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Baltimore Highlands, MD, United States

Conway J.D.,Rubin Institute for Advanced Orthopedics
Orthopedic Clinics of North America | Year: 2010

This article focuses on comparing patient morbidity with harvesting bone graft for the treatment of nonunions from three different sites. Anterior iliac crest graft is the most commonly used site; however, the posterior iliac crest and intramedullary canal provide greater quantities of bone. The anterior and posterior iliac crests also have some donor site complications such as nerve injury and persistent pain. The intramedullary canal, when compared with anterior and posterior iliac crest, offers the largest quantity of bone graft with the least amount of patient donor site morbidity. The intramedullary canal also appears to be a bone graft source that can be reharvested, unlike the anterior and posterior iliac crest donor sites. © 2010 Elsevier Inc. All rights reserved.

McElroy M.J.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

The negative effects of obesity following total joint arthroplasty, such as increased morbidity and mortality, have been well documented in literature. However, little is known about whether specific body mass indices can be used as cutoffs to determine which patients are most at risk for having a poor postoperative outcome. We evaluated the effects of differing levels of obesity as measured by body mass index (BMI) on implant survivorship, Knee Society scores, complications, and radiographic outcomes. A systematic review of the literature was performed to identify all studies reporting outcomes of total knee arthroplasty in obese (30 ≤ BMI < 40 kg/m2) and morbidly obese patients (40 ≤ BMI < 50 kg/m2). Twenty-four studies were identified in our literature search. At a mean 5-year follow-up, morbidly obese patients (88%) had significantly lower implant survivorship than obese patients (95%) and nonobese patients (97%). Significantly, lower postoperative mean Knee Society objective and function scores (71 and 60 points) were observed for morbidly obese patients than for nonobese patients (75 and 90 points), but obese patients did not have significantly lower Knee Society objective and function scores than nonobese patients (78 and 84 points). Complication rates for nonobese, obese, and morbidly obese patients were 9, 15, and 22%, respectively, all of which were significantly different. However, no significant difference was observed in the incidence of radiolucent lines that were 12, 19, and 14%, respectively. Thus, we conclude that a BMI greater than 40 kg/m2 may be used as a cutoff to help guide patient education and treatment options for primary total knee arthroplasty. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pivec R.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Knee stiffness following primary total knee arthroplasty (TKA) is a well-recognized problem which leads to poor patient outcomes and may limit patient activities of daily living. Manipulation under anesthesia (MUA) is one option for the treatment of knee stiffness. However, there has been controversy regarding the safety and long-term efficacy of this procedure. A systematic review of the literature was performed to identify studies that reported the clinical outcomes and measured range of motion for patients undergoing MUA. Fourteen studies (913 patients) reported range of motion results following MUA at up to 10-year follow-up. The mean premanipulation and final range of motion were 66 and 99 degrees, respectively. Compared with preoperative range of motion, the gain in the range-of-motion arc at 1-, 5-, and 10-year follow-up was 30, 33, and 33 degrees, respectively. Complications were rare with only two reported periprosthetic fractures, resulting in an incidence of 0.2%. MUA for a stiff primary TKA is an efficacious procedure to restore range of motion. Early gains in motion appear to be maintained at long term, and in some cases patients may gradually improve further at mid-term follow-up. The risk of periprosthetic fracture is low, making MUA a safe option for improving knee range of motion. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Costa C.R.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Despite high survivorship for total knee arthroplasty, many reports have described low patient-satisfaction rates. Standard parapatellar approaches have been linked with decreased quadriceps muscle strength, which may in turn lead to prolonged rehabilitation and altered kinematics. Although technically demanding, minimally invasive techniques offer the potential for shorter recovery times and improved strength. Our purpose was to compare perioperative factors, the clinical and radiographic outcomes, complications, and survivorship of several minimally invasive approaches to each other and to the conventional medial parapatellar approach. A total of 23 level I or II studies were reviewed. There were no statistically significant differences in perioperative factors, clinical or radiographic outcomes, survivorship, or complication rates between patients the various minimally invasive approaches to a standard approach. The only significant difference observed was in recovery of quadriceps muscle function (shorter in patients who had a minimally invasive approach). The minimally invasive lateral approach had more complications than the other minimally invasive approaches. The mini-midvastus approach had the best clinical outcomes at 1 and 3 months when compared with other minimally invasive approaches and standard approaches. The mini-subvastus approach had the lowest rate of complications, overall. Further multicenter randomized trials are needed to determine the minimally invasive approach that best improves outcomes while minimizing complications. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Johnson A.J.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Knee osteoarthritis causes debilitating pain, and results in characteristic gait changes. Some authors believe that a system of neuromuscular retraining may improve these parameters. We therefore evaluated a novel brace that combines pneumatic joint unloading and active swing-assist to assess: (1) differences in pain levels or medication usage; (2) reductions in additional interventions; (3) changes in quadriceps muscle strength; and (4) improvements in specific gait measurements after 3 months. A prospective pilot series of 10 knee osteoarthritis patients who had exhausted other nonoperative treatment measures were enrolled. These patients were compared with the previous 15 knee osteoarthritis patients who met similar criteria, but were not braced. Quadriceps muscle strength was measured, as were pain levels, and additional interventions such as injections or total knee arthroplasty procedures. Gait parameters measured included: walking speed, total range-of-motion, knee flexion at foot-strike, and knee adduction moment. All but one of the compliant patients reported a decrease of at least two pain points after 3 months of use. There was one additional intervention in the brace cohort versus a statistical increase of 10 in the nonbrace cohort. All patients who were compliant with the brace showed an increase in thigh girth measurements, compared with none in the nonbrace cohort. Braced patients experienced retained improvements in at least one gait parameter including improved walking speed, total range of motion, and improved knee-angle at heel strike. The mean improvement in knee adduction moment was a decrease of 0.2255 Nm/kg (range, 0.56 to 0.564 Nm/kg), showing a mean improvement of 48% (range, 16 to 76% of original peak moment). The use of a brace that has features including a combination of unloader characteristics along with active swing-assist, provided neuromuscular retraining benefits for patients who have knee osteoarthritis. In summary, although quite encouraging, future larger scale and prospective randomized studies need to assess the potential benefits of this brace for treating knee osteoarthritis. Level II. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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