The Clinical Use of Bone Stimulators--Jeff Anglen, MD, FACS

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Delay or failure of healing in long bone fracture is a common clinical problem confronting the orthopaedic surgeon, and can have significant impact on the quality of life for patients who have it. One treatment option for this problem is the use of electrical or ultrasonic bone stimulation. Electrical signals can be delivered with an implantable direct current stimulator, or noninvasively using inductive or capacitive coupling to induce currents in the tissues. Low-intensity ultrasound can speed the healing of fresh fractures. Although regarded with skepticism by many physicians, there is abundant evidence from clinical studies of the effectiveness of these treatments. In addition to dozens of retrospective reports, randomized, prospective, double-blind controlled trials have shown the efficacy of electrical stimulation for nonunion and ultrasound for speeding healing. Patients with unacceptable deformity, synovial pseudarthrosis, or large gaps are generally not good candidates for this treatment modality. This article is a review of the clinical literature regarding treatment of long bone nonunion with bone stimulators. (Journal of the Southern Orthopaedic Association 12(2):46–54, 2003) Key words: bone stimulator, delayed union, nonunion

Orthopaedic Malpractice Claims in the VA Medical System--Gary Rubin, MD, Alan Dean, MD, and Herbert S. Schwartz, MD

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This study was undertaken to delineate the outcome of orthopaedic malpractice claims in the Veterans Affairs Medical Center (VAMC) system compared with the private sector. All orthopaedic administrative tort (malpractice) claims handled by the Office of Regional Counsel in Nashville, Tennessee during the 5-year period (8/93–7/98) were analyzed. Attention was directed at: 1) the number and type of claims, 2) the disposition of the claims, 3) the average award or settlement and range in size of awards (indemnity), and 4) the length of time required to process and dispose of each claim. These data were compared to those compiled in that segment of the private sector represented in the database of Physician Insurers Association of America (PIAA) for a similar five years (1/90–12/94). Twenty-six claims were filed in the 5-year study period and 22 were adjudicated by December 1999. Fourteen of 22 (64%) were defended successfully and eight (36%) resulted in an award to the claimant plaintiff. In the private sector those figures were 69% and 31%, respectively. The VAMC average indemnity was $20,404 (range, 3500–$100,000) versus $145,200 in the private sector. Approximately 1% of all awards in the private sector were greater than $1,000,000. The length of time required by the VAMC to process and dispose of each claim ranged from 6 to 59 months and averaged 15.2 months. The settlement rate of orthopaedic medical malpractice claims involving the VAMC and the private sector is similar. It appears that the average award is greater in the private sector. This may reflect more claims and lesser awards in the VAMC. In both systems, most claims do not result in an indemnity. (Journal of the Southern Orthopaedic Association 12(2):56–59, 2003) Key words: malpractice, orthopaedic surgery, torts, Veterans Administration

Treatment of Forefoot Ulcers with Tendon Lengthenings--J. Monroe Laborde, MD, MS

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Forefoot ulcers are a common complication of neuropathy. Trans-tibial amputation too often becomes necessary when progressive infection develops secondary to ulcers of the forefoot. Tendon lengthening appears to be an effective treatment for plantar forefoot ulcers in patients with neuropathy and forefoot ulceration. (Journal of the Southern Orthopaedic Association 12(2):60–65, 2003) Key words: diabetic neuropathy, foot ulcers, tendon lengthening

Osteoblastoma of the Clavicle--K. J. Faber, MD, FRCSC, S. D. Patterson, MBChB, FRCSC, J. G. Heathcote, MB, FRCPC, and R. R. Richards,MD, FRCSC

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A 14-year-old female with a 1-year history of a painful clavicle mass underwent resection and reconstruction with an intercalated autograft and rigid plate fixation. The histopathology was diagnostic for osteoblastoma. Although a clavicle mass is a common entity following clavicle trauma, less common disorders such as bone tumors need to be considered in the differential diagnosis. Osteoblastoma is an uncommon, benign bone tumor representing 1% of all primary bone tumors. An extensive review of the literature reveals only one reported case of clavicular osteoblastoma. (Journal of the Southern Orthopaedic Association 12(2):66–70, 2003) Key words: clavicle, histopathology, osteoblastoma, treatment

Effect of Patient-Controllable Factors on Survivorship of Primary Total Hip Arthroplasty--Kate Nellans, BS, Thomas P. Schmalzried, MD, and William Macaulay, MD

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The identification of factors that may affect the eventual survivorship of primary total hip arthroplasty is essential. The surgeon needs this information to assist in the patient selection process and to mold patient expectations. Patients may then be counseled regarding factors within their control, and this information may affect long-term behavior. For a given patient, how might the surgeon best advise that person to prolong the longevity and functionality of his or her hip replacement? (Journal of the Southern Orthopaedic Association 12(2):72–74, 2003) Key words: compliance, patient factors, survivorship, total hip arthroplasty

Hybrid Total Hip Arthroplasty: State-of-the-Art in the New Millennium?--Adam Reese, BS, and William Macaulay, MD

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Clinical results from the past 30 years have proven total hip arthroplasty (THA) to be an effective technique for treating arthritic and degenerative conditions of the hip. Though there is little question concerning the effectiveness THA in general, significant debate exists concerning the best technique for performing the procedure. Sir John Charnley’s concept of low-friction arthroplasty (LFA), considered to be the gold standard for THA, employs a cemented fixation technique for both the femoral and acetabular components. Over time, the merits of cemented fixation have been called into question as significant percentages of LFA implants failed and required revision surgery. Hybrid total hip arthroplasty is a variation of LFA that employs cemented fixation of the femoral component with cementless fixation of the acetabular component. Intermediate-term clinical results of hybrid THA have shown it to be a promising technique, with revision rates of both the femoral and acetabular components superior to Charnley LFA studies at similar lengths of follow-up. Though these results are encouraging, long-term data from the hybrid THA studies are required before a conclusion can be made as to whether the hybrid method is in fact superior to the LFA technique for performing THA. (Journal of the Southern Orthopaedic Association 12(2):75–78, 2003) Key words: arthroplasty, hip, hybrid

Cemented Total Hip Arthroplasty: Still Relevant in the New Millennium?--Richard Iorio, MD, and Seneki Kobayashi, MD, PhD

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Total hip arthroplasty can be performed successfully using cement or cementless technology. Cemented femoral stems can achieve enduring long-term suvivorship as long as meticulous surgical technique is utilized and patient selection is appropriate. Cemented acetabular components should only be utilized in patients with less than 10 years of remaining life expectancy. Critical risk factors for cemented total hip arthroplasty include atrophic osteoarthritis on the acetabular side and unfavorable femoral geometry for the femoral stem such as ‘‘the stove-pipe’’ canal. Rapid polyethylene wear and oseolysis are rarely seen in contemporary cemented total hip arthroplasty performed with a smooth, tapered, collarless femoral stem with a highly polished head and a well-designed acetabular component. (Journal of the Southern Orthopaedic Association 12(2):79–82, 2003) Key words: all-polyethylene acetabular component, cement, Charnley, polymethylmethacrylate, total hip arthroplasty

The Cementless Femoral Stem Revisited--George S. Macari, MD, Rida A. Kassim, MD, Patrick Yoon, MD, and Khaled J. Saleh, MD, MSc, FRCSC

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Despite the success of Sir John Charnley’s cemented total hip arthroplasty (THA), large numbers of patients demonstrated mechanical failure due to loosening. The two main initial concerns were infection and wear. With the recent advances in antibiotics and aseptic techniques and with improvement in surgical technique, the incidence of infection has decreased tremendously. Subsequently, the issues of wear and osteolysis have become the main concern. Initially attributing these problems to so-called ‘‘cement disease,’’ clinicians sought out alternative methods of fixation; hence arose cementless femoral stem fixation. This article provides an overview of our modern understanding of cementless femoral stem fixation, focusing on design issues and outcomes. Particular attention is paid to three areas of continuing controversy with regard to the uncemented femoral stem: geometric design, material composition, and type and extent of porous coating. (Journal of the Southern Orthopaedic Association 12(2):83–89, 2003) Key words: cementless, femoral component, hip replacement

Surgical Approaches to Total Hip Arthroplasty--Daniel Kelmanovich, Michael L. Parks, MD, Raj Sinha, MD, PhD, and William Macaulay

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Surgical exposure of the hip for trauma, infection, or reconstruction can be adequately accomplished through a variety of surgical approaches. This article describes in detail five classic approaches to the hip: Smith-Petersen (anterior), Watson-Jones (anterolateral), Hardinge (direct lateral), transtrochanteric, and posterolateral. In addition, recently described mini-incision posterior and anterior approaches are outlined. (Journal of the Southern Orthopaedic Association 12(2):90–94, 2003) Key words: approach, lateral, mini-incision, posterior

Blood Conservation in Primary Total Hip Arthroplasty--Matthew S. Hepinstall, MD, Clifford W. Colwell Jr., MD, and William B. Macaulay, MD

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Total hip arthroplasty is characterized by significant blood loss. The principal aim of blood management in joint replacement surgery is to minimize both the risks associated with surgical blood loss and the risks associated with allogenic blood transfusion. In the 1980s, the AIDS epidemic triggered the development of a variety of innovative approaches to conserving blood and reducing the need for allogenic transfusion to replace surgical blood loss. Subsequently, the safety of the blood supply was dramatically improved, changes in surgical technique led to decreased surgical blood loss, and changes in transfusion thresholds made the need for transfusion less common. The review re-examines the options available for the management of blood loss in total joint replacement and defines parameters that can be used preoperatively to predict which patients are likely to benefit from these interventions, given the clinical realities of the 21st century. (Journal of the Southern Orthopaedic Association 12(2):95–102, 2003) Key words: blood transfusion, hip arthroplasty, surgical blood loss

Thromboembolic Complications After Total Hip Arthroplasty--Rida A. Kassim, MD, Khaled J. Saleh, MD, MSc, FRCSC, Mohamed Badra, MD, Tim Moran, and Justin L. Esterberg, MD

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Thromboembolic disorders are worrisome complications following total hip arthroplasty, and the best way to address such complications is by prevention. Several regimens have been advocated to decrease the risk of thromboembolic disorders. A combination of pharmacologic and nonpharmacologic measures helps reduce the incidence of deep venous thrombosis and, hence, pulmonary embolization. (Journal of the Southern Orthopaedic Association 12(2):103–105, 2003) Key words: complications, deep vein thrombosis, hip replacement, total hip arthroplasty

Alternative Bearing Surfaces in Total Hip Arthroplasty--V. Christopher Inzerillo, MD, and Jonathan P. Garino, MD

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Polyethylene wear and extension of indications of total hip arthroplasty into younger and younger age groups have pushed manufacturers to develop more durable bearing surfaces. Standard polyethylene, the plastic used for the first 3 decades of hip replacement, virtually ceases to exist in its original form. Modifications of the processing, including sterilization in an inert environment and cross-linking, have demonstrated some improvements in wear. Hard-on-hard bearings such as ceramic-on-ceramic and metal-on-metal also have demonstrated extremely low wear. This article reviews the pros and cons of the alternative bearing options available to assist in the proper bearing selection for a particular patient. (Journal of the Southern Orthopaedic Association 12(2):106–111, 2003) Key words: alternative bearings, ceramic-on-ceramic, ceramics, cross-linked polyethylene, metal-onmetals, total hip

Systemic Complications Following Total Hip Arthroplasty--Rida A. Kassim, MD, Khaled J. Saleh, MD, MSc, FRCSC, George Almacari, MD, Mohamed Badra, MD, Kevin Young, and Justin L. Esterberg, MD

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Total hip arthroplasty (THA) has stood the test of time in improving the human quality of life. However, there remain associated complications. Although there is a low incidence of complications, the typical complications following THA have been well described in the literature, including infection, dislocation, wear, thromboembolic disorders, and intraoperative fracture. Knowledge of the systemic complications of THA can dramatically affect patient outcomes. (Journal of the Southern Orthopaedic Association 12(2):112–116, 2003) Key words: complications, hip replacement, total hip arthroplasty

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