails and reamers, and notch compatibility were gathered. RESULTS: The results were compiled and recorded. A "technical tricks" section was included that highlights reduction and fixation techniques. CONCLUSIONS: This update further empowers surgeons to use all the tools available when treating periprosthetic femur fractures and allows efficient identification of the compatibility of different TKR designs with various intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Cue Ball Arthroplasty With Humeroradial Total Elbow Arthroplasty (TEA) Revision: An Approach to Managing Infection and Severe Ulnar Bone Loss in TEA.

Total elbow arthroplasties (TEA) have become more prevalent as indications expand. However, TEA complications remain a treatment conundrum. One such complication, periprosthetic joint infections (PJIs) have been reported to occur in up to 12% of all TEA procedures. Irrigation and debridement with retention of hardware and antibiotic suppression has a high failure rate. Two stage revisions of TEA, while more morbid, is an effective approach with previous studies showing a 79% eradication rate. These cases are often associated with periprosthetic bone loss, adding to the surgical complexity. In our case report, we present the case of a 59 year old diabetic male with a primary TEA secondary to a distal humerus fracture who developed a deep infection and was successfully treated with explantation, cue ball antibiotic cement arthroplasty, and humeroradial revision. This case report will discuss the cue ball antibiotic spacer technique and humeroradial revision as a salvage procedure in TEA revisions in the setting of extensive ulnar bone loss.

The Effect of Metal Instrumentation on Patient and Surgical Team Scatter Radiation Exposure Using Mini C-Arm in a Simulated Forearm Fracture Fixation Model.

INTRODUCTION: To our knowledge, no studies have studied the effect of metal instrumentation (MI) in the field of fluoroscopy regarding changes in the intensity, direction of scatter, and degree of radiation exposure to the patient and surgical team. The goal of this study was to determine whether the presence of MI increases scatter radiation exposure to the patient and surgical team when using a mini C-arm in the horizontal and vertical positions. METHODS: Four trials were conducted using a lamb limb specimen and a mini C-arm to simulate a forearm/wrist fracture fixation scenario. Radiation scatter percentages were measured with the mini C-arm in a vertical and horizontal position with and without the presence of MI (a six-hole 3.5-mm limited-contact dynamic compression plate attached to the specimen with six cortical screws and a self-retaining retractor) using a parallel plate radiation detector. RESULTS: The patient, scrub technician, circulating nurse, and anesthesiologist were exposed to no detectable radiation. In the horizontal position with the presence of MI, there was a 181-fold increase in scatter radiation exposure to the first assistant's eyes (0.016% versus 2.893%, 1.4 × 10-6 Sv/min versus 3.5 × 10-5 Sv/min) and increased exposure to the surgeon's hands compared with the horizontal position with no MI. In the vertical position, the scatter radiation received by the first assistant's eyes increased (zero versus 2.9 × 10-6 Sv/min) with MI present, whereas the only radiation measured for the surgeon was in the right hand which did not change with MI present (2.2 × 10-5 Sv/min). DISCUSSION: MI in the field of fluoroscopy increases scatter radiation exposure to a degree that may place the first assistant's yearly eye exposure in excess of the International Commission on Radiological Protection limit. Surgeons and their assistants should wear lead aprons, thyroid shields, and leaded glasses and minimize the usage of fluoroscopy with MI in the field.

Intraosseous Plating for the Management of Cortical Defects.

The management of fractures with segmental bone loss or abundant comminution on the far cortex is often complicated by deformity or frank hardware failure. Using plate constructs that rely on off-axis loading may not be sufficient to support the limb until healing occurs. There are a number of techniques to mitigate this problem, notably the use of intramedullary nails and bicolumnar plating of the fracture. These techniques are not always possible and do come with the biologic cost of additional surgery. In this article, the authors present a technique along with 2 case examples of using plates in an intraosseous location that was described by Dr Mast in his classic orthopaedic text. By placing these plates in the intramedullary space and then interdigitating fixation from the standard cortical plate, a rigid "I-beam" of fixation can be created to mitigate the eccentric loading placed on extraosseous plates. This technique is especially useful in situations in which intramedullary nails are precluded (comminuted intraarticular and some periprosthetic fractures).