Femoral Head Autograft Can Reliably Reconstruct Dysplastic Acetabula Through the Direct Anterior Approach for Total Hip Arthroplasty.

Background: Bone deficiencies in dysplastic acetabula create technical difficulties during total hip arthroplasty (THA). Bulk femoral head autograft (FHA) is one method to increase cup coverage and bone stock of the true acetabulum; however, only limited data exist on its efficacy through a direct anterior approach (DAA). This study aimed to evaluate the outcomes of FHA during THA via a DAA in dysplastic hips. Methods: Retrospective review of 34 patients (41 hips) with hip dysplasia (Crowe I-III) who underwent primary THA via a DAA with FHA at a single institution was performed. Surgical procedures were performed on a traction table with intraoperative fluoroscopy and highly porous-coated cup placement in the true acetabulum. Patients were assessed clinically and radiographically at a minimum of 2 years postoperatively (range, 2 to 7). Results: The average modified Harris Hip Score improved from 31.9 ± 10.8 to 94.1 ± 5.8, Merle d'Aubigné Hip Score from 7.5 ± 2.8 to 16.6 ± 1.1, and visual analog pain score from 7.9 ± 2.7 to 1.4 ± 1.4 (all P < .001). All hips had an "anatomic" inferomedial cup position postoperatively, with an average increase in horizontal coverage of 43.4%. Mean postoperative limb-length discrepancy improved from 21.8 ± 16.1 mm to 1.6 ± 5.7 mm (P < .001). There were no cases of revision THA, nor complications such as dislocation, infection, or osteolysis. Conclusion: Reconstructing dysplastic acetabula (Crowe I-III) with FHA during THA can be successfully accomplished via the DAA with increased acetabular bone stock and accurate correction of limb-length discrepancy.

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital.

INTRODUCTION: Rapid recovery protocols (RRPs) for total joint arthroplasty (TJA) can reduce hospital length of stay (LOS) and improve patient care in select cohorts; however, there is limited literature regarding their utility in marginalized patient populations. This report aimed to evaluate the outcomes of an institutional RRP for TJA at a safety net hospital. METHODS: A retrospective review of 573 primary TJA patients was done, comparing the standard recovery protocol (n = 294) and RRP cohorts (n = 279). Measured outcomes included LOS, 90-day complications, revision surgeries, readmissions, and emergency department visits. RESULTS: The mean LOS reduced from 3.0 ± 3.1 days in the standard recovery protocol cohort to 1.6 ± 0.9 days in the RRP cohort (P < 0.001). The RRP cohort had significantly fewer 90-day complications (11.1% versus 21.4%, P = 0.005), readmissions (1.4% versus 5.8%, P = 0.007), and revision surgeries (1.4% versus 4.4%, P = 0.047). CONCLUSION: A RRP for primary TJA can be successfully implemented at a safety net hospital with a shorter LOS and fewer acute adverse events. Such protocols require a coordinated, multidisciplinary effort with strict adherence to evidence-based practices to provide high-quality, value-based surgical health care to an underserved cohort.

Anterior Total Hip Arthroplasty With Bulk Femoral Head Autograft in a Patient With Camurati-Engelmann Disease.

Camurati-Engelmann disease (CED) is an extremely rare, sclerosing bone disorder of intramedullary ossification with only 300 reported cases worldwide. The pathogenesis is related to activating mutations in transforming growth factor beta 1, which results in bilateral, symmetric hyperostosis affecting primarily the diaphysis of long bones. Despite effective pharmacological treatment options, the diagnosis of CED is problematic owning to its rarity and variability of clinical presentation. We present a patient with known CED with advanced early hip osteoarthritis, secondary to underlying hip dysplasia, for which she underwent a successful total hip arthroplasty via a direct anterior approach with the use of bulk femoral head autograft to reconstruct her native acetabulum.

Implementation of an enhanced recovery protocol at a safety net hospital : a silver lining to COVID-19?

AIMS: This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. METHODS: A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. RESULTS: The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. CONCLUSION: Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a 'silver lining' to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871-878.

Do scores of the USMLE Step 1 and OITE correlate with the ABOS Part I certifying examination?: a multicenter study.

BACKGROUND: The US Medical Licensing Examination (USMLE) and Orthopaedic In-Training Examination (OITE) are commonly used to select medical students or residents, respectively. Knowing how well these examinations predict performance on the American Board of Orthopaedic Surgery (ABOS) Part I certifying examination is important to provide evaluations for medical students and residents. Previous studies comparing the OITE scores with the ABOS Part 1 scores have been limited to one program. QUESTIONS/PURPOSES: Therefore, we compared the scores on the USMLE Step 1 and OITE examinations with those on the ABOS Part I certifying examination using data from four ACGME approved residency programs. METHODS: We reviewed 202 resident files from 1996 to 2008 from four programs in the same geographic region. Of those, 181 (90%) had complete records. De-identified data were used to compare USMLE Step 1 scores, OITE percentile rank scores, and ABOS Part I percentile rank scores. Pearson coefficients and receiver operator curves were calculated to assess the relationships between tests. RESULTS: We found a correlation of 0.53 between the USMLE Step 1 and ABOS Part I, and an average correlation of 0.50 for postgraduate years (PGY) 2 through 5 OITE scores and ABOS Part I. There was a stepwise increase in correlation from PGY 2 through PGY 5 between the OITE scores and ABOS scores. Those who averaged in the 27th percentile or lower on the OITE had a 57% chance of failing the ABOS Part I examination. CONCLUSION: USMLE Step 1 scores correlated with ABOS Part I certifying examination scores, and we therefore believe it may be used as one factor in resident selection. Use of the OITE scores in guiding education and feedback appears to be justified.

Joint and long-bone gunshot injuries.

Gunshot wounds remain a major clinical problem, with the number of nonfatal gunshot wounds reported as 60,000 to 80,000 per year in the United States. Bone or joint injuries comprise a major portion of gunshot wound injuries. It is paramount for orthopaedic surgeons to be thorough in their treatment of patients with these injuries. Intra-articular injuries remain a source of significant clinical morbidity because of joint stiffness, arthritis, and the risk of infection. Treatment of long-bone fractures is a challenging clinical problem, and further studies are needed to investigate modern treatment methods. Lead toxicity is a potential risk for patients with gunshot injuries, particular for those with joint injuries. The clinician's recognition of the signs and symptoms of lead toxicity is important to achieve the best care for these patients.

Failed distal biceps tendon repair using a single-incision EndoButton technique and its successful treatment: case report.

Surgical repair has become a mainstay in the treatment of ruptures of the distal biceps tendon and multiple surgical techniques have been described advocating anatomic or near-anatomic repair. Fixation with an EndoButton technique has been shown to have superior fixation strength and durable clinical outcomes. Here, we describe a case of failed EndoButton fixation of the distal biceps tendon, and its successful treatment.

Gunshot wounds: epidemiology, wound ballistics, and soft-tissue treatment.

The extremities are the most common anatomic location for gunshot wounds. Because of the prevalence of gunshot injuries, it is important that orthopaedic surgeons are knowledgeable about caring for them. The most common injuries seen with gunshot wounds are those of the soft tissues. Nonsurgical management of patients who have gunshot wounds with minimal soft-tissue disruption has been successfully accomplished in emergency departments for several years; this includes extremity wounds without nerve, intra-articular, or vascular injury. Stable, nonarticular fractures of an extremity have also been successfully treated with either minimal surgical or nonsurgical methods in the emergency department. Indications for surgical treatment include unstable fractures, intra-articular injuries, a significant soft-tissue injury (especially with skin loss), vascular injury, and/or a large or expanding hematoma.

The use of knee braces, part 1: Prophylactic knee braces in contact sports.

Surrogate knee model biomechanical studies have indicated that off-the-shelf braces provide 20% to 30% greater resistance to a lateral blow when the knee is in full extension. Custom functional braces doubled the protective effects and proved effective with the knee in some flexion. Although functional performance studies are not consistent, preventive knee braces may slow straight-ahead sprint speed, cause early fatigue, and increase muscular relaxation pressures, energy expenditure, blood lactate levels, maximal torque output, oxygen consumption, and heart rate. Two epidemiologic studies have been performed. At West Point, a randomized control study of 71 injuries in 1396 cadets indicated knee brace effectiveness with a statistically higher rate of injury in the control group (3.4/1000 exposures) than in the braced group (1.5/1000 exposures), with the most significance for medial collateral ligament sprains in defensive players. The Big Ten Conference conducted a descriptive study of 100 medial collateral ligament sprains among 987 players in different positions, strings, and types of session. Brace-wear tendency varied directly with the unbraced player counterpart's risk of medial collateral ligament sprain, with the nonplayer linemen experiencing both the greatest risk of unbraced practice session injury (0.0801 injuries/1000 exposures) and the highest incidence of brace wear (85%). During practices, there was a nonsignificant but very consistent reduction in injury rate for braced players in every position and string. During games, there was also a reduced rate for linemen and the linebacker/tight end group. The study concluded that although the issue is not closed, preventive knee braces appear to offer some protection to the medial collateral ligament from a contact injury involving a valgus blow, but there may be negative effects on performance level, leg cramping, and fatigue symptoms.

Predictors of reoperation following operative management of fractures of the tibial shaft.

BACKGROUND: Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors. OBJECTIVE: We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures. DESIGN: Retrospective observational study. SETTING: Level 1 trauma center. METHODS: We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure

Application of an antibiotic intramedullary nail in the management of a large metacarpal bone defect.

Contaminated wounds and infected nonunions of the hand are not amenable to primary internal fixation and grafting. Antibiotic-impregnated cement intramedullary nails have been used in the lower extremity in the treatment of these fractures but have not been described in the hand. This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. We describe an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand using readily available operating room equipment. The antibiotic-impregnated cement intramedullary nail can be placed temporarily until definitive internal fixation and grafting occur.

Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures.

BACKGROUND: The aims of the study were (1) to determine the cumulative two to twenty-year survivorship of the hip after open reduction and internal fixation of displaced acetabular fractures, (2) to identify factors predicting conversion to total hip arthroplasty or hip arthrodesis, and (3) to create a predictive model that calculates an individual's probability of early need for total hip arthroplasty or hip arthrodesis. METHODS: Eight hundred and sixteen acetabular fractures treated with open reduction and internal fixation by one surgeon over a twenty-six-year period were analyzed. Cumulative two to twenty-year Kaplan-Meier survivorship analyses of the hip, including best and worst-case scenarios, were performed with total hip arthroplasty or hip arthrodesis as the end point. Univariate and multivariate Cox regression analyses were performed to identify negative predictors, which were then used to construct a nomogram for predicting an individual's probability of needing an early total hip arthroplasty. RESULTS: The cumulative twenty-year survivorship of the 816 hips available for follow-up was 79% at twenty years. The best and worst-case scenarios corresponded to cumulative twenty-year survivorship of 86% and 52%, respectively. Significant independent negative predictors were nonanatomical fracture reduction, an age of more than forty years, anterior hip dislocation, postoperative incongruence of the acetabular roof, involvement of the posterior acetabular wall, acetabular impaction, a femoral head cartilage lesion, initial displacement of the articular surface of ≥ 20 mm, and utilization of the extended iliofemoral approach. CONCLUSIONS: Open reduction and internal fixation of displaced acetabular fractures was able to successfully prevent the need for subsequent total hip arthroplasty within twenty years in 79% of the patients. The results represent benchmark comparative data for any future and past studies on the outcome of surgical fixation of acetabular fractures.

Gunshot wounds to the acetabulum.

OBJECTIVES: To classify the fracture patterns of gunshot wounds to the acetabulum; identify the associated injuries and complications; determine the predictors of poor outcome and deep infection; and propose a treatment algorithm based on the results. DESIGN: Retrospective review of two trauma registry databases over a 13-year period. SETTING: Multicenter study. PATIENTS: Thirty-nine gunshot wounds to the acetabulum (38 patients). INTERVENTION: Treatment strategy was based on infection control by treating bowel and bladder injury, presence/absence of intra-articular lead, pattern, and stability of the fracture. MAIN OUTCOME MEASUREMENTS: Merle d'Aubigné score, rate of failures, and complications. Multivariate logistic regression analysis to detect predictors of poor outcome and deep infection. RESULTS: There were 32 simple (82%) and seven (18%) associated fracture patterns. Bowel injuries were the most common associated injures. There was a 54% major complication rate. Significant predictors of poor outcome were high-velocity missile, involvement of the acetabular dome, abdominal injury, nerve injury, vascular injury, and male gender. Significant factors associated with deep infection were presence of a bowel injury with primary anastomosis of the bowel and an associated fracture pattern. CONCLUSIONS: The Letournel classification system can be applied to describe these injuries. The successful treatment of the bowel injury directly correlates to infection control. Diverting colostomy is associated with a reduction of the infection rate. Overall, gunshot wounds to the acetabulum are catastrophic injuries with a high complication rate and poor functional outcome. A multidisciplinary algorithm is proposed for treatment of these complex injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Mechanical failure of the long gamma nail in two proximal femur fractures.

Mechanical failure of the long gamma nail was encountered in two elderly patients with proximal femur fractures over a 6-month period. One of the patients had a known history of lymphoma. The other patient had a history of rheumatoid arthritis but no history of cancer or other metabolic bone disease. Both nails failed at the junction of the compression screw and the nail. The angle of failure of the nail was the same in both cases. The index of suspicion for imminent mechanical failure of the gamma nail should be higher in pathologic fractures and fractures which are malreduced during nailing.

Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes.

OBJECTIVES: Gunshot wounds (GSW) affecting the genitourinary (GU) system in civilians are uncommon. This study describes the incidence, anatomic distribution, demographics, associated injuries, management, and outcomes after civilian GU GSW. METHODS: A Level 1 Trauma Center Registry was used to retrospectively identify all patients who sustained GU GSW (January 1997-December 2008). Patient information was abstracted from the Registry, medical, and autopsy records. Multivariate regression detected significant factors associated with mortality. RESULTS: Of 2941 civilian GSW patients, 309 (10.5%) sustained GU injury with/without associated injuries. Mean age was 30.4 ± 11.9 years (range 6.6-80.6 years); 289 patients (93.5%) were male. Mean Injury Severity Score (ISS) 22.2 ± 15.4 (1-75). Incidence of GU GSW increased during the study period. GSW affected the kidneys (55%), scrotum (21%), bladder (19%), testicle (12%), penis (8%), some patients having more than 1 GU organ injured. A total of 284 patients (92%) experienced at least 1 other organ injury. Most GU GSW were managed surgically (mean 2.2 ± 2.0; 0-13 surgeries/patient). There was a 27% (n = 84) overall mortality, with 16% (n = 50) dead on arrival. Mortality and ISS were correlated (P = 0.002; hazard ratio = 3.0; 95% confidence interval 3.0-3.0CI). Large vessel, head/neck, kidney, vascular, heart, lung, spine, and spinal cord injury were statistically significant risk factors for death. CONCLUSIONS: GU injury occurred in 10.5% of 2941 civilian GSW patients. Associated injuries were very common, with many cases involving multiple organs. Most injuries (90%) were managed surgically. Mortality is usually the result of associated nongenitourinary injuries. A high index of suspicion for injuries affecting other organs is necessary in managing GU GSW trauma patients.

Internal fixation of symphyseal disruption resulting from childbirth.

OBJECTIVES: To investigate the clinical and radiographic results after operative treatment of complete symphyseal disruption resulting from childbirth and to evaluate residual pain and implant failure in relation to the timing of surgery. DESIGN: Retrospective study. SETTING: Tertiary pelvis and acetabulum care unit at a general hospital. PATIENTS: Ten consecutive women with complete symphysis disruption associated with childbirth were included from a database of 603 patients with pelvic fracture. No patients with this diagnosis were excluded. All patients were followed until clinical healing of the symphysis or union of the fusion. INTERVENTION: Open reduction and internal fixation in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients). Fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment in chronic cases (greater than 6 months, three patients). MAIN OUTCOME MEASUREMENT: Analyzed variables included the Lindahl score, maintenance of postoperative reduction, implant failure, malunion, and necessity of reoperation. RESULTS: Mean age of the patients was 32 years (range, 24-37 years). Mean follow up was 29 months (range, 5-139 months). The mean postoperative Lindahl score was 68 ± 14.6 points (range, 38-80 points). There were three excellent, four good, two fair, and one poor result. Fair or poor results occurred in one subacute and two chronic cases. There were two revision surgeries. One patient underwent implant removal resulting from dyspareunia 3.1 years postoperatively. One subacute patient had conversion to symphyseal fusion after implant failure as a result of a fall 11 years after index surgery. Major complications occurred in two and minor complications in three patients. Radiographic loosening of implants was observed in all subacute cases. All fusions healed and symptoms improved at last follow up. CONCLUSIONS: Operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor-induced complete symphysis pubis disruption.

The utility of bladder catheterization in total hip arthroplasty.

The use of a urinary bladder catheter in patients having a total hip arthroplasty is controversial. Universal insertion of an indwelling catheter before a total hip arthroplasty, and insertion of a catheter postoperatively as necessary, are accepted variations of care. From 1993 to 1999, 719 patients having primary, unilateral total hip arthroplasties were randomized by surgeons into two groups: a group of patients who had universal preoperative insertion of an indwelling bladder catheter (340 patients) and an observation group who had catheterization as needed (379 patients). Catheterization was required for 295 of these 379 patients (77.8%). Patients were followed up using a total hip arthroplasty database, which recorded all complications. Six patients (1.8%) in the universal catheter insertion group had a urinary tract infection develop. Nine patients (2.4%) in the catheter as necessary group had a urinary tract infection develop. There was no significant difference in incidence of urinary tract infections between the two groups. Female gender and increasing age were associated with a higher incidence of urinary tract infection in both groups. The average length of stay in the hospital for the universal catheter group was 4.8 days, and the average length of stay for the catheter as necessary group was 4.5 days. There was no significant difference in length of stay in the hospital between the two groups. The universal catheter group had an average 590 dollars higher hospital cost for their total hip arthroplasties, which was significant. Routine preoperative bladder catheterization may not be warranted in patients having total hip arthroplasties. Postoperative catheterization as necessary may be more cost effective.

All-polyethylene and metal-backed tibial components in total knee arthroplasty: a matched pair analysis of functional outcome.

A group of 98 patients who had primary unilateral total knee arthroplasty (TKA) with cemented, posterior-stabilized knee implants for osteoarthritis were matched for age, diagnosis, weight, body mass index, and presence of comorbid conditions. The patients were followed up with clinical, radiographic, and outcome measures including SF-36 scales and patient outcome questionnaires. Forty-nine patients had all-polyethylene tibial implants (APT), and 49 patents had metal backed tibial implants (MBT) with similar knee implant design and articular geometry. There is no difference among these patient cohorts in the clinical performance or functional outcome of TKA using APT or MBT components in primary TKA at intermediate term follow-up. In consideration of concerns about polyethylene wear, osteolysis, and cost associated with MBT components, these findings may present an opportunity for quality improvement and cost savings with increased utilization of APT in TKA operations.