Topics of General Orthopaedic
Levernia CJ, Sierra RJ, Gomez-Marin O [Univ of Miami, Fla]
Smoking and Joint Replacement : Resource Consumption and Short Term Outcome
Clin Orthop 367: 172-180, 1999
The many adverse effects of smoking extend to surgical procedures, and delayed healing of skin flaps and higher complication rates in treatment of nonunions in patients who smoke have been well documented by microvascular and trauma surgeons.
Short-term outcome was better for smokers who quit than for current smokers indicates the importance of smoking cessation before surgical procedures.
Gautier E, Ganz K, Krugel N, et al (LHopital Cantonal, Fribourg, Switzerland)
Anatomy of the Medial Femoral Circumflex Artery and Its Surgical Implications
J Bone Joint Surg Br 82-B: 679-683, 2000
The peripheral extracapsular division of the deep branches of the medial femoral circumflex artery (MFCA), is of most importance to the hip surgeon.
Twelve fresh cadavers, none with evidence of previous trauma or surgery to the hip were studied. Neoprene latex was injected into the femoral or internal iliac arteries. Dissections were carried out by sequential anterior and posterior surgical approaches after polymerization of the latex.
The findings in detail are interesting. It was found that the MFCA originated from the profunda femoris artery in 20 specimens and from the common femoral in four.
There were 5 consistent branches of the MFCA:
(i) Superficial – between the pectineus and adductor longus
(ii) Ascending – to the adductor brevis, adductor magnus, and obturator externus.
(iii) Acetabular – giving off the foveolar artery (medial epiphyseal artery).
(iv) The descending which courses between the quadratus femoris and adductor magnus – supplying the ischiocrural muscles.
(v) The deep branch to the head of the femur.
Five main peripheral anastomoses of the MFCA were identified. All were extracpasular.
In 3 specimens, dislocation of the head of the femur did not influence the natural course and tension of the extracapsular deep branch and
INTRACAPSULAR branches of the MFCA, as long as the obturator externus was left attached.
Iatrogenic avascular necrosis of the head of the femur, can be avoided by a proper understanding of the extracapsular anatomy of the MFCA and its surrounding structures.
Efforts to preserve the obturator externus muscle would be of value if carried out without compromising exposure.
Diliberti T, Botte MJ, et al (Univ of California, San Diego)
Anatomical Considerations Regarding the Posterior Interosseous Nerve During Posterolateral Approaches to the Proximal Part of the Radius
J Bone Joint Surg Am 82-A: 809-813, 2000
The authors stress that the safest approach to the lateral aspect of the proximal part of the radius is with the forearm in pronation.
Pronating the forearm places the nerve at less risk during exposure of the radio-humeral joint than with forearm supinated.
32 cadaveric specimens were studied. The posterolateral approach between the anconeus and extensor carpi ulnaris was utilized to expose the posterior interosseous nerve.
While pronation enables safe exposure of at least the proximal 38mm of the lateral aspect of the radius, supination reduced the proximal safe zone to a low of 2mm.
Ramnemark A, Nilsson M, et al (Umea Univ, Sweden)
Stroke, a Major and Increasing Risk Factor for Femoral Neck Fracture
Stroke 31: 1572-1577, 2000
Stroke increases a persons risk for both osteoporosis and falls.
Hip fracture is hence common among stroke patients, and most often affects the paretic side.
In a study of patients aged 65 years and over, who had undergone surgery for femoral neck fracture, it was found that a verified previous stroke had occurred in 152(27.4%) of the 568 patients with femoral neck fracture.
Though most of the patients with femoral neck fracture were women, men were more likely (than women) to have had a stroke (39% vs 27.4%).
Survival rate was significantly reduced in the previous stroke group.
Rodgers A, for the Pulmonary Embolism Prevention (PEP) Trial Collaborative Group (Univ of Auckland, New Zealand; et al)
Prevention of Pulmonary Embolism and Deep Vein Thrombosis With Low Dose Aspirin: Pulmonary Embolism Prevention (PEP) Trial
Lancet 355: 1295-1302, 2000
This randomized placebo-controlled Pulmonary Embolism Prevention (PEP) trial was carried out with low-dose aspirin.
13,356 patients undergoing surgery for hip fractures, and another 4088 patients undergoing elective anthroplasty received 160 mg daily of either aspirin or placebo,starting preoperatively and continuing for 35 days.
They were allowed to get any other thromboprophylaxis deemed necessary.
It was found that patients in the aspirin group had proportional decreases in pulmonary embolism (PE) of 43% and in symptomatic deep-vein thrombosis of 29%.
The findings show that aspirin decreases the risk of PE and deep vein thrombosis by at least a third during the period of increased risk.
Niskanen RO, Korkala OL, et al (Lahti Central Hosp, Finland)
Drainage Is of No Use in Primary Uncomplicated Cemented Hip and Knee Arthroplasty for Osteoarthritis: A Prospective Randomized Study
J Arthroplasty 15: 567-569, 2000
The necessity for a postoperative drain after cemented hip and knee arthroplasty was examined.
A prospective randomized study was conducted of 58 patients with primary cemented hip arthroplasty and of 39 patients with primary cemented knee arthroplasty.
Low molecular weight heparin was administered to all patients, and elastic dressings on the legs for 3 days.
Prostheses were fixed with anti-bioticcontaining cement, and knee operations were done under tourniquet.
A closed-suction drain was used in 27 patients after hip arthroplasty and 20 after knee arthroplasty; no drainage was used for 31 patients after hip arthroplasty and 19 patients after knee arthroplasty.
It was found that the clinical parameters seemed to be equal regardless of presence or absence of a drain.
Hence, the authors have discontinued usage of drains in uncomplicated cemented primary hip and knee arthroplasties for osteoarthritis.
Urban RM, Jacobs JJ, Tomlinson MJ, et al (Rush-Presbyterian-St Lukes Med Ctr, Chicago)
Dissemination of Wear Particles to the Liver, Spleen, and Abdominal Lymph Nodes of Patients With Hip or Knee Replacement
J Bone Joint Surg Am 82-A: 457-477, 2000
The presence of and histologic response to the products of joint prosthesis wear in the liver, spleen, and lymph nodes were assessed in a study including 44 postmortem subjects and 2 biopsy specimens, 31 of whom had undergone total hip or knee replacement surgery.
Special studies were done to confirm the presence of metallic and polyethylene particles.
For one of the 2 living patients, titanium alloy particles had caused a visceral granulomatous reaction and hepatosplenomegaly.
68% of patients with implants had metallic wear particles in the para-aortic lymph nodes.
38% postmortem specimens showed dissemination of metallic particles to the liver or spleen.
Patients with failed prosthesis have higher rates of particles in the liver or spleen. Usually, the concentration of particles is low and they usually cause no clinical problems. However, for patients with joint replacement who have large amounts of particulate debris, prompt revision surgery may be indicated.
Lonner JH, Siliski JM, et al (Univ of Pennsylvania, Philadelphia)
Simultaneous Femoral Osteotomy and Total Knee Arthroplasty for Treatment of Osteoarthritis Associated With Severe Extra-Articular Deformity
J Bone Joint Surg Am 82-A: 342-348, 2000
The authors retrospectively reviewed the use of simultaneous corrective osteotomy and TKA to treat 11 patients with osteoarthritis of the knee and ipsilateral extra-articular angular deformity of the femur.
They found this technically challenging treatment quite effective.
Kagan A II (Orthopedics and Sports Medicine, Fort Myers, Fla)
Rotator Cuff Tears of the Hip
Clin Orthop 368: 135-140, 1999
Patients with trochanteric bursitis have findings of local tenderness and weakness of hip abduction.
Surgical release of the iliotibial band over the greater trochanter may be required when conservative measures do not relieve symptoms.
The authors report a series of 7 such patients who also had a partial tear of the gluteus medius tendon at its attachment to the greater trochanter.
All patients thought that the surgery was successful in alleviating pain. All but one, returned to full activities.
One patient with persistent weakness had electromyographically documented denervation of the gluteus medius which was attributed to lumbar radiculopathy.