Digital radiography is becoming the standard of care for many hospitals and clinics worldwide. The introduction of this new standard has led to the development of arthroplasty templating software. We sought to compare our results using the standard acetate method with the new software method. Our digital preoperative plan was accurate to within 1 size in 78% of the acetabular components and 90% of the femoral components. The manually templated plan was accurate to within 1 size in 67% of the acetabular components and 82% of the femoral components. There did not appear to be any correlation between body mass index and inaccuracies in the preoperative template. Digital templating is an accurate tool to preoperatively plan total hip arthroplasty. The accuracy demonstrated in this study should be achieved easily with any digital templating software. The benefit comes from the ability to scale the templates to the actual x-ray magnification. We expect that this improved accuracy over traditional acetate templating will enhance our ability to restore normal hip biomechanics.

Patients will often perceive a change in lower limb length after total knee arthroplasty (TKA). From this observed finding, we asked how frequently does a change in limb length occur after TKA. Preoperative and postoperative full-length standing radiographs were obtained for 102 knees in 98 patients who underwent TKA. Digital radiography software was used to measure the mechanical axis and limb length of the operative and nonoperative legs. Overall, 83% of the knees measured showed an increase in limb length after TKA. Preoperative varus alignment was associated with an average lengthening of 5.2 mm. Preoperative valgus alignment was associated with an average lengthening of 8.4 mm. Patients with a valgus deformity greater than 10° demonstrated the greatest average lengthening. It is the conclusion of this study that limb lengthening occurs frequently after TKA, back to a length similar to the nonoperative limb.

The best operative technique for achieving appropriate postoperative alignment following total knee arthroplasty (TKA) remains controversial, with proponents of extramedullary, intramedullary and computer-assisted techniques. One hundred ninety-two consecutive patients undergoing TKA were prospectively evaluated with full-length lower extremity radiographs. Patients underwent cemented TKA using femoral and tibial intramedullary instrumentation. Digital radiographs were analyzed using PACS (AGFA Healthcare, Ridgefield Park, NJ) software. Tibial component alignment was measured in the coronal and sagittal planes. Tibial component slope averaged 3.89° + 1.96 for the cruciate-retaining components and averaged 1.7° + 1.92 for PS components. The average coronal tibial component alignment was 90.00°, and 99% were within 3° of neutral mechanical alignment with only 2 (1%) outliers. Intramedullary instrumentation resulted in excellent postoperative tibial component and lower extremity alignment.

The objective of this study was to determine the inter- and intraobserver reliability of plain films as compared with CT scans in quantitatively measuring articular displacement in acetabular fractures utilizing a standardized measurement technique. Three independent reviewers compared the standardized measurement technique to direct measurement of the articular displacement. Weighted kappa statistics were performed to assess the inter- and intraobserver agreement. The standardized method of measurement showed slightly better inter- (0.24) and intraobserver (0.36) reliability for measuring articular displacement, as compared to direct measurement (0.12 and 0.22). Measurements using CT scans showed higher inter- (0.3) and intraobserver (0.43) reliability, when compared to plain radiographs (0.27 and 0.36). Measurements performed on fracture patterns which did not include a posterior wall component had higher inter- (0.41) and intraobserver (0.44) reliability, when compared to patterns with posterior wall fractures (0.12 and 0.22). Based on these results, it was concluded that the use of the standardized method of measurement, as described by Borrelli etal., was not superior to direct measurement of articular displacement.

While limb length discrepancy is a well-recognized complication following total hip arthroplasty, little is known about how limb length is affected by total knee arthroplasty (TKA). The purpose of this study is to investigate the frequency and characteristics of limb length changes that occur following TKA.

An unobstructed view of the proximal femur is a necessity in total hip arthroplasty for proper femoral preparation and to minimize the risk of femoral fractures and damage to the proximal soft tissues. A novel leverage technique is described that uses a trial head and liner to improve femoral visualization for the posterolateral approach. The cup fulcrum technique may minimize the risk of component malposition and damage, femoral fractures, and wound complications. Because there is no additional instrumentation or cost associated with this technique, it should prove useful for all surgeons who perform total hip arthroplasty through the posterolateral approach.

Ceramics have been used as a bearing surface in total hip arthroplasty (THA) for more than 30 years. Properties of this material which make it particularly attractive for this application include its hardness, high compression strength, and excellent wettability. The low incidence of biologically significant particle generation and clinically significant osteolysis with the use of ceramics in THA reflects these properties. However, low fracture toughness and linear elastic behavior demonstrated by ceramic make it prone to breakage under stress. Improvements in the processing of ceramic as well as advances in engineering of head-neck articulations and liner design have led to an overall decrease in the incidence of ceramic fracture and dislocation. This article reviews the science behind the use of ceramics in THA, the clinical results of ceramics in THA, including complications unique to this bearing surface, and future directions for the application of ceramics in THA.

An anomalous origin of the long head of the biceps tendon (LHBT) from the rotator cable has not been described in the orthopaedic surgery literature. This case report describes the intraoperative findings of this aberrant origin, found incidentally during diagnostic arthroscopy. The concept of the rotator cable and crescent is discussed, and a literature review of aberrant anatomy of the LHBT origin is included.

Use of the rim-fit technique in revision acetabular surgery was reviewed for 20 hips in 18 patients. Defects at revision surgery included isolated medial segmental and global cavitary deficiencies with largely intact peripheral rim. A cementless acetabular component is placed to achieve a press-fit against the bony acetabular rim after morselized allograft and/or autograft was placed behind the cup. The average follow-up period was 68.3 months (5.7 years) (range, 27-112 months). Cup migration was assessed using digital radiography. Average vertical migration was 1.02 mm superiorly, and average horizontal migration was 0.8 mm medially. The abduction angle changed on average by 0.25 degrees. Use of the rim-fit technique for treatment of cavitary acetabular defects is associated with component stability and minimal component migration.

This study seeks to evaluate the clinical outcomes of a second primary total knee arthroplasty in patients whose initial (contralateral) primary total knee arthroplasty was complicated by stiffness. We retrospectively compared the preoperative and postoperative range of motion and Knee Society Scores from a study group of 15 patients with an age-matched control group. Statistical analysis did not reveal a significant difference in final postoperative range of motion or Knee Society Scores between the 2 groups. However, there was a statistically significant higher rate of closed manipulation in the study group. Therefore, although the study group did show a higher rate of early stiffness, eventual functional outcome was comparable with a nonstiffness control group.

During the past 2 years, we treated five patients with acral myxoinflammatory fibroblastic sarcoma at our institution. Four patients presented with a firm, painless mass in the hand that appeared over several months. One patient discovered a painless mass in his shoulder region. The five patients initially were diagnosed as having benign conditions and treated with intralesional or marginal excision by referring physicians, only to have the lesion reappear as sarcoma. Each patient was treated with wide resection of the tumor bed. Acral myxoinflammatory fibroblastic sarcoma is a rare, but increasingly recognized sarcoma of the distal extremities, which often is confused with benign lesions. Surgeons should be familiar with this tumor’s clinical, radiographic, and histologic appearances as it has a high rate of recurrence and can metastasize.

During the past 2 years, we treated five patients with acral myxoinflammatory fibroblastic sarcoma at our institution. Four patients presented with a firm, painless mass in the hand that appeared over several months. One patient discovered a painless mass in his shoulder region. The five patients initially were diagnosed as having benign conditions and treated with intralesional or marginal excision by referring physicians, only to have the lesion reappear as sarcoma. Each patient was treated with wide resection of the tumor bed. Acral myxoinflammatory fibroblastic sarcoma is a rare, but increasingly recognized sarcoma of the distal extremities, which often is confused with benign lesions. Surgeons should be familiar with this tumor's clinical, radiographic, and histologic appearances as it has a high rate of recurrence and can metastasize.

Pain arising from the chest area creates anxiety in children and their parents, often leading to unnecessary activity restriction, school absences, and medical utilization. A thorough but pragmatic evaluation requires a grasp of the pathophysiology of several organ systems and an understanding of epidemiologic and behavioral patterns specific to children. Few symptoms in pediatrics test a clinician's skill more than chest pain. Though the etiology is frequently benign, it is often uncertain, and sprinkled among cases of chest pain are potentially fatal conditions.This review summarizes chest pain in children of all ages, with particular emphasis on adolescents. We review the organic causes including musculoskeletal trauma, strain and inflammation, respiratory conditions such as occult asthma, pneumonia and bronchitis, and the important role of esophageal disease. We discuss the relatively minor role of cardiac disease, but highlight the conditions that are vital to consider, such as arrhythmia, mitral valve disease, Kawasaki syndrome, Marfan syndrome, and cocaine use. Anxiety, depression, and other psychological factors often further complicate the presentation. A pediatrician's best tools are diagnostic acumen, which may be lifesaving, and supportive dialogue, to impart reassurance to a worried family.We explore the most common and most lethal causes by age, organ system, and predisposing illness. We review the neuroanatomic considerations important in visceral, chest wall, and mediastinal pain, and the sensation within the lung, airways, and pleurae. Lastly, we highlight pragmatic 'take-home' tips for the clinician, most of which involve good history-taking and physical examination, but also include the utility of basic testing that can detect the rare cases of fatal cardiopulmonary disease.

OBJECTIVE:The purpose of this study was to evaluate the awareness and use of a supermarket-shelf labeling program designed to encourage shoppers to make food choices that promote heart health.DESIGN:A shelf-labeling program was implemented in 18 supermarkets serving minority communities in Detroit, Mich. Customers were given an exit survey to determine awareness and use of the program.SUBJECTS/SETTING:Three hundred sixty-one subjects were sampled. Sixty-six percent of the sample was female, 67% African-American, and the sample population had a mean age of 51.6 years +/- 18.5 SD.RESULTS:Overall awareness of the program was 28.8%. Awareness among minorities was significantly higher when compared with whites (35.3% vs 20.8%; P = .02). Gender, age, and education level were not predictive of program awareness but people screened for cardiovascular disease risk factors (elevated low-density lipoprotein or total cholesterol levels and/or elevated blood pressure) in the previous year had greater awareness than those not screened (32.6% vs 13.6%, P = .06). Use of the program was 56% among subjects aware of the program. This did not differ significantly by gender, age, or ethnicity.STATISTICAL ANALYSIS:Awareness and use were evaluated with respect to ethnicity, gender, education, race, age, and previous screening history. For purposes of analysis, African-American, Hispanic, and Asian-American respondents were combined into one group called "all minorities." The other group of respondents was called "whites." Between-group differences in categorical variables were analyzed using a chi 2 statistic.CONCLUSIONS:Awareness of the shelf-labeling program was modest, but highest among African-Americans. Subjects recently screened for cardiovascular disease risk had greater program awareness. This difference was not statistically significant. Use was relatively high among those aware of the program, suggesting that shelf labels have the potential to increase the selection of foods that promote heart health in predominately low-income, minority populations.