Re-evaluation of pectoralis major height as an anatomic reference for humeral height in fracture hemiarthroplasty.

BACKGROUND: Shoulder replacement may be indicated for complex proximal humeral fractures. The primary reason for disappointing results is the nonanatomic position of the prosthesis because the normal anatomic landmarks are disrupted when fractured. An anatomic reference outside of the zone of injury may facilitate proper positioning of fracture arthroplasty reconstructions. It is unknown whether the measurement from the top of the pectoralis major tendon (PMT) to the top of the humeral head is related to patient height. MATERIALS AND METHODS: PMT measurements were performed on 21 pairs of cadaveric shoulders. A second group of PMT measurements was performed on 107 patients receiving a shoulder magnetic resonance imaging scan. A third PMT comparison group was included using historical measurements from 20 pairs of cadaveric shoulders. All heights, sexes, and ages were known. Statistical analysis used mixed-effects linear regression models. RESULTS: A consistent association between patient height and PMT was found, with a mean distance from the top of the PMT to the top of the humeral head of 58.9 mm in men and 55.2 mm in women. For every 10-mm increase in patient height over 1.7 m, there is a 1.7-mm increase in PMT (P = .01). Age was not associated with PMT distance (P > .5). CONCLUSIONS: A predictable measurement from the upper portion of the PMT to the top of the humeral head exists to guide implant height in fracture hemiarthroplasty and may be approximated by use of patient height and sex.

The Frank Stinchfield Award: the impact of socioeconomic factors on outcome after THA: a prospective, randomized study.

BACKGROUND: Most studies of total hip arthroplasty (THA) focus on the effect of the type of implant on the clinical result. Relatively little data are available on the impact of the patient's preoperative status and socioeconomic factors on the clinical results following THA. QUESTIONS/PURPOSES: We determined the relative importance of patient preoperative and socioeconomic status compared to implant and technique factors in predicting patient outcome as reflected by scores on commonly utilized rating scales (eg, Harris Hip Score, WOMAC, SF-12, degree of patient satisfaction, or presence or severity of thigh pain) following cementless THA. METHODS: All patients during the study period were offered enrollment in a prospective, randomized study to receive either a titanium, tapered, proximally coated stem; or a Co-Cr, cylindrical, extensively coated stem; 102 patients were enrolled. We collected detailed patient data preoperatively including diagnosis, age, gender, insurance status, medical comorbidities, tobacco and alcohol use, household income, educational level, and history of treatment for lumbar spine pathology. Clinical evaluation included Harris Hip Score, SF-12, WOMAC, pain drawing, and UCLA activity rating and satisfaction questionnaire. Implant factors included stem type, stem size, fit in the canal, and stem-bone stiffness ratios. Minimum 2 year followup was obtained in 95% of the enrolled patients (102 patients). RESULTS: Patient demographics and preoperative status were more important than implant factors in predicting the presence of thigh pain, dissatisfaction, and a low hip score. The most predictive factors were ethnicity, educational level, poverty level, income, and a low preoperative WOMAC score or preoperative SF-12 mental component score. No implant parameter correlated with outcome or satisfaction. CONCLUSION: Socioeconomic factors and preoperative status have more impact on the clinical outcome of cementless THA than implant related factors. LEVEL OF EVIDENCE: Level I, prospective, randomized clinical trial. See the guidelines online for a complete description of level of evidence.

Is there a benefit to drains with a Kocher-Langenbeck approach? A prospective randomized pilot study.

BACKGROUND: Closed suction drainage is a routine part of wound management for patients undergoing surgical treatment of acetabulum fractures. This pilot study seeks to determine if there is a difference in wound healing for a Kocher-Langenbeck approach with and without the use of drains. METHODS: We conducted a prospective, randomized study including 39 patients with acetabulum fractures treated through a Kocher-Langenbeck approach. During wound closure, patients were randomized into two groups: 20 patients (group I) received drains and 19 (group II) were closed without drains. All were followed up for drain output, quality and quantity of drainage, signs of infection, and duration of drainage. Patients were then evaluated at 2 weeks and 8 weeks for wound healing and any signs of infection. RESULTS: By the 8-week follow-up, all wounds healed without any signs of infection. There was no difference in the average number of days of drainage between groups: 7.45 days and 7.95 days for group I and group II, respectively (p = 0.37). There were two wound complications (5.13%), with one in each group. Both complications consisted of cellulitis without signs of deep infection and had complete resolution with intravenous antibiotics. A post hoc power analysis determined that a test population of 1,264 patients would be needed to show a reduction in wound drainage time by 1 day. CONCLUSION: With the numbers available in this pilot study, we showed no benefit to the use of drains for acetabular surgery performed through a Kocher-Langenbeck approach.

Proximally versus fully porous-coated femoral stems: a multicenter randomized trial.

UNLABELLED: There are two broad-based categories of cementless femoral component designs: proximally porous-coated and fully porous-coated. While both have been widely used, there remains debate regarding differences in clinical outcome scores, relative incidence of thigh pain, and development of stress shielding. We investigated these variables in a multicenter prospective randomized blinded clinical trial of 388 patients from three centers: 198 patients had a proximally porous-coated tapered cementless femoral component and 190 patients had a fully porous-coated cementless femoral component. A minimum followup of 2 years (mean, 6.7 years; range, 2.0-8.65 years) was available in 367 of the 388 patients (95%). We observed no differences in age at surgery, body mass index, or preoperative clinical outcome scores (WOMAC, SF-12, Harris hip score, UCLA activity, thigh pain) with the two groups. We determined serial bone density changes in a subcohort of 72 patients from two of the three centers. The postoperative clinical outcome scores were similar at all followup intervals, and we observed no differences in the incidence of thigh pain at any time. Bone density reduction in Gruen Zone 7 was greater with the fully coated stem than the proximally coated stem (24% versus 15% reduction, respectively). Both fully and proximally coated stems performed well, with no clinical differences at 2 years' followup, except in bone mineral density evaluations. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Bilateral patellar dislocation associated with alpha-mannosidase deficiency.

Mannosidosis is an extremely rare genetic disease characterized by a deficiency of the lysosomal enzyme, alpha-mannosidase. This enzyme is necessary for cleavage of mannose from many glycoproteins. In the absence of this enzyme, mannose accumulates in cells throughout the body, including the joints and the synovium. This disease causes many skeletal changes including dysostosis multiplex, synovial hypertrophy, and Charcot-type joints. We report the case of a girl, aged 9 years and 6 months, who developed bilateral patellar dislocation and severe synovial hypertrophy secondary to alpha-mannosidase deficiency. Her disease was further complicated by Charcot elbow and bilateral hip and elbow avascular necrosis.

The Effect of Arthroscopic Rotator Interval Closure on Glenohumeral Volume.

The role of rotator interval in shoulder pathology and the effect of its closure are not well understood. In addition, the effect of rotator interval closure on intra-articular glenohumeral volume (GHV) remains unknown. We conducted a study to quantify the GHV reduction obtained with an arthroscopic rotator interval closure and to determine whether medial and lateral interval closures resulted in different degrees of volume reduction. We dissected 8 fresh-frozen cadaveric shoulders (mean age, 64.4 years) to the level of the rotator cuff. Volumetric measurements were taken before and after medial and lateral rotator interval closure incorporating the superior glenohumeral ligament and the upper portion of the subscapularis. Arthroscopic closure of the rotator interval with 2 sutures reduced GHV by a mean of 45%. More volume reduction resulted with use of a single lateral interval closure stitch than with use of a single medial stitch (35% vs 24%; P < .02). Arthroscopic rotator interval closure with 2 plication stitches is a powerful tool in reducing intracapsular volume of the shoulder and may be a useful adjunct in restoring glenohumeral stability. If a single plication stitch is preferred, a lateral stitch (vs a medial stitch) can be used for a significantly larger reduction in shoulder volume.

Sequential volume reduction with capsular plications: relationship between cumulative size of plications and volumetric reduction for multidirectional instability of the shoulder.

PURPOSE: To quantify the relationship between the amount of shoulder capsule imbricated with a simple stitch and the degree of glenohumeral volume reduction in a multidirectional instability model. Secondary purposes were to identify the number of arthroscopic plication stitches required to reduce the shoulder volume equal to that of an open lateral-based inferior capsular shift and to compare volume reductions between suture anchor and suture-only capsular plication stitches. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric shoulders (mean age, 64.4 years) were dissected to the level of the rotator cuff. A viscous liquid was injected into each joint, and measurements were taken before and after six 1-cm arthroscopic capsular plication stitches were performed. The sizes of the capsular plications were measured to quantify the amount of capsule imbricated with each simple stitch. A repeated random-intercept regression model was fitted for each outcome, with significance set at P = .05. RESULTS: There was a near-linear relationship, with each 1 cm of total plication equaling 10% volume reduction up to 4.0 cm. After this, each additional 1-cm plication stitch resulted in 2% to 6% more reduction (mean, 4%). Five simple plication stitches reduced the volume by 52% in the suture anchor group and 49% in the suture-only group. The suture anchor achieved 3% greater volumetric reduction than the suture-only plication stitches, but this effect was not statistically significant (P = .06). Conclusion/ CLINICAL RELEVANCE: A 1-cm capsular plication stitch results in a roughly 10% volume reduction of the glenohumeral joint. Five simple capsular plication stitches result in a volume reduction equivalent to an open lateral-based capsular shift.

Open repair of acute Achilles tendon ruptures.

Although the Achilles tendon is the strongest in the body, it also is the most often ruptured. Achilles tendon rupture most often occurs during sports activities in middle-aged men. Operative repair of a ruptured Achilles tendon can be accomplished with a variety of techniques, ranging from open repair, to minimally invasive technique, to endoscopic-assisted repair. This article focuses on open repair of acute Achilles tendon rupture. Surgical techniques, rehabilitation protocol, and the authors' preferred method are described.

Patellar resurfacing compared with nonresurfacing in total knee arthroplasty. A concise follow-up of a randomized trial.

Patellar resurfacing in total knee arthroplasty remains controversial. This study compared the long-term clinical outcomes of total knee arthroplasties performed with and without the patella resurfaced and is an update of a previous report. Eighty-six patients (118 knees) underwent primary total knee replacement and were randomized into two groups: those treated with and those treated without resurfacing of the patella. Outcomes included the scores according to the Knee Society clinical rating system, the scores according to a forty-one-question patellofemoral-specific patient questionnaire, patient satisfaction, global and anterior knee pain scores, radiographic findings, and complications and revisions. Fifty-seven patients (seventy-eight knees) were followed for a minimum of ten years. No significant differences were identified between the two groups in terms of the range of motion, Knee Society scores, satisfaction, global knee pain, or anterior knee pain. The overall revision rates in the original series of 118 knees were 12% in the nonresurfacing group and 9% in the resurfacing group. Seven patients (12%) in the nonresurfacing group and two patients (3%) in the resurfacing group underwent revision for a reason related to a patellofemoral problem. On the basis of these findings, we concluded that, with the type of total knee arthroplasty used in our patients, similar results may be achieved with and without patellar resurfacing.

Current management of idiopathic clubfoot questionnaire: a multicentric study.

A survey was mailed to 541 members of the Pediatric Society of North America to define currently accepted treatment options in the management of talipes equinovarus. Four hundred sixteen (77%) responses were received, representing a total of 6125 years in practice (average of 17.4 years per physician) and 8595 clubfeet treated in the past year (average of 26 feet treated per physician). While specific trends were reported and great variability exists, certain principles are universal: initial nonoperative management followed by surgery for persisting deformities. A renewed interest in Ponseti's techniques of casting and surgery to address specific persisting deformities was reflected in this survey.

Winner of the 2003 James A. Rand Young Investigator's Award. Early failure of cementless mobile-bearing total knee arthroplasty.

A consecutive series of 82 cementless mobile-bearing total knee arthroplasties performed was studied to determine the reliability of cementless tibial component fixation. The indications for surgery in all cases were osteoarthritis with only mild or moderate deformity. Evaluation consisted of a Knee Society clinical score (KSCS) and radiographic evaluation preoperatively and at annual follow-up. Minimum 2-year follow-up was obtained in 73 of 82 knees (89%). Results were compared to those of a subsequent consecutive series of 76 knees (66 with 2-year follow-up) performed with a mobile-bearing TKA with cemented components with the same indications, implant, technique, and length of follow-up. Six of 73 cementless mobile-bearing TKAs (8%) underwent tibial component revision for symptomatic subsidence and failure of ingrowth compared to 0/66 revisions in the cemented group (P<.05). Patients with cementless mobile-bearing TKA also had a significantly lower KSCS (161 versus 184, P<.05), significantly higher incidence of pain rated more than mild (23% versus 7%, P<.01) and a trend toward less arc of motion (106 degrees versus 115 degrees, P<.2). The results do not support the hypothesis that mobile-bearing TKA imparts the advantage of reliable tibial bone ingrowth.