Total Hip Arthroplasty Reduces Pain and Improves Function in Patients With Spondyloepiphyseal Dysplasia: A Long-Term Outcome Study of 50 Cases

BACKGROUND

Spondyloepiphyseal dysplasia (SED) is rare genetic condition which leads to skeletal and joint deformities that can predispose patients to degenerative joint disease. There are limited reports on the results of total hip arthroplasty (THA) in this patient population. The purpose of this study is to review clinical and radiographic outcomes of THA performed in patients with SED at one institution.

METHODS

Among 43,917 patients undergoing primary THA from 1970 to 2015, we identified 50 THAs performed in 29 patients with SED; 21 patients underwent bilateral THA (none simultaneous). There were 16 females and 13 males; mean age, body mass index, and height were 39 years, 28.7 kg/m², and 145 cm, respectively. All patients were able to ambulate prior to the THA. Mean follow-up was 11 years (range 2-38).

RESULTS

Mean implant survival for primary THA in SED patients at the 5, 10, and 20-year time points was 96%, 85%, and 55%, respectively. Thirteen patients required revision THA, most commonly for polyethylene wear (n = 6) and aseptic loosening (n = 5), and 4 additional patients underwent nonrevision reoperations. Prior to surgery, 90% of patients had severe or moderate pain, which was reduced to 8% of patients postoperatively (P < .001). Mean Harris Hip Score improved from 47 to 87 (P < .001). Prior to surgery, 64% of patients required gait aids, which reduced to 34% postoperatively (P < .001).

CONCLUSION

THA provided significant pain reduction and improvement in function, with a majority of patients ambulating independently following the procedure. There was a high incidence of complications following THA in patients with SED, most commonly secondary to polyethylene wear and osteolysis from conventional polyethylene and historical implants.

LEVEL OF EVIDENCE

Level IV, Therapy.

Low dose radiotherapy is associated with local complications but not disease control in sacral chordoma

BACKGROUND

We reviewed the disease control and complications of the treatment of sacrococcygeal chordoma from four tertiary cancer centers with emphasis on the effects of radiotherapy in surgically treated patients.

METHODS

A total of 193 patients with primary sacrococcygeal chordoma from 1990 to 2015 were reviewed. There were 124 males, with a mean age of 59 ± 15 years and a mean follow-up of 7 ± 4 years. Eighty-nine patients received radiotherapy with a mean total dose of 61.8 ± 10.9 Gy.

RESULTS

The 10-year disease-free and disease-specific survival was 58% and 72%, respectively. Radiation was not associated with local recurrence (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.59-2.17; P = 0.71), metastases (HR, 0.93; 95% CI, 0.45-1.91; P = 0.85) or disease-specific survival (HR, 0.96; 95% CI, 0.46-2.00; P = 0.91). Higher doses (≥70 Gy; HR, 0.52; 95% CI, 0.20-1.32; P = 0.17) may be associated with reduced local recurrence. Radiotherapy was associated with wound complications (HR, 2.76; 95% CI, 1.64-4.82;, P < 0.001) and sacral stress fractures (HR, 4.73; 95% CI, 1.88-14.38; P < 0.001).

CONCLUSIONS

In this multicenter review, radiotherapy was not associated with tumor outcome but associated with complications. The routine use of radiotherapy with en-bloc resection of sacrococcygeal chordomas should be reconsidered in favor of a selective, individualized approach with a radiation dose of ≥70 Gy.

Outcomes of Primary Total Knee Arthroplasty in Patients With Ehlers-Danlos Syndromes

BACKGROUND

Ehlers-Danlos syndromes (EDS) are connective tissue disorders that cause defects in collagen synthesis or processing, resulting in joint hypermobility. Following total knee arthroplasty (TKA), concern exists that hypermobility will affect the outcome as prosthesis relies on soft tissues for stability. The purpose of this study is to investigate the outcome of TKA in the setting of EDS compared to patients undergoing TKA for osteoarthritis (OA).

METHODS

We identified 16 patients (20 knees) with EDS who underwent a TKA between 2001 and 2016. Patients were matched 1:2 (n = 40) on age, gender, body mass index, and surgical date to patients undergoing TKA for OA.

RESULTS

We found no difference in age, body mass index, or follow-up between the cohorts (P > .05). EDS patients had significantly more surgical interventions prior to TKA (P = .03) and were more likely to require constrained components (x² = 0.002). Following TKA, 4 patients in the EDS group and 9 patients in the matched cohort underwent a reoperation for any reason including 1 revision in the EDS cohort and 3 in the OA cohort. We found no significant difference in reoperation or revision rates between the cohorts (P > .05). There was no difference in Knee Society Scores between groups at last follow-up (P = .63) or radiographic evidence of loosening.

CONCLUSION

Although patients with EDS were more likely to require a constrained component, they are not at increased risk of revision or reoperation following TKA in the intermediate term.

Proximal Femoral Allograft-Prosthetic Composites: Do They Really Restore Bone? A Retrospective Review of Revision Allograft-Prosthetic Composites

BACKGROUND

Large bone deficiencies are a challenging problem, historically treated with an allograft-prosthetic composite (APC) or megaprosthesis. There were several advantages of the APC compared with early megaprostheses, including the theoretical benefit of restoring bone stock. To our knowledge, there are no studies that have evaluated this claim. Our purpose was to review our institution's experience with APCs of the proximal femur that underwent revision for an aseptic cause and determine if the allograft bone was retained or removed during the revision procedure.

METHODS

We identified 203 proximal femoral allograft prosthetic composites placed from 1988 through 2014. Twenty-seven of these patients underwent a revision because of an aseptic cause. Three categories were devised to classify the amount of allograft retention: type A, complete allograft retention; type B, partial retention; and type C, no allograft retention.

RESULTS

The mean time from the initial APC to revision surgery was 5 years. The most common indication for revision included failure of the allograft (loosening or fracture). At the time of revision, there were 3 type A cases (11%), 4 type B cases (15%), and 20 type C cases (74%). Three of the 4 type B cases used the retained allograft as a strut graft around a newly inserted megaprosthesis.

CONCLUSION

The results of this study are contradictory to previous literature that suggests APCs restore bone stock. In this series, the allograft was retained in only a small percentage of cases when the APC was revised for an aseptic cause.

LEVEL OF EVIDENCE

IV.

Morbid Obesity Increases the Risk of Postoperative Wound Complications, Infection, and Repeat Surgical Procedures Following Upper Extremity Limb Salvage Surgery for Soft Tissue Sarcoma

BACKGROUND

Obesity is a known risk factor for wound complications; however, unlike elective upper extremity procedures, where obesity can be modified preoperatively, excision of soft tissue sarcomas (STSs) is not elective, and as such, obesity cannot be modified. There is a paucity of data concerning the impact of obesity on wound healing in upper extremity sarcoma surgery.

METHODS

A total of 261 (159 males and 102 females) patients with a STS of the upper extremity from 2006-2014 were reviewed. The mean age and body mass index (BMI) were 56 (18-97) years and 26.6 (15.4-40.8) kg/m², respectively. Sixty-nine patients (26%) were classified as obese (BMI ⩾30 kg/m²): class I (obese, BMI = 30-34.9 kg/m²; n = 48, 18%), class II (severely obese, BMI = 35.0-39.9 kg/m²; n = 16, 6%), and class III (morbidly obese, BMI ≥ 40 kg/m²; n = 5, 2%). Functional outcomes were also compared between obese and nonobese patients using the Musculoskeletal Tumor Society (MSTS) 1993 rating system and Toronto Extremity Salvage Scores (TESS).

RESULTS

Forty-nine patients (19%) sustained a wound dehiscence, delayed healing, or infection. Class III obesity increased the risk of wound complications (hazard ratio [HR] = 8.19, 95% confidence interval [CI] = 1.96-22.96, P < .001) and infection (HR = 10.09, 95% CI = 1.60-34.83, P = .01). There was no difference in the mean TESS (93 vs 90, P = .13) or MSTS93 (95 vs 93, P = .39) between obese and nonobese patients.

CONCLUSIONS

The results of this study indicate morbid obesity significantly increased the risk of a postoperative wound complication and infection. However, following upper extremity limb salvage surgery, obese patients should expect to have excellent functional outcome.

Can a reverse shoulder arthroplasty be used to revise a failed primary reverse shoulder arthroplasty?: Revision reverse shoulder arthroplasty for failed reverse prosthesis

AIMS

Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA.

PATIENTS AND METHODS

We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10).

RESULTS

Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01).

CONCLUSION

Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493-98.

Free Composite Serratus Anterior-Latissimus-Rib Flaps for Acute One-Stage Reconstruction of Gustilo IIIB Tibia Fractures

Gustilo IIIB injuries of the tibia with segmental bone loss continue to be a difficult reconstructive problem. The serratus anterior-latissimus-rib (SALR) composite flap consists of bone and muscle; this flap can provide soft tissue coverage and vascularized bone in a single surgical procedure. The purpose of this study is to describe the use of the SALR flap for the treatment of a large open tibia fracture with segmental bone loss, with a specific focus on postoperative complications, limb salvage, and time to union. We reviewed the medical records of patients undergoing an SALR flap (n = 5) for the treatment of Gustilo Type IIIB tibia fractures within 1 month of injury. We compared the mechanism of injury, injury severity score, time from injury to free tissue transfer, complications, and time to radiographic and clinical union. All patients were male, with a mean age of 25 years. On average, patients underwent free tissue transfer within 1 week of injury. The average time to radiographic union was 7 months. Two patients underwent reoperation. There were no graft failures. Free SALR flaps can be a useful option for the treatment of high-energy tibia fractures with extensive soft tissue and bone loss. These flaps provide immediate osseous and soft tissue reconstruction with an acceptable complication profile.

Long-Term Outcome of Hip Arthroplasty in the Setting of Synovial Chondromatosis

BACKGROUND

Synovial chondromatosis (SC) is a rare disease involving cartilaginous metaplasia of synovial tissue. Treatment via synovectomy and loose body removal alone results in elevated recurrence rates, with up to 1 in 5 patients requiring conversion to a hip arthroplasty. The purpose of this study is to investigate outcomes of hip arthroplasty in the setting of SC, focusing on (1) disease-specific survival, (2) implant survivorship and complications, and (3) clinical outcomes.

METHODS

We identified 26 patients with histologically confirmed SC who underwent hip arthroplasty between 1970 and 2015. Mean follow-up and patient age were 10 years (range 2-35) and 55 years (range 26-82), respectively. At the time of arthroplasty, 21 (81%) patients had "active" disease and underwent synovectomy. No constrained acetabular components were used. Six patients (23%) had a preoperative flexion contracture.

RESULTS

The 15-year disease-free survival was 89%. Recurrence occurred in 3 patients at a mean of 0.8 years (range 0.03-1.2) postoperatively. Thirteen patients (50%) sustained a complication [most commonly aseptic loosening (n = 3, 12%)] and 7 required revision surgery. The 10-year and 15-year revision-free survival was 82% and 64%, respectively. Mean Harris Hip Score improved significantly from 50 (range 23-85) preoperatively to 82 (range 44-100) postoperatively (P < .001).

CONCLUSION

Arthroplasty with simultaneous synovectomy provides reliable pain relief and excellent disease-specific survival at long-term follow-up; however, revision and complication rates were high.

Long-Term Outcomes of Pedicled Gastrocnemius Flaps in Total Knee Arthroplasty

BACKGROUND

Deficient soft tissue following total knee arthroplasty (TKA) can jeopardize outcome. The gastrocnemius flap is an important means of providing coverage of a knee with deficient soft tissue. There is a paucity of long-term studies on the use of the gastrocnemius flap in the setting of TKA. The purpose of this study was to review the outcomes after the use of pedicled gastrocnemius flaps for coverage of a soft-tissue defect at the time of TKA.

METHODS

Eighty-three patients in whom a gastrocnemius flap had been used to cover the site of a primary (n = 18) or revision (n = 65) TKA over a 25-year period were identified. There were 48 women (58%) and 35 men (42%) with a mean age and body mass index (BMI) of 65 years and 32.6 kg/m. The mean wound size was 49 cm, and the wound was most commonly located over the anterior aspect of the knee/patellar tendon (n = 33). Patients were followed to the time of implant or flap revision, amputation, or death or for a minimum of 2 years (mean, 8 years). Clinical outcomes were assessed using the Knee Society Score (KSS) for pain and the KSS for function. The Kaplan-Meier method was used to assess revision and amputation-free survival. Risk factors for amputation and revision were identified with Cox regression.

RESULTS

The 10-year revision and amputation-free survival rates following gastrocnemius flap coverage were 68% and 79%, respectively. The risk of implant failure was increased by morbid obesity (BMI of ≥40 kg/m) (hazard ratio [HR] = 2.82, 95% confidence interval [CI] = 1.09 to 7.32, p = 0.03) and ≥5 prior surgical procedures on the knee (HR = 2.68, 95% CI = 1.04 to 6.88, p = 0.04). The risk of amputation was increased in patients with ≥5 prior surgical procedures (HR = 10.76, 95% CI = 2.38 to 48.58, p = 0.002), an age of ≥65 years (HR = 4.94, 95% CI = 1.10 to 22.09, p = 0.03), and a wound size of ≥50 cm (HR = 3.29, 95% CI = 1.14 to 9.53, p = 0.02). Preoperatively the mean KSSs for pain and function were 46 and 28, and these scores significantly (p < 0.05) improved to 78 and 43, respectively, at the time of follow-up.

CONCLUSIONS

The gastrocnemius flap reliably provides coverage of components used in complex knee reconstruction. A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stem Cells Combined With Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study

BACKGROUND

Randomized trials have shown the benefits of injecting bone marrow-derived mesenchymal stem cells (BmMSCs) after standard hip decompression in patients with osteonecrosis of the femoral head. However, the combination of BmMSCs and platelet-rich plasma (PRP) injected into the femoral head after decompression has not been reported previously. This study reports the results in a preliminary series of patients with osteonecrosis of the femoral head treated with BmMSCs plus PRP.

QUESTIONS/PURPOSES

(1) What is the survivorship free from reoperation, hip arthroplasty, and femoral head collapse in a preliminary series of patients with osteonecrosis of the femoral head treated with BmMSCs plus PRP? (2) Is there a change in the degree of femoral head involvement based on modified Kerboul angle? (3) What were the scores observed for pain and function at last followup? (4) Was there a difference in survivorship free from reoperation as a function of in vitro MSC count and viability?

METHODS

Twenty-two consecutive patients (35 hips; 11 men and 11 women) with corticosteroid-induced osteonecrosis who met study inclusion criteria were enrolled; none declined participation, and none was lost to followup, although one patient (two hips) died within a year of the procedure for reasons unrelated to it, and five patients (seven hips) did not undergo MRI at the 1-year followup. All patients had precollapse osteonecrosis, rated either University of Pennsylvania Stage 1 (n = 4) or Stage 2 (n = 31 hips). Mean age and body mass index were 43 years and 31 kg/m, respectively. Patients underwent pre- and postoperative radiographs and MRI to assess femoral head involvement using the modified Kerboul angle. Absolute cell count and colony-forming unit (CFU) assays were used to assess MSC abundance and viability of the bone marrow obtained at the time of surgery. Patients were followed at regular intervals to assess clinical response to treatment with a mean followup of 3 years (range, 2-4 years). The change in femoral head involvement was assessed with the modified Kerboul angle; the Harris hip score was used to assess clinical outcome; and conversion to THA, reoperation, and survivorship free from femoral head collapse were analyzed with the Kaplan-Meier method on a per-hip basis.

RESULTS

Survivorship free from THA, any procedure, and femoral head collapse was 84% (95% confidence interval [CI], 75%-93%), 67% (95% CI, 55%-79%), and 93% (95% CI, 76%-98%), respectively, at 3 years postoperatively; two patients (four hips) underwent a second decompression and MSC injection for persistent pain without signs of radiographic collapse. All patients with collapse underwent THA. The mean modified Kerboul angle improved from 205° ± 47° to 172° ± 48° postoperatively (mean change -30° ± 6°, p = 0.01). A greater proportion of patients who underwent an additional procedure had a modified Kerboul grade of 3 or 4 preoperatively (80% [four of five] versus 13% [four of 30 Grade 1 or 2; odds ratio, 26; 95% CI, 2-296; p = 0.005). Preoperatively the mean Harris hip score was 57 ± 12, which improved to 85 ± 15 (mean change 28 ± 3, p < 0.001) at most recent followup. Patients undergoing a reoperation or THA had a lower mean concentration of nucleated cells/mL (5.5 x 10 ± 2.8 x 10 cells/mL versus 2.3 x 10 ± 2.2 x 10 cells/mL, p = 0.02) and lower mean CFUs (13 ± 6 versus 19 ± 7, p = 0.04) compared with those who did not.

CONCLUSIONS

Core hip decompression with injection of concentrated bone marrow plus PRP improved pain and function; > 90% of hips in this series were without collapse at a minimum of 2 years. In this preliminary study, successful results were seen when nucleated cell count was high and modified Kerboul grade was low. Further randomized studies are needed to determine this procedure's efficacy versus core decompression or nonoperative treatment alone.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Component Fracture in the Kotz Modular Femoral Tibial Reconstruction System: An Under-Reported Complication

BACKGROUND

Primary bone tumors of the femur are commonly reconstructed using an endoprosthesis. Different modes of implant failure have been described, including structural failure; although uncommon, this may be an under-reported complication. The purpose of this study is to examine the rates and risk factors for implant fracture of the Kotz Modular Femoral Tibial Reconstruction system (KMFTR).

METHODS

Two hundred twenty-one patients (95 women and 126 men) who underwent a KMFTR reconstruction were reviewed. Twenty-seven patients (12%) sustained a prosthetic fracture. The mean time to fracture was 7 years postoperatively. The fractured component most commonly involved the distal femur (n = 21) and a screw hole in the stem (n = 12). In patients with stem fractures (n = 21), the mean intramedullary stem diameter was 12 mm and the mean extramedullary component length was 18 cm.

RESULTS

Compared to patients who did not fracture, those with a prosthetic fracture had a significantly smaller stem diameter (12 vs 14 mm, P = .001) and a significantly longer extramedullary component length (18 vs 15 cm, P = .04). There was no difference between the preoperative and postoperative Toronto Extremity Salvage Scores (P = .98), Musculoskeletal Tumor Society 87 (P = .78), or Musculoskeletal Tumor Society 93 (P = 1.0) ratings for patients with or without a prosthetic fracture.

CONCLUSION

This study shows that fracture is an under-reported complication associated with the KMFTR stem. We identified an endoprosthetic component fracture rate of 12%. Patients with smaller stem diameter and longer resection lengths were more likely to sustain a stem fracture. Subsequent revision provides a durable means of reconstruction, with no significant loss of patient function.

Allograft-Prosthetic Composite Reconstruction for Massive Proximal Humeral Bone Loss in Reverse Shoulder Arthroplasty

Background

Allograft-prosthetic composite (APC) reconstruction of the humerus represents an appealing surgical technique when implantation of a reverse prosthesis is considered in the setting of substantial proximal humeral bone loss^1-4. Humeral APCs have been successfully performed in the past with a non-reverse shoulder prosthesis^4,5. Reconstruction of the proximal part of the humerus with an allograft provides adequate support and fixation for the humeral component, allows restoration of length and lateral offset, and provides an opportunity for soft-tissue reattachment when needed. On the basis of the available peer-reviewed data, healing at the allograft-host junction is reliable, and complication rates, including instability, are relatively low^3,6.

Description

Once the glenoid reverse component has been implanted, a proximal humeral allograft is prepared to receive the humeral component of a reverse arthroplasty. The allograft is procured by our institutional bone and tissue bank, purchased from a number of vendors. The graft is selected after review of the description and radiographs provided by the vendor. The priority is to obtain a graft with sufficient length and soft tissues attached. If possible, the graft selected should have a diameter close to the diameter of the humerus of the recipient. The desired allograft length is selected on the basis of preoperative planning and intraoperative measurements, and the distal portion of the allograft is resected accordingly. Depending on the length of the defect, host bone quality, and surgeon preferences, the humeral component may or may not bypass the host-graft junction. The stem bypasses the host-graft junction for shorter APCs, as well as when the bone quality of the native humerus is compromised. Cemented fixation into the graft is universally used. Compression plating is used for graft-to-host fixation, supplemented by implantation of the stem across the junction in selected cases. Care is taken during the freehand cut to obtain optimal contact and compression. Once the ideal humeral bearing thickness has been selected, the polyethylene bearing is implanted and the joint relocated. If the posterior cuff can be repaired to cuff allograft, sutures are placed prior to relocation and are tied after relocation. Other musculotendinous units, such as the deltoid or pectoralis major, are repaired to the allograft if needed.

Alternatives

Implantation of a reverse prosthesis with a proximal humeral metal body (a so-called tumor prosthesis) is the main alternative to proximal humeral APC reconstruction. In patients with shorter defects, adequate soft-tissue tension may be obtained by implanting a glenosphere with a large inferior eccentricity and cementing the humeral component in a more proximal position than is usually performed. Alternatively, when implantation of the glenoid component of a reverse prosthesis is not possible, a hemiarthroplasty-APC construct may be performed^1,4,5,7-10, adding a synthetic sleeve such as an aortic Dacron graft to enhance soft-tissue stability if needed.

Rationale

When reverse arthroplasty is performed in the setting of substantial humeral bone loss, the humeral component may be poorly supported and at risk for loosening. In addition, the absence of proximal humeral bone stock may lead to shortening and/or loss of lateral offset. Finally, the posterosuperior cuff, subscapularis, deltoid, and pectoralis tendons may remain detached. The potential consequences of humeral bone loss in the setting of reverse arthroplasty include humeral loosening, dislocation, and poor active motion (particularly poor active elevation). Allograft reconstruction of the proximal part of the humerus provides an opportunity for better support of the component, restoration of humeral length and lateral offset, and attachment sites for the musculotendinous structures around the shoulder, if needed.

Allograft-Prosthetic Composite Reconstruction for Massive Proximal Humeral Bone Loss in Reverse Shoulder Arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) performed in the setting of massive proximal humeral bone loss often requires special reconstructive techniques. Restoration of the proximal part of the humerus with an allograft provides a number of theoretical benefits, including implant support, restoration of humeral length, deltoid tensioning, and an opportunity to repair the posterior aspect of the cuff to improve strength in external rotation and repair of the subscapularis to improve stability. However, reverse allograft-prosthesis composites (APCs) are costly, are technically demanding to use, and can be compromised by progressive allograft resorption.

METHODS

Between 2005 and 2012, the lead author used an APC reconstruction in 8 primary and 18 revision RTSAs (26 patients; mean age, 62 years; mean body mass index, 27.9 kg/m). The indications for the primary RTSAs included severe proximal humeral bone loss after trauma (n = 5) and tumor resection (n = 3). The indications in the revision setting were failed hemiarthroplasty (n = 11), anatomic total shoulder arthroplasty (n = 4), and reverse arthroplasty (n = 3). The most common reason for revision was instability (n = 10). A compression plate was used for graft-to-host fixation in all shoulders. Shoulders were assessed for pain, motion, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, Neer score, revision or reoperation, radiographic evidence of graft union or resorption, and implant fixation. The mean duration of follow-up was 4 years (range, 2 to 10 years).

RESULTS

RTSA using an APC construct resulted in substantial improvements in pain scores (p < 0.0001), elevation (p < 0.0001), and external rotation (p = 0.004). With the numbers available, there were no significant differences in clinical outcomes between primary and revision cases. No patients required revision surgery for nonunion at the host-allograft junction. The mean time to union was 7 months, with 1 patient requiring bone-grafting for delayed union. Other complications included dislocation, deep infection, graft fracture, and periprosthetic fracture distal to the previous APC construct in 1 patient each. The 2 and 5-year revision-free survival rate was 96%.

CONCLUSIONS

Reconstruction of proximal humeral bone loss with an APC at the time of primary or revision RTSA is safe and effective, with acceptable functional outcomes and complication rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Durability of Hemiarthroplasty for Pathologic Proximal Femur Fractures

BACKGROUND

The hip is a common location for metastatic tumors. Due to the high loads placed through the proximal femur, surgery is often indicated to provide pain relief and restore function. Historically, these lesions are reconstructed with a hemiarthroplasty; however, there are few reports on the outcome of these reconstructions. The purpose of this study is to evaluate the outcome of hemiarthroplasty for the treatment of proximal femur metastatic disease, with a specific focus on the rates of conversion to total hip arthroplasty (THA).

METHODS

One hundred ninety-nine patients (102 women, 97 men) were treated using a hemiarthroplasty to reconstruct the proximal femur for metastatic disease between 1992 and 2014. Mean age and body mass index were 62 years and 27.4 kg/m², respectively. The most common site of primary disease was the breast (n = 63). The most common location for the metastatic disease was the femoral neck (n = 148). Mean follow-up for surviving patients was 4 years.

RESULTS

Over the course of the study, 2 (1%) patients underwent conversion to a THA due to groin pain and degenerative changes. In addition, complications occurred in 12% of patients, most commonly a deep venous thrombosis (n = 5). Following the procedure, mean Harris Hip Score and Musculoskeletal Tumor Society 1993 scores were 73 and 63%, respectively.

CONCLUSION

Reconstruction of the proximal femur with a hemiarthroplasty endoprosthesis provides a majority of patients with a durable means of reconstruction, with a low rate of conversion to THA.

What Factors Influence the Outcome of Surgically Treated Soft Tissue Sarcomas of the Hand and Wrist?

BACKGROUND

Soft tissue sarcomas (STS) of the hand are exceedingly rare. The aim of this study was to review our institution's experience with STS of the hand to identify factors affecting outcomes and survivorship.

METHODS

We retrospectively reviewed the records of 46 hand STS treated with definitive surgery at our institution between 1992 and 2013. Pertinent demographics as well as information regarding the surgical procedure, and disease status at latest follow-up were reviewed. Mean age at diagnosis was 38 years with a mean follow-up of 5 years.

RESULTS

The most common tumor subtypes were epithelioid (n = 10) and synovial sarcoma (n = 8). Sixty-one percent were superficial in location. Thirty-three patients had had a nononcologic resection prior to definitive surgical treatment at our institution. Ultimately, negative margins were obtained in all cases. Local recurrence was observed in 5 patients and distant metastases in 14 patients. Tumor sizes ≥2 cm, American Joint Committee on Cancer (AJCC) grade, and depth of the tumor were found to adversely affect the outcome in terms of disease-free and overall survival. Reexcision of an inadvertently excised tumor at an outside institution did not adversely affect the outcome. The 10-year overall and disease-free survival was 72% and 63%.

CONCLUSIONS

Local recurrence after a wide excision was observed infrequently; however, distant disease was relatively common. Tumors with a size ≥2 cm were associated with a worse disease-free and overall survival, highlighting the aggressive nature of these tumors.

The role age plays in the outcomes and complications of shoulder arthroplasty

BACKGROUND

This investigation used age as a continuous variable to estimate implant survival and the risk of complications.

METHODS

Prospectively collected data were used to analyze 5494 consecutive shoulder arthroplasties performed from 1970 to 2012. Patients were a mean age of 67 years. The association between the age at the index procedure and the risk for each outcome was assessed using Cox regression and smoothing spline analysis.

RESULTS

Older age was associated with a decreased risk of revision surgery, revision for mechanical failure, and reoperation but with a higher risk for thromboembolic events. Reoperation rates also decreased in a linear fashion with older ages (P < .001). The risk of revision surgery decreased in a linear fashion between the ages of 40 and 85, with a 3% decreased risk of revision per 1-year increase in age (P < .01). This association held true in a multivariate model and when specific procedures were separated out. Compared with patients aged <50 years, patients aged from 50 to 65 years (P < .001) and those >65 years (P < .001) have decreased risks of revision surgery. The risk of a revision surgery in a patient aged >50 years was significantly decreased (~13% reduction in risk for each year; P < .001). There was a subtle association between older age and decreased rates of infection (P = .01).

CONCLUSIONS

There is a strong association between older age and decreased rates of revision surgery and reoperation after shoulder arthroplasty, with a striking association with decreased rates of mechanical failure. These are important considerations when counseling younger patients regarding their risks.

Use of a shorter humeral stem in revision reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component.

METHODS

During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2).

RESULTS

At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P < .001), with a postoperative 91% satisfaction rate as well as postoperative American Shoulder and Elbow Surgeons score of 68 and Simple Shoulder Test score of 6.7. At most recent radiographic follow-up, 1 (5%) patient had grade 3 humeral lucency.

CONCLUSIONS

Preserving bone stock through conversion to a shorter reverse humeral stem in the revision setting is a reasonable option with good short- to intermediate-term results and low rates of humeral complications. Using the shorter stem components provides adequate stability and high rates of humeral component ingrowth.

Long-term outcome of knee arthroplasty in the setting of pigmented villonodular synovitis

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferation of the synovium, commonly affecting the knee. Arthroplasty can successfully manage arthrosis in this population; however, outcome data is limited. The purpose of this study was to investigate the oncologic and functional outcome of patients undergoing total knee arthroplasty (TKA) in the setting of PVNS.

METHODS

48 patients were identified at our institution with histologically confirmed PVNS that subsequently received TKA. The cohort consisted of 28 females and 20 males with a mean age and body mass index of 61years and 29.2kg/m². 37patients had "active" disease, defined as diffuse in 40 patients and focal in eight. Mean follow-up was 14years.

RESULTS

The 10-year disease free-survival was 88%. Recurrence occurred in 6 patients and was treated with synovectomy and revision arthroplasty (n=4), local excision (n=1) and transfemoral amputation (n=1). 25 patients sustained at least 1 complication, most commonly decreased knee range of motion. Complications resulted in revision TKA in 10 patients (21%). There was no difference (P=0.74) between mean pre- and postoperative ROM; however, there was a significant reduction in the number of patients with a flexion contracture >15° (P=0.03). The mean Knee Society score and functional score significantly improved following surgery (P<0.001).

CONCLUSIONS

This study indicates arthroplasty in the setting of PVNS improves patient function and reduces the presence of flexion contractures. Patients with a history of PVNS should be cautioned when undergoing arthroplasty on the elevated risk of subsequent procedures.

LEVEL OF EVIDENCE

Level III.

Cement-within-cement technique in revision reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the complications and results of cement-within cement-humeral fixation in revision reverse shoulder arthroplasty.

METHODS

In 38 shoulders, a cemented humeral component was revised to a cemented reverse humeral component using a cement-within-cement technique. The mean follow-up time was 3.7 (2.0-7.0) years. Clinical, radiologic, and hard outcomes were assessed using the Kaplan-Meier survival method, Fisher exact test, and Student t-test.

RESULTS

The average operative time for the cement-within-cement technique was 153 minutes. There were 7 (18%) nondisplaced intraoperative fractures involving the greater tuberosity that occurred on implant removal; all healed at last follow-up. A second revision surgery was performed in 3 (8%) patients who underwent cement-in-cement humeral component revision for glenoid loosening (n = 1), periprosthetic instability associated with glenoid loosening (n = 1), and periprosthetic humerus fracture (n = 1). The overall implant revision-free survival at 2 and 5 years was 95% and 91%, respectively. Patients experienced significant pain relief, improvements in their shoulder range of motion, and high satisfaction. There was 1 "at-risk" humeral component (grade 4 or higher humeral lucency, moderate subsidence) that did not undergo revision surgery. There were 2 other humeral components with grade 3 humeral lucency, no subsidence.

CONCLUSIONS

Cement-within-cement fixation of the humeral component in revision reverse shoulder arthroplasty is associated with a reasonable operative time, good medium-term survival rates, and good pain relief and functional outcomes with low complications. This technique is an important consideration to preserve humeral bone stock and potentially humeral component and implant stability.

Outcomes and Complications of Reconstruction with Use of Free Vascularized Fibular Graft for Spinal and Pelvic Defects Following Resection of a Malignant Tumor

BACKGROUND

Following resection of malignant tumors of the spine and pelvis, reconstructive surgeons often face large structural defects. Unlike reconstruction in the extremities, wherein a free vascularized fibular graft (FVFG) is a highly utilized option for segmental osseous reconstruction, there are limited data on the use of an FVFG in the spine and pelvis. The aim of this study was to review our institution's experience with reconstruction with use of an FVFG following oncological resection in the spine and pelvis.

METHODS

We reviewed 24 cases involving the use of an FVFG in reconstruction of segmental osseous defects of the spine and pelvis following oncological resection from 2000 to 2015. The cohort consisted of 12 male and 12 female patients with a mean age of 37 years and a mean follow-up of 5 years. Fifty-four percent of the reconstructions were spinopelvic or sacropelvic.

RESULTS

The overall 2, 5, and 10-year rate of survival was 76%, 55%, and 37%, respectively. With regard to disease-free survival, the overall 2, 5, and 10-year rate was 81%, 72%, and 48%. The overall rate of union was 86%, with a mean time to union of 7 months. Complications were common, with 83% of the patients sustaining at least 1 postoperative complication. Following the procedure, the mean Musculoskeletal Tumor Society rating was 53%.

CONCLUSIONS

An FVFG provides a durable means of reconstruction of osseous defects in the spine and pelvis. Although patient function was acceptable following these large reconstructions, the rate of postoperative complications was high.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High Rate of Local Recurrence and Complications Following Total Knee Arthroplasty in the Setting of Synovial Chondromatosis

BACKGROUND

Synovial chondromatosis is a rare, monoarticular arthropathy due to synovial metaplasia. There is a paucity of data examining the outcome of total knee arthroplasty (TKA) in the setting of synovial chondromatosis. The purpose of this study is to investigate the outcome and function in patients undergoing TKA for management of synovial chondromatosis.

METHODS

Twenty patients who received TKA for synovial chondromatosis over a 25-year period were identified for analysis and followed for a mean of 7 years. There were 12 males and 8 females, with a mean age and body mass index of 63 years and 30.7 kg/m². Seventeen patients had "active" disease at the time of surgery.

RESULTS

The 5-year disease-free survival was 73%. Five patients sustained a recurrence that was treated with synovectomy and revision TKA (n = 2), observation (n = 2), and transfemoral amputation (n = 1) due to malignant degeneration to chondrosarcoma. One of the revision TKA patients underwent a transfemoral amputation 4 months later for recurrence. The overall rate of amputation was 10%. Nine patients (45%) sustained a complication, most commonly decreased knee motion (n = 7), leading to a revision TKA in 3 patients (15%). Mean preoperative knee range of motion was 73°, which improved to 97° postoperatively. The Knee Society Score and functional assessment improved from 35 and 42 preoperatively to 74 and 67 following TKA.

CONCLUSION

TKA in the setting of synovial chondromatosis improves patient function and knee range of motion; however, there is a high rate of local recurrence and complications.

Increasing Body Mass Index Is Associated with Worse Outcomes After Shoulder Arthroplasty

BACKGROUND

Although obesity is associated with increased complication rates after lower-extremity arthroplasty, there is a relative paucity of studies examining the effect of body mass index (BMI) on shoulder arthroplasty. The purpose of this investigation was to evaluate the effect of BMI on implant survival and the rate of complications after shoulder arthroplasty.

METHODS

Using an institutional total joint registry, 4,567 consecutive shoulder arthroplasty cases from 1970 to 2013 were studied. The mean BMI was 29.7 kg/m (range, 14 to 66 kg/m), with 1,622 patients (36%) with a BMI of 30 to 40 kg/m and 297 patients (7%) with a BMI of >40 kg/m. There were 2,493 female patients (55%). BMI was dichotomized after examination of the smoothing spline curve. The associations of factors and complications were assessed using Cox proportional hazard regression analysis.

RESULTS

Increasing BMI was associated with an increased risk of a revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection, and it was negatively associated with risk of a periprosthetic fracture. The risk of a revision surgical procedure increased in a linear fashion with increasing BMI (hazard ratio [HR], 1.05, or a 5% increased risk per 1 unit of BMI; p = 0.03). Increased BMI was also associated with an increased risk of revision for mechanical failure (HR, 1.05; p = 0.004). In a multivariate model, the association of BMI and risk of a revision for any reason, revision for mechanical failure, and reoperation maintained significance (p ≤ 0.02). The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection (HR, 1.09; p = 0.03).

CONCLUSIONS

Increasing BMI is strongly associated with increased rates of revision surgical procedures and postoperative complications after shoulder arthroplasty. It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty in Patients with Cerebral Palsy: A Cohort Study Matched to Patients with Osteoarthritis

BACKGROUND

The spasticity and increased muscle tone observed in patients with cerebral palsy can lead to hip degeneration, subluxation, and pain. Currently, there is hesitation to perform total hip arthroplasty in patients with cerebral palsy because of fears of early wear and dislocation. The purpose of this study was to review the outcomes of total hip arthroplasty in patients with cerebral palsy and to compare outcomes with those of matched patients with a diagnosis of osteoarthritis.

METHODS

Over a 24-year period, 39 patients undergoing a total hip arthroplasty with a diagnosis of cerebral palsy were identified. The cohort included 26 male patients (67%), and the mean patient age was 49 years. The mean follow-up was 7 years. Patients with cerebral palsy were matched 1:2 with a group of patients undergoing total hip arthroplasty for osteoarthritis.

RESULTS

There was no difference in the rate of reoperation, implant survival, or complications, specifically dislocation. Prior to the surgical procedure, all patients had severe or moderate pain, and postoperatively no patient had moderate or severe pain. Twenty-three patients had an improvement in their ability to independently walk, and all preoperative hip flexion contractures were corrected (n = 9). There was also a significant improvement (p < 0.0001) in functional Harris hip scores.

CONCLUSIONS

This study refutes previous evidence showing increased risk of complications following total hip arthroplasty in patients with cerebral palsy. Total hip arthroplasty is a durable treatment option and provides clinically important pain relief and functional improvement in patients with cerebral palsy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes

Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.

Metal or Modularity: Why Do Metal-Backed Tibias Have Inferior Outcomes to All-Polyethylene Tibial Components in Patients With Osteoarthritis

BACKGROUND

Biomechanical studies have suggested improved stress distribution in metal-backed (MB) compared to all-polyethylene (AP) tibias, but such potential benefits have not been realized clinically. The purpose of this investigation was to analyze the outcomes of AP components in patients with primary osteoarthritis and compare the results to those obtained with MB tibial components in total knee arthroplasty (TKA).

METHODS

We reviewed 11,653 patients undergoing primary TKA for osteoarthritis. There were 9999 (86%) MB (8470 modular and 1529 monoblock) and 1654 (14%) AP tibial components. All patients had at least 2 years of clinical follow-up with mean follow-up of 8 years (range, 2-30 years).

RESULTS

Mean survivorship for all primary TKAs at the 5-year, 10-year, 15-year, and 20-year time points was 97%, 92%, 86%, and 78%. AP tibial components were found to have improved survivorship when compared to modular and monoblock MB counterparts (P < .0001). Likewise, AP tibial components were found to have lower rates of tibial component loosening (P < .0001), tibial osteolysis, and component fracture. Furthermore, the AP group had improved survival rates in most age-groups except <55 years where there was no difference. AP tibial components demonstrated improved survival for all body mass index (BMI) groups except in patients with a BMI ≤25 kg/m² where there was no difference.

CONCLUSION

AP tibial components had significantly improved implant survival across all age-groups and most BMI categories in patients who underwent TKA for osteoarthritis. Given these outcomes, AP tibias are a reasonable option, regardless of patient age and BMI.

The outcome and complications of vascularised fibular grafts

AIMS

Free vascularised fibular grafting has been used for the treatment of large bony defects for more than 40 years. However, there is little information about the risk factors for failure and whether newer locking techniques of fixation improve the rates of union. The purpose of this study was to compare the rates of union of free fibular grafts fixed with locking and traditional techniques, and to quantify the risk factors for nonunion and failure.

PATIENTS AND METHODS

A retrospective review involved 134 consecutive procedures over a period of 20 years. Of these, 25 were excluded leaving 109 patients in the study. There were 66 men and 43 women, with a mean age of 33 years (5 to 78). Most (62) were performed for oncological indications, and the most common site (52) was the lower limb. Rate of union was estimated using the Kaplan-Meier method and risk factors for nonunion were assessed using Cox regression. All patients were followed up for at least one year.

RESULTS

The rate of union was 82% at two years and 97% at five years. Union was achieved after the initial procedure in 76 patients (70%) at a mean of ten months (3 to 19), and overall union was achieved in 99 patients (91%). No surgical factor, including the use of locked fixation or supplementary corticocancellous bone grafts increased the rate of union. A history of smoking was significantly associated with a risk of nonunion.

DISCUSSION

Free vascularised fibular grafting is a successful form of treatment for large bony defects. These results suggest that the use of modern techniques of fixation does not affect the risk of nonunion when compared with traditional forms of fixation, and smoking increases the risk of nonunion following this procedure. Cite this article: Bone Joint J 2017;99-B:134-8.

What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?

Soft tissue sarcomas of the foot and ankle are common. Currently, there exist limited data on prognostic variables. The aim of this study was to review our institution's experience with soft tissue sarcomas of the foot and ankle to identify factors affecting outcomes and survivorship. We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size ≥3 cm in maximal dimension was the greatest risk factor in mortality. Posttreatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were ≥3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications.

LEVELS OF EVIDENCE

Level IV: Retrospective Case Series.

Single-Anesthetic Versus Staged Bilateral Total Hip Arthroplasty: A Matched Cohort Study

BACKGROUND

There is debate regarding the role of single-anesthetic versus staged bilateral total hip arthroplasty (THA) for patients with end-stage bilateral osteoarthritis. Studies have shown that single-anesthetic bilateral THA is associated with systemic complications, but there are limited data comparing patient outcomes in a matched setting of bilateral THA.

METHODS

We identified 94 patients (188 hips) who underwent single-anesthetic bilateral THA. Fifty-seven percent of the patients were male. Patients had a mean age of 52.2 years and body mass index of 27.1 kg/m. They were matched 1:1 on the basis of sex, age (±1 year), and year of surgery (±3 years) to a cohort of patients undergoing staged bilateral THA. In the staged group, there was <1 year between procedures (range, 5 days to 10 months). Mean follow-up was 4 years for each group.

RESULTS

Patients in the single-anesthetic group experienced shorter total operating room time and length of stay. There was no difference (hazard ratio [HR] = 0.73, p = 0.50) in the overall revision-free survival in patients undergoing single-anesthetic or staged bilateral THA. The risks of reoperation (HR = 0.69, p = 0.40), complications (HR = 0.83, p = 0.48), and mortality (HR = 0.47, p = 0.10) were similar. Single-anesthetic bilateral THA reduced the total cost of care (by 27%, p = 0.0001).

CONCLUSIONS

In this matched cohort analysis, single-anesthetic bilateral THA was not associated with an increased risk of revision, reoperation, or postoperative complications, while decreasing cost. In our experience, single-anesthetic bilateral THA is a safe procedure that, for certain patients, offers an excellent means to deal with bilateral hip osteoarthritis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Glenoid Bone-Grafting in Revision to a Reverse Total Shoulder Arthroplasty: Surgical Technique

Introduction

Reverse shoulder arthroplasty has emerged as a very good treatment option for patients in salvage situations, such as the revision setting with glenoid bone loss.

Indications & Contraindications

Step 1 Preoperative Evaluation and Planning

For patients undergoing revision shoulder arthroplasty, perform the preoperative evaluation with radiographs, computed tomography (CT), and digital templating software as they play a key role (Video 1).

Step 2 Surgical Approach and Humeral Component Management

Perform all operations with the patient in the beach-chair position.

Step 3 Glenoid Component Removal and Preparation

Glenoid exposure is the key to the operation.

Step 4 Assessment of Glenoid Bone Stock and Bone-Grafting Algorithm

Use bone graft if the glenoid is thought to be inadequate for stable fixation in an acceptable position.

Step 5-A Manage a Peripheral Defect with ≥50% Implant-Bone Contact with a Structural Allograft or Humeral Autograft

When a peripheral defect contributes to either glenoid anteversion (anterior) or retroversion (posterior), but the implant has ≥50% contact with the native bone, consider using a structural autograft from the local humerus (preferred), if available, or a structural allograft (Video 1).

Step 5-B Manage a Peripheral Defect with <50% Implant-Bone Contact with a Structural Autograft from the Iliac Crest or Proximal Part of the Humerus

In shoulders with a peripheral defect with <50% contact with the native glenoid and substantial alterations in glenoid version, consider using a structural autograft from the proximal part of the humerus (preferred), if available, or the iliac crest (Figs. 2-A, 2-B, 2-C, and 3; Video 1).

Step 5-C Manage a Central Defect with ≥30% Implant-Bone Contact with Morselized Bone-Grafting Allograft or Autograft

In shoulders with a central defect with ≥30% contact between the baseplate and the native glenoid, with adequate primary stability of the central screw and/or peg, use morselized local autograft (preferred), if available, or corticocancellous allograft, to restore the lateral offset of the native glenoid and implant-bone contact area.

Step 5-D Manage a Central Global Defect with <30% Implant-Bone Contact with a Structural Autograft from the Iliac Crest or Proximal Part of the Humerus

As a large central or global deficiency can lead to excessive glenoid medialization (Figs. 4-A, 4-B, and 4-C), use a structural tricortical autograft from the iliac crest to restore glenoid structure and support implantation, as well as increase the offset of the glenoid component, enhancing stability and potentially reducing the risk of scapular notching⁸.

Step 5-E Manage a Superior Defect with <50% Implant-Bone Contact and Loss of Tilt with a Structural Autograft from the Iliac Crest or Proximal Part of the Humerus

For a superior deficiency with <50% contact between the implant and the native bone and a loss of neutral tilt, avoid superior tilt as it is critical to obtain either neutral or inferior tilt of the glenoid (keep this in mind when placing the central cannulated Kirschner wire for drilling the central screw) and use structural autograft for larger defects to prevent superior tilt, with the source of the graft preferentially from the humeral neck resection; however, if there is not adequate proximal humeral bone, a tricortical graft from the ipsilateral iliac crest can be used.

Step 6 Placement of Baseplate Screws and Glenosphere and Implantation of the Humeral Component

Step 7 Postoperative Care

Results

In our practice, glenoid bone-grafting was performed in 29% of the 143 shoulders revised using reverse components².

Pitfalls & Challenges

Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis

BACKGROUND

Surgical treatment of proximal humeral fractures in the elderly pose challenges in decision making. Reverse total shoulder arthroplasty (RTSA) has been established as a reliable option for salvage of failed hemiarthroplasty, although few studies have analyzed RTSA after failed open reduction with internal fixation (ORIF). This study evaluated the outcomes of patients with failed osteosynthesis who undergo salvage RTSA compared with patients undergoing primary RTSA for proximal humeral fractures.

METHODS

We retrospectively reviewed 18 patients who underwent primary RTSA for acute proximal humeral fractures and 26 patients who underwent arthroplasty after failed ORIF at our institution between 2003 and 2013. Minimum follow-up was 2 years, with a mean follow-up 3 years (range, 2.0-6.0 years).

RESULTS

There are no statistically significant differences in clinical outcomes between the two cohorts in the American Shoulder and Elbow Surgeons scores and in the most recent forward flexion or external rotation. The salvage RTSA cohort experienced a higher complication rate (8%), including dislocation and aseptic loosening. The primary RTSA cohort had a 5% complication rate, with 1 late prosthetic joint infection requiring reoperation.

CONCLUSION

Although RTSA after failed ORIF has a higher rate of complications compared with acute RTSA, the revision and reoperation rate as well as clinical outcomes and shoulder function remained comparable. When a surgeon approaches these complex fractures in patients with poor underlying bone stock, this study supports acute arthroplasty or ORIF with the knowledge that salvage RTSA still has the potential to achieve good outcomes if osteosynthesis fails.

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.

Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience

AIMS

The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs).

PATIENTS AND METHODS

From our hospital's prospectively collected database we identified all patients who had undergone a revision THA between 1969 and 2011 which involved the femoral stem. The patients' medical records and radiographs were examined and the relevant data extracted. Post-operative periprosthetic fractures were classified using the Vancouver system. A total of 5417 revision THAs were identified.

RESULTS

There were 668 intra-operative fractures, giving an incidence of 12%. Fractures were three times more common with uncemented stems (19%) than with cemented stems (6%) (p < 0.001). The incidence of intra-operative femoral fracture varied by uncemented stem type: fully-coated (20%); proximally-coated (19%); modular fluted tapered (16%) (p < 0.05). Most fractures occurred during the insertion of the femoral component (35%). One-third involved the diaphysis and 26% were of the calcar: 69% were undisplaced. There were 281 post-operative fractures of the femur (20-year probability = 11%). There was no difference in risk for cemented and uncemented stems. Post-operative fractures were more common in men < 70 years (p = 0.02). Periprosthetic fractures occurred earlier after uncemented revision of the femoral component, but later after a cemented revision. The most common fracture type was a Vancouver B1 (31%). Of all post-operative fractures, 24% underwent open reduction and internal fixation and 15% revision arthroplasty.

CONCLUSION

In revision THA, intra-operative fractures occurred three times more often with an uncemented stem. Many were undisplaced diaphyseal fractures treated with cerclage fixation. While the risk of post-operative fracture is similar between uncemented and cemented components, they occur at notably different times depending on the type of stem fixation.

TAKE HOME MESSAGE

In revision THA, intra-operative periprosthetic femoral fractures occur three times more often with uncemented stems. Many are non-displaced diaphyseal fractures treated with cerclage fixation. While postoperative fracture risks are equivalent between uncemented and cemented components, they occur at notably different time periods based on stem fixation type.

Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience

AIM AND METHODS

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

RESULTS

There were 564 intra-operative fractures (1.7%); 529 during uncemented stem placement (3.0%) and 35 during cemented stem placement (0.23%). Intra-operative fractures were more common in females and patients over 65 years (p < 0.001). The majority occurred during placement of the femoral component (60%), and involved the calcar (69%). There were 557 post-operative fractures (20-year probability: 3.5%; 95% confidence interval (CI) 3.2 to 3.9); 335 fractures after placement of an uncemented stem (20-year probability: 7.7%; 95% CI 6.2 to 9.1) and 222 after placement of a cemented stem (20-year probability: 2.1%; 95% CI 1.8 to 2.5). The probability of a post-operative fracture within 30 days after an uncemented stem was ten times higher than a cemented stem. The most common post-operative fracture type was a Vancouver AG (32%; n = 135), with 67% occurring after a fall. In all, 36% (n = 152) were treated with revision arthroplasty.

CONCLUSION

In summary, intra-operative fractures occur 14 times more often with uncemented stems. Female patients over 65 years of age are at highest risk. Post-operative fractures are also most common with uncemented stems, but are independent of age or gender. Cumulative risk of post-operative periprosthetic femur fracture was 3.5% at 20 years.

TAKE HOME MESSAGE

Intra-operative fractures occur 14 times more often with uncemented stems, particularly with female patients over 65 years of age, while post-operative fracture risk is independent of age or gender, but still increased with uncemented stems.

Subcutaneous Fat Thickness Is Associated With Early Reoperation and Infection After Total Knee Arthroplasty in Morbidly Obese Patients

BACKGROUND

Morbid obesity has been associated with increased complications after primary total knee arthroplasty (TKA), but previous studies have failed to take factors such as body composition and fat distribution into consideration. The aims of this study were to (1) assess the interobservable and intraobservable reliabilities of measuring anterior knee subcutaneous fat thickness on lateral knee radiographs and (2) determine if these measurements associate with early complications in patients with morbid obesity.

METHODS

Using a retrospective case-control analysis, we reviewed 1689 primary TKAs performed in morbidly obese patients at our institution from 1995 to 2012. All patients (n = 58) who required reoperation for wound complication or infection within 90 days were compared to a matched cohort of morbidly obese patients who did not require early reoperation. Distances from patella skin (prepatellar thickness) and tibial tubercle skin (pretubercular thickness) were measured on routine lateral knee radiographs and associated with outcomes.

RESULTS

Intraobserver and interobserver reliabilities were excellent for both measurements. Knees in the reoperation group had significantly greater prepatellar (P = .0001) and pretubercular (P = .0006) soft tissue thickness. Prepatellar thickness ≥15 mm and pretubercular thickness ≥25 mm increased the risk of early reoperation by 2.0× (P = .0003) and 1.6× (P = .023), respectively, and were more predictive measurements than body mass index.

CONCLUSION

Anterior knee subcutaneous fat thickness can be reproducibly measured on lateral knee radiographs and is associated with a significantly increased risk of early reoperation for wound complications and infection after primary TKA in morbidly obese patients.

Outcomes of primary reverse shoulder arthroplasty in patients with morbid obesity

BACKGROUND

Obesity is a risk factor for worse outcomes in anatomic shoulder arthroplasty. The purpose of this investigation was to determine outcomes of primary reverse shoulder arthroplasty (RSA) in patients with morbid obesity.

METHODS

We reviewed all primary RSAs performed on morbidly obese (body mass index [BMI] ≥40 kg/m(2)) patients from 2005 to 2012 at our institution with at least 2 years of follow-up. The study included 41 patients (57% female), the mean BMI was 44 kg/m(2), and the mean age was 67.7 years.

RESULTS

The only intraoperative complication was an inferior glenoid fracture that remained stable after glenosphere implantation. At a mean follow-up of 3.2 years (range 2-7.36 years), 2 patients (5%) required revision surgery for infection (n = 1) and humeral loosening (n = 1). Survival was 98% at 2 years and 92% at 5 years. Additional postoperative complications included ulnar neuropathy (n = 1) and heterotopic ossification (n = 2). Pain relief was excellent, with 93% reporting moderate or severe pain preoperatively compared with 2% postoperatively (P < .001). Shoulder abduction improved from 49° to 142° and external rotation from 17° to 50° (P < .001). The average American Shoulder and Elbow Surgeons score was 71.1. At the most recent follow-up, no patients had glenoid lucency, 1 (2%) had humeral lucency, and 2 (5%) had inferior scapular notching. Laborers had higher risk for revision surgery (P = .01), and females had worse functional outcomes and shoulder motion (P < .02).

CONCLUSIONS

RSA is a successful procedure in morbidly obese patients (BMI ≥40 kg/m(2)). At intermediate follow-up, there is good implant survival with a reasonable complication rate and excellent pain relief.

All-Polyethylene Tibial Components: An Analysis of Long-Term Outcomes and Infection

BACKGROUND

There is debate regarding tibial component modularity and composition in total knee arthroplasty (TKA). Biomechanical studies have suggested improved stress distribution in metal-backed tibias; however, these results have not translated clinically. The purpose of this study was to analyze the outcomes of all-polyethylene components and to compare the results to those with metal-backed components.

METHODS

We reviewed 31,939 patients undergoing a primary TKA over a 43-year period (1970-2013). There were 28,224 (88%) metal-backed and 3715 (12%) all-polyethylene tibial components. The metal-backed and all-polyethylene groups had comparable demographics with respect to gender, age and body mass index (BMI). Mean follow-up was 7 years.

RESULTS

The mean survival for all primary TKAs at the 5-, 10-, 20- and 30-year time points was 95%, 89%, 73%, and 57%, respectively. All-polyethylene tibial components were found to have a significantly improved (P < .0001) survivorship when compared with their metal-backed counterparts. All-polyethylene tibial components were also found to have a significantly lower rate of infection, instability, tibial component loosening, and periprosthetic fracture. The all-polyethylene group had improved survival rates in all age groups, except in patients 85 years old or greater, where there was no significant difference. All-polyethylene tibial components had improved survival for all BMI groups except in the morbidly obese (BMI ≥ 40) where there was no significant difference.

CONCLUSION

All-polyethylene tibial components had significantly improved implant survival, reduced rates of postoperative infection, fracture, and tibial component loosening. All polyethylene should be considered for most of the patients, regardless of age and BMI.

Functional and oncologic outcome of cemented endoprosthesis for malignant proximal femoral tumors

BACKGROUND

Cemented endoprosthetic replacement is an option for reconstruction of the proximal femur to achieve limb salvage. Existing outcome studies combine benign and malignant conditions, or group endoprostheses from multiple areas into one cohort. We sought to examine a series of endoprosthetic replacements of the proximal femur for a malignant process.

METHODS

We reviewed 204 patients who underwent an endoprosthesis for a malignant process of the proximal femur with at least 2-year follow-up. Mean age was 59 years, with 55% being male. The most common pathology was metastatic disease (n = 120, 59%). Mean follow-up was 7 years (2-22 years). Mean time to death was 2 years (range 2 weeks-18 years). A bipolar component was used in 93% of patients.

RESULTS

5-year survival was 8% in patients with metastatic disease and 54% for patients with primary disease. Local recurrence and metastatic disease developed in 5 and 19 patients with a primary sarcoma. Following the procedure the mean Harris Hip and Musculoskeletal Tumor Society Scores were 75 and 18.

CONCLUSION

Patients typically succumb to their disease prior to implant failure; however, endoprosthetic replacement provides patients with an acceptable means of functional recovery with an acceptable complication profile. J. Surg. Oncol. 2016;114:501-506. © 2016 Wiley Periodicals, Inc.

Decreased Osteogenic Activity of Mesenchymal Stem Cells in Patients With Corticosteroid-Induced Osteonecrosis of the Femoral Head

BACKGROUND

Osteonecrosis (ON) of the femoral head occurs when cells of trabecular bone spontaneously die. Mesenchymal stem cells (MSCs) have been introduced into the femoral head in an attempt to halt progression of the disease. The purpose of this study was to functionally compare MSCs in patients with ON of the femoral head with patients without.

METHODS

Mesenchymal stem cells were isolated from 20 patients with corticosteroid-induced ON and 10 controls without. Colony-forming unit and proliferation assays were used to assess MSC proliferation. Mesenchymal stem cells were differentiated into bone, fat, and cartilage. Functional assays were used to quantify the differentiation capacity.

RESULTS

Control MSCs demonstrated greater cellular growth potential and improved ability to differentiate into bone.

CONCLUSION

The decreased ability to differentiate into bone may be a reason why patients treated with autologous MSC infusion fail regenerative treatment strategies and progress to collapse.

Insulin Dependence Increases the Risk of Failure After Total Knee Arthroplasty in Morbidly Obese Patients

The aims of this study were to compare the outcomes between nondiabetic (n=1284), type II diabetic (n=530), and insulin-dependent type II diabetic (n=164) morbidly obese (body mass index ≥40 kg/m(2)) patients undergoing primary total knee arthroplasty at 6-year follow-up. Patients with type II diabetes mellitus (DM) had similar outcomes when compared with non-DM patients. However, patients with insulin dependence had an increased risk of reoperation (hazard ratio [HR], 1.8; P=.005), revision (HR, 2; P=.02), and periprosthetic joint infection (HR, 2.1; P=.03), as well as decreased 10-year implant survivorship (84% vs 92%; P=.01) when compared to non-DM patients. Prospective studies should further evaluate outcomes and optimization measures within this population.

LEVEL OF EVIDENCE

Level III-prognostic study.

Long term outcomes of cemented endoprosthetic reconstruction for periarticular tumors of the distal femur

BACKGROUND

In order to achieve an oncological margin during limb salvage surgery for tumors of the distal femur, part or the entire knee joint is frequently sacrificed. Endoprosthetics make limb salvage possible through restoration of a functional extremity. Currently there remains a paucity of data concerning their long-term outcomes and associated risk factors for failure.

METHODS

We identified 152 patients who underwent an endoprosthetic reconstruction for an oncological process of the distal femur between 1972 and 2013. The mean follow-up was 10years. Mean age and body mass index (BMI) were 39years and 25.8 respectively. The most common pathology was osteosarcoma (n=78, 48%). Outcomes were compared to a control group of 20,643 patients undergoing total knee arthroplasty (TKA) for degenerative joint disease (DJD) during the same time period.

RESULTS

The mean five-, 10-, 15-, 20-, and 25-year revision-free survival for an endoprosthesis was 76%, 63%, 51%, 36%, and 28%. Compared to the five-, 10-, 15-, 20-, and 25-year survival of 95%, 90%, 82%, 74%, and 67% for control TKAs (p<0.0001 at all-time points). Overall limb survival was 93%, with 11 patients undergoing amputation. There was no difference in implant survival comparing modular and custom endoprostheses.

CONCLUSION

The results of this study show that given the complexity of these operations, the rate of revision surgery following endoprosthetic replacement is high. Nevertheless, the use of these modular reconstructions leads to a high rate of limb salvage (93%) over a 25-year period at our institution.

LEVEL OF EVIDENCE

Level III.

Ceramic Femoral Heads for All Patients? An Argument for Cost Containment in Hip Surgery

Trunnionosis and taper corrosion have recently emerged as problems in total hip arthroplasty (THA). No longer restricted to metal-on-metal bearings, these phenomena now affect an increasing number of metal-on-polyethylene THAs and are exacerbated by modularity. Resulting increases in metal toxicity and patient morbidity, and the added costs of toxicity surveillance and revision surgery, will place a substantial economic burden on many health systems. Although they are more expensive than cobalt-chrome heads, ceramic femoral heads make metal toxicity a nonissue. In this article, we provide a theoretical framework for debating whether use of ceramic femoral heads in all THA patients could represent a more cost-effective option.

Direct Anterior Versus Posterior Simultaneous Bilateral Total Hip Arthroplasties: No Major Differences at 90 Days

We conducted a study to compare 90-day outcomes of patients who underwent simultaneous bilateral total hip arthroplasties (THAs) through the direct anterior (DA) approach (n = 19 patients) or the posterior approach (n = 21) over a 2-year period (2012-2014). Compared with patients in the posterior group, patients in the DA group had longer operative times (153 vs 106 min; P < .001) and longer anesthesia times (257 vs 221 min; P = .007) but were more likely to be discharged home (100.0% vs 71.4%; P = .02). DA THA was associated with a larger amount of intraoperative blood salvage (1.4 vs 0.5 unit; P = .003), but the groups had similar postoperative hemoglobin levels (10.6 vs 10.3 g/dL; P = .49) and allogenic blood transfusion rates (0% vs 14.3%; P = .23). Simultaneous bilateral THAs can be safely performed through either the DA approach or the posterior approach. Outcomes at 90 days are similar.

The Chitranjan Ranawat Award: Running Subcuticular Closure Enables the Most Robust Perfusion After TKA: A Randomized Clinical Trial

BACKGROUND

Maintaining robust perfusion is an important physiologic parameter in wound healing. The effect of different closure techniques on wound perfusion after total knee arthroplasty (TKA) has not been established previously and may have implications for wound healing.

QUESTIONS/PURPOSES

We asked whether a running subcuticular, vertical mattress, or skin staple closure technique enables the most robust wound perfusion after TKA as measured by laser-assisted indocyanine green angiography (LA-ICGA) in patients without specific risk factors for wound healing complications.

METHODS

Forty-five patients undergoing primary TKA without comorbidities known to impact wound healing and perfusion were prospectively randomized to receive superficial skin closure with one of the following techniques: (1) running subcuticular (3-0 monofilament); (2) vertical mattress (2-0 nylon); or (3) skin staples. Twenty procedures were performed by RTT, 15 by RJS, and 10 by FHS. All surgeons used an anterior skin incision over the medial third of the patella in combination with a median parapatellar arthrotomy. Perfusion was assessed with a LA-ICGA device and software system immediately after closure to quantify fluorescence. Twenty-seven points were assessed immediately after closure in the operating room in each patient (nine along the incision and nine pairs medial and lateral to the incision). Mean incision perfusion was determined from the nine points along the incision with higher values indicating greater blood flow. Mean perfusion impairment was determined by calculating the difference between the nine pairs of surrounding skin and the nine points along the incision with smaller values indicating less perfusion impairment. These parameters were compared with analysis of variance (ANOVA) and subsequent pairwise comparisons with an unadjusted analysis as well as a multivariate analysis that adjusted for age, sex, and body mass index. Patients were followed for a mean of 7 months after surgery (range, 3-12 months) for possible incision-related complications. No patents were lost to followup.

RESULTS

Running subcuticular closure demonstrated the best overall perfusion. Mean incision perfusion in fluorescent units with SD was as follows: running subcuticular, 64 (16); vertical mattress, 32 (18); and staples, 19 (7) (ANOVA p < 0.001). The running subcuticular closure demonstrated the least impairment of perfusion among the closures compared. Mean perfusion impairment was as follows: running subcuticular, 21 (12); vertical mattress, 37 (24); and staples, 69 (27) (ANOVA p < 0.001). All Tukey-adjusted pairwise comparisons from both metrics likewise favored the subcuticular closure (p < 0.001) both before and after adjusting for age, sex, and body mass index. One patient in the vertical mattress cohort experienced a surgical site infection; no other wound-related complications were observed in this study.

CONCLUSIONS

The method of closure can influence skin and soft tissue perfusion after TKA. Running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing. However, the clinical importance of these findings remains uncertain, because patients in this study were selected because they lacked risk factors for wound healing complications. Studies with this modality in specific patient populations at higher risk for wound complications will be necessary to quantify the clinical advantage of using running subcuticular closure.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Posttraumatic Total Knee Arthroplasty Continues to Have Worse Outcome Than Total Knee Arthroplasty for Osteoarthritis

Small studies have shown that patients who undergo TKA following a distal femur and/or tibial plateau fracture have inferior results. The purpose of this study was to evaluate the mid-term outcomes of a large group of patients undergoing TKA following periarticular knee fractures. We identified 531 patients who underwent a TKA following a periarticular fracture from 1990 to 2012; comparing outcomes to 19,641 patients undergoing primary TKA for osteoarthritis. Periarticular fracture significantly increased the risk of revision TKA, infection and complications. There was no difference in the need for revision TKA or infection based on fracture location. Patients with TKA following a periarticular fracture have worse overall revision free survival compared to with OA, with 1 in 4 patients requiring revision TKA by 15 years.

Elution of High Dose Amphotericin B Deoxycholate From Polymethylmethacrylate

Fungal periprosthetic joint infections are rare, devastating complications of arthroplasty. There is conflicting evidence as to the efficacy of amphotericin B elution from cement spacers. The purpose of this study was to determine whether concentrations of amphotericin B released from bone cement over time would be efficacious in treating a periprosthetic infection. A continuous flow chamber was used to evaluate the in vitro release of amphotericin from cement beads containing 7.5% amphotericin. Following polymerization, 3.3% of the initially loaded amphotericin B was detected. The peak mean concentration eluted from the bone cement was 0.33 μg/mL at 8 hours. The AUC0-24 was 2.79 μg/mL/h; 0.20% of the amphotericin B was released. In conclusion, amphotericin B is released from bone cement at a clinically useful concentration.