Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 472 | Issue 2 | Feb, 2014


Seth S. Leopold MD, Lee Beadling BA, Matthew B. Dobbs MD, Mark C. Gebhardt MD, Paul A. Lotke MD, Paul A. Manner MD, Clare M. Rimnac PhD, Montri D. Wongworawat MD

Osteogenic Gene Expression Correlates With Development of Heterotopic Ossification in War Wounds

Korboi N. Evans MD, MS, Benjamin K. Potter MD, Trevor S. Brown PhD, Thomas A. Davis PhD, Eric A. Elster MD, Jonathan A. Forsberg MD

Heterotopic ossification (HO) is a frequent complication of modern wartime extremity injuries. The biological mechanisms responsible for the development of HO in traumatic wounds remain elusive.

Orthopaedic Surgery Education in India

Paul J. Dougherty MD, Anil Sethi MD, Anil K. Jain MS, MAMS, FAMS, FRCS(Eng)

The John Charnley Award: Diagnostic Accuracy of MRI Versus Ultrasound for Detecting Pseudotumors in Asymptomatic Metal-on-Metal THA

Donald S. Garbuz MD, MHSc, Brian A. Hargreaves PhD, Clive P. Duncan MD, MSc, Bassam A. Masri MD, David R. Wilson DPhil, Bruce B. Forster MSc, MD

The prevalence of pseudotumors in patients with large-head metal-on-metal (MOM) THA has been the subject of implant recalls and warnings from various regulatory agencies. To date, there is no consensus on whether ultrasound or MRI is superior for the detection of pseudotumors.

The 2013 Frank Stinchfield Award: Diagnosis of Infection in the Early Postoperative Period After Total Hip Arthroplasty

Paul H. Yi BA, Michael B. Cross MD, Mario Moric MS, Scott M. Sporer MD, MS, Richard A. Berger MD, Craig J. Della Valle MD

Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postoperative period after total hip arthroplasty (THA) because normal cues from the physical examination often are unreliable, and serological markers commonly used for diagnosis are elevated from the recent surgery.

The Otto Aufranc Award. On the Etiology of the Cam Deformity: A Cross-sectional Pediatric MRI Study

Sasha Carsen MD, MBA, Paul J. Moroz MD, MSc, Kawan Rakhra MD, Leanne M. Ward MD, Hal Dunlap MD, John A. Hay PhD, R. Baxter Willis MD, Paul E. Beaulé MD

Femoroacetabular impingement (FAI) has been recognized as a common cause of hip pain as well as a cause of hip arthritis, yet despite this, little is known about the etiology of the cam morphology or possible risk factors associated with its development.

Partial Two-stage Exchange for Infected Total Hip Arthroplasty: A Preliminary Report

Timothy E. Ekpo DO, Keith R. Berend MD, Michael J. Morris MD, Joanne B. Adams BFA, Adolph V. Lombardi MD

One common approach to the infected total hip arthroplasty (THA) calls for a staged revision, including removal of all components. However, removal of well-fixed femoral components can result in bone loss and compromised fixation; it is not known whether it is effective to leave a well-fixed femoral component in situ, remove only the acetabular component, débride thoroughly, place a spacer, and delay reimplantation.

Risk Factors for Early Revision After Primary Total Hip Arthroplasty in Medicare Patients

Kevin J. Bozic MD, MBA, Edmund Lau MS, Kevin Ong PhD, Vanessa Chan MPH, Steven Kurtz PhD, Thomas P. Vail MD, Harry E. Rubash MD, Daniel J. Berry MD

Patient, surgeon, health system, and device factors are all known to influence outcomes in THA. However, patient-related factors associated with an increased risk of early failure are poorly understood, particularly in elderly patients.

Does the Direct Anterior Approach in THA Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach?

José A. Rodriguez MD, Ajit J. Deshmukh MD, Parthiv A. Rathod MD, Michelle L. Greiz PT, Prashant P. Deshmane MD, Matthew S. Hepinstall MD, Amar S. Ranawat MD

Newer surgical approaches to THA, such as the direct anterior approach, may influence a patient’s time to recovery, but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy.

Causes and Frequency of Unplanned Hospital Readmission After Total Hip Arthroplasty

William W. Schairer MD, David C. Sing BS, Thomas P. Vail MD, Kevin J. Bozic MD, MBA

Total hip arthroplasty (THA) is a beneficial and cost-effective procedure for patients with osteoarthritis. Recent initiatives to improve hospital quality of care include assessing unplanned hospital readmission rates. Patients presenting for THA have different indications and medical comorbidities that may impact rates of readmission.

MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

Danyal H. Nawabi MD, FRCS(Orth), Stephanie Gold BA, Steven Lyman PhD, Kara Fields MS, Douglas E. Padgett MD, Hollis G. Potter MD

Adverse local tissue reactions (ALTR) around metal-on-metal (MOM) hip arthroplasties are increasingly being recognized as a cause of failure. These reactions may be associated with intraoperative tissue damage and complication rates as high as 50% after revision. Although MRI can identify ALTR in MOM hips, it is unclear whether the MRI findings predict those at revision surgery.

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

Ibrahim J. Raphael MD, Eric H. Tischler BA, Ronald Huang MD, Richard H. Rothman MD, PhD, William J. Hozack MD, Javad Parvizi MD, FRCS

The most effective agent for prophylaxis against venous thromboembolic disease after total joint arthroplasty (TJA) remains unknown. The paucity of literature comparing different methods of pulmonary embolism (PE) prophylaxis and fear of litigation make it difficult for surgeons to abandon the use of aggressive chemical prophylaxis.

Does Femoral Neck to Cup Impingement Affect Metal Ion Levels in Hip Resurfacing?

Michel J. Le Duff MA, Alicia J. Johnson BA, Andrew J. Wassef MD, Harlan C. Amstutz MD

Impingement of the femoral neck with the acetabular component after metal-on-metal hip resurfacing arthroplasty (HRA) is a possible cause of edge loading and accelerated bearing wear. No attempt has been made to correlate radiographic impingement signs and blood metal ion levels.

Risk of Impingement and Third-body Abrasion With 28-mm Metal-on-metal Bearings

Ian C. Clarke PhD, Jean-Yves Lazennec MD, Adrien Brusson MSc, Christina Savisaar PhD, John G. Bowsher PhD, Michelle Burgett BA, Thomas K. Donaldson MD

Concerns have been raised about the sequelae of metal-on-metal (MoM) bearings in total hip arthroplasty (THA). However, retrieval studies, which offer the best insight into the clinically relevant mechanisms of MoM wear, have followed predictable trends to date such as indicting cobalt-chromium (CoCr) metallurgy, cup design, high conformity between the head and cup, “steep cups,” “microseparation,” and “edge wear.”

High Rate of Infection After Aseptic Revision of Failed Metal-on-Metal Total Hip Arthroplasty

Cody C. Wyles BS, Robert E. Demark MD, Rafael J. Sierra MD, Robert T. Trousdale MD

Evidence suggests some metal-on-metal (MOM) THAs have higher rates of failure and subsequent revision than other bearing surfaces. However, there are few studies demonstrating how these patients fare after revision.

High Frequency of Adverse Local Tissue Reactions in Asymptomatic Patients With Metal-on-Metal THA

Thomas K. Fehring MD, Susan Odum PhD, Robert Sproul MD, Jessica Weathersbee PA-C

The key to successful management of patients with metal-on-metal (MOM) THAs is to diagnose adverse local tissue reactions (ALTRs) early. ALTRs have been described in asymptomatic patients with resurfacing arthroplasties. Whether this concerning finding applies to modular MOM THAs is unknown.

High Complication Rate After Revision of Large-head Metal-on-metal Total Hip Arthroplasty

Jacob T. Munro MBChB, Bassam A. Masri MD, Clive P. Duncan MD, MSc, Donald S. Garbuz MD, MHSc

Previous studies have indicated poor outcomes in patients having revision of hip resurfacing resulting from adverse local tissue reaction and pseudotumor.

Stability and Trunnion Wear Potential in Large-diameter Metal-on-Metal Total Hips: A Finite Element Analysis

Jacob M. Elkins MD, PhD, John J. Callaghan MD, Thomas D. Brown PhD

Large-diameter femoral heads for metal-on-metal THA hold theoretical advantages of joint stability and low bearing surface wear. However, recent reports have indicated an unacceptably high rate of wear-associated failure with large-diameter bearings, possibly due in part to increased wear at the trunnion interface. Thus, the deleterious consequences of using large heads may outweigh their theoretical advantages.

What Causes Unexplained Pain in Patients With Metal-on metal Hip Devices? A Retrieval, Histologic, and Imaging Analysis

Danyal H. Nawabi MD, FRCS (Orth), Nader A. Nassif MD, Huong T. Do MA, Kirsten Stoner MEng, Marcella Elpers BS, Edwin P. Su MD, Timothy Wright PhD, Hollis G. Potter MD, Douglas E. Padgett MD

Adverse tissue reactions associated with metal-on-metal (MOM) hips are common in resurfacing and total hip arthroplasty (THA) designs. The etiology of these reactions in painful, well-positioned arthroplasties is inconsistently described.

Hip Resurfacing Does Not Improve Proprioception Compared With THA

Brian Larkin MD, Humaa Nyazee MPH, John Motley PT, ATC, Ryan M. Nunley MD, John C. Clohisy MD, Robert L. Barrack MD

Proposed benefits of total hip resurfacing arthroplasty over total hip arthroplasty (THA) include better proprioception, but this has not been rigorously tested or validated.

Taper Design Affects Failure of Large-head Metal-on-metal Total Hip Replacements

Nader A. Nassif MD, Danyal H. Nawabi MD, Kirsten Stoner MEng, Marcella Elpers BS, Timothy Wright PhD, Douglas E. Padgett MD

Large-head metal-on-metal (MoM) hip arthroplasties have demonstrated poor survival. Damage at the taper-trunnion junction is a contributing factor; however, the influence of junction design is not well understood.

Do Jumbo Cups Cause Hip Center Elevation in Revision THA? A Computer Simulation

Chima Nwankwo BS, Nick N. Dong MS, Christopher D. Heffernan BS, Michael D. Ries MD

Acetabular revision THA with use of a large (jumbo) cup is an effective treatment for many cavitary and segmental peripheral bone defects. However, the jumbo cup may result in elevation of the hip center and protrusion through the anterior acetabular wall as a result of the oversized geometry of the jumbo cup compared with the physiologic acetabulum.

Are Short Fully Coated Stems Adequate for “Simple” Femoral Revisions?

Matthew W. Tetreault MD, Sanjai K. Shukla MD, Paul H. Yi BA, Scott M. Sporer MD, Craig J. Della Valle MD

Many studies suggest long femoral components should be used in revision THA. However, longer stems are more difficult to insert and reduce femoral bone stock for future revisions.

Elevation of Serum Tumor Necrosis Factor α in Patients with Periprosthetic Osteolysis: A Case-Control Study

R. Krishna Chaganti MD, Edward Purdue PhD, Thomas P. Sculco MD, Lisa A. Mandl MD

Periprosthetic osteolysis is the leading reason for THA revision. The relationship of serum biomarkers with severe radiographic periprosthetic osteolysis has not been defined but may be important to direct future research and clinical therapeutics.

Tapered Fluted Titanium Stems in the Management of Vancouver B2 and B3 Periprosthetic Femoral Fractures

Jacob T. Munro MBChB, Donald S. Garbuz MD, MHSc, Bassam A. Masri MD, Clive P. Duncan MD, MSc

Surgeons have several implant choices when managing Vancouver B2 and B3 periprosthetic fractures about the hip. Few long-term studies have reported outcomes for tapered fluted titanium stems.

Periprosthetic Femur Fractures Treated With Modular Fluted, Tapered Stems

Matthew P. Abdel MD, David G. Lewallen MD, Daniel J. Berry MD

Treatment of periprosthetic femur fractures is challenging, and high failure and complication rates have been reported in many series. The optimal techniques and implants for the management of Vancouver B2 and B3 fractures remain in debate.

Periprosthetic Fractures Around a Cementless Hydroxyapatite-coated Implant: A New Fracture Pattern Is Described

William N. Capello MD, James A. D’Antonio MD, Marybeth Naughton BS

Periprosthetic fractures can occur both intraoperatively and postoperatively with implantation of cementless tapered stems.

High Survivorship With a Titanium-encased Alumina Ceramic Bearing for Total Hip Arthroplasty

James A. D’Antonio MD, William N. Capello MD, Marybeth Naughton BS

Although ceramic-on-ceramic bearings for total hip arthroplasty (THA) show promising results in terms of bearing-surface wear, fracture of the bearing, insertional chips, and squeaking remain a concern.

Treatment of Femoral Head Osteonecrosis in the United States: 16-year Analysis of the Nationwide Inpatient Sample

Aaron J. Johnson MD, Michael A. Mont MD, Audrey K. Tsao MD, Lynne C. Jones PhD

Many surgical interventions are used to treat osteonecrosis of the femoral head. The instance and distribution of these various procedures may give some insight into the practicing community’s understanding of the efficacy of these treatments. We therefore sought to determine trends in the types and numbers of procedures performed for atraumatic osteonecrosis from 1992 through 2008 in the United States.

Short-term Wear Evaluation of Thin Acetabular Liners on 36-mm Femoral Heads

Aaron J. Johnson MD, MS, LaQuawn Loving MS, Lizeth Herrera BS, Ronald E. Delanois MD, Aiguo Wang PhD, Michael A. Mont MD

Dislocation remains the leading cause of revision THA. One approach to decreasing prosthetic dislocation risk has been the use of larger femoral head component sizes. The upper limit of head size in metal-on-polyethylene hip arthroplasty has historically been limited because of concerns about increased wear on thin polyethylene components. It is not known to what degree this concern should apply to more wear-resistant polyethylene components.

Durable Fixation Achieved With Medialized, High Hip Center Cementless THAs for Crowe II and III Dysplasia

Danyal H. Nawabi MD, Morteza Meftah MD, Denis Nam MD, Amar S. Ranawat MD, Chitranjan S. Ranawat MD

A high hip center total hip arthroplasty (THA) for dysplasia allows more complete socket coverage by native bone at the expense of abnormal hip biomechanics. Despite poor results with cemented components, intermediate-term results with cementless cups at a high hip center have been promising, but there are few reports at long-term followup without bone graft.

High Complication Rate in Revision Total Hip Arthroplasty in Juvenile Idiopathic Arthritis

Stuart B. Goodman MD, PhD, Katherine Hwang MS, Susanna Imrie PT, MS

Revision total hip arthroplasty (THA) in patients with juvenile idiopathic arthritis (JIA) is challenging as a result of the patient’s young age, systemic disease, multiple affected joints, small proportions, and bone loss. The intermediate- to long-term results of these surgeries remain unknown.

Surgical Technique: Gluteus Maximus and Tensor Fascia Lata Transfer for Primary Deficiency of the Abductors of the Hip

Leo A. Whiteside MD

Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons.

Muscle Strength and Functional Recovery During the First Year After THA

Dana L. Judd PT, DPT, Douglas A. Dennis MD, Abbey C. Thomas PhD, ATC, Pamela Wolfe MS, Michael R. Dayton MD, Jennifer E. Stevens-Lapsley PT, PhD

Patients undergoing total hip arthroplasty (THA) often are satisfied with the decrease in pain and improvement in function they achieve after surgery. Even so, strength and functional performance deficits persist after recovery, but these remain poorly characterized; knowledge about any ongoing strength or functional deficits may allow therapists to design rehabilitation programs to optimize recovery after THA.

Hip Dysplasia Is More Severe in Charcot-Marie-Tooth Disease Than in Developmental Dysplasia of the Hip

Eduardo N. Novais MD, Sara D. Bixby MD, John Rennick MSc, Patrick M. Carry BA, Young-Jo Kim MD, PhD, Michael B. Millis MD

Patients with Charcot-Marie-Tooth disease may develop hip dysplasia. Hip geometry in these patients has not been well described in the literature.

Is Intraarticular Pathology Common in Patients With Hip Dysplasia Undergoing Periacetabular Osteotomy?

Benjamin G. Domb MD, Justin M. Lareau MD, Hasan Baydoun MD, Itamar Botser MD, Michael B. Millis MD, Yi-Meng Yen MD, PhD

Periacetabular osteotomy (PAO) enables correction of bony acetabular deficiency in the setting of hip dysplasia. Patients with insufficient acetabular coverage often have intraarticular pathology, but the degree of this pathology has been incompletely characterized. We have used arthroscopy as an adjunct to PAO to further delineate intraarticular pathology in patients with hip dysplasia with mechanical symptoms.

Vitamin D Insufficiency in Patients With THA: Prevalence and Effects on Outcome

Carlos J. Lavernia MD, Jesus M. Villa MD, David A. Iacobelli MD, Mark D. Rossi PhD

The consequences of vitamin D insufficiency in the elderly remain controversial. The prevalence and potential effects of its chronic insufficiency on quality of life and physical function in patients undergoing THA have received little attention.

Local Alendronic Acid Elution Increases Net Periimplant Bone Formation: A Micro-CT Analysis

J. Dennis Bobyn PhD, Rebecca Thompson MEng, Letitia Lim MD, Jenny Ann Pura BSc, Kristian Bobyn BA, Michael Tanzer MD

Fixation of cementless orthopaedic implants is not always achieved, particularly in challenging scenarios such as revision surgery, trauma, and tumor reconstruction. An adjunct therapy for improving implant fixation would improve the reliability and durability of certain reconstructive procedures.

The Effect of Infrapatellar Fat Pad Excision on Complications After Minimally Invasive TKA: A Randomized Controlled Trial

Piya Pinsornsak MD, Kittipon Naratrikun MD, Sukanis Chumchuen MD

The infrapatellar fat pad is one of the structures that obscures exposure in minimally invasive total knee arthroplasty (MIS TKA). Most MIS TKA surgeons (and many surgeons who use other approaches as well) excise the fat pad for better exposure of the knee. There is still controversy about the result of fat pad excision on patella baja, pain, and function.

Anteroposterior Translation Does Not Correlate With Knee Flexion After Total Knee Arthroplasty

Yoshinori Ishii MD, Hideo Noguchi MD, Mitsuhiro Takeda MD, Junko Sato MD, Shin-ichi Toyabe MD

Stiffness after a TKA can cause patient dissatisfaction and diminished function, therefore it is important to characterize predictors of ROM after TKA. Studies of AP translation in conscious individuals disagree whether AP translation affects maximum knee flexion angle after implantation of a highly congruent sphere and trough geometry PCL-substituting prosthesis in a TKA.

Coexisting Lumbar Spondylosis in Patients Undergoing TKA: How Common and How Serious?

Chong Bum Chang MD, PhD, Kun Woo Park MD, Yeon Gwi Kang MS, Tae Kyun Kim MD, PhD

Information on the coexistence of lumbar spondylosis and its influence on overall levels of pain and function in patients with advanced knee osteoarthritis (OA) undergoing total knee arthroplasty (TKA) would be valuable for patient consultation and management.

Do Abdominal Cutouts in Thoracolumbosacral Orthoses Increase Pulmonary Function?

Donna Frownfelter PT, DPT, MA, CCS, RRT, FCCP, Karen Stevens PT, DPT, MS, OCS, Mary Massery PT, DPT, DSc, Gene Bernardoni RPh, CO

Thoracolumbosacral orthoses (TLSOs) are effective in their intended purpose of limiting spinal movement but tend to restrict rib cage and abdominal motion. Incorporating an abdominal cutout, allowing abdominal excursion, may reduce the restraint on abdominal expansion associated with inhalation and thereby reduce pulmonary compromise.

Can Ulnar Variance Be Used to Detect Overstuffing After Radial Head Arthroplasty?

Jun-Gyu Moon MD, PhD, Jin-Ho Hong MD, Nitin Bither MD, Won-Yong Shon MD, PhD

Overstuffing of the radiocapitellar joint during metallic radial head arthroplasty has been reported to cause loss of elbow flexion, capitellar erosion, and early-onset osteoarthritis. Although this is known, there is no agreed-on measurement approach to determine whether overstuffing has occurred.

Recombinant Human BMP-2 Increases the Incidence and Rate of Healing in Complex Ankle Arthrodesis

Mitchell S. Fourman MPhil, Eugene W. Borst BA, Eric Bogner MD, S. Robert Rozbruch MD, Austin T. Fragomen MD

Although its FDA-approved applications are limited, the pro-osteogenic benefits of recombinant human BMP-2 (rhBMP-2) administration have been shown in off-label surgical applications. However, the effects of rhBMP-2 on ankle fusions are insufficiently addressed in the literature, which fails to include a case-control study of adequate sample size to evaluate the efficacy of rhBMP-2 treatment.

Assessing Shoulder Motion in Children: Age Limitations to Mallet and ABC Loops

Michael L. Pearl MD, Fabian Bunt BS, Michaela Pearl BS, Nina Lightdale-Miric MD, Susan Rethlefsen PT, DPT, Jennifer Loiselle OTRL

Shoulder ROM and function of the shoulder are difficult to evaluate in young children. There has been no determination of the age at which children can comply with the current assessment tools in use, but doing so would be important, because it gives us more accurate insight into the development and assessment of shoulder functional ROM in young children.

Is Tibialis Anterior Tendon Transfer Effective for Recurrent Clubfoot?

Kelly Gray B App Sc (Physiotherapy), Joshua Burns PhD, David Little MBBS, FRACS(Orth), PhD, Michael Bellemore MBBS, FRACS, Paul Gibbons MBBS, FRCS(Orth), FRACS

Tibialis anterior tendon transfer surgery forms a part of Ponseti management for children with congenital talipes equinovarus who, after initial correction, present with residual dynamic supination. Although retrospective studies support good outcomes, prospective longitudinal studies in this population are lacking.

The Efficacy of Single-stage Open Intramedullary Nailing of Neglected Femur Fractures

P. R. J. V. C. Boopalan MS, Azad Sait D Ortho, Thilak Samuel Jepegnanam MS, Thomas Matthai MS, Viju Daniel Varghese MS

Neglected femur fractures are not rare in the developing world. Treatment options include single-stage open reduction and intramedullary nailing, or open release, skeletal traction, and then second-stage open intramedullary nailing, with bone grafting. Single-stage procedures have the potential advantage of avoiding neurovascular complications secondary to acute lengthening, but they require a second operation, with potentially increased resource use and infection risk.

Reply to the Letter to the Editor: Adverse Reactions of Artificial Bone Graft Substitutes: Lessons Learned From Using Tricalcium Phosphate geneX®

Joerg Friesenbichler MD, Werner Maurer-Ertl MD, Patrick Sadoghi MD, Ulrike Pirker-Fruehauf MD, Koppany Bodo MD, Andreas Leithner MD

Erratum to: Local Alendronic Acid Elution Increases Net Periimplant Bone Formation: A Micro-CT Analysis

J. Dennis Bobyn PhD, Rebecca Thompson MEng, Letitia Lim MD, Jenny Ann Pura BSc, Kristian Bobyn BA, Michael Tanzer MD

Erratum to: Surgical Hip Dislocation for Treatment of Femoroacetabular Impingement: Factors Predicting 5-year Survivorship

Simon D. Steppacher MD, Carmen Huemmer MD, MSc, Joseph M. Schwab MD, Moritz Tannast MD, Klaus A. Siebenrock MD

Painful Forearm Mass in a 75-year-old Man

Scott J. Schoenleber MD, Andrew E. Rosenberg MD, H. Thomas Temple MD
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