Indications for the use of osteochondral allografts for orthopaedic surgical applications are increasing with improved surgical techniques and advancing experience. Modern tissue banks have developed harvesting, processing, and storage methods that ensure an adequate, safe supply of grafts. Continued research is necessary to find a technique that maximizes chondrocyte viability and metabolism both during storage and implantation. The majority of published data on the use of osteochondral allografts has focused on the management of osteochondral defects about the knee. Successful outcomes following these procedures have led to increased interest in their application to pathology affecting other joints including the shoulder and ankle. The current paper aims to review the basic science and clinical applications of osteochondral allografts.

Purpose: Nonunions of the upper and lower extremity have been associated with pain and functional deficits. Recent studies have demonstrated that healing of these nonunions is associated with pain relief and both subjective and objective functional improvement. The purpose of this study was to determine which patient and surgical factors correlated with successful healing of a nonunion following surgical intervention. Methods: Between September 2004 and February 2008, all patients with a “long bone nonunion” presenting to our academic trauma service were enrolled in a prospective data base. Baseline functional, demographic and pain status was obtained. Follow-up was obtained at 3, 6, and 12 months following surgical intervention, with longer follow-up as possible. One hundred and thirty-four patients with a variety of fracture nonunions were operated on by four different fellowship trained trauma surgeons with experience ranging from 2 to15 years and variable nonunion surgery loads. Patients were stratified into one of three groups: 1. Patients who healed following one surgical intervention, 2. those who healed following multiple surgical intervention, and 3. those who failed to heal (remain ununited or underwent amputation). Healing was determined radiographically and clinically. Complications were recorded. Logistic regression analysis was performed to assess the cor-relation between specific baseline and surgical characteristics and healing. Results: A minimum of 1 year follow-up was available for all 134 patients. One hundred and one patients (76%) with a mean age of 50 years healed at a mean of 6 months (range, 3 to 16) after one surgery. Twenty-two patients (16%) with a mean age of 47 years, who required more than one intervention, healed their nonunions at a mean of 11 months (range, 4 to 23). Eleven patients (8%) with a mean age of 50 years failed to heal at an average of 12 months follow-up. Complication rates were 11%, 68%, and 100% respectively for those who healed following one procedure, multiple procedures, and those who never healed. Higher surgeon volume (greater than 10 cases per year) was associated with 85% increased healing rates (OR = 0.15, 0.05-0.47 CI). The presence of a postoperative complication was associated with a 9 times lower likelihood of successful union as well (OR = 9.0, 2.6-31.7 CI). Patient age, sex, BMI, initial injury mechanism, tobacco use, and initial injury characteristics did not correlate with failure to heal. Conclusion: Our data is similar to other studies assessing outcomes following other complex reconstructive procedures. It appears that more experienced (higher volume) reconstructive surgeons and the development of fewer postoperative complications is associated with greater success following repair of a long bone nonunion. Infection at any point during treatment is associated with failure to achieve successful union.

Although the presence of patellar tilt usually implies a tight lateral retinaculum and unhealthy pressure distributions within the patellar cartilage, it is possible for the bony portion of the patella to appear tilted while the articular cartilage is in fact fully congruous in a medial-lateral direction. We call this “congruous tilt.” In such cases, a patient may not suffer from an excessive lateral pressure phenomenon, despite the presence of tilt. Materials and Methods: One hundred and forty-nine knee MRIs were evaluated with respect to patellar tilt and Wiberg morphology. Results: Thirty-one patellae were tilted (tilt angle > 10°). Twenty-five of 31 patellae demonstrated normal morphology in the axial plane (Wiberg 2). One of these 25 tilted patellae demonstrated congruous tilt. Three of 31 patellae were of the Wiberg type 3(a long lateral facet, a very short medial facet). In two out three of these, the tilt was deemed to be congruous. Conclusion: Based on this preliminary study, a tilted patella of the Wiberg 3 variety is likely to demonstrate congruous tilt. It remains to be determined whether patients with congruous tilt are less prone to pain but more prone to instability than their incongruous counterparts.

ncidental bone tumors are, by definition, asymptomatic lesions that are discovered through routine radiographs obtained for other reasons. Generally, these lesions are benign and latent, requiring no further intervention except observation. However, occasionally these radiographs will detect benign aggressive processes or even malignant lesions that do require further treatment and referral to a tumor specialist. Oftentimes, there are characteristic findings on radiographs that are pathognomonic. Knowledge of these findings can simplify the treatment algorithm for a practicing general orthopaedist. This article will describe radiographic characteristics of benign and malignant bone lesions and their typical presentations. It will then focus on the types of bone lesions that are often found incidentally by routine radiography. Specific recommendations, including recommendation for referrals to orthopaedic tumor specialists, will be noted for lesions described. Most malignant lesions will present with pain and a constellation of history and physical exam findings that will signal the patient to seek medical care; although they will be mentioned for the sake of comparison and completeness, they will not be the focus of this review.

Purpose: Accurate prediction of autograft size for anterior cruciate ligament reconstruction can assist in preoperative planning and decision-making regarding graft choices. This study seeks to determine the accuracy of MRI measurements by comparing intraoperative measurements of the patella, semitendinosis, and gracilis tendons while correlating these measurements with patient anthropometric data such as gender, height, and weight. Methods: A series of 20 consecutive patients were enrolled who underwent a magnetic resonance imaging study of the knee and proceeded with surgical reconstruction of the anterior cruciate ligament. Intraoperative measurements of the diameter of semitendinosis and gracilis tendons or width of patella tendon were compared to radiographic measurements obtained on the MRI. These measurements were analyzed using a paired t-test as well as regression analysis to evaluate strength of correlation between measurements and also to determine correlation with height, weight, and gender. Results: There was no statistical difference between intraoperative and radiographic measurements (p > 0.05). There was strong correlation (Pearson r = 0.98, p = 0.00) found between intraoperative and radiographic measurements of the autograft tendons. Weaker correlation was seen with gender, height, and weight with intraoperative measurements. Conclusions: Measuring the diameter of the semitendinosis and gracilis tendons and patellar width on MRI can give an accurate prediction of actual intraoperative sizes of these anatomic structures. Height, weight, and gender were also correlated with tendon sizes implying that a patient of female gender or of smaller stature in height or weight may have smaller tendon sizes. Routine use of preoperative MRI measurements can guide surgeons with specific graft preferences to other surgical options if the graft is measured to be insufficient in size.

Purpose: Our aim was to determine whether the administration of intravenous tranexamic acid is a safe and effective means of reducing blood loss associated with hip and knee replacement surgery. Method: Sequential cohort study analysing hemoglobin titers, transfusion rates, and the occurrence of venous thromboembolism in patients undergoing hip and knee replace-ments with and without the administration of tranexamic acid at the time of induction. Finally, a cost benefit analysis was performed. Results: Two hundred and seventy-three patients were included in our study. We demonstrated that 1 gram of tranexamic acid administered intravenously at the time of induction significantly reduces operative blood loss and transfusion rates (p < 0.05). Moreover, the use of tranexamic acid reduces the costs associated with surgery. Conclusions: The administration of 1 gram of intravenous tranexamic acid is a safe and effective means of reducing operative blood loss and blood transfusion rates in patients undergoing hip and knee replacements.

Recent resurgence in the interest of barbed suture has extended its application to wound closures in total joint surgery. Improved suture biomaterials and barb geometry has lead to consideration for its use in various orthopedic procedures including arthroplasty. The reported superior wound tensile stress distribution, no need for knots, and ability to close multiple layers with one suture make it an attractive option for deep wound closure after total joint surgery. However, inherent to the design of this suture are barbs that pose a risk of glove perforation and the potential for the transmission of blood borne pathogens. This study reports no increase in the incidence of glove perforation with use of barbed suture for deep wound closure after total joint arthroplasty.

Spine Tango is currently the only international spine registry in existence. It was developed under the auspices of Eurospine, the Spine Society of Europe, and is hosted at the University of Bern, Switzerland. The HJD Spine Center successfully tested Spine Tango during a 3-month pilot study and has since expanded documentation activities to more surgeons. Workflow integration and dedicated research staff are key factors for such an endeavor. Participation enables benchmarking against national and international peers and outcome research and quality assurance of surgical and non-surgical treatments.

The footprint is thought to be an important fact in rotator cuff repairs and has been used to compare various cuff fixation techniques. The following experiment used two different measurement sensors to evaluate the footprint as it is affected by suture tensions in a transosseous equivalent suture bridge repair. It was found that suture tension has a direct effect on footprint contact area and pressure and thus could affect healing and fixation stability and should be characterized in any study of comparative fixation techniques.

A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstrated a multiloculated cystic mass adjacent to the radial aspect of the scaphoid, which was intimately associated with and appeared to arise from the wall of the radial artery and its dorsal branch. The mass was surgically resected. The histological analysis confirmed the presence of adventitial cystic disease (ACD) of the radial artery. In addition, within a year time span, a second 34-year-old male patient presented with a palpable mass in the right hand. Imaging demonstrated a cystic mass encasing the dorsal carpal branch of the radial artery and its terminal vessels to the thumb and index finger. The diagnosis of ACD was raised based on MR imaging. Histological analysis confirmed the presence of an adventitial cyst. ACD of the arteries is a rare disorder of unknown etiology, which usually involves the popliteal artery. Less common sites of involvement include the external iliac, common femoral, radial, and ulnar arteries. To our knowledge, there have only been six previous case reports of adventitial cystic disease involving the radial artery. The imaging features, histology, differential diagnosis, pathogenesis, and treatment are discussed.

Although bilateral anterior dislocation of shoulder is not that uncommon, there have been only 12 published reports on bilateral anterior fracture dislocation of shoulder. The associated fractures have mostly been greater tuberosity fractures with bilateral three part fractures being reported in only two cases. To our knowledge, a bilateral four part anterior fracture dislocation of the shoulder has not yet been reported in the English literature. We here report a case of bilateral anterior fracture dislocation with four part fracture of both proximal humeri in a 60-year-old male due to electrocution. Considering the comparatively old age of the patient and excessive comminution of both the fractures, a bilateral hemiarthroplasty was done. At the last follow-up after more than 2 years, the patient was pain free with ability to comfortably carry out most of the activities of daily life. Through our case report, we highlight the rarity of the condition and review the available literature on the subject. We also emphasize the importance of meticulous perioperative planning when dealing with such cases to ensure a satisfactory long-term outcome.

Distal radius fractures are among the most commonly en-countered fractures in the extremities. Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Complications of volar plating include extensor and flexor tendon rupture. Here we present a case report of an extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with locked plate.

Acinetobacter baumanniiis an emerging gram-negative nosocomial pathogen that rarely causes infections in orthopaedic patients. We report a case of imipenem-resistant Acinetobacter baumanniiparaarticular infection of the knee occurring in a healthy patient following one ambulatory ste-roid injection for the treatment of quadriceps tendinopathy. The infection was reduced by early surgical debridement of infected tissues, abscess drainage, and prolonged antibiotic therapy with colistin. To our knowledge, this is the first case in the literature reporting such an infection following single steroid injection in orthopaedic patients.

Wire breakage and migration is a known complication of using a wire tension band construct to treat displaced patella fractures. We report a case of a broken K-wire that migrated from the patella completely into the proximal tibia without complication 9 years after the index surgery. This report highlights the fact that wire migration can occur long after fracture healing and be relatively asymptomatic. But because the complications of wire migration can be deadly, it requires diligence on the part of the physician to educate the patient that new knee pain after operative fixation requires formal evaluation by the treating surgeon.

Hibernoma is an uncommon, benign tumor of brown fat origin. The distribution of this tumor originally was described as following the location of persistent brown fat within the subcutaneous tissue of the thorax (especially the periscapular and interscapular regions), neck, axilla, shoulder, and retroperitoneum. Recently, hibernoma was described as being most common in the thigh.

Osteochondral defects of the femoral head are rare and principles of treatment include anatomic reduction, rigid fixation, enhancement of blood supply, and restoration of articular congruity. In this report, we present a case where the defect of the femoral head was treated with surgical dislocation of hip anteriorly and mosaicplasty. At 3-year follow-up, the patient was symptom free with near complete incorporation of the graft radiographically. Our observations in this case suggest that mosaicplasty with an open approach is an alternative treatment in the osteochondral defects of the femoral head.

Indications for the use of osteochondral allografts for orthopaedic surgical applications are increasing with improved surgical techniques and advancing experience. Modern tissue banks have developed harvesting, processing, and storage methods that ensure an adequate, safe supply of grafts. Continued research is necessary to find a technique that maximizes chondrocyte viability and metabolism both during storage and implantation. The majority of published data on the use of osteochondral allografts has focused on the management of osteochondral defects about the knee. Successful outcomes following these procedures have led to increased interest in their application to pathology affecting other joints including the shoulder and ankle. The current paper aims to review the basic science and clinical applications of osteochondral allografts.

Purpose: Nonunions of the upper and lower extremity have been associated with pain and functional deficits. Recent studies have demonstrated that healing of these nonunions is associated with pain relief and both subjective and objective functional improvement. The purpose of this study was to determine which patient and surgical factors correlated with successful healing of a nonunion following surgical intervention. Methods: Between September 2004 and February 2008, all patients with a “long bone nonunion” presenting to our academic trauma service were enrolled in a prospective data base. Baseline functional, demographic and pain status was obtained. Follow-up was obtained at 3, 6, and 12 months following surgical intervention, with longer follow-up as possible. One hundred and thirty-four patients with a variety of fracture nonunions were operated on by four different fellowship trained trauma surgeons with experience ranging from 2 to15 years and variable nonunion surgery loads. Patients were stratified into one of three groups: 1. Patients who healed following one surgical intervention, 2. those who healed following multiple surgical intervention, and 3. those who failed to heal (remain ununited or underwent amputation). Healing was determined radiographically and clinically. Complications were recorded. Logistic regression analysis was performed to assess the cor-relation between specific baseline and surgical characteristics and healing. Results: A minimum of 1 year follow-up was available for all 134 patients. One hundred and one patients (76%) with a mean age of 50 years healed at a mean of 6 months (range, 3 to 16) after one surgery. Twenty-two patients (16%) with a mean age of 47 years, who required more than one intervention, healed their nonunions at a mean of 11 months (range, 4 to 23). Eleven patients (8%) with a mean age of 50 years failed to heal at an average of 12 months follow-up. Complication rates were 11%, 68%, and 100% respectively for those who healed following one procedure, multiple procedures, and those who never healed. Higher surgeon volume (greater than 10 cases per year) was associated with 85% increased healing rates (OR = 0.15, 0.05-0.47 CI). The presence of a postoperative complication was associated with a 9 times lower likelihood of successful union as well (OR = 9.0, 2.6-31.7 CI). Patient age, sex, BMI, initial injury mechanism, tobacco use, and initial injury characteristics did not correlate with failure to heal. Conclusion: Our data is similar to other studies assessing outcomes following other complex reconstructive procedures. It appears that more experienced (higher volume) reconstructive surgeons and the development of fewer postoperative complications is associated with greater success following repair of a long bone nonunion. Infection at any point during treatment is associated with failure to achieve successful union.

Although the presence of patellar tilt usually implies a tight lateral retinaculum and unhealthy pressure distributions within the patellar cartilage, it is possible for the bony portion of the patella to appear tilted while the articular cartilage is in fact fully congruous in a medial-lateral direction. We call this “congruous tilt.” In such cases, a patient may not suffer from an excessive lateral pressure phenomenon, despite the presence of tilt. Materials and Methods: One hundred and forty-nine knee MRIs were evaluated with respect to patellar tilt and Wiberg morphology. Results: Thirty-one patellae were tilted (tilt angle > 10°). Twenty-five of 31 patellae demonstrated normal morphology in the axial plane (Wiberg 2). One of these 25 tilted patellae demonstrated congruous tilt. Three of 31 patellae were of the Wiberg type 3(a long lateral facet, a very short medial facet). In two out three of these, the tilt was deemed to be congruous. Conclusion: Based on this preliminary study, a tilted patella of the Wiberg 3 variety is likely to demonstrate congruous tilt. It remains to be determined whether patients with congruous tilt are less prone to pain but more prone to instability than their incongruous counterparts.

ncidental bone tumors are, by definition, asymptomatic lesions that are discovered through routine radiographs obtained for other reasons. Generally, these lesions are benign and latent, requiring no further intervention except observation. However, occasionally these radiographs will detect benign aggressive processes or even malignant lesions that do require further treatment and referral to a tumor specialist. Oftentimes, there are characteristic findings on radiographs that are pathognomonic. Knowledge of these findings can simplify the treatment algorithm for a practicing general orthopaedist. This article will describe radiographic characteristics of benign and malignant bone lesions and their typical presentations. It will then focus on the types of bone lesions that are often found incidentally by routine radiography. Specific recommendations, including recommendation for referrals to orthopaedic tumor specialists, will be noted for lesions described. Most malignant lesions will present with pain and a constellation of history and physical exam findings that will signal the patient to seek medical care; although they will be mentioned for the sake of comparison and completeness, they will not be the focus of this review.

Purpose: Accurate prediction of autograft size for anterior cruciate ligament reconstruction can assist in preoperative planning and decision-making regarding graft choices. This study seeks to determine the accuracy of MRI measurements by comparing intraoperative measurements of the patella, semitendinosis, and gracilis tendons while correlating these measurements with patient anthropometric data such as gender, height, and weight. Methods: A series of 20 consecutive patients were enrolled who underwent a magnetic resonance imaging study of the knee and proceeded with surgical reconstruction of the anterior cruciate ligament. Intraoperative measurements of the diameter of semitendinosis and gracilis tendons or width of patella tendon were compared to radiographic measurements obtained on the MRI. These measurements were analyzed using a paired t-test as well as regression analysis to evaluate strength of correlation between measurements and also to determine correlation with height, weight, and gender. Results: There was no statistical difference between intraoperative and radiographic measurements (p > 0.05). There was strong correlation (Pearson r = 0.98, p = 0.00) found between intraoperative and radiographic measurements of the autograft tendons. Weaker correlation was seen with gender, height, and weight with intraoperative measurements. Conclusions: Measuring the diameter of the semitendinosis and gracilis tendons and patellar width on MRI can give an accurate prediction of actual intraoperative sizes of these anatomic structures. Height, weight, and gender were also correlated with tendon sizes implying that a patient of female gender or of smaller stature in height or weight may have smaller tendon sizes. Routine use of preoperative MRI measurements can guide surgeons with specific graft preferences to other surgical options if the graft is measured to be insufficient in size.

Purpose: Our aim was to determine whether the administration of intravenous tranexamic acid is a safe and effective means of reducing blood loss associated with hip and knee replacement surgery. Method: Sequential cohort study analysing hemoglobin titers, transfusion rates, and the occurrence of venous thromboembolism in patients undergoing hip and knee replace-ments with and without the administration of tranexamic acid at the time of induction. Finally, a cost benefit analysis was performed. Results: Two hundred and seventy-three patients were included in our study. We demonstrated that 1 gram of tranexamic acid administered intravenously at the time of induction significantly reduces operative blood loss and transfusion rates (p < 0.05). Moreover, the use of tranexamic acid reduces the costs associated with surgery. Conclusions: The administration of 1 gram of intravenous tranexamic acid is a safe and effective means of reducing operative blood loss and blood transfusion rates in patients undergoing hip and knee replacements.

Recent resurgence in the interest of barbed suture has extended its application to wound closures in total joint surgery. Improved suture biomaterials and barb geometry has lead to consideration for its use in various orthopedic procedures including arthroplasty. The reported superior wound tensile stress distribution, no need for knots, and ability to close multiple layers with one suture make it an attractive option for deep wound closure after total joint surgery. However, inherent to the design of this suture are barbs that pose a risk of glove perforation and the potential for the transmission of blood borne pathogens. This study reports no increase in the incidence of glove perforation with use of barbed suture for deep wound closure after total joint arthroplasty.

Spine Tango is currently the only international spine registry in existence. It was developed under the auspices of Eurospine, the Spine Society of Europe, and is hosted at the University of Bern, Switzerland. The HJD Spine Center successfully tested Spine Tango during a 3-month pilot study and has since expanded documentation activities to more surgeons. Workflow integration and dedicated research staff are key factors for such an endeavor. Participation enables benchmarking against national and international peers and outcome research and quality assurance of surgical and non-surgical treatments.

The footprint is thought to be an important fact in rotator cuff repairs and has been used to compare various cuff fixation techniques. The following experiment used two different measurement sensors to evaluate the footprint as it is affected by suture tensions in a transosseous equivalent suture bridge repair. It was found that suture tension has a direct effect on footprint contact area and pressure and thus could affect healing and fixation stability and should be characterized in any study of comparative fixation techniques.

A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstrated a multiloculated cystic mass adjacent to the radial aspect of the scaphoid, which was intimately associated with and appeared to arise from the wall of the radial artery and its dorsal branch. The mass was surgically resected. The histological analysis confirmed the presence of adventitial cystic disease (ACD) of the radial artery. In addition, within a year time span, a second 34-year-old male patient presented with a palpable mass in the right hand. Imaging demonstrated a cystic mass encasing the dorsal carpal branch of the radial artery and its terminal vessels to the thumb and index finger. The diagnosis of ACD was raised based on MR imaging. Histological analysis confirmed the presence of an adventitial cyst. ACD of the arteries is a rare disorder of unknown etiology, which usually involves the popliteal artery. Less common sites of involvement include the external iliac, common femoral, radial, and ulnar arteries. To our knowledge, there have only been six previous case reports of adventitial cystic disease involving the radial artery. The imaging features, histology, differential diagnosis, pathogenesis, and treatment are discussed.

Although bilateral anterior dislocation of shoulder is not that uncommon, there have been only 12 published reports on bilateral anterior fracture dislocation of shoulder. The associated fractures have mostly been greater tuberosity fractures with bilateral three part fractures being reported in only two cases. To our knowledge, a bilateral four part anterior fracture dislocation of the shoulder has not yet been reported in the English literature. We here report a case of bilateral anterior fracture dislocation with four part fracture of both proximal humeri in a 60-year-old male due to electrocution. Considering the comparatively old age of the patient and excessive comminution of both the fractures, a bilateral hemiarthroplasty was done. At the last follow-up after more than 2 years, the patient was pain free with ability to comfortably carry out most of the activities of daily life. Through our case report, we highlight the rarity of the condition and review the available literature on the subject. We also emphasize the importance of meticulous perioperative planning when dealing with such cases to ensure a satisfactory long-term outcome.

Distal radius fractures are among the most commonly en-countered fractures in the extremities. Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Complications of volar plating include extensor and flexor tendon rupture. Here we present a case report of an extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with locked plate.

Acinetobacter baumanniiis an emerging gram-negative nosocomial pathogen that rarely causes infections in orthopaedic patients. We report a case of imipenem-resistant Acinetobacter baumanniiparaarticular infection of the knee occurring in a healthy patient following one ambulatory ste-roid injection for the treatment of quadriceps tendinopathy. The infection was reduced by early surgical debridement of infected tissues, abscess drainage, and prolonged antibiotic therapy with colistin. To our knowledge, this is the first case in the literature reporting such an infection following single steroid injection in orthopaedic patients.

Wire breakage and migration is a known complication of using a wire tension band construct to treat displaced patella fractures. We report a case of a broken K-wire that migrated from the patella completely into the proximal tibia without complication 9 years after the index surgery. This report highlights the fact that wire migration can occur long after fracture healing and be relatively asymptomatic. But because the complications of wire migration can be deadly, it requires diligence on the part of the physician to educate the patient that new knee pain after operative fixation requires formal evaluation by the treating surgeon.

Hibernoma is an uncommon, benign tumor of brown fat origin. The distribution of this tumor originally was described as following the location of persistent brown fat within the subcutaneous tissue of the thorax (especially the periscapular and interscapular regions), neck, axilla, shoulder, and retroperitoneum. Recently, hibernoma was described as being most common in the thigh.

Osteochondral defects of the femoral head are rare and principles of treatment include anatomic reduction, rigid fixation, enhancement of blood supply, and restoration of articular congruity. In this report, we present a case where the defect of the femoral head was treated with surgical dislocation of hip anteriorly and mosaicplasty. At 3-year follow-up, the patient was symptom free with near complete incorporation of the graft radiographically. Our observations in this case suggest that mosaicplasty with an open approach is an alternative treatment in the osteochondral defects of the femoral head.