October 2007  Volume XXXVI No. 10 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

E-FOCUS ON DIAGNOSTIC CHALLENGES

141	Retrofascial Bilateral Psoas Abscess in a 6-Year-Old Child Cláudio Santili, MD, Miguel Akkari, MD, Gilberto Waisberg, MD, Clóris Kessler, MD, and Susana dos Reis Braga, MD Cláudio Santili, MD, Pediatric Orthopedics and Traumatology Group, Orthopedics and Traumatology Department, Pavilhão Fernandinho Simonsen—Santa Casa de São Paulo, Faculty of Medical Sciences, Rua Cesário Motta Junior, 112-CEP: 01221-020, Vila Buarque, São Paulo, Brasil (tel, 55-11-221-2395; fax, 55-11-221-2395; e-mail, ortopediatrica@yahoo.com.br). Abstract not available. Introduction provided instead. Retrofascial abscess of the psoas muscle was first described by Herman and Mynter in 1881 and is considered a rare disease.1-5 Possible etiologies for the primary form of the disease are trauma, skin infection, lymph node suppuration, and nutritional and socioeconomic factors; the secondary form results mainly from Crohn’s disease or tuberculosis.1,2,6-8 Classic features of the disease are a triad of insidious installation of flank pain, limping, and flexion contracture of the ipsilateral hip, normally accompanied by consumptive signs and symptoms.1,2,6,9,10 Among the differential diagnoses are hip and sacroiliac septic arthritis, lymphadenitis, lymphoma, pelvic inflammatory disease, osteomyelitis of the spine, sarcoma on the thigh,1 psoas and retroperitoneal tumors,11,12 hematoma of the psoas,13 and avascular necrosis of the hip. Ultrasonography and computed tomography (CT) are the main, complementary examinations used to diagnose the disease.1,4,6,14-18 Treatment consists of percutaneous puncture or open drainage, followed by appropriate antibiotic therapy.1,6,9,12,19 Prognosis is good, even though mortality rates are 2.5% for the primary form, 20% for the secondary form, and up to 100% in cases of late diagnosis and inadequate treatment.3,4,8,20 In this article, we present the case of a 6-year-old boy with bilateral psoitis. Psoitis affects both muscles simultaneously in less than 1% of cases; approximately 500 cases have been reported worldwide.8,21 Am J Orthop. 2007;36(10):E141-E143.
144	Delayed Clinical Presentation of Hemorrhagic Pericardial Effusion in a Patient Receiving Warfarin Sodium Robert F. Hillyard, MD Robert F. Hillyard, MD, 370 Ninth Avenue, Suite 205, Salt Lake City, UT 84103 (tel, 801-408-8700; fax, 801-408-8732; e-mail, robert.hillyard@intermountainmail.org). Abstract not available. Introduction provided instead. Acute hemorrhagic pericardial effusion is a condition that may coexist with other injuries in patients with multiple trauma. Pericardial tamponade caused by hemorrhagic effusion is an emergent condition that requires prompt treatment.1 Subacute presentation has been reported,1 and anticoagulation of a patient with blunt chest trauma may lead to delayed presentation.2 In treating patients with multiple trauma, some orthopedic surgeons may assume the role of primary attending physician after other trauma issues are thought to be resolved. Not infrequently, patients with blunt chest injury will also have lower extremity fractures. Anticoagulation may be indicated in these patients, and orthopedic surgeons may become responsible for managing this aspect of patient care. In this scenario, orthopedic surgeons may be the first to encounter signs and symptoms associated with hemorrhagic pericardial effusion or tamponade. In this report, I present a case of hemorrhagic pericardial effusion with tamponade in a patient in his late 30s with blunt chest trauma and multiple fractures who was anticoagulated with warfarin sodium but did not clinically manifest the effusion until 45 days after injury. Am J Orthop. 2007;36(10):E144-E147.
148	Childhood Leukemia Presenting as Sternal Osteomyelitis Andreas H. Gomoll, MD Andreas H. Gomoll, MD, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 850 Boylston St., Chestnut Hill, MA 02467 (tel, 617-732-9813; fax, 617-732-9730). Abstract not available. Introduction provided instead. Musculoskeletal manifestations are the presenting complaint in up to 20% of patients with pediatric leukemia.1 Therefore, orthopedic surgeons often become involved before a formal diagnosis of leukemia has been made. Because of similarities in presentation, many of these patients are initially diagnosed with osteomyelitis, transient synovitis, or arthritis, resulting in a delay in appropriate treatment. We present a case of a sternal lesion initially diagnosed and treated as osteomyelitis. We hope this case report raises awareness of this important and potentially lethal entity. Am J Orthop. 2007;36(10):E148-E150.
151	Synovial Osteochondromatosis of the Carpometacarpal Joint Hiroatsu Nakashima, MD, Hideshi Sugiura, MD, Yoshihiro Nishida, MD, Yoshihisa Yamada, MD, and Naoki Ishiguro, MD Hiroatsu Nakashima, MD, Department of Orthopaedic Surgery, Aichi Hospital, Aichi Cancer Center, 18 Kuriyado, Kakemachi, Okazaki-City, 444-0011, Japan (tel,+81-564-21-6251; fax, +81-564-21-6467; e-mail, hnakasima@acc-aichi.com). Abstract not available. Introduction provided instead. Synovial osteochondromatosis is an uncommon lesion characterized by cartilagenous and osseous metaplasia of the synovial membrane of the joint and the tendon sheath. It is classically monoarticular, and is found in large joints such as the knees, hips, shoulders, and ankles; it rarely occurs in the small joints of the hand. We present an extremely rare case of synovial osteochondromatosis involving the carpometacarpal joint of the thumb. Am J Orthop. 2007;36(10):E151-E152.

FOCUS ON JOINT REPLACEMENT

518	Guest Editorial—“I’ll Take the Puron” Jess H. Lonner, MD Jess H. Lonner, MD, Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107. Abstract not available. Am J Orthop. 2007;36(10):518-519.
520	Periprosthetic Infection in a Nutshell Elie Ghanem, MD, Fereidoon M. Jaberi, MD, and Javad Parvizi, MD Javad Parvizi, MD, 925 Chestnut St, Philadelphia, PA 19107 (tel, 267-339-3617; fax, 215-503-0580; e-mail, parvj@aol.com). Abstract not available. Am J Orthop. 2007;36(10):520-525.
526	The “Banana Peel” Exposure Method in Revision Total Knee Arthroplasty Amit Lahav, MD, and Aaron A. Hofmann, MD Aaron A. Hofmann, MD, Department of Orthopedics, Orthopedics Center, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT 84108 (tel, 801-587-5457; fax, 801-587-5411; e-mail, aaron.hofmann@hsc.utah.edu). We present an exposure technique, the “banana peel,” that has been used exclusively for revision total knee arthroplasty (TKA) for more than 20 years. We retrospectively reviewed use of this technique in 102 consecutive patients (mean age, 62 years; range, 41-92 years) who underwent tibial-femoral stemmed revision TKA. There were 5 deaths, leaving 97 patients (98 knees) for the study. The technique involves peeling the patella tendon as a sleeve off the tibia, leaving the extensor mechanism intact with a lateral hinge of soft tissue. A quadriceps “snip” is also done proximally. Patients with a minimum follow-up of 24 months were included. Telephone interviews and chart reviews were conducted, and Knee Society scores were obtained. Mean follow-up was 39 months (range, 24-56 months). No patient reported disruption of the extensor mechanism or decreased ability to extend the operative knee. Mean Knee Society score was 176 (range, 95-200). Mean postoperative motion was 106°. No patient reported pain over the tibial tubercle. The banana-peel technique for exposing the knee during revision TKA is a safe method that can be used along with a proximal quadriceps snip and does not violate the extensor mechanism, maintaining continuity of the knee extensors. Am J Orthop. 2007;36(10):526-529.
530	Impact of Surgeon Handedness and Laterality on Outcomes of Total Knee Arthroplasties: Should Right-Handed Surgeons Do Only Right TKAs? Samir Mehta, MD, and Paul A. Lotke, MD Samir Mehta, MD, Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce St (2 Silverstein), Philadelphia, PA 19104 (tel, 215-432-7432; fax, 215-349-8690; e-mail, samir.mehta@uphs.upenn.edu). In this study, we examined the impact of surgeon handedness on total knee arthroplasty (TKA) outcomes. From 1997 to 2001, a right-handed surgeon performed 728 primary TKAs while standing on the side of the operative extremity—377 on the right and 351 on the left. Extension and Knee Society Function and Pain scores were significantly better for right knees than for left knees 1 year after surgery. This is the first report that shows that handedness can play a role in TKA outcomes. Reasons for the difference have not been determined but may be related to dexterity or proprioception. A surgeon should be aware of this potential problem and take precautions to prevent diminished results when operating. Am J Orthop. 2007;36(10):530-533.
534	Surgical Challenges in Complex Primary Total Hip Arthroplasty Sathappan S. Sathappan, MD, Eric J. Strauss, MD, Daniel Ginat, BS, Vidyadhar Upasani, BS, and Paul E. Di Cesare, MD Paul E. Di Cesare, MD, Department of Orthopaedics, University of California at Davis School of Medicine, 4860 Y Street, Suite 3800, Sacramento, CA 95817 (tel, 916-734-2958; fax, 916-734-7904; e-mail, pedicesare@aol.com). Complex primary total hip arthroplasty (THA) is defined as primary THA in patients with compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip. Intraoperatively, provisions must be made for the possible use of modular implants and/or bone grafts. In this article, we review the principles of preoperative, intraoperative, and postoperative management of patients requiring a complex primary THA. Am J Orthop. 2007;36(10):534-541.
545	Effect of Distal Stem Geometry on Interface Motion in Uncemented Revision Total Hip Prostheses Kevin L. Kirk, DO, Benjamin K. Potter, MD, Ronald A. Lehman, Jr., MD, and John S. Xenos, MD Benjamin K. Potter, MD, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Building 2, Clinic 5A, Washington, DC, 20307 (tel, 202-782-6574; fax, 202-782-6845; e-mail: kyle.potter@us.army.mil). In this study, we compared differences in motion at the bone-prosthesis interface in femora in which a fluted, tapered, or cylindrical distal stem design had been implanted in a revision total hip arthroplasty model. Paired, fresh-frozen, cadaveric femora underwent resection of the proximal femur to simulate the proximal femoral bone loss often present during revision total hip arthroplasty and implantation with either a fluted, tapered stem or a clinically proven cylindrical stem. Specimens were then preloaded and subjected to a synchronous axial and torsional load with continuous monitoring of axial displacement and rotation. For the fluted, tapered stem, mean axial and rotational displacements were 13.33 μm and 9.81 μm, respectively, compared with 18.37 μm and 13.40 μm for the cylindrical stem (both Ps<.05). Therefore, the fluted, tapered stem design that was tested demonstrated superior initial biomechanical stability compared with that of the clinically proven cylindrical design tested. However, both stems demonstrated motion below the threshold necessary for bony ingrowth. Knowledge of the initial biomechanical properties of different stem designs may assist the revision joint surgeon in choosing the optimal prosthesis for implantation. Am J Orthop. 2007;36(10):545-549.
550	Incidence of Patellar Clunk With a Modern Posterior-Stabilized Knee Design Jess H. Lonner, MD, Jeff G. Jasko, MS, Hari P. Bezwada, MD, David G. Nazarian, MD, and Robert E. Booth, Jr, MD Jess H. Lonner, MD; Booth, Bartolozzi, and Balderston Orthopaedics; 800 Spruce St; Philadelphia, PA 19107 (tel, 215-829-2222; fax, 215-829-2478; e-mail, LonnerJ@pahosp.com). Patellar clunk is an uncommon complication of posterior-stabilized total knee arthroplasty (TKA), though the incidence has been reported to be as high as 7.5% with some posterior-stabilized implants, and the etiology is multifactorial. Femoral component design has been implicated as a major cause of this complication. This series compares the incidence of patellar clunk with 2 different knee prostheses, the Insall-Burstein II (IB) and the NexGen Legacy PS (NG), both manufactured by Zimmer (Warsaw, Ind). One-hundred fifty consecutive posterior-stabilized TKAs were in each group, and the groups were similar in surgical approaches and techniques. Insall-Salvati (IS) ratios and joint-line positions were measured on preoperative and postoperative x-rays. Knee Society Clinical and Functional scores were calculated. Incidence of patellar clunk was reduced from 4% with the IB design to 0% with the NG design. IS ratios, joint-line positions, and clinical outcomes were no different between the groups. It appears that femoral component design may play a substantial role in development of patellar clunk after posterior-stabilized TKA. Am J Orthop. 2007;36(10):550-553.
554	Effects of a Preoperative Femoral Nerve Block on Pain Management and Rehabilitation After Total Knee Arthroplasty Robert P. Good, MD, Michael H. Snedden, MD, Frank C. Schieber, MS, and Andrea Polachek, RN, ONC Robert P. Good, MD, Chief Service of Orthopedic Surgery, Bryn Mawr Hospital, 130 S Bryn Mawr Ave, Bryn Mawr, PA 19010 (tel, 610-527-2727; fax, 610-527-1588; email, rpg@orthspec.com). The objective of this prospective, randomized, double-blind study was to determine if preoperative administration of a femoral nerve block reduces the amount of morphine needed for postoperative analgesia after total knee arthroplasty (TKA). Forty-two patients undergoing TKA were randomly assigned to receive either a femoral nerve block (0.50% bupivacaine hydrochloride with epinephrine 1:200,000) or matching placebo. Results showed postoperative morphine use was significantly lower in patients who received the nerve block (25.5 vs 37.5 mg, P = .016); however, the 2 groups had similar pain scores and rehabilitative outcomes. In general, a preoperative femoral nerve block is a safe and effective adjunct for decreasing morphine use for post-TKA analgesia. Am J Orthop. 2007;36(10):554-557.
558	An Unusual Cause of Failure of a Total Knee Replacement David F. Dalury, MD David F. Dalury, MD, Orthopaedic Associates, 8322 Bellona Ave, Suite 100, Baltimore, MD 21204 (tel, 410-337-7900; fax, 410-821-1334; e-mail, ddalury@gmail.com). Abstract not available. Am J Orthop. 2007;36(10):558-559.
560	Baastrup Disease Paul D. Clifford, MD Paul D. Clifford, MD, Department of Radiology, Applebaum Outpatient Center, University of Miami, 1115 NW 14th St, Miami, FL 33136-2106 (tel, 305-243-5449; fax,305-243-8422; e-mail, pclifford@med.miami.edu). Abstract not available. Am J Orthop. 2007;36(10):560-561.

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