OCTOBER 2008 VOLUME XXXVII NUMBER 10 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

171	Anomalous Bronchial Anatomy Complicating One-Lung Ventilation for Anterior Correction of Adolescent Idiopathic Scoliosis Steven M. Presciutti, BS, Alexander R. Vaccaro, MD, George D. Picetti III, MD, Zoe Brown, MD, Brian C. Friel, BA, and Corbett D. Winegar, MD Mr. Presciutti is Medical Student, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Abstract not available. Introduction provided instead. The standard protocol for placing anterior instrumentation to correct adolescent idiopathic scoliosis often requires 1-lung ventilation, which can be accomplished by using a double-lumen endotracheal tube to deflate the other lung or by using a bronchial blocker with a single-lumen endotracheal tube to block air from going through selected tracheal passageways. We report the case of a patient whose trifurcation at the carina made placement of a double-lumen endotracheal tube technically challenging. After multiple failed attempts at placement, the surgery was aborted. One week later, a bronchial blocker was placed, and surgery was performed.   Am J Orthop. 2008;37(10):E171-E172.
173	Unusual Case of Secondary Scoliosis in a 20-Year-Old Man Patrick J. Messerschmitt, MD, and Jeffery L. Stambough, MD, MBA Dr. Messerschmitt is Orthopaedic Surgery Resident, University Hospitals Case Medical Center, Cleveland, Ohio. Abstract not available. Introduction provided instead. Secondary, or sciatic, scoliosis is a reactive spinal deformity caused by an underlying pain source. Sciatic scoliosis is 1 of 3 scoliosis subtypes first described in 1980 by McPhee and O’Brien.1 The other 2 subtypes are idiopathic scoliosis and structural defect. In most cases, children and adolescents presenting with idiopathic scoliotic curves have no pain.2 In contrast, secondary scoliosis usually has a pain component and can occur with disc herniation, spondylolisthesis, and osteoid osteoma. Secondary scoliosis presents as a continuum of physical and radiographic findings. Patients affected by secondary scoliosis are often pediatric patients and have a clearly demonstrable painful lesion. In some cases, however, the pain source is unclear. This de novo spinal deformity begins as a nonstructural type of scoliosis secondary to a painful focus, which is readily reversible with treatment of the painful lesion. Residual structural scoliosis curves may occur, particularly when there is a long delay between diagnosis and treatment. Signs and symptoms of disc herniation in adolescents and children may develop slowly and insidiously. The clinical presentation differs from the typical picture in the adult population, but the transition point is not precise from adolescent to adult. Adults may bend, list, or tilt in response to pain but seldom have nonstructural scoliosis. In this report, we present a case that reinforces the importance of serial examination and follow-up even in the absence of neurologic findings or an overt pain source. A review of the literature on epidemiology, pathophysiology, and management is included. Am J Orthop. 2008;37(10):E173-E176.
177	Surgical Anatomy of the Sacrum Rongming Xu, MD, Nabil A. Ebraheim, MD, and Nicholas K. Gove, MD Dr. Xu is Assistant Professor, Department of Orthopaedic Surgery, Medical College of Ohio, Toledo, Ohio. Treatment in spinal disorders, sacroiliac joint disruption, and sacral fractures may involve instrumentation of the sacrum. Proper screw placement is essential for obtaining adequate bony purchase for solid fixation. Injury to adjacent vital structures during screw placement remains a major concern because of the complex anatomy of the sacrum. This article reviews the bony anatomy of the sacrum. Am J Orthop. 2008;37(10):E177-E181.
182	Chronic Lateral Ankle Pain Secondary to an Anomalous Peroneus Longus Joseph A. Abboud, MD, and Enyi Okereke, MD Dr. Abboud is Clinical Assistant Professor of Orthopaedic Surgery, 3B Orthopaedics, University of Pennsylvania Health System, Philadelphia, Pennsylvania. Abstract not available. Introduction provided instead. The differential for chronic lateral ankle pain is broad and includes lateral ankle instability, subtalar instability, tarsal coalition, peroneal tendon subluxation, peroneal tendon rupture, longitudinal peroneal tendon tear, peroneal tendonitis, tenosynovitis, and lumbosacral radiculopathy. Disorders of the peroneal tendons have seldom been reported. Although peroneus brevis disorders have been described more often in the literature, peroneus longus problems are gaining more recent attention.1 Much of the literature regarding both tendons is in the form of case reports.2-4 Tenosynovitis, longitudinal ruptures or partial tears of the peroneus longus tendon, and pathologic changes isolated to the os peroneum are the major pathologic conditions associated with the peroneus longus.1 Am J Orthop. 2008;37(10):E182-E185.

503	Guest Editorial—Surgeon as Hero Jess H. Lonner, MD Dr. Lonner, this journal’s Associate Editor for Adult Reconstruction, is Director, Knee Replacement Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania. Abstract not available. Am J Orthop. 2008;37(10):503-504.
506	Conversion Total Hip Replacement After Malunited Intertrochanteric Fracture: A Technical Note Aasis Unnanuntana, MD, and Stuart B. Goodman, MD, PhD Dr. Unnanuntana is Orthopaedic Surgeon, Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California. Malunited intertrochanteric fracture involves anatomical changes such as medialization of the femoral canal and intramedullary remodeling and sclerosis. These changes introduce difficulties that are not ordinarily encountered with routine total hip replacement. Possible intraoperative complications include spiral femoral fracture during hip dislocation and failure to identify the femoral canal. Therefore, recognizing the anatomical changes before and during surgery is crucial. In this article, we describe specific surgical steps and techniques by which these problems may be avoided, thus minimizing potential complications. Am J Orthop. 2008;37(10):506-509.
510	Reconstruction of the Failed Acetabular Component Using Cemented Shells and Impaction Grafting in Revision Hip Arthroplasty Paul S. Issack, MD, PhD, Burak Beksac, MD, David L. Helfet, MD, Robert L. Buly, MD, and Thomas P. Sculco, MD Dr. Issack is Fellow, Orthopaedic Trauma and Adult Reconstructive Surgery, Hospital for Special Surgery, New York, New York. Cemented revision techniques have been used with variable success in the reconstruction of the failed acetabular component. Diminished cement–bone interlock secondary to diminished cancellous bone quality and quantity may contribute to the observed high rates of aseptic loosening of this construct in the revision setting. Nevertheless, this technique may still be an option in the elderly patient with limited function or life expectancy. Impaction bone grafting in conjunction with cemented acetabular cups has been reported to result in good midterm results. The reconstruction is challenging and tedious and requires meticulous execution for success. When performed well, impaction grafting can result in survivorship rates equaling those seen using cementless hemispheric cups with the additional advantage of increasing acetabular bone stock. Am J Orthop. 2008;37(10):510-512.
513	Total Knee Arthroplasty in Patients With Parkinson’s Disease: Impact of Early Postoperative Neurologic Intervention Samir Mehta, MD, Jonathan P. VanKleunen, MD, Robert E. Booth, MD, Paul A. Lotke, MD, and Jess H. Lonner, MD Dr. Mehta is Chief, Orthopaedic Trauma Service, and Assistant Professor, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. The impact of Parkinson’s disease (PD) on the outcomes of total knee arthroplasty (TKA) is not well understood. The purpose of this study was to evaluate whether early medical management of PD affects TKA outcomes. We retrospectively reviewed the cases of 34 patients (39 knees) who had PD and underwent TKA. Patients received a preoperative/immediate-postoperative neurologic consultation (n = 13) or a delayed consultation (n = 21). Clinical outcomes and functional recovery were assessed with the Knee Society scoring system and the Unified Parkinson’s Disease Rating Scale (UPDRS). There were no significant preoperative differences between the 2 cohorts. Mean follow-up was 36 months. Compared with the delayed-consultation group, the preoperative/immediate-postoperative consultation group had a 2.5-day shorter length of stay after surgery and 19 points more improvement in Knee Society Pain and Function scores. In addition, there was statistically significant improvement in UPDRS Severity scores in the preoperative/immediate consultation group but not in the delayed-consultation group. Early neurologic consultation in patients with PD can significantly decrease length of stay and improve early outcomes after TKA. Am J Orthop. 2008;37(10):513-516.
517	Mechanical Evaluation of Unipolar Hip Spacer Constructs Frederick J. Kummer, PhD, Eric Strauss, MD, Kevin Wright, MD, Erik N. Kubiak, MD, and Paul E. Di Cesare, MD Dr. Kummer is Associate Director, Musculoskeletal Research Center, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York. The strengths of 3 hip spacer constructs—Steinmann pins, a short intramedullary nail (both cement-incorporated), and a Charnley prosthesis—were determined and compared with the strength of a commercially available hip spacer. The hip prosthesis construct was more than twice as strong as the other 2 constructs and was equivalent in strength to the commercial spacer. For spacer applications in which limited weight-bearing is anticipated, the hip prosthesis construct appears more efficacious, but its pros and cons should be compared with those of the commercial product. Am J Orthop. 2008;37(10):517-518.
519	Initial Stability of Press-Fit Acetabular Components: An In Vitro Biomechanical Study Khaled J. Saleh, MD, MSc, FRCSC, Brian Bear, MD, Mathias Bostrom, MD, Timothy Wright, PhD, and Thomas P. Sculco, MD Dr. Saleh is Professor, Departments of Orthopaedic Surgery & Public Health Sciences, and Division Head and Fellowship Director, Adult Reconstruction, University of Virginia Health System, Charlottesville, Virginia. Component shape, surface finish, and presence of holes for adjuvant screw fixation should all affect initial stability and hence long-term fixation of total hip acetabular components. We conducted a study to determine stability against edge loading and torsion in commercial implants that differed in these design variables. Components were seated into synthetic cancellous bone blocks, and loads and insertion energies necessary to seat the components were measured. Components were then edge-loaded or twisted to failure. Compared with several hemispherical components, an elliptical component without holes and sintered beads had significantly more stability under both loading conditions. The presence of more holes in hemispherical components significantly improved stability in edge loading but not in torsion. Finally, plasma-spray and small-bead coatings showed improved stability compared with fiber-mesh and large-bead coatings. Am J Orthop. 2008;37(10):519-522.
524	Correlation of Postoperative Epidural Analgesia With Morbidity and Mortality Following Total Knee Replacement in Medicare Patients Christopher L. Wu, MD, James S. Demeester, MD, Robert Herbert, David N. Maine, MD, Andrew J. Rowlingson, BA, and Lee A. Fleisher, MD Dr. Wu is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland. It is unclear whether perioperative epidural analgesia is associated with a decrease in mortality in patients who undergo orthopedic procedures. We examined 35,878 patients’ data obtained from a random sample of Medicare beneficiaries who underwent elective total knee replacement. Division of patients into 2 groups was based on presence or absence of billing for postoperative epidural analgesia. Outcomes assessed were death and major morbidity 30 days after surgery. Multivariate regression analysis revealed no between-groups difference in mortality 30 days after surgery. Postoperative epidural analgesia was not associated with lower incidence of mortality or major morbidity in Medicare patients who underwent elective total knee replacement. Am J Orthop. 2008;37(10):524-527.
528	Eight-Year Follow-Up of Total Knee Arthroplasty in a Patient With an Ipsilateral Below- Knee Amputation Emmanuel K. Konstantakos, MD, Ryan P. Finnan, MD, and Anil B. Krishnamurthy, MD Dr. Konstantakos is Orthopaedic Resident, Department of Orthopaedic Surgery, Wright State University, Dayton, Ohio. Abstract not available. Am J Orthop. 2008;37(10):528-530.
531	Distal Humerus Nonunion After Failed Internal Fixation: Reconstruction With Total Elbow Arthroplasty Dawn M. LaPorte, MD, Michael S. Murphy, MD, and J. Russell Moore, MD Dr. LaPorte is Assistant Professor, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland. In nonunion after distal humerus fracture, osteoporosis, devascularized fracture fragments, and periarticular fibrosis limit potential reconstructive options. We assessed pain relief, functional gains, and complications in 12 patients whose long-standing, painful nonunions after previous treatment with rigid internal fixation were reconstructed with a semiconstrained total elbow arthroplasty, frequently with a triceps-sparing approach and anterior ulnar nerve transposition. At mean follow-up of 63 months, 11 patients had good pain relief and a good or excellent functional result: mean flexion/extension, 134° to 18°; mean total arc of motion, 117°; mean pronation/supination, 74° to 69°. Despite the 75% rate of complications (8), semiconstrained total elbow arthroplasty provides a viable treatment for this difficult problem. Am J Orthop. 2008;37(10):531-534.

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