Anterior glenohumeral instability complicated by bone loss is a challenging problem and, when severe, may require surgical treatment with bone grafting. We review our institution’s experience with humeral head and glenoid bone grafting for large Hill-Sachs lesions and glenoid defects. Materials and Methods: Patients who underwent intra-articular bone reconstruction for Hill-Sachs and large glenoid defects for anterior instability at our institution during 2002-2008 were retrospectively reviewed. Those who had undergone concomitant humeral head replacement were excluded. Six patients were identifed as having undergone allograft or autograft iliac crest bone graft reconstruction of the glenoid, with four available for full follow-up (average 39 months; range, 7 to 63). Five patients were identifed as having undergone humeral head allograft reconstruction and four were available for full follow-up (average 28 months; range, 11 to 40). The remaining three patients were available for telephone follow-up. American Shoulder and Elbow Society (ASES) and University of California, Los Angles (UCLA) scores were recorded and radiographs obtained. Results: Average postoperative ASES and UCLA scores for glenoid bone graft patients were 91 and 33, respectively. Average postoperative ASES and UCLA scores for humeral bone graft patients were 85.3 and 28.4, respectively. Glenoid bone graft shoulders, when compared to the opposite normal side, lost an average of 3° of forward fexion, 10° of external rotation, and two levels of internal rotation. Humeral head bone-grafted shoulders, lost an average of 23° of forward fexion, 8° of external rotation, and two levels of internal rotation. No episodes of recurrent subluxation or dislocations were reported. Radiographs showed no evidence of graft resorption or hardware prominence. Conclusions: Bone grafting procedures around the shoulder for the treatment of instability provided relief from recurrent instability and good functional results.

Lupus nephritis is one of the most serious manifestations of systemic lupus erythematosus (SLE). African Americans generally have a more severe presentation and more often progress to end stage renal disease (ESRD) than Caucasians. Several studies point to higher creatinine, low complement levels, thrombocytopenia, anemia, hypertension, and proliferative glomerulonephritis as predictors of ESRD in lupus nephritis within multi-ethnic cohorts. The purpose of the current study was to correlate clinical, serological, and immunological variables with the development of ESRD requiring dialysis in the African American population. Materials and Methods: A small retrospective study was performed with African American patients who had been diagnosed with lupus nephritis and biopsied between 1996 and 2006. Clinical, serological, and immunological variables were investigated. Chi square, t-test, ANOVA, and univariate and multivariable logistic regression models were applied to identify predictors of adverse outcome (ESRD requiring dialysis) in 67 patients with lupus nephritis. Sub-group analyses were performed in some cases to evaluate differences among the different classes. Results: Renal function was more depressed in the pro-liferative forms of lupus nephritis. Erythrocyte sedimentation rate (ESR) was increased mostly in classes III, IV, and V. Complement levels were uniformly decreased in the population studied. Nonetheless, C4 was more signifcantly depressed in the proliferative forms of lupus nephritis. We found that higher creatinine values (defned as creatinine greater than 1.2), low glomerular fltration rate (GFR) defined as GFR less than 60 mL/min/1.73 m2), class IV lupus nephritis, and hypertension are associated with ESRD in this population. On the other hand, class V lupus nephritis patients had signifcantly less risk to progress to ESRD (p values < 0.05). On subgroup analysis, neither low C3 nor low C4 levels were associated with ESRD requiring dialysis. Conclusion: As previously noted in other studies, hypertension, higher creatinine, roliferative nephritis, and decreased GFR are associated with ESRD requiring dialysis.

Fractures of the distal humerus can be diffcult to treat due to the periarticular nature of these injuries and the complexity of the elbow joint. Although anatomic and timely repair of the distal humerus with meticulous handling of soft tissues and appropriate postoperative therapy all help to optimize results, an open fracture presents other challenges that may limit successful outcomes in spite of these measures. Open fractures have been found to affect younger males involved in high-energy injuries, as well as older, osteoporotic females involved in lower energy situations. Successful manage- ment of these injuries requires urgent and aggressive soft tissue management, skeletal stabilization, and treatment of neurovascular insult (if applicable). This article presents a review of the current literature available concerning the epidemiology, assessment and examination, treatment op- tions, complications, and outcomes of patients with open distal humerus fractures.

Background: Previous acoustic emission (AE) studies of the hip have proposed using AE for the diagnosis of mus- culoskeletal conditions and assessing the clinical status (loosening, wear, etc.) of prostheses. However, these inves- tigations have had problems with spurious signal noises or complicated measurement techniques, or both. Purpose: We performed a study on 98 patients to evaluate the feasibility of employing ultrasonic emis- sion (UE) to determine total hip arthroplasty (THA) status, using a simple, hand-held measurement system that has addressed some of the prior problems with hip AE studies. Methods: UE was recorded from both hips of study patients during walking and sitting activities. The patients had 79 metal-on-polyethylene implants, and at least 15 each with ceramic-on-polyethylene, ceramic-on-ceramic and metal-on-metal articulations; 10 young subjects with- out THA were similarly recorded as controls. Data were obtained from waveform analysis and standard UE signal parameters. Patient radiographs were evaluated for THA status, and wear measurements were made for metal-on- polyethylene articulations. Results: There were distinct types of UE waveforms produced; one was typical of the control subjects as well as some patients. We did not fnd an apparent relationship among these waveform types and type of THA bearing, length of implantation or wear measurements in the metal on polyethylene bearings. Conclusions: Our results suggest that it maybe possi- ble to assess the status of THA by UE signals, but further studies are necessary to quantify this finding. The clinical relevance of this investigation is that a simple, in-office screening means for THA patients could indicate those patients who require closer follow-up and monitoring.

The role of aspirin in the prevention of heterotopic ossifca- tion (HO) following total hip arthroplasty (THA) has been debated. This retrospective comparative study assesses the results of 167 total hip arthroplasties (THAs) performed between August 1998 and April 2005 on 150 consecu- tive patients (17 bilaterals) who were 70 years of age and under by a single orthopaedic surgeon. A comparison of the incidence and severity of HO between those patients who received aspirin (325 mg bid) with those who received Cou- madin® (wafarin) for pharmacologic thromboprophylaxis. Surgery was performed through a posterolateral approach, with an enhanced soft tissue repair. There were 34 patients (35 hips) in the aspirin group and 68 patients (82 hips) in the Coumadin® group. All patients received prophylaxis for 6 weeks postoperatively. HO was classifed according to Brooker and colleagues using anterior-posterior (AP) radiographs at last follow-up (range, 1 to 8 years). There were four hips (11.4%) with HO in the aspirin group and 28 (34.2%) in the Coumadin® group (p = 0.012). HO class III and IV was not detected in the aspirin group, but was in seven hips in the Coumadin® group (p = 0.13). Males had an incidence of HO of 40.4% (19 of 47 hips) and females had an incidence of 18.6% (13 of 70 hips) (p = 0.009). Males who received aspirin developed HO in 22.2% (4 of 18 hips), compared to 51.7% (15 of 29 hips) in the Cou- madin® group (p = 0.045). No females (0 of 17 hips) who received aspirin developed HO, compared to 24.5% (13 of 53 hips) in females who received Coumadin® (p = 0.024). In this analysis, aspirin thromboprophylaxis decreased the prevalence of HO following elective THA in both females and males. This effect was not seen in patients who received Coumadin® after surgery.

Reverse total shoulder arthroplasty (rTSA) implants are intended to restore stability and function to shoulders with rotator cuff defciency. The implant consists of a glenosphere projecting from a glenoid baseplate and articulating in a socket at the proximal end of a humeral component. De- spite the demonstrated clinical effcacy, little information is available regarding the joint forces about this construct and the stability of the glenoid component against these forces. Our hypotheses were that the joint forces about the rTSA were comparable to that about a normal shoulder joint, and that the micromotion between the baseplate and the scapula against these loads would be suffciently low to induce bone ingrowth. To investigate this, a custom testing rig was constructed to simulate active shoulder elevation in fresh-frozen shoulder specimens. The forces about the rTSA were calculated and found to include compressive and shear forces up to 0.7 and 0.4 BW, respectively. In contrast to a normal shoulder, where the joint forces peak at 90° of abduction, forces about the rTSA were highest at about 60° of abduction. These forces were then applied in cyclic loading conditions to the glenoid baseplate, and the micromotion of the implant relative to the bone was measured in the four quadrants of the component. For two different rTSA designs (DePuy Delta III® and Encore RSP®) and in the entire range of the fxation testing, the cyclical micromotions were always less than 62 µm. Thus, under loading conditions similar to physiological shoulder elevation, micromotion of the gle- noid component was suffciently low and within previously published limits to induce bone ingrowth.

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specifc treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause signifcant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, includ- ing the identifcation of associated injuries and emergency methods of provisional pelvic stabilization.

Fewer United States rheumatologists perform or utilize musculoskeletal ultrasound (MSUS) than those in Europe, though this disparity is narrowing. To document perceptions and use of MSUS in the U.S. rheumatology community, we sent an anonymous electronic survey to American College of Rheumatology (ACR) physicians and tailored versions to fellows and program directors. A separately-conducted sur- vey was sent to a smaller group of rheumatologists already utilizing MSUS. Acknowledging survey bias, we found that 20% of rheumatologists and fellows who responded are uti- lizing MSUS, and those using it primarily do so for diagnosis and injection guidance. Many rheumatologists across the country think that ultrasound should become a standard tool in rheumatology training, practice, and research. Despite an inherent survey bias likely overstating interest in MSUS, this study is valuable as the frst to document this trend among U.S. rheumatologists.

The clubfoot deformity associated with Weber type I tibial hemimelia, a rare congenital disorder, is rigid and diffcult to correct. Surgeons have utilized a variety of treatment methods. Since the 1960s, some adopted the Syme amputa- tion to produce a weightbearing lower limb. Others began to explore alternatives such as the Ilizarov technique, ankle reconstruction, and casting, which salvage the foot but have produced mixed results. The current investigators suggest that the Ponseti method, a minimally invasive technique, can produce a functional weightbearing foot. Two cases were treated with the Ponseti method, including a percutaneous Achilles tenotomy and post-cast bracing. After a minimum of 2-years follow-up, both are ambulatory.

Various treatment options exist for distal radius fractures, and the complications associated with operative and nonop- erative management are well documented in the literature. While surgical management with the use of various buttress and locked plating constructs has gained popularity, the long-term outcomes of these plating techniques have not yet signifcantly demonstrated improved outcomes, as compared to adequately reduced nonoperative measures. Furthermore, this operative technique can be associated with failures and complications. We present a case report of one volar-plate construct requiring revision, secondary to loss of fracture reduction, with no evidence of implant loosening or failure. A literature review on the complications associated with these plate constructs is also presented.

The use of arthroscopic techniques for excision of the pre-patellar bursa has become more common in recent years for the treatment of prepatellar bursitis. The current literature includes several case series that report few complications with this technique. We report the case of a 73-year-old male who sustained a low-energy patella tendon rupture 2 months after arthroscopic resection of the prepatellar bursa. We hypothesize that during arthroscopic excision of the prepatellar bursa there was an iatrogenic injury to the patellar tendon, which contributed to the subsequent rupture. Surgical repair was successfully performed using an open technique with a 1-year follow-up. To our knowledge, this is the frst case report of patella tendon rupture following arthroscopic excision of the prepatellar bursa.

Anterior glenohumeral instability complicated by bone loss is a challenging problem and, when severe, may require surgical treatment with bone grafting. We review our institution’s experience with humeral head and glenoid bone grafting for large Hill-Sachs lesions and glenoid defects. Materials and Methods: Patients who underwent intra-articular bone reconstruction for Hill-Sachs and large glenoid defects for anterior instability at our institution during 2002-2008 were retrospectively reviewed. Those who had undergone concomitant humeral head replacement were excluded. Six patients were identifed as having undergone allograft or autograft iliac crest bone graft reconstruction of the glenoid, with four available for full follow-up (average 39 months; range, 7 to 63). Five patients were identifed as having undergone humeral head allograft reconstruction and four were available for full follow-up (average 28 months; range, 11 to 40). The remaining three patients were available for telephone follow-up. American Shoulder and Elbow Society (ASES) and University of California, Los Angles (UCLA) scores were recorded and radiographs obtained. Results: Average postoperative ASES and UCLA scores for glenoid bone graft patients were 91 and 33, respectively. Average postoperative ASES and UCLA scores for humeral bone graft patients were 85.3 and 28.4, respectively. Glenoid bone graft shoulders, when compared to the opposite normal side, lost an average of 3° of forward fexion, 10° of external rotation, and two levels of internal rotation. Humeral head bone-grafted shoulders, lost an average of 23° of forward fexion, 8° of external rotation, and two levels of internal rotation. No episodes of recurrent subluxation or dislocations were reported. Radiographs showed no evidence of graft resorption or hardware prominence. Conclusions: Bone grafting procedures around the shoulder for the treatment of instability provided relief from recurrent instability and good functional results.

Lupus nephritis is one of the most serious manifestations of systemic lupus erythematosus (SLE). African Americans generally have a more severe presentation and more often progress to end stage renal disease (ESRD) than Caucasians. Several studies point to higher creatinine, low complement levels, thrombocytopenia, anemia, hypertension, and proliferative glomerulonephritis as predictors of ESRD in lupus nephritis within multi-ethnic cohorts. The purpose of the current study was to correlate clinical, serological, and immunological variables with the development of ESRD requiring dialysis in the African American population. Materials and Methods: A small retrospective study was performed with African American patients who had been diagnosed with lupus nephritis and biopsied between 1996 and 2006. Clinical, serological, and immunological variables were investigated. Chi square, t-test, ANOVA, and univariate and multivariable logistic regression models were applied to identify predictors of adverse outcome (ESRD requiring dialysis) in 67 patients with lupus nephritis. Sub-group analyses were performed in some cases to evaluate differences among the different classes. Results: Renal function was more depressed in the pro-liferative forms of lupus nephritis. Erythrocyte sedimentation rate (ESR) was increased mostly in classes III, IV, and V. Complement levels were uniformly decreased in the population studied. Nonetheless, C4 was more signifcantly depressed in the proliferative forms of lupus nephritis. We found that higher creatinine values (defned as creatinine greater than 1.2), low glomerular fltration rate (GFR) defined as GFR less than 60 mL/min/1.73 m2), class IV lupus nephritis, and hypertension are associated with ESRD in this population. On the other hand, class V lupus nephritis patients had signifcantly less risk to progress to ESRD (p values < 0.05). On subgroup analysis, neither low C3 nor low C4 levels were associated with ESRD requiring dialysis. Conclusion: As previously noted in other studies, hypertension, higher creatinine, roliferative nephritis, and decreased GFR are associated with ESRD requiring dialysis.

Fractures of the distal humerus can be diffcult to treat due to the periarticular nature of these injuries and the complexity of the elbow joint. Although anatomic and timely repair of the distal humerus with meticulous handling of soft tissues and appropriate postoperative therapy all help to optimize results, an open fracture presents other challenges that may limit successful outcomes in spite of these measures. Open fractures have been found to affect younger males involved in high-energy injuries, as well as older, osteoporotic females involved in lower energy situations. Successful manage- ment of these injuries requires urgent and aggressive soft tissue management, skeletal stabilization, and treatment of neurovascular insult (if applicable). This article presents a review of the current literature available concerning the epidemiology, assessment and examination, treatment op- tions, complications, and outcomes of patients with open distal humerus fractures.

Background: Previous acoustic emission (AE) studies of the hip have proposed using AE for the diagnosis of mus- culoskeletal conditions and assessing the clinical status (loosening, wear, etc.) of prostheses. However, these inves- tigations have had problems with spurious signal noises or complicated measurement techniques, or both. Purpose: We performed a study on 98 patients to evaluate the feasibility of employing ultrasonic emis- sion (UE) to determine total hip arthroplasty (THA) status, using a simple, hand-held measurement system that has addressed some of the prior problems with hip AE studies. Methods: UE was recorded from both hips of study patients during walking and sitting activities. The patients had 79 metal-on-polyethylene implants, and at least 15 each with ceramic-on-polyethylene, ceramic-on-ceramic and metal-on-metal articulations; 10 young subjects with- out THA were similarly recorded as controls. Data were obtained from waveform analysis and standard UE signal parameters. Patient radiographs were evaluated for THA status, and wear measurements were made for metal-on- polyethylene articulations. Results: There were distinct types of UE waveforms produced; one was typical of the control subjects as well as some patients. We did not fnd an apparent relationship among these waveform types and type of THA bearing, length of implantation or wear measurements in the metal on polyethylene bearings. Conclusions: Our results suggest that it maybe possi- ble to assess the status of THA by UE signals, but further studies are necessary to quantify this finding. The clinical relevance of this investigation is that a simple, in-office screening means for THA patients could indicate those patients who require closer follow-up and monitoring.

The role of aspirin in the prevention of heterotopic ossifca- tion (HO) following total hip arthroplasty (THA) has been debated. This retrospective comparative study assesses the results of 167 total hip arthroplasties (THAs) performed between August 1998 and April 2005 on 150 consecu- tive patients (17 bilaterals) who were 70 years of age and under by a single orthopaedic surgeon. A comparison of the incidence and severity of HO between those patients who received aspirin (325 mg bid) with those who received Cou- madin® (wafarin) for pharmacologic thromboprophylaxis. Surgery was performed through a posterolateral approach, with an enhanced soft tissue repair. There were 34 patients (35 hips) in the aspirin group and 68 patients (82 hips) in the Coumadin® group. All patients received prophylaxis for 6 weeks postoperatively. HO was classifed according to Brooker and colleagues using anterior-posterior (AP) radiographs at last follow-up (range, 1 to 8 years). There were four hips (11.4%) with HO in the aspirin group and 28 (34.2%) in the Coumadin® group (p = 0.012). HO class III and IV was not detected in the aspirin group, but was in seven hips in the Coumadin® group (p = 0.13). Males had an incidence of HO of 40.4% (19 of 47 hips) and females had an incidence of 18.6% (13 of 70 hips) (p = 0.009). Males who received aspirin developed HO in 22.2% (4 of 18 hips), compared to 51.7% (15 of 29 hips) in the Cou- madin® group (p = 0.045). No females (0 of 17 hips) who received aspirin developed HO, compared to 24.5% (13 of 53 hips) in females who received Coumadin® (p = 0.024). In this analysis, aspirin thromboprophylaxis decreased the prevalence of HO following elective THA in both females and males. This effect was not seen in patients who received Coumadin® after surgery.

Reverse total shoulder arthroplasty (rTSA) implants are intended to restore stability and function to shoulders with rotator cuff defciency. The implant consists of a glenosphere projecting from a glenoid baseplate and articulating in a socket at the proximal end of a humeral component. De- spite the demonstrated clinical effcacy, little information is available regarding the joint forces about this construct and the stability of the glenoid component against these forces. Our hypotheses were that the joint forces about the rTSA were comparable to that about a normal shoulder joint, and that the micromotion between the baseplate and the scapula against these loads would be suffciently low to induce bone ingrowth. To investigate this, a custom testing rig was constructed to simulate active shoulder elevation in fresh-frozen shoulder specimens. The forces about the rTSA were calculated and found to include compressive and shear forces up to 0.7 and 0.4 BW, respectively. In contrast to a normal shoulder, where the joint forces peak at 90° of abduction, forces about the rTSA were highest at about 60° of abduction. These forces were then applied in cyclic loading conditions to the glenoid baseplate, and the micromotion of the implant relative to the bone was measured in the four quadrants of the component. For two different rTSA designs (DePuy Delta III® and Encore RSP®) and in the entire range of the fxation testing, the cyclical micromotions were always less than 62 µm. Thus, under loading conditions similar to physiological shoulder elevation, micromotion of the gle- noid component was suffciently low and within previously published limits to induce bone ingrowth.

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specifc treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause signifcant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, includ- ing the identifcation of associated injuries and emergency methods of provisional pelvic stabilization.

Fewer United States rheumatologists perform or utilize musculoskeletal ultrasound (MSUS) than those in Europe, though this disparity is narrowing. To document perceptions and use of MSUS in the U.S. rheumatology community, we sent an anonymous electronic survey to American College of Rheumatology (ACR) physicians and tailored versions to fellows and program directors. A separately-conducted sur- vey was sent to a smaller group of rheumatologists already utilizing MSUS. Acknowledging survey bias, we found that 20% of rheumatologists and fellows who responded are uti- lizing MSUS, and those using it primarily do so for diagnosis and injection guidance. Many rheumatologists across the country think that ultrasound should become a standard tool in rheumatology training, practice, and research. Despite an inherent survey bias likely overstating interest in MSUS, this study is valuable as the frst to document this trend among U.S. rheumatologists.

The clubfoot deformity associated with Weber type I tibial hemimelia, a rare congenital disorder, is rigid and diffcult to correct. Surgeons have utilized a variety of treatment methods. Since the 1960s, some adopted the Syme amputa- tion to produce a weightbearing lower limb. Others began to explore alternatives such as the Ilizarov technique, ankle reconstruction, and casting, which salvage the foot but have produced mixed results. The current investigators suggest that the Ponseti method, a minimally invasive technique, can produce a functional weightbearing foot. Two cases were treated with the Ponseti method, including a percutaneous Achilles tenotomy and post-cast bracing. After a minimum of 2-years follow-up, both are ambulatory.

Various treatment options exist for distal radius fractures, and the complications associated with operative and nonop- erative management are well documented in the literature. While surgical management with the use of various buttress and locked plating constructs has gained popularity, the long-term outcomes of these plating techniques have not yet signifcantly demonstrated improved outcomes, as compared to adequately reduced nonoperative measures. Furthermore, this operative technique can be associated with failures and complications. We present a case report of one volar-plate construct requiring revision, secondary to loss of fracture reduction, with no evidence of implant loosening or failure. A literature review on the complications associated with these plate constructs is also presented.

The use of arthroscopic techniques for excision of the pre-patellar bursa has become more common in recent years for the treatment of prepatellar bursitis. The current literature includes several case series that report few complications with this technique. We report the case of a 73-year-old male who sustained a low-energy patella tendon rupture 2 months after arthroscopic resection of the prepatellar bursa. We hypothesize that during arthroscopic excision of the prepatellar bursa there was an iatrogenic injury to the patellar tendon, which contributed to the subsequent rupture. Surgical repair was successfully performed using an open technique with a 1-year follow-up. To our knowledge, this is the frst case report of patella tendon rupture following arthroscopic excision of the prepatellar bursa.