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1.  What Are Risk Factors for Intraoperative Humerus Fractures During Revision Reverse Shoulder Arthroplasty and Do They Influence Outcomes? 
With the increase in shoulder arthroplasty rates, the number of perioperative complications, such as periprosthetic fractures, continues to be a rise; however, the risk factors and incidence of intraoperative complications, such as fractures, during revision reverse shoulder arthroplasty are not well established.
We evaluated patients receiving a reverse shoulder arthroplasty to determine (1) the frequency and characteristics of intraoperative humerus fractures, (2) the risk factors for fracture, (3) the complications associated with treatment of fractures, and (4) clinical and functional outcomes after treatment.
Using one institution’s total joint registry, we performed a retrospective analysis of medical records of 224 patients (230 shoulders) who underwent revision surgery to reverse shoulder arthroplasty, from 2005 to 2012, for failed total shoulder arthroplasty. Reverse shoulder arthroplasty was used when there was a deficient rotator cuff, prior instability, or deficient glenoid bone stock. Intraoperative periprosthetic humerus fractures occurred in 36 shoulders (16%) (36 patients). The clinical outcome analysis included 29 patients with a minimum 2-year clinical followup (mean followup, 3.1 years; range, 2.0−6.3 years). The control group consisted of 188 patients (194 shoulders), and it was used for risk-factor calculation; whereas only 150 patients (154 shoulders) in the control group had a minimum 2-year followup, and thus only 150 patients (154 shoulders) made up the comparators (controls) for outcome-analysis comparisons. Risk factors were assessed using univariate analysis with odds ratios (OR), whereas implant survival and complications were assessed using the Kaplan-Meier method.
Three displaced and 33 nondisplaced fractures occurred during revision reverse total shoulder arthroplasties. Most of the fractures (81%) occurred during component removal of cemented (n = 11) and cementless (n = 25) components. Intraoperative fractures only were treated with stabilization of the prosthetic stem in 28 patients, while adjunctive internal fixation was used in eight patients. Risk of intraoperative periprosthetic fractures was increased by factors including female sex (n =18 women; OR, 2.41; range, 1.11−5.68; p = 0.03); history of instability (n = 27; OR, 2.65; range, 1.18−5.93; p = 0.02); and prior hemiarthroplasty (n = 22; OR, 2.34; range, 1.13−4.84; p = 0.03). There were two postoperative fractures in patients who had an intraoperative fracture and both were treated nonoperatively. Overall, three (8%) revision procedures were performed in patients with intraoperative fractures, with 2- and 5-year survivorship estimates of 94% and 85%, respectively, compared with 89% and 84%, respectively for patients without an intraoperative fracture (p = 0.45). At latest followup, patients experienced good postoperative pain relief, improved shoulder abduction, and good American Shoulder and Elbow Surgeon and Simple Shoulder Test scores.
Intraoperative humeral fractures occur in approximately 16% of shoulders undergoing revision surgery. Fractures during revision reverse TSA are not uncommon secondary to the risks of component removal in revision surgery and poor remaining bone stock. The risk seems to be greatest for female patients, patients with instability, and patients who have undergone previous hemiarthroplasties. Intraoperative humeral fractures should be approached in a systematic way to achieve anatomic reduction and stable fixation. When properly stabilized, these fractures appear not to substantially influence overall final outcome. This study provides a foundation for future investigation of methods to reduce the risk for intraoperative humeral fractures attributable to reverse revision TSA.
Level of Evidence
Level III, therapeutic study.
PMCID: PMC4562920  PMID: 26162412
2.  Elbow rheumatoid elbow: surgical treatment options 
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by peripheral polyarthritis. The elbow joint is estimated to be involved in 20 to 65 % of the patients with RA. The development of new pharmacologic agents and the adoption of early therapeutic interventions have translated into milder forms of polyarticular destruction. As a result, the traditional crippled rheumatoid patient has been replaced by rheumatoid patients with higher activity levels, higher expectations, and more demands on any reconstructive procedures performed. When nonoperative treatment is insufficient, surgery may be considered. Arthroscopic synovectomy has become the procedure of choice for rheumatoid patients with uncontrolled symptoms. Patients with more advanced joint destruction can be considered for elbow arthroplasty. Interposition arthroplasty may be considered for patients interested in avoiding the potential complications of elbow arthroplasty.
PMCID: PMC4896871  PMID: 27056576
Rheumatoid arthritis; Synovectomy; Elbow arthroscopy; Total elbow arthroplasty; Interposition arthroplasty
3.  The Mark Coventry Award 
Although highly porous metals have demonstrated excellent bone ingrowth properties and so are an intriguing option for fixation in total knee arthroplasty (TKA), some surgeons are skeptical about the durability of uncemented tibial fixation and the potential for soft tissues to adhere to these porous metals and perhaps cause knee stiffness or pain.
The purpose of this study was to compare, in the context of a randomized clinical trial, a highly porous metal tibia compared with a traditional modular cemented tibia in terms of survivorship, Knee Society scores, range of motion (ROM), and complications.
From 2003 to 2006, 397 patients (age 67.8 ± 8.7 years; 54% female) were randomized to three groups: (1) traditional modular cemented tibia; (2) cemented highly porous metal tibia; and (3) uncemented highly porous metal tibia. The same posterior-stabilized femoral component and patella component were cemented in every case. Stratified randomization was done for surgeon, patient’s age, sex, and body mass index. Survivorship at 5 years was compared between the groups, as were Knee Society scores, ROM, and complications. Radiographic assessment included alignment, radiolucency, and implant migration/loosening. Patients were followed until death, revision, or for a minimum of 2 years (mean, 5 years; range, 2–9 years). Four patients were lost to followup before 2 years.
Highly porous metal tibias (both uncemented and cemented) were no different from traditional cemented modular tibial modular components in terms of survivorship at 5 years using a intention-to-treat analysis (96.8% [1]; 97.6% [2]; 96.7% [3]; p = 0.59). A per-protocol analysis revealed that no highly porous metal tibia was revised for aseptic loosening. Highly porous metal tibias performed comparably to traditional cemented modular tibias in terms of Knee Society scores, ROM, and the frequency of complications.
At 5 years this randomized clinical trial demonstrated that highly porous metal tibias provided comparably durable fixation and reliable pain relief and restoration of function when compared with a traditional cemented modular tibia in TKA.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC4390908  PMID: 24687433
5.  Anconeus Interposition Arthroplasty: Mid- to Long-term Results 
Radiocapitellar arthritis and/or proximal radioulnar impingement can be difficult to treat. Interposition of the anconeus muscle has been described in the past as an alternative option in managing arthritis, but there are little published data about relief of pain and restoration of function over the long term in patients treated with this approach.
We sought (1) to determine whether interposition of the anconeus muscle in the radiocapitellar and/or proximal radioulnar joint relieves pain and restores elbow function; and (2) to identify complications and reoperations after anconeus interposition arthroplasty.
Between 1992 and 2012, we surgically treated 39 patients having radiocapitellar arthritis and/or proximal radioulnar impingement with an anconeus interposition arthroplasty. These were performed for situations in which capitellar and/or radial head pathology was deemed not amenable to implant replacement. We had complete followup on 29 of them (74%) at a minimum of 1 year (mean, 10 years; range, 1–20 years). These 29 patients (21 males, eight females) had interposition of the anconeus muscle at the radiocapitellar joint (10 elbows), the proximal radioulnar joint (two elbows), or both (17 elbows). Their mean age at the time of surgery was 39 years (range, 14–58 years). The reasons for the previous determination or the indications included lateral-side elbow symptoms after radial head resection (eight elbows), failed internal fixation of radial head fracture (two elbows), failed radial head replacement with or without capitellar replacement (four elbows), osteoarthritis and Essex-Lopresti injury (six elbows), failed internal fixation of distal humeral fracture involving the capitellum (two elbows), posttraumatic osteoarthritis involving the lateral compartment (one elbow), lateral compartment osteoarthritis associated with chondropathies (three elbows), and primary osteoarthritis affecting the lateral compartment (three elbows). Patient-reported outcome tools included the quick-Disabilities of the Arm, Shoulder and Hand (quick-DASH) and the Mayo Elbow Performance Score (MEPS); we also performed a chart review for complications and reoperations.
During the followup duration, the mean MEPS was significantly improved from (mean ± SD) 64 ± 17 points before surgery to 82 ± 14 points after surgery (p < 0.001) with 21 elbows (72%) graded as excellent or good at most recent followup. The mean quick-DASH score was 24 ± 17 points (n = 25) at latest evaluation. Two patients (7%) had perioperative complications, including wound dehiscence (one elbow) and transient posterior interosseous nerve palsy (one elbow). Seven patients (24%) underwent additional surgery.
Anconeus arthroplasty provides a reasonable surgical alternative in the armamentarium of procedures to address pathology at the radiocapitellar and/or proximal radioulnar joint. This procedure is especially attractive when other alternatives such as radial head replacement may be problematic secondary to capitellar erosion or marked proximal radius bone loss.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC4048403  PMID: 24872196
6.  Transverse Coronoid Fracture: When Does It Have to Be Fixed? 
After elbow fracture-dislocation, surgeons confront numerous treatment options in pursuing a stable joint for early motion. The relative contributions of the radial head and coronoid, in combination, to elbow stability have not been defined fully.
The purpose of this study was to evaluate the effect of an approximately 50% transverse coronoid fracture and fixation in the setting of an intact or resected radial head on coronal (varus/valgus) and axial (internal and external rotational) laxity in (1) gravity varus stress; and (2) gravity valgus stress models.
Kinematic data were collected on six fresh-frozen cadaveric upper extremities tested with passive motion throughout the flexion arc under varus and valgus gravity stress with lateral collateral ligaments reconstructed. Testing included coronoid fracture and osteosynthesis with and without a radial head.
In the varus gravity stress model, fixation of the coronoid improved varus stability (fixed: 1.6° [95% confidence interval, 1.0–2.2], fractured: 5.6° [4.2–7.0], p < 0.001) and internal rotational stability (fixed: 1.8° [0.9–2.7], fractured: 5.4° [4.0–6.8], p < 0.001), but radial head fixation did not contribute to varus stability (intact head: 2.7° [1.3–4.1], resected head: 3.8° [2.3–5.3], p = 0.4) or rotational stability (intact: 2.7° [0.9–4.5], resected head: 3.9° [1.5–6.3], p = 0.4). With valgus stress, coronoid fixation improved valgus stability (fixed: 2.1° [1.0–3.1], fractured: 3.8° [1.8–5.8], p < 0.04) and external rotation stability (fixed: 0.8° [0.1–1.5], fractured: 2.1° [0.9–3.4], p < 0.04), but the radial head played a more important role in providing valgus stability (intact: 1.4° [0.8–2.0], resected head: 7.1° [3.5–10.7], p < 0.001).
Fixation of a 50% transverse coronoid fracture improves varus and internal rotatory laxity but is unlikely to meaningfully improve valgus or external rotation laxity. The radial head, on the other hand, is a stabilizer to resist valgus stress regardless of the status of the coronoid.
Clinical Relevance
Determination as to whether it is necessary to fix a coronoid fracture should be based on the stability of the elbow when tested with a varus load. The elbow may potentially be stable with fractures involving less than 50% of the coronoid. Under all circumstances, the radial head should be fixed or replaced to ensure valgus external rotatory stability.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3477-1) contains supplementary material, which is available to authorized users.
PMCID: PMC4048411  PMID: 24585321
7.  Revision Allograft Reconstruction of the Lateral Collateral Ligament Complex in Elbows With Previous Failed Reconstruction and Persistent Posterolateral Rotatory Instability 
Primary reconstruction of the lateral collateral ligament complex (LCLC) using graft tissue restores elbow stability in many, but not all, elbows with acute or chronic posterolateral rotatory instability (PLRI). Revision reconstruction using a tendon allograft is occasionally considered for persistent PLRI, but the outcome of revision ligament reconstruction in this setting is largely unknown.
We determined whether revision allograft ligament reconstruction can (1) restore the stability and (2) result in improved elbow scores for patients with persistent PLRI of the elbow after a previous failed primary reconstructive attempt and in the context of the diverse pathology being addressed.
Between 2001 and 2011, 160 surgical elbow procedures were performed at our institution for the LCLC reconstruction using allograft tissue. Only patients undergoing revision allograft reconstruction of the LCLC for persistent PLRI with a previous failed primary reconstructive attempt using graft tissue and at least I year of followup were included in the study. Eleven patients (11 elbows) fulfilled our inclusion criteria and formed our study cohort. The cohort consisted of six female patients and five male patients. The mean age at the time of revision surgery was 36 years (range, 14–59 years). The revision allograft reconstruction was carried out after a mean of 3 years (range, 2.5 months to 9 years) from a failed attempted reconstruction of the LCLC. Osseous deficiency to some extent was identified in the preoperative radiographs of eight elbows. Mean followup was 5 years (range, 1–12 years).
Revision allograft reconstruction of the LCLC restored elbow stability in eight of the 11 elbows; two of the three elbows with persistent instability were operated on a third time (at 6 and 7 months after allograft revision reconstruction). For elbows with no persistent instability, the mean Mayo Elbow Performance Score at most recent followup was 83 points (range, 60–100 points), and six elbows were rated with a good or excellent result. All patients with persistent instability had some degree of preoperative bone loss.
Revision allograft reconstruction of the LCLC is an option for treating recurrent PLRI, although this is a complex and resistant problem, and nearly ½ of the patients in this cohort either had persistent instability and/or had a fair or poor elbow score.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4048414  PMID: 24728663
8.  Radial Head Reconstruction in Elbow Fracture-Dislocation: Monopolar or Bipolar Prosthesis? 
Monopolar and bipolar radial head prosthetic arthroplasties have been used successfully to treat elbow fracture-dislocation with unsalvageable radial head fractures. The relative stability of these two designs in different clinical situations is a topic of ongoing investigation.
We tested the effects of monopolar and bipolar fixed-neck prosthetic radial head implants on improvement in elbow coronal and axial plane laxity in a terrible triad biomechanical model that accounted for lateral collateral ligament integrity and the presence of a transverse coronoid fracture.
Kinematic data were collected on six fresh-frozen cadaveric upper extremities tested with passive motion throughout the flexion arc. Varus and valgus gravity stress were applied with the wrist in neutral position. A lateral collateral ligament reconstruction was simulated. We assessed instability after radial head resection and reconstruction with either a monopolar or bipolar implant in the presence of a transversely fractured (Regan and Morrey Type 2) or fixed coronoid process.
With collateral ligament integrity, no difference was detected, with the numbers available, in valgus laxity between implants under valgus stress (p = 1.0). Laxity improvement with each prosthesis was higher when the coronoid was fractured (mean ± SD: monopolar: 7.4° ± 1.6°, p < 0.001; bipolar: 6.4° ± 1.6°, p = 0.003) than when it was fixed (monopolar: 4.0° ± 1.6°, p = 0.02; bipolar: 4.2° ± 1.6°, p = 0.01). With the numbers available, there was no difference in external rotation laxity between implants under valgus stress (p = 1.0). The greatest stabilizing effect of the prostheses occurred when the coronoid was fractured (monopolar: 3.3° ± 1.2°, p = 0.15; bipolar: 3.3° ± 1.2°, p = 0.17). Radial head arthroplasty offered no substantial stability under varus stress for varus or internal rotation laxity.
In our terrible triad cadaveric model, coronoid fixation was effective in improving varus laxity with a monopolar or bipolar prosthesis in place. Also, both types of prostheses were effective in improving valgus and external rotation laxity to the elbow, regardless of coronoid status. With collateral ligaments reconstructed, no large kinematic differences were noted between implants regardless of the varus-valgus position or whether the coronoid was fractured or fixed.
Clinical Relevance
The data from our cadaveric model support the use of either implant type in terrible triad injuries if the collateral ligaments are intact or reconstructed.
PMCID: PMC4048430  PMID: 24867446
9.  Implant sonication for the diagnosis of prosthetic elbow infection 
Periprosthetic infection is a potentially devastating complication of elbow arthroplasty, associated with formation of microbial biofilm on the implant surface. The definitive microbiologic diagnosis of periprosthetic infection after elbow arthroplasty may be difficult to establish. Our study aim was to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of fluid derived from vortexing and bath sonication of the explanted hardware (a biofilm-sampling strategy).
Materials and methods
Patients undergoing revision elbow arthroplasty at our institution between July 2007 and July 2010, from each of whom 2 or more periprosthetic tissue cultures and 1 implant sonicate culture were obtained, were studied. A standardized definition of orthopedic implant—associated infection was applied.
We identified 27 subjects with aseptic failure and 9 with prosthetic elbow infection. Rheumatoid arthritis was the most common underlying disorder. The Coonrad-Morrey prosthesis was the most common type of implant used. The sensitivities of implant sonicate and periprosthetic tissue culture were 89% and 55%, respectively (P = .18), and the specificities were 100% and 93%, respectively (P = .16). Coagulase-negative staphylococci (n = 7) and Staphylococcus aureus (n = 2) were isolated in cases of infection.
Culture of the implant by sonication is at least as sensitive as periprosthetic tissue culture to detect prosthetic elbow infection.
Level of evidence
Level I, Diagnostic Study.
PMCID: PMC3910532  PMID: 22078323
Prosthetic joint infection; elbow prosthesis; implant; sonication; biofilm; periprosthetic tissue
10.  Proximal Humerus Fractures in the Elderly Can Be Reliably Fixed With a “Hybrid” Locked-plating Technique 
Controversy exists regarding the best treatment of proximal humerus fractures in the elderly. Recent studies of open reduction and internal fixation have demonstrated high complication rates.
We asked whether (1) open reduction and internal fixation could be performed with low rates of immediate and delayed complications, (2) reduction of these fractures could be maintained over time by evaluating long-term radiographs and visual analog pain scores, and (3) 6-week immobilization would lead to disabling stiffness by evaluating postoperative motion and functional scores.
Patients and Methods
We retrospectively reviewed all 35 patients older than 75 years with displaced proximal humerus fractures treated using a “hybrid” technique between 2002 and 2008. All patients were immobilized for 6 weeks after surgery. Thirteen of the 35 patients either died or developed severe dementia during followup. The analysis included 22 patients followed a minimum of 1 year (mean, 3 years; range, 1–6.7 years).
There were no early or late reoperations in this series. An acceptable reduction was achieved in 89% of the shoulders and maintained over time. All fractures healed. Osteonecrosis was noted on radiographs in 11% of the shoulders. Six weeks of immobilization did not lead to disabling stiffness. At most recent followup, mean active elevation was 141°, mean active internal rotation L1, mean active external rotation 36°, and mean American Society of Shoulder and Elbow Surgeons score 68.
Utilizing this approach, open reduction and internal fixation followed by 6-week immobilization results in a low rate of reoperation and good functional outcomes for elderly patients with proximal humerus fractures.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3210261  PMID: 21479762
11.  Total Elbow Arthroplasty 
Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked. Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor linked implants, since they prevent instability and allow replacement for a wider spectrum of indications. Inflammatory arthropathies such as rheumatoid arthritis represent the classic indication for elbow arthroplasty. Indications have been expanded to include posttraumatic osteoarthritis, acute distal humerus fractures, distal humerus nonunions and reconstruction after tumor resection. Elbow arthroplasty is very successful in terms of pain relief, motion and function. However, its complication rate remains higher than arthroplasty of other joints. The overall success rate is best for patients with inflammatory arthritis and elderly patients with acute distal humerus fractures, worse for patients with posttraumatic osteoarthritis. The most common complications of elbow arthroplasty include infection, loosening, wear, triceps weakness and ulnar neuropathy. When revision surgery becomes necessary, bone augmentation techniques provide a reasonable outcome.
PMCID: PMC3093740  PMID: 21584200
Arthroplasty; elbow; rheumatoid arthritis; elbow fractures; osteoarthritis.
12.  Total Shoulder Arthroplasty 
Shoulder arthroplasty has been the subject of marked advances over the last few years. Modern implants provide a wide range of options, including resurfacing of the humeral head, anatomic hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty and trauma-specific implants for fractures and nonunions. Most humeral components achieve successful long-term fixation without bone cement. Cemented all-polyethylene glenoid components remain the standard for anatomic total shoulder arthroplasty. The results of shoulder arthroplasty vary depending on the underlying diagnosis, the condition of the soft-tissues, and the type of reconstruction. Total shoulder arthroplasty seems to provide the best outcome for patients with osteoarthritis and inflammatory arthropathy. The outcome of hemiarthroplasty for proximal humerus fractures is somewhat unpredictable, though it seems to have improved with the use of fracture-specific designs, more attention to tuberosity repair, and the selective use of reverse arthroplasty, as well as a shift in indications towards internal fixation. Reverse shoulder arthroplasty has become extremely popular for patients with cuff-tear arthropathy, and its indications have been expanded to the field of revision surgery. Overall, shoulder arthroplasty is a very successful procedure with predictable pain relief and substantial improvements in motion and function.
PMCID: PMC3093753  PMID: 21584206
Arthroplasty; shoulder; osteoarthritis; shoulder fractures; cuff-tear arthropathy; reverse arthroplasty.
13.  C-Reactive Protein, Erythrocyte Sedimentation Rate and Orthopedic Implant Infection 
PLoS ONE  2010;5(2):e9358.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been shown to be useful for diagnosis of prosthetic hip and knee infection. Little information is available on CRP and ESR in patients undergoing revision or resection of shoulder arthroplasties or spine implants.
We analyzed preoperative CRP and ESR in 636 subjects who underwent knee (n = 297), hip (n = 221) or shoulder (n = 64) arthroplasty, or spine implant (n = 54) removal. A standardized definition of orthopedic implant-associated infection was applied. Receiver operating curve analysis was used to determine ideal cutoff values for differentiating infected from non-infected cases. ESR was significantly different in subjects with aseptic failure infection of knee (median 11 and 53.5 mm/h, respectively, p = <0.0001) and hip (median 11 and 30 mm/h, respectively, p = <0.0001) arthroplasties and spine implants (median 10 and 48.5 mm/h, respectively, p = 0.0033), but not shoulder arthroplasties (median 10 and 9 mm/h, respectively, p = 0.9883). Optimized ESR cutoffs for knee, hip and shoulder arthroplasties and spine implants were 19, 13, 26, and 45 mm/h, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 89 and 74% for knee, 82 and 60% for hip, and 32 and 93% for shoulder arthroplasties, and 57 and 90% for spine implants. CRP was significantly different in subjects with aseptic failure and infection of knee (median 4 and 51 mg/l, respectively, p<0.0001), hip (median 3 and 18 mg/l, respectively, p<0.0001), and shoulder (median 3 and 10 mg/l, respectively, p = 0.01) arthroplasties, and spine implants (median 3 and 20 mg/l, respectively, p = 0.0011). Optimized CRP cutoffs for knee, hip, and shoulder arthroplasties, and spine implants were 14.5, 10.3, 7, and 4.6 mg/l, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 79 and 88% for knee, 74 and 79% for hip, and 63 and 73% for shoulder arthroplasties, and 79 and 68% for spine implants.
CRP and ESR have poor sensitivity for the diagnosis of shoulder implant infection. A CRP of 4.6 mg/l had a sensitivity of 79 and a specificity of 68% to detect infection of spine implants.
PMCID: PMC2825262  PMID: 20179760
14.  Midterm to Long-term Followup of Staged Reimplantation for Infected Hip Arthroplasty 
Most reports on two-stage reimplantation have focused on the short-term cure rate of infection, but little is known about long-term reinfection-free survival or mechanical durability. We retrospectively reviewed 168 patients (169 hips) with infected arthroplasty, all of whom had two-stage reimplantation for the treatment of an infected total hip arthroplasty between 1988 and 1998. In the second stage, the femoral component was fixed with antibiotic-loaded bone cement in 121 hips; the remaining femoral components and all acetabular components were uncemented. The minimum followup time was 2 years (mean, 7 years; range, 2–16 years). At most recent followup, 12 hips (7.1%) were reoperated on for reinfection and 13 hips (7.7%) were revised for aseptic loosening or osteolysis. Apparently aseptic loosening occurred on one or both sides of the joint in 24 hips (14.2%). The 10-year survivals free of reinfection and mechanical failure were 87.5% and 75.2% respectively. Nineteen hips dislocated and eight underwent revision surgery for instability. The method of femoral component fixation, either with or without cement, did not correlate with risk of infection, loosening, or mechanical failure. Based on these results, the method of fixation used for the femoral component during two-stage reimplantation surgery should be based on the surgeon’s preference for fixation combined with the assessment of femoral bone stock.
Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2600996  PMID: 18813895
15.  Microbiologic Diagnosis of Prosthetic Shoulder Infection by Use of Implant Sonication▿  
Journal of Clinical Microbiology  2009;47(6):1878-1884.
We recently described a sonication technique for the diagnosis of prosthetic knee and hip infections. We compared periprosthetic tissue culture to implant sonication followed by sonicate fluid culture for the diagnosis of prosthetic shoulder infection. One hundred thirty-six patients undergoing arthroplasty revision or resection were studied; 33 had definite prosthetic shoulder infections and 2 had probable prosthetic shoulder infections. Sonicate fluid culture was more sensitive than periprosthetic tissue culture for the detection of definite prosthetic shoulder infection (66.7 and 54.5%, respectively; P = 0.046). The specificities were similar (98.0% and 95.1%, respectively; P = 0.26). Propionibacterium acnes was the commonest species detected among culture-positive definite prosthetic shoulder infection cases by periprosthetic tissue culture (38.9%) and sonicate fluid culture (40.9%). All subjects from whom P. acnes was isolated from sonicate fluid were male. We conclude that sonicate fluid culture is useful for the diagnosis of prosthetic shoulder infection.
PMCID: PMC2691098  PMID: 19261785
16.  Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia 
International Orthopaedics  2004;29(1):42-46.
Fifty-four consecutive acute Achilles tendon ruptures were treated with end-to-end suture augmented with gastrocnemius fascial flaps. Surgery was performed within 24 h. Mean patient age was 35 (23–57) years, and 46 were men. Mean follow-up time was 4.8 (2–8) years. At follow-up, the mean visual analogue scale for pain was 0.49, and the mean AOFAS ankle–hindfoot score was 95 (74–100) points. Fifty-three patients were able to stand on their tiptoes for 30 s and perform repeated toe raises, and 50 patients were able to perform single-limb hopping. Complications included rerupture in one case, deep infection in three cases, delayed wound healing in eight cases, and deep venous thrombosis in one case. Reconstruction of acute ruptures of the Achilles tendon augmented with gastrocnemius-soleus fascial flaps provided a good outcome but was associated with a high complication rate.
PMCID: PMC3456949  PMID: 15526200
17.  Comparison of wear and osteolysis in hip replacement using two different coatings of the femoral stem 
International Orthopaedics  2004;28(4):206-210.
We compared the clinical and radiographic results of two matched series of total hip arthroplasties, one with hydroxyapatite-coated femoral stems, the other with a similar but porous-coated femoral stem. The prevalence of radiographic osteolysis was 16% in hips with hydroxyapatite-coated stems and 43% in hips with porous-coated femoral stems. In hips with hydroxyapatite-coated stems, osteolysis was always limited to Gruen zones 1 and 7. In contrast, distal osteolysis was present around 26% of the porous-coated stems. At 7 years, the survival-free rate of distal osteolysis was 100% in hips with hydroxyapatite-coated stems but 90% in hips with porous-coated stems (p=0.04). Circumferential hydroxyapatite coating of the femoral component reduced the occurrence of osteolysis and eliminated distal osteolysis at 5–10 years of follow-up. In addition, hydroxyapatite coating did not alter the wear rate.
PMCID: PMC3456935  PMID: 15118841

Results 1-17 (17)