Hip Disarticulation in Wound Care: A Case Series.

Background: Hip disarticulation (HD) is a radical lower extremity amputation performed by carefully transecting all muscles and nerves surrounding the hip joint and separating the leg at the joint capsule. It is considered a last resort to be used as a life-preserving measure under emergent circumstances due to high rates of morbidity and mortality. Methods: This case series presents 4 patients who underwent HD. The procedure was performed due to various indications including necrotizing fasciitis, gangrene, stump necrosis from previous above-the-knee amputation, and septic joint secondary to chronic osteomyelitis, 3 of which were planned and 1 was emergent. Results: The procedure was performed successfully in all 4 patients. Furthermore, all patients were eventually discharged to home or to a long-term care facility for wound care or rehabilitation. Conclusions: Overall, HD should be reserved as a life-saving treatment for various indications including infections that fail other modalities, limb ischemia, trauma, and malignancy. Ideally, this procedure would be planned and performed on proper candidates; however, HD should still be a consideration in the emergent setting regardless of most optimal patients due to its life-saving potential.

Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, and Rotation: A Comparative, Gait-Analysis Study.

INTRODUCTION: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared. MATERIALS AND METHODS: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts. RESULTS: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66° , [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects. CONCLUSION: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.

A Case for the Brace: A Critical, Comprehensive, and Up-To-Date Review of Static Progressive Stretch, Dynamic, and Turnbuckle Braces for the Management of Elbow, Knee, and Shoulder Pathology.

BACKGROUND: Non-operative management of the elbow, shoulder, and knee typically includes braces, such as the: static progressive stretch (SPS), turnbuckle, and dynamic. However, a paucity of literature exists comparing these three bracing modalities. Therefore, the purpose of this study was to evaluate the current literature on the various bracing modalities for physicians and patients managing elbow, shoulder, or knee joint complications. Specifically, we compared the use of 1) static progressive stretch, 2) dynamic, and 3) turnbuckle braces for the a) elbow, b) knee, and c) shoulder. MATERIALS AND METHODS: A PubMed search on dynamic, SPS, and turnbuckle bracing for the elbow, knee, and shoulder joints was performed. Studies that addressed clinical outcomes and relied primarily on the brace for improvement of patient outcomes and not on surgery were included. Because individually-fabricated braces are extremely costly, require great fabrication skill, and are unique to the patient they were specifically designed for, their results are not generalizable to the greater patient population and were, therefore, not included in this analysis. A total of 14 elbow, 24 knee, and 4 shoulder studies met criteria. RESULTS: Elbow-Patients wore the SPS brace for 90 minutes, compared to 8 hours for the turnbuckle and 20 hours for the dynamic brace. The SPS and turnbuckle brace had similar increases in range of motion (ROM) of 37°. The SPS brace was found to provide patients with the greatest reduction in flexion contracture, 26°. There are similar increases in flexion ROM between the SPS and dynamic elbow bracing modalities. Shoulder- The mean duration of use for an SPS was only six weeks compared to the two months required for the dynamic shoulder brace. The dynamic shoulder brace protocol involved upwards of 24 hours per day or night as patients were instructed to wear the brace at all times. Patients treated with both the SPS and dynamic braces had excellent pain outcomes. Knee-The most commonly followed SPS knee brace protocol was one to three sessions per day which lasted from seven to nine weeks, while for the dynamic brace the time period ranged from six to eight weeks. The SPS brace reported a mean increase in ROM of 31°. There was a lack of evidence for the dynamic and turnbuckle knee braces for their accurate assessment. The SPS studies reported the greatest response to flexion improvement with a mean increase of flexion by 22°. Meanwhile, the reported mean flexion increase with a dynamic knee brace was only 7°. CONCLUSION: Based on the most current literature available, the authors highly recommend the use of SPS for the elbow, shoulder, and knee. Static progressive stretch bracing has an easy patient protocol, a short duration of use, and excellent outcomes. Additionally, the lack of evidence for turnbuckle and dynamic braces is concerning. Overall, the static progressive stretch brace has shown excellent results in the outcomes assessed in this review and should be a first recommendation for patients suffering from elbow, knee, and/or shoulder pathology.

A Comparison of Relative Value Units in Primary versus Revision Total Ankle Arthroplasty.

INTRODUCTION: To determine the effort required to provide a service, the United States Medicare uses Relative Value Units (RVUs). Consequently, higher RVUs are assigned to the procedures or services that require more effort, which ultimately means the physician will be properly compensated for the additional effort required. In total ankle arthroplasty (TAA), revision cases usually are more technically challenging and require more effort than primary TAA. Therefore, the purpose of this study was to compare the: 1) RVUs; 2) length-of-surgery; 3) RVU per unit of time between primary and revision total ankle arthroplasty; and 4) the individualized idealized surgeon annual cost difference analysis. MATERIALS AND METHODS: We utilized the American College of Surgeons, National Surgical Quality Improvement Program database from 2008 to 2015 to identify patients who underwent either a primary Current Procedural Terminology [CPT]: 27702) or revision (CPT: 27703) TAA. There were a total of 653 patients, 586 of which underwent a primary, and 67 who underwent a revision, TAA. The mean RVUs, length of surgery (in minutes), and RVU per minute, were calculated. Dollar amount per minute, per case, per day, and per year, to find an individualized idealized surgeon annual cost difference, were also calculated. An analysis of variance was used to compare variables between primary and revision TAA. A p-value of less than 0.05 was used to determine statistical significance. RESULTS: The mean RVU was significantly higher in revision versus primary TAA (16.93 vs. 14.41, p=0.001). However, there was no significant difference in the mean lengths of surgery between primary and revision TAA (160 vs. 157 minutes, p=0.613). Additionally, the mean RVU per minute was significantly higher in revision versus primary TAA (0.13 vs. 0.10, p=0.001). CONCLUSION: Based on the results of this study, it appears that revision TAA cases are appropriately assigned a higher RVU per minute for performing them as they require more effort and are more challenging compared to the primary TAA. Furthermore, not only did the revision cases have lower mean lengths of surgery, but they also maintained a higher RVU per minute. Therefore, orthopaedists can use this information to further help them yield the best potential practice design.

Radiographic Classification Systems for Osteonecrosis of the Knee: A Review of Literature.

Knee osteonecrosis is a rare, yet debilitating disease that can lead to knee joint destruction and can be associated with significant pain and disability. Various imaging modalities have different roles in the diagnosis, staging, management, and determination of the prognosis in knee osteonecrosis. Plain radiographic images can show gross joint destruction and secondary arthritic changes. In addition, magnetic resonance imaging (MRI) has become the gold-standard imaging modality to diagnose osteonecrosis. Multiple classification systems have been developed for knee osteonecrosis based on these imaging modalities. The goal of these systems is to stage the disease and guide management. Better understanding of the pattern of the lesions and its morphometric characteristics may allow surgeons to reach a better consensus regarding the timing of surgical treatment, choice of implant, and overall disease prognosis in these unique patients. Due to the relative paucity of evidence, this review was conducted to evaluate different radiological classification systems utilized in osteonecrosis of the knee joint.

Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?

INTRODUCTION: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081. CONCLUSIONS: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

The Röttinger approach for total hip arthroplasty: technique, comparison to the direct lateral approach and review of literature.

BACKGROUND: Multiple approaches to the hip joint have been developed utilizing various intervals and/or intermuscular planes when performing a total hip arthroplasty (THA), each proposing certain advantages. Of these, the Röttinger approach (modified anterolateral or Watson-Jones) is potentially muscle-sparing. Multiple studies have demonstrated favorable outcomes with this approach. However, others showed more complications with a slow learning curve. Due to the paucity of evidence we conducted this study to: (I) present our operative experience and technique of the Röttinger approach; (II) compare short-term complications and operative room (OR) times of this approach to the direct lateral; and (III) review the available literature. METHODS: This was a review of a longitudinally maintained single-surgeon database of patients who underwent primary THA using either the Röttinger or direct lateral approach. A total of 100 consecutive patients (100 hips) who underwent primary unilateral THA using the Röttinger approach between April 1st, 2012 and April 30th, 2015 were identified. These patients were compared to another cohort of 147 consecutive patients (147 hips) who underwent the procedure using the direct lateral approach (of Hardinge). The operative technique for the Röttinger approach involves accessing the hip joint through muscle-sparing technique between the tensor fascia lata and gluteus medius muscles. We evaluated and compared the short-term complications and the mean operative times for each cohort. In addition, we performed a literature search on the clinical studies that reported on the Röttinger approach using the following databases; PubMed, EMBASE, EBSCO Host, and SCOPUS. Studies published between January 1st of 2000 and September 1st of 2017 were reviewed. We included only studies that compared this approach to other standard approaches and excluded single-cohort case series, case reports, cadaveric studies, and studies not in English language. RESULTS: At mean follow-up time of 12 weeks (range, 6 to 24 weeks), there were two patients in the Röttinger cohort who experienced lateral femoral cutaneous nerve palsies (2%), which were self-limited and resolved at 6 and 12 weeks. In the direct lateral cohort, there was one hip dislocation (2%) at 6 weeks post-operatively, which was successfully managed by a closed reduction. In patients who received the Röttinger approach, mean OR time was 130 minutes (range, 74 to 202 minutes), compared to the direct lateral cohort mean of 111 minutes (range, 71 to 222 minutes). Our literature analysis covered 2,252 patients who received the Röttinger approach vs. 19,941 patients who underwent variety of other standard approaches including anterior, direct lateral, and posterior. At final follow up (range, 6 to 52 months), patients who underwent the Röttinger approach demonstrated comparable clinical outcomes and complications to patients who underwent primary THA using other approaches. CONCLUSIONS: In this analysis of a single-surgeon experience of the Röttinger approach compared to the direct lateral, we presented our experience with the technique and demonstrated the safety and feasibility of this relatively novel approach. Our study results demonstrated that patients who underwent this approach had similar short-term complications and OR times to those who underwent the direct lateral approach. Additionally, our findings agree with previous comparative studies that demonstrated similar outcomes of this approach. Therefore, it can be used as an alternative for primary THA.