Showing papers in "Bulletin of the Hospital for Joint Diseases in 2001"

Subtrochanteric fractures. A review of treatment options.

Abstract: Subtrochanteric fractures of the femur were originally grouped with comminuted intertrochanteric fractures. However, they pose their own distinct management problems mainly due to biomechanical differences in stability and are now considered separately. There are several classification systems but the most widely accepted is the one proposed by Seinsheimer in 1978. Many different methods have been employed in the management of this group of fractures with varying rates of success. The management has altered as new implants have been developed to try to overcome the shortfalls of the existing implants. This study is a review of the literature and was carried out using Medline and the Cochrane Library to look at the management methods employed in the past and today. Most of the published articles are retrospective uncontrolled reports of the results of management and it is difficult to suggest management principles from them. The other main shortcoming is that, although there are several devices available on the market for the management of these fractures, most of the literature concerns one or two of them. The results reported examine union rates and failure of implants leading to reoperation. This is a crude outcome measure, and there is very little in the literature regarding patient function. In order to provide evidence-based advice on the best management options for these difficult fractures, future studies should be designed as randomized controlled trials and place more emphasis on studying patients' outcomes.

The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail

Abstract: To compare the intrinsic stability of two distal interlocking screw orientations for tibial nailing of distal third tibial diaphyseal fractures without isthmal support, six Depuy (Warsaw, Indiana) tibial intramedullary nails were implanted in simulated distal tibiae The constructs received both two parallel (medial to lateral) and two perpendicular (one medial to lateral, one anterior to posterior) distal interlocking screws in a random order Angular, translational, and torsional displacements of the nails were measured in response to 70 N proximal applications of anterior, posterior, medial, and lateral loads, and a 77 Newton-meter torsional load There were no differences in medial or lateral angulations between the screw orientations (average: 25 degrees, p > 08) Angulation in the sagittal plane (anterior and posterior) was slightly less for parallel screw fixation (16 degrees versus 24 degrees), but this was not statistically significant (p > 01) Rotational angulation was higher in the parallel (average: 99 degrees) versus the perpendicular (average: 81 degrees) screw orientation, but these results were not statistically significant (p > 01) Pure translation did not occur in either the parallel or perpendicular screw orientations These results indicate that fixation stability of these tibial intramedullary nails is not significantly influenced by distal interlocking screw orientation in response to sagittal, coronal, or rotational forces

Peripheral Nerve Injuries and Repair in the Upper Extremity

Abstract: Summary Peripheral nerve injuries are commonly seen as a result ofdomestic, industrial, or military trauma. Sharp objects usu-ally cause these nerve injuries. When assessing these inju-ries, it is important to evaluate each nerves’ motor and sen-sory function. One must be cognizant of associated injuriessuch as fractures, vascular damage, and musculotendinouslacerations. The time since the injury, level of injury, andage of the patient are important prognosticators impactingthe return of function. Intraoperatively, one must assess thevascularity of the soft tissue bed and the nerve itself, thenerve gap, conduction, and the topography of the fasciclesto insure proper orientation. Application of the principlesof nerve repair (magnification, minimal tension, meticu-lous soft tissue handling, experienced surgeon and staff)can enhance the chances for a successful result. Addition-ally, to maximize functional recovery following peripheralnerve repair, a carefully planned program of postoperativeoccupational therapy and rehabilitation must be instituted.

Traumatic spondylolisthesis of the axis: 42 cases.

Abstract: Fourty-two patients (34 males and 8 female) with traumatic spondylolisthesis of the axis were studied in a retrospective review There were 20 stable and 22 unstable fractures. The 22 unstable fractures were treated surgically: 16 anterior interbody fusion (10 non-plated and 6 plated), 4 pedicle screw fixation for osteosynthesis of the fractured pedicles, and 2 posterior wire fixation for flexion and axial load injury. For all non-surgical cases, head halter tractions for 1 to 8 weeks was prescribed and a cervical orthosis was worn for an additional 6 to 18 weeks. The surgical cases underwent 5 to 7 days of preoperative and 1 to 4 weeks of post-operative head halter traction. In all cases pedicle fractures united after 13 weeks on average in group treated conservatively, 12 weeks (11 to 13 weeks) in the posterior wiring group, 8 weeks (7 to 9 weeks) in the group in which pedicle screws were used, and 11 weeks (9 to 15 weeks) in the anterior fusion group (13 weeks in non-plated, and 8 weeks in plated). There were no differences in patterns of anterior fusion between those in the non-plated and plated groups. There were no non-unions of fractured pedicles and there was no late instability of the C2-C3 or neurological complications. In 2 cases in the posterior surgery group, there was mild nuchal discomfort and some rigidity for a short while postoperatively. Final outcomes were good in all cases.

Surgical technique and functional results of irreparable cuff tears reconstructed with the long head of the biceps tendon.

Abstract: The purpose of the study was to evaluate the results obtained from patients who were treated with open surgical technique using the long head of the biceps tendon for irreparable tears of the rotator cuff tendons. Between May 1992 and January 1997, 14 patients underwent rotator cuff reconstruction of irreparable tears at our clinic. These patients were evaluated before and after a minimum follow-up of 26 months (mean: 40.2 months) following surgery with the Constant's functional score. The long heads of the biceps tendons were found to be hypertrophied in all 14 shoulders and in 10 of them they were also subluxated. After re-seating the surgically enlarged biceps tendon onto the center of the uncovered head region, the biceps tendon to cuff tendon repair and the biceps tenodesis were done in all shoulders. The mean functional Constant's score before surgery was 46.7 points (poor) and the mean postoperative score at the final follow-up was 75.35 points (good). Satisfactory results were achieved in 85.7% of the patients. These results suggest that this surgical technique can be used to attain a painless and functional shoulder after irreparable cuff tear reconstruction.

Robotics and computer-assisted orthopaedic surgery.

Abstract: These are just a few representative applications of the synergistic use of computer and robotic technology assisting the orthopaedic surgeon. While the individual systems are certain to change over time, the basic principles of correlating radiographic and anatomic data through a registration process, and displaying additional instrument or implant information through smart tools and surgical navigation are certain to become an increasingly important aspect of joint arthroplasty, deformity correction, and spinal and trauma surgery. Only the orthopaedic surgeon who clearly understands the goals, applications, and limitations of these systems can decide which are appropriate for his patients, his hospital, and his practice. Determining the cost and time benefits, both before and after an obligatory "learning curve" requires a complex interaction of capital investments, time savings, and outcome research on both safety and efficacy issues. The orthopaedist who understands and applies these technologies will help his patients to achieve the best possible care. Excellent resources in the literature on this topic include the September, 1998, issue of Clinical Orthopaedics and Related Research, a symposium on "Computer-Assisted Orthopaedic Surgery: Medical Robots and Image Guided Surgery"; Guest editor, Anthony M. DiGioia, III, MD. Also, the January, 2000, issue of Operative Techniques in Orthopaedics, "Medical Robotics and Computer-Assisted Orthopaedic Surgery. Guest editors: Anthony M. DiGioia, III, M.D. and Branislav Jaramaz, Ph.D. Additional Internet based information is available from the Journal of Computer Aided Surgery (formerly: Journal of Image Guided Surgery), at http://journals.wiley.com/.

The ACL-deficient knee: Natural history and treatment options

Abstract: Injury to the anterior cruciate ligament removes the major stabilizing structure to anterior tibial translation. The initial trauma may lead to meniscal and cartilage damage, predisposing the knee to early degenerative changes. Moreover, a knee with an isolated ACL rupture may have recurrent episodes of instability that can lead to a similar degenerative course. At this time, one cannot accurately predict which patients will tolerate ACL deficiency, and which patients will not. Current long-term studies support a progressive worsening condition in the ACL and meniscal deficient knees. Physical therapy together with lifestyle modifications may be necessary. Those unwilling to make these types of changes or those with associated injuries may benefit from ACL reconstruction.

Indications and Surgical Techniques for Digit Replantation

Abstract: Summary Finger amputations are devastating, life-changing inju-ries. They can occur from many different types of in-jury, but most often are caused by power tools or ma-chinery in the workplace. Modern microvascular surgicaltechniques have enabled surgeons to successfully reat-tach fingers that have been amputated at almost level ofinjury. Patient outcome and digit viability have improvedas surgeons have gained more experience with microvas-cular techniques, and have narrowed the operative indi-cations for replantation. Currently, replantation is rec-ommended for amputated thumbs, multiple digitamputations, and single digit amputations distal to theFDS insertion, as well as all amputations in children.Replantation surgery is technically demanding. Suc-cess relies on patient selection, meticulous operativetechnique, and postoperative monitoring. Most patientshave successful outcomes with at least protective sensa-tion and useful range of motion in the replanted digit.Though complications, including joint stiffness, tendonadhesions, malunion, and cold intolerance are not infre-quent, patient satisfaction following replantation is high.

Complications of total hip arthroplasty: Neurovascular injury, leg-length discrepancy, and instability

Abstract: Total hip arthroplasty has revolutionized the treatment of end-stage hip arthritis and is felt to be among the most cost effective of all medical interventions available. As a result of the combination of the high success rate, increasing population age, and increasing clinical indications for total hip arthroplasty the absolute number of complications experienced will inevitably increase. A thorough understanding of the more common complications following total hip arthroplasty aids in optimizing patient outcomes and allows for improved patient education during preoperative counseling. This review focuses on some of the aseptic complications of total hip arthroplasty including neurovascular injury, leg-length discrepancy, and instability.

The relationship between postoperative ligament balance and preoperative varus deformity in total knee arthroplasty.

Abstract: We hypothesize that in knees with severe varus deformities, varus-valgus ligament imbalance tends to remain postoperatively after total knee arthroplasty. The purpose of this study was to evaluate the correlation between preoperative varus deformity and postoperative ligament balance quantitatively measured by stress radiograph using Telos SE in total knee arthroplasty. In this study, 44 knee arthroplasties in 32 patients were evaluated. We defined the angle in varus and valgus stress as "varus angle" and "valgus angle," and the sum of varus angle and valgus angle as "sum of varus-valgus angle." There was a significant correlation between preoperative lateral femoral angle and varus angle (p < 0.0001, r = 0.56), which means that postoperative ligament imbalance tends to remain in knees with preoperative varus deformities. There was a significant correlation between the postoperative period and the sum of varus-valgus angle, which suggests that knees with total knee arthroplasty have potential to increase laxity postoperatively.

Osteoid Osteoma in the Base of the Coracoid Process of the Scapula Excision by Anterior Approach: A Case Report

Abstract: Osteoid osteoma in the base of the coracoid process of the scapula is very rare and diagnosis and treatment often is delayed. A lesion in this atypical location may seem surgically unreachable. This report is of a case of osteoid osteoma in the base of coracoid process in a 14-year-old female. The lesion had been diagnosed as a nontumorous condition and overlooked for four years. Computed tomography and magnetic resonance imaging revealed a nidus in the base of the coracoid process. The en bloc excision of the osteoid osteoma was managed by an anterior approach using an osteotomy of the coracoid process. A 12-month follow-up examination revealed no symptoms and computed tomography showed bone healing with no recurrence of the tumor.

Hydatid disease of the left femur: a case report.

Abstract: Osseous hydatid disease is a rare but serious condition. Treatment is difficult because of the progressive course of the bone involvement and generally admitted algorithm about osseous hydatid disease. We report a six-year follow-up of a case with involvement of the left femur, treated with an unconnected surgical method and albendazole, In this patient a I cm segment of the cortex between the trochanteric region to supracondylar area of the left femur was removed. The medullary cavity of the left femur was irrigated for 5 minutes with 20% hyper-Saline solution, and removed without causing any damage. The medullary cavity was curettaged meticulously and irrigated for 6 minutes with 0.9% saline solution. The bone defect was filled with bone cement. Albendazole was administered during the postoperative period. At the sixth year postoperatively, the patient was pain free. All serological tests were normal. Radiologic evaluation showed no evidence of disease recurrence. Meticulous preoperative planning, excision of all the cysts, and an effective regimen of chemotherapy will reduce recurrence. Bone scintigraphy is an important diagnostic method during the follow-up period.

Patients' recollection of day case knee arthroscopy procedure

Abstract: A prospective study of 103 consecutive patients who underwent day case knee arthroscopy was performed. The purpose was to evaluate the information delivery system, patient comprehension, and issues of informed consent pertaining to day case arthroscopy procedures. There were 34 females and 69 males in the study group and their mean age was 38.6 years (range: 14.4 to 74.9 years). The diagnosis, procedure, and aftercare were explained to the patients in the outpatients clinic by a trained nurse and by the operating surgeon just prior to the operation. The nurse before the operation gave the patients an information booklet. Postoperatively the patients were informed about the findings and diagnosis prior to their discharge from the day care facility. Patients were requested to complete a questionnaire. Three weeks later they were given the same questionnaire, prior to consultation, in the outpatient clinic. These two forms were compared with the operative findings and diagnosis documented in the copy of the questionnaire completed by the surgeon as well as the case notes. Most patients (38.8%; 40 patients) had no recollection; 3.9% (4 patients) had partial recollection at their consultation three weeks later; 19.4% (20 patients) found that the arthroscopic photograph was not helpful in making them understand the procedure; and 9.7% (10 patients) found the information booklet to be unhelpful. Further, 23.3% (24 patients) said that it would not help if the booklet were sent to them prior to the operation. The recollection rate was also correlated to their position on the operating list, to ascertain the effect of the anesthetic. There was a 65.9% (58 patients) recollection rate in those patients who were on the first half of the list and there was only a 33.33% recollection rate in those patients who were last or second to the last [p = 0.0225]. We recommend regular evaluation and improvement in the communication and information delivery system provided to patients.

Lateral ankle and subtalar instability

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Post-traumatic thumb reconstruction.

Abstract: Many options exist for the management of post-traumatic thumb reconstruction. While the single most important factor for determining the most appropriate procedure is the level of the amputation, many other factors must be considered including patient considerations regarding function and cosmesis as well as the nature of the injury and the expertise of the surgeon. Patients must be included in the decision-making process and their needs and expectations must be clearly defined and addressed. The patient who is most concerned with cosmesis rather than function is more likely to be satisfied with a prosthesis than with even the most cutting-edge surgical procedure.

The effect of screw type on the fixation of depressed fragments in tibial plateau fractures.

Abstract: The ability of various screw types to stabilize depressed tibial plateau fractures was determined in a biomechanical study using a Sawbones ® model. Two sizes of both cancellous and cortical screws were evaluated for both support from below and through the depressed fragment. As a general trend, cancellous bone screws provided a greater resistance to fragment displacement than cortical bone screws, and screws with a smaller thread diameter provided greater resistance to displacement than screws of the same thread type with a larger diameter. These results agree with the accepted standard that cancellous screws provide better fixation for tibial plateau fractures, but also are counterintuitive in that smaller screws provided greater fixation than larger screws of the same type.

Exercise intensity based on heart rate while walking in spastic cerebral palsy.

Abstract: We examined the heart rate (HR) of subjects with spastic cerebral palsy (CP) in order to estimate exercise intensity while walking. The subjects were 17 subjects with CP (14.0 +/- 3.7 years of age) containing 7 subjects rated as level 1, 4 subjects rated as level 2, and 6 subjects rated as level 3 by the Gross Motor Function Classification System, and 7 normal subjects (12.4 +/- 2.8 years of age) were used as a controls. Even in subjects whose gross motor function was excellent (rated as level 1), the HR significantly increased while walking when compared to normal subjects (p < 0.05), although the walking speed between the groups was not different. According to the HR, the exercise intensity while walking was adapted from weakly to moderately and thought to be appropriate for exercise. On the other hand, walking speed was significantly reduced in the subjects rated as level 2 and 3 (p < 0.05), and the HR increased significantly (p < 0.05). Seven of the ten subjects rated as either level 2 or 3 showed a high HR of over 150 beats/min while walking. The HR while walking of the two subjects rated as level 3 continued to increase although the walking speed was kept constant. The walking exercise would be too strong and become detrimental to such subjects.

Hydroxyapatite-coated total hip replacements in patients 65 years of age and over.

Abstract: Prospective review examined 69 patients aged over 65 years (mean: 73 years; range: 65 to 85 years) who underwent 72 primary hydroxyapatite-coated total hip replacements by one surgeon. The femoral component used was titanium alloy coated by hydroxyapatite on the proximal third and the acetabular component was spherical and unthreaded, coated with hydroxyapatite. All patients were evaluated clinically by Harris Hip Score and radiologically using Engh's criteria with a mean follow-up of 86 months (range: 29 months to 10 years). Preoperative radiologic evaluation for osteoporotic bone using the Singh index was performed. Average Harris Hip Score increased from 45 before surgery to 89 at last follow-up. Two femoral and one-acetabular components were shown to probably be loose, but none was definitely loose or unstable by Engh's criteria. There was no correlation between clinical and radiologic results with respect to age, sex, and preoperative diagnosis. In contrast, significant statistical correlation was demonstrated between Charnley groups A or B, and group C, with regard to the Harris Hip Score (p = 0.047). There was no correlation between Charnley groups and radiological results. There was no statistical difference between patients with osteoporotic bone (Singh 1-3) and non-osteoporotic bone (Singh 4-6) with respect to clinical and radiologic evaluation. These early clinical and radiologic results compare favorably with those of hydroxyapatite-coated total hip replacements for younger patients and cemented total hip replacements in older patients. We recommended that hydroxyapatite-coated total hip replacements should not be reserved for younger patients. They can be used safely in patients over 65 years of age, promising minimal postoperative thigh pain and satisfactory clinical and radiologic results.

Orthopaedic manifestations of systemic lupus erythematosus.

Abstract: Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease of unknown origin. It affects multiple organ systems, but most frequently the musculoskeletal system. Highly variable manifestations include small and large joint involvement, spinal involvement, periarticular tissue symptoms, and complications associated with chronic steroid use such as osteonecrosis, osteoporosis, and stress fractures. The following review summarizes the common orthopaedic manifestations of SLE.

Magnetic resonance imaging observation of the conus medullaris.

Abstract: We examined the anatomical height and shape of the conus medullaris in 602 cases using magnetic resonance imaging. The peak of the distribution of the conus height was at the middle one-third of L1. The comparison of the conus level had no significant relationships with age or sex, but the juvenile group had more a caudal distribution of the conus level. The shape of the conus medullaris was classified into three types, and the type B was most frequently observed.

Effect of Piriformis Versus Trochanteric Starting Point on Fixation Stability of Short Intramedullary Reconstruction Nails

Abstract: Recently, a new, shorter IM nail using two 6 mm reconstruction screws for proximal fixation was introduced in two versions for femoral insertion: piriformis fossa (FAN) and greater trochanter (TAN). These nails were compared experimentally for their fixation stability, proximal load transmission, and failure strength in an unstable intertrochanteric fracture model in cadaveric femurs. Vertical and axial loads were first applied to the intact femurs. Fractures were created, subsequent fixation applied, and the femurs underwent a series of both vertical and axial loading tests. There was no significant difference in strain readings between the nails for either axial loading or cyclical loading. There was no statistically significant difference between the loads to failure for the trochanteric nails and the standard antegrade nails. The average ultimate load for the FAN and TAN nails were 3010 N and 2830 N respectively. These two nails performed very similarly throughout our testing.

Arthroscopic stabilization of anterior shoulder instability: a historical perspective.

Abstract: The role of arthroscopic procedures in the management of glenohumeral instability continues to evolve and represents an effective alternative for addressing the pathology associated with this condition. Patient selection criteria, operative techniques, and implants all continue to evolve and have resulted in improved rates of success. Arthroscopic procedures benefit patients by avoiding the common morbidities associated with the disruption of the anterior soft tissues, including a loss of external rotation associated with open procedures. Arthroscopic procedures remain technically demanding and require skills to address all of the existing pathology. The surgeon must be prepared to address many conditions beyond the Bankart lesions including glenoid bone lesions. capsular laxity, rotator interval lesions, and SLAP lesions. In addition to the documentation of recurrence, the success of this procedure must be evaluated within the context of retained ranges of motion, recovery time, proprioceptive control, and the return to prior levels of activity. Further studies are necessary to continue to validate the efficacy of arthroscopic stabilization.

Management of Orthopaedic Injuries in Polytrauma Patients

Abstract: Appropriate management of a polytrauma patient begins at the scene of the accident. Early initiation of Advanced Trauma Life Support (ATLS) protocols by emergency medical personnel and rapid transport to an appropriate facility is essential to maximize a patient’s chance of survival. Fifty percent of trauma deaths occur within minutes of the accident, usually due to hemorrhage or head injuries. Thirty percent of deaths occur within hours from similar causes. The remaining 20% of deaths occur days to weeks following the injury, typically from sepsis or multiple organ failure. For patients who have sustained major injuries, treatment at a designated regional trauma center that treats a significant volume of trauma patients has been shown to correlate with better survival rates. 1,2 A large percentage of trauma patients have orthopaedic injuries. Management of isolated long bone fractures is relatively simple; however, treatment of these and more complex injuries (i.e., pelvis and acetabulum fractures) in the multiply injured patient is more challenging. Pelvis and long bone fractures cause significant systemic complications that affect the physiological status of the patient. These systemic effects will potentially alter the overall treatment of the patient. Orthopaedic injuries in the polytrauma patient must be addressed in the context of the entire patient, not just as isolated fractures. Initial Management Standard ATLS protocols administered by an organized trauma team are critical. Initial assessment should include the standard airway, breathing, circulation, disability (neurological) survey, followed by careful physical examination to identify all injuries. Standard trauma series radiographs, including an anteroposterior chest, anteroposterior pelvis, and lateral of the cervical spine with visualization from the occiput to T1, should be obtained. Life-threatening injuries, including orthopaedic injuries such as an unstable pelvis fracture, need to be addressed first. Limb-threatening and spinal injuries follow closely behind. These include open fractures, compartment syndromes, and fractures with associated vascular disruptions. These injuries need to be addressed prior to performing more elective skeletal stabilization and reconstruction.

Soft-tissue principles for orthopaedic surgeons.

Abstract: Meticulous handling of the tissues, reversal of known patient risk factors, and attention to detail can avoid many soft-tissue complications. Prompt management or consultation of a soft-tissue expert may reduce the morbidity and need for extensive reconstructive procedures.

Tethered cord in a patient with multiple vertebral segmentation defects: a case report.

Abstract: Short trunk dwarfism with multiple vertebral segmentation defects (MVSD) represents a heterogeneous group of disorders characterized by the presence of multiple vertebral and rib abnormalities. A two and one-half year-old female with the spondylothoracic dysostosisform of MVSD is presented. In addition to skeletal anomalies, a lumbar hemangioma, bilateral foot deformities, distal leg atrophy and weakness, and areflexia at the ankles were present. An underlying neuropathic process was suspected. Results of urodynamic studies were suggestive of a neurogenic bladder. Magnetic resonance imaging of the spine demonstrated a tethered spinal cord. Although various brain and spinal cord anomalies have been described in MVSD, this is the first reported case, to our knowledge, of a tethered spinal cord in a patient with MVSD. We recommend that the management of patients with MVSD include comprehensive neurological evaluation and monitoring with appropriate electrodiagnostic, urodynamic, and neuroimaging studies.