Structural Allograft Supporting a Trabecular Metal Cup Provides Durable Results in Complex Revision Arthroplasty.

BACKGROUND: Revision total hip arthroplasty (THA) is challenging specially in the presence of severe acetabular bone deficiency. We report the use of a highly porous revision shell augmented by structural allograft to provide structural support and coverage to the acetabular component. METHODS: We identified 56 patients (58 hips) undergoing revision THA, where a trabecular metal revision cup was supported by structural allograft. Mean follow-up was 5.4 years (range 2-12 years). Preoperatively acetabular bone defects were classified as Paprosky 2A in 6 hips (10%), 2B in 12 hips (21%), 2C in 12 hips (21%), 3A in 11 hips (19%), and 3B in 17 hips (29%). Structural allograft configuration was classified as type 1 (flying buttress) in 13 hips, type 2 (dome support) in 23 hips, and type 3 (footings) in 17 hips, with 5 hips having combined configurations. RESULTS: All hips showed evidence of union between the allograft and host bone at latest follow-up, 14 hips had partial resorption of the allograft that did not affect cup stability. Three acetabular components demonstrated failure of ingrowth. Survivorship-free from radiographic acetabular loosening as end point was 94% at 5 years. The 5-year survivorship with revision for any reason as end point was 90%. CONCLUSION: Trabecular metal shells combined with structural bone allograft in revision THA demonstrate excellent midterm survival, with 94% of acetabular components obtaining stable union onto host bone at 5 years. Allograft restored bone stock with minimal resorption, and when it occurred did not alter the survivorship of the acetabular component.

A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. METHODS: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. RESULTS: One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges-Lehmann median difference [95% CI] = -1 [-2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal -2 [-3 to -1]; P < 0.001; average -0.8 [-1.3 to -0.2]; P = 0.003; and liposomal bupivacaine: maximal -3 [-4 to -2]; P < 0.001; average -1.4 [-2.0 to -0.8]; P < 0.001). CONCLUSIONS: Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

Functional outcome measures of patients following hemipelvectomy.

BACKGROUND: Major amputations are indicated for curative treatment of some tumors of the pelvis. Previous literature suggests that patients with a hemipelvectomy amputation are more efficient walking with crutches than using a prosthesis. OBJECTIVES: The purpose of this study was to evaluate whether modern prosthetic use after hemipelvectomy may be a viable option for patients than in the past. STUDY DESIGN: Case control trial. METHODS: We identified five patients who underwent hemipelvectomy amputation and fit with high-level prosthetic components. Patients were evaluated using a timed up and go, 5-m walk, 400-m walk, and stair climb tests to evaluate functional performance with a prosthesis and without. Short Form-36 scores were collected as well. These results were compared to matched controls. RESULTS: There was a trend for faster locomotion using crutches over wearing a prosthesis in the timed up and go, and 5-m and 400-m walk; no difference was seen in stair climbing. Short Form-36 scores showed decreased physical component score, but equal mental component score compared to the general population. CONCLUSION: Our results show that in addition to advances in surgical techniques, prosthetic rehabilitation and management are beginning to optimize functional mobility with the prosthesis. CLINICAL RELEVANCE: Patients who use a modern prosthesis following hemipelvectomy demonstrated good clinical function with and without their prosthesis. Although health status scores were decreased in the physical component, mental component scores were equal to healthy controls.

Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy.

OBJECTIVE: Prosthetic rehabilitation after pelvic-level amputation (hemipelvectomy/hip disarticulation) is difficult, and because of this, many patients are never fit with a prosthetic limb. The objectives of the study were to evaluate the characteristics of successful prosthetic users and to determine what factors are associated with successful prosthetic fitting and use. DESIGN: The authors identified 43 patients who underwent hip disarticulation/hemipelvectomy between 2000 and 2010 and were candidates for prosthetic fitting at the authors' institution. The medical records of these patients were then reviewed for pertinent demographic and medical characteristics to identify the profile of successful prosthetic users. RESULTS: Of 43 patients, 18 (43%) successfully used a prosthetic limb. The only preoperative factor associated with unsuccessful prosthetic fitting was coronary artery disease. Specifically, age, body mass index, other medical comorbidities, and demographic characteristics were not associated with successful or unsuccessful prosthetic fitting. Successful users wore their prosthesis an average of 5.8 hrs/day, and most ambulated with one or both hands free. CONCLUSIONS: Successful prosthetic rehabilitation after hemipelvectomy and hip disarticulation is possible. Increased body mass index, advanced age, depression, and other comorbidities should not discourage prosthetic rehabilitation. Most patients that undergo prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis for most of the day.

Atypical presentation of fat embolism syndrome after gunshot wound to the foot.

A 42-year-old man sustained a gunshot wound to the foot, which caused multiple fractures of the tarsal bones. Over the course of 6 hours, he became obtunded and began to experience respiratory compromise and neurologic symptoms. On magnetic resonance imaging, he was found to have innumerable tiny infarcts consistent with fat embolism syndrome. He was placed in a spanning external fixator. The patient remained in a coma for 6 weeks after injury but gradually regained function. Fat embolism syndrome is classically described as resulting from injury to the diaphysis of a long bone, but it can occur secondary to trauma of the foot. Neurovascular status must be continually evaluated in the setting of any bony trauma, and index of suspicion should remain high when neurologic deficits are encountered.

Hemipelvectomy: high-level amputation surgery and prosthetic rehabilitation.

The hemipelvectomy, most commonly performed for pelvic tumor resection, is one of the most technically demanding and invasive surgical procedures performed today. Adequate soft tissue coverage and wound complications after hemipelvectomy are important considerations. Rehabilitation after hemipelvectomy is optimally managed by a multidisciplinary integrated team. Understanding the functional outcomes for this population assists the rehabilitation team to counsel patients, plan goals, and determine discharge needs. The most important rehabilitation goal is the optimal restoration of the patient's functional independence. Factors such as age, sex, etiology, level of amputation, and general health play important roles in determining prosthetic use. The three main criteria for successful prosthetic rehabilitation of patients with high-level amputation are comfort, function, and cosmesis. Recent advances in hip and knee joints have contributed to increased function. Prosthetic use after hemipelvectomy improves balance and decreases the need for a gait aid. Using a prosthesis helps maintain muscle strength and tone, cardiovascular health, and functional mobility. With new advances in prosthetic components, patients are choosing to use their prostheses for primary mobility.