August 2007  Volume XXXVI No. 8 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

117	The Effect of Obesity on Quality-of-Life Improvement After Total Knee Arthroplasty David A. McQueen, MD, Michael J. Long, PhD, Amit M. Algotar, MBBS, John R. Schurman, MD, and Vinay G. Bangalore, MD David A. McQueen, MD, Department of Surgery, Section Orthopaedics, University of Kansas School of Medicine — Wichita, Via Christi Regional Medical Center — St. Francis, 929 N. St. Francis St., Wichita, KS 67214 (tel, 316-268- 5988; fax, 316-291-7799; e-mail, dmcqueen@via-christi.org). Obesity has been consistently implicated as a major risk factor in the development and progression of osteoarthritis (OA), and total joint arthroplasty (TJA) has emerged as one of the most efficacious and cost-effective OA treatments. The effectiveness of this treatment manifests itself in both clinical and quality of life (QOL) measures. Given the interrelatedness of obesity and OA, and given the success of TJA in improving QOL, we conducted a study to determine whether obesity would adversely affect QOL improvement in 50 patients who underwent primary total knee arthroplasty for primary knee OA. Our results show that, 6 months after surgery, QOL measures improved more for obese patients than for overweight patients and patients with ideal body weight. Am J Orthop. 2007;36(8):E117-E127
121	Concurrent Opening Wedge Osteotomy and Total Knee Replacement in a Patient With Posttraumatic Arthritis and a Varus Tibial Malunion Amit Lahav, MD, and Frank R. DiMaio, MD Frank R. DiMaio, MD, Chairman, Department of Orthopaedic Surgery, Chief, Division of Adult Joint Reconstruction, Winthrop University Hospital, 259 First St, Mineola, NY 11501 (tel, 516-663-4798; fax, 516-663-3015; e-mail, fdimaio@winthrop.org). Abstract not available. Introduction provided instead. Combined extra-articular deformity of the tibia along with osteoarthritis of the knee joint can present a challenging reconstructive procedure for the orthopedic surgeon. The knee can be approached with staged procedures or via a 1-stage approach for full correction of the deformity and alignment at the time of joint arthroplasty. We present a case of concurrent opening wedge tibial osteotomy and total knee arthroplasty for the correction of a severe varus deformity in the presence of an extra-articular tibial deformity, medial compartment arthritis, and a leg-length discrepancy. This report presents another option for a single-stage operative procedure while combining technologies to address posttraumatic arthritis with tibial deformity. Am J Orthop. 2007;36(8):E121-E123
124	Autofusion of the Cervical Spine in 2 Children Following Open Biopsy of Langerhans Cell Histiocytosis Sumeet Garg, MD, Harish Hosalkar, MD, and John P. Dormans, MD John P. Dormans, MD, Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Wood Building, Second Floor, Philadelphia, PA 19104 (tel, 215-590-1527; fax, 215-590-1501; e-mail, dormans@email.chop.edu). Abstract not available. Introduction provided instead. Spontaneous interbody and spinous process fusion are known sequelae of chronic granulomatous disease. In particular, spinal tuberculosis frequently leads to the development of spontaneous fusion. Prior series have reported rates of osseous fusion in spinal tuberculosis from 29% to 73%.1-4 Spontaneous fusion of the cervical spine has also been noted following treatment of traumatic injuries with halo traction.5-8 In general, these are short-segment fusions of diseased or injured spinal levels and do not limit cervical spine range of motion to an extent that affects normal daily activities. An extensive search of the MEDLINE database did not reveal any reports in the English language of spontaneous fusion of the cervical spine following open biopsy. All combinations of the terms fusion and spine with biopsy, histiocytosis, and langerhans were reviewed. In the course of conducting long-term follow-up of Langerhans cell histiocytosis of the spine in children, 2 children who had open biopsy of the cervical spine presented at 5 and 6 years of follow-up with spontaneous fusion: one in the anterior elements and the other in the posterior elements.9 Patients were informed that data concerning their cases would be submitted for publication. Am J Orthop. 2007;36(8):E124-E126

FOCUS ON CERVICAL SPINE

398	Guest Editorial—Professionalism and Conflict of Interest in New Technology Introduction Edward N. Hanley, MD Edward N. Hanley, MD, Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina. Abstract not available. Am J Orthop. 2007;36(8):398-399
400	5 Points on Rheumatoid Arthritis in the Cervical Spine: What You Need to Know Adam L. Wollowick, MD, Andew M. Casden, MD, Paul L. Kuflik, MD, and Michael G. Neuwirth, MD Michael G. Neuwirth, MD, Spine Institute of New York, 10 Union Square East, Suite 5P, New York, NY 10003, tel, 212-844-8692; fax, 212-844-6677; email, mneuwirt@chpnet.org) Abstract not available. Am J Orthop. 2007;36(8):400-406
407	FDA Medical Device Approval: Things You Didn't Learn in Medical School or Residency Barbara Buch, MD Barbara Buch, MD, Office of Device Evaluation, Center for Devices and Radiological Health, Food and Drug Administration HFZ-410, Rockville, MD 20850. The Food and Drug Administration (FDA) does more than regulate food and drug products. Through its medical device evaluation process, FDA affects every orthopedic surgeon's practice and every orthopedic patient every day. FDA regulations affect the development of each orthopedic device in some way, from the product’s inception to its senescence, but the regulatory process and what the FDA’s stamp of approval means are not part of the curriculum in medical school or residency. Each device follows a specific pathway from manufacture to physician use and patient care depending on the assessment of risk associated with the device or classes of devices. The evaluation of safety and effectiveness involves a complex process of biomechanical, engineering, preclinical, laboratory, clinical, and epidemiological assessment. How different types of devices get to the patient are reviewed, and the basics of the regulatory process are explained in this paper. Common myths are set straight, and FDA’s concerns with “off-label” use are discussed. The role of the orthopedic surgeon in the regulatory process is also introduced. Am J Orthop. 2007;36(8):407-412
413	Advances in Technology and Surgical Technique in Spine Surgery Rohit Verma, MD, Farhan Siddiqi, MD, Jason S. Lipetz, MD, Christopher Samujh, BS, and Jeff S. Silber, MD, DC Jeff S. Silber, MD, DC, Department of Orthopaedic Surgery, Long Island Jewish Medical Center, 865 Northern Blvd, Great Neck, NY 11021 (tel, 516-918-6300; e-mail, jeffsilber@msn.com). This comprehensive review article encompasses a broad variety of topics within the spinal literature and includes an update on the latest technology and techniques for the spine. Am J Orthop. 2007;36(8):413-417
421	Characterization of Graft Subsidence in Anterior Cervical Discectomy and Fusion With Rigid Anterior Plate Fixation Dino Samartzis, DSc, MSc, Rex A. W. Marco, MD, Louis G. Jenis, MD, Nitin Khanna, MD, Robert J. Banco, MD, Edward J. Goldberg, MD, and Howard S. An, MD Howard S. An, MD, Department of Orthopedic Surgery, Rush­Presbyterian­St. Luke’s Medical Center, 1725 W Harrison St, Suite 1063 POB, Chicago, IL 60612 (tel, 312-243-4244; fax, 312-942-1516; e-mail, han@ortho4.pro.rpslmc.edu). This study addressed radiographically the evaluation, presence, location, and degree of subsidence with secondary focus on the various clinical parameters and outcomes in 32 patients who underwent anterior cervical discectomy and fusion (ACDF) with tricortical iliac crest bone grafts and rigid anterior plate fixation. Postoperative follow-up plain radiographs were evaluated to determine subsidence on lateral neutral images by measuring the change in height of interscrew distance (ISD) and anterior (AVD), mid (MVD), and posterior (PVD) vertebral endplate-to-endplate vertical distances. Clinical functional outcome and various risk factors were also addressed. A 100% fusion rate was achieved, no instrumentation-related complications were noted, and mild graft subsidence occurred in each patient after the initial 2 months of surgery. Mean AVD, MVD, and PVD were 1.2 mm, 0.4 mm and 0.6 mm, respectively. Mean ISD was 0.6 mm. Percent change for AVD, MVD, PVD, and ISD was 2.3%, 0.8%, 1.2%, and 1.2%, respectively. Subsidence was more pronounced at the anterior vertebral graft–endplate interface (P<.05). Satisfactory clinical results were reported in 90.9% of the patients. With such a sample size, age, sex, smoking status, plate design, graft type, and operative or number of fused levels did not demonstrate statistically significant differences to the degree of subsidence. This paper has shown that ACDF with tricortical bone grafts and rigid plating is associated with slight subsidence, graft load-sharing, high fusion rate, and excellent clinical outcome. Am J Orthop. 2007;36(8):421-427
429	Outpatient Anterior Cervical Discectomy and Fusion Mark Erickson, MD, Brandon S. Fites, MD, Michael T. Thieken, MD, and Alan W. McGee, MD Alan Mcgee, MD, Orthopaedics Northeast, 5050 North Clinton Street, Fort Wayne, IN 46825 (tel, 260-484-8551; fax, 260-484-8271) The study reported here examined patient safety and satisfaction in 56 patients with cervical radiculopathy secondary to foraminal stenosis or a herniated disc who underwent a total of 58 outpatient anterior cervical discectomy and fusion (ACDF) procedures with iliac crest bone graft or fibular allograft. Patients were discharged 0.8 hour to 6.5 hours (mean, 2.4 hours) after surgery and received 3 home health care visits over 24 hours. Of the 45 satisfaction questionnaires that were completed, 43 (95.6%) indicated patients were satisfied or very satisfied with the surgery, and 35 (77.8%) indicated patients would have the procedure performed on an outpatient basis again. Eleven (19.6%) of the 56 patients did not respond to a satisfaction questionnaire. Outpatient ACDF has high patient satisfaction but does not compromise patient safety. Am J Orthop. 2007;36(8):429-432
433	Risk for Infection After Anterior Cervical Fusion: Prevention With Iodophor-Impregnated Incision Drapes Kingsley R. Chin, MD, Nikolas London, MD, Albert O. Gee, MD, and Henry H. Bohlman, MD Kingsley R. Chin, MD, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St (2 Silverstein), Philadelphia, PA 19104 (tel, 617-697-5442; fax, 215-349-5928; e-mail, kingsleychin@hotmail. com). Cervical spine infections can have disastrous consequences, but techniques for minimizing infections should be evidence based. In this article, we report the incidence of spine infections in a large cohort of consecutive patients who underwent anterior cervical fusions without iodophor-impregnated incision drapes (3M Ioban; 3M Health Care, St. Paul, Minn) covering the surgical site. We reviewed the records of 581 consecutive patients (294 men, 287 women) who underwent 616 anterior cervical fusions without such drapes over the incision site and who were followed for 1 to 21 years after surgery. Mean age at the time of surgery was 52 years (range, 17-83 years). There was 0% incidence of cervical spinal infections in the group. Need for iodophor-impregnated incision drapes during anterior cervical fusion was not demonstrated. These drapes added unnecessary cost and may decrease skin mobility, making adequate exposure more difficult. Am J Orthop. 2007;36(8):433-435
439	Dislocation of the Proximal Tibiofibular Joint in Association With a Tibial Shaft Fracture: Two Case Reports and a Literature Review Bryce A. Johnson, MD, Maneesh R. Amancharla, MD, and Bradley R. Merk, MD Bradley R. Merk, MD, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 645 N Michigan Ave, Suite 910, Chicago, IL 60611 (tel, 312-908-7937; fax, 312-908-8479; e-mail, bmerk@nmff.org). Dislocation of the proximal tibiofibular joint (PTFJ) in association with a displaced tibial shaft fracture and an intact fibula is an exceedingly rare injury. We present 2 cases of tibia fractures associated with an intact fibula and a PTFJ dislocation. The first case involves a man who sustained a closed spiral fracture of the distal tibial shaft, with an intact fibula, an anterolaterally dislocated PTFJ, and a partial tear of the lateral collateral ligament. The tibia was percutaneously plated, and the PTFJ was reduced and then stabilized with temporary screw fixation. The second case involves a woman who sustained a closed fracture of the tibia in association with a PTFJ dislocation. The tibia was fixed with an intramedullary nail, and the PTFJ was similarly reduced and fixed with a temporary screw. We also provide a brief literature review focusing on classification of PTFJ dislocations, mechanism of injury, associated injuries, and treatment options. These cases underscore the need to assess the PTFJ in the setting of a displaced tibial shaft fracture in the presence of an intact fibula. Am J Orthop. . 2007;36(8):439-441

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