Purpose:  This study compares the clinical and radiographic results of unicompartmental knee arthroplasty with all polyethylene and metal backed tibial implants.
Methods: This is a comparative prospective analysis of consecutive cohorts of 142 all-polyethylene and 88 metal backed unicompartmental (UKA) tibial components implanted with a minimally invasive technique. These groups were then compared with a cohort of 75 metal backed UKA performed through a traditional arthrotomy. The three groups were similar in demographics and knee pathology.  Outcome assessment included knee scores, range of motion, radiographic analysis, and complications.  Knee Society scores were assessed preoperatively and again at 6 weeks, 1, and 3 years post-op.  Statistical analysis included ANOVA, chi squared, and Wilcoxon rank sum.
Results:  While all 3 groups showed significant improvement in knee scores, the metal backed implants had better knee scores (p=.037) and pain scores (p=.024) at 1 year but were equal at 3 years.  The minimally invasive knees had better range of motion at 3 years than the traditional UKA group (p=.026).  Postoperative limb alignment and implant position were similar for the 3 groups.  At 1 and 3 years, the incidence of radiolucent zones beneath the tibial implant was higher with all polyethylene implants (p=.0042), but did not correlate with pain or function (p=.919).  Complications and re-operations were more frequent in knees with all polyethylene tibial components.
Conclusion:  While satisfactory results can be obtained with all three techniques, better clinical and radiographic results may be obtained in UKA with metal backed tibial components.

Investigation performed at the Indiana Orthopaedic Hospital, Indianapolis, Indiana.  Spontaneous avulsion or rupture of the gluteus medius and minimus tendons is a debilitating source of lateral hip pain and is thought to be an uncommon yet often under recognized or misdiagnosed condition.^1-3  Patients presenting with ruptures of the gluteus medius or minimus tendons are often diagnosed as having “greater trochanteric pain syndrome”(GTPS) which is a term often used to denote a common clinical syndrome that is usually classified as trochanteric bursitis.^{1, 4}   Patients with lateral hip pain or GTPS and gluteal ruptures  are often treated for bursitis and therefore go undiagnosed. This is thought to be due to the difficulty in diagnosing this condition by routine history and physical examination and magnetic resonance imaging (MRI) may be necessary for an accurate diagnosis.^{2, 5-7}
     Common conditions associated with GTPS include degenerative diseases of the lumbar spine, hip arthritis, pelvic obliquity, iliotibial band and abductor tendonitis, and difference in leg lengths of the lower  limbs.^{4, 8, 9}   The cause of tendinosis and ruptures of the gluteus medius and minimus tendons is uncertain. The causes may be related to local mechanical trauma or predisposing systemic conditions related to tendon ruptures.^{10, 11}   The gluteus medius and minimus have been regarded as part of the abductor apparatus or the “rotator cuff of the hip”, analogous to the rotator cuff of the shoulder which may predispose to rupture in the same manner.^12-14
     We report the clinical presentation, radiographic findings and surgical management of a patient diagnosed with bilateral spontaneous ruptures of the gluteus medius and minimus tendons. Our patient is unique in that the patient was young, had bilateral ruptures and no predisposing condition for tendon rupture. In addition, the ruptures occurred 5 years apart.  The patient granted permission for submission of data concerning her case for publication.
     Case Report - A forty-two-year-old woman was referred for evaluation of a seven month history of moderate to severe debilitating right lateral hip pain. She initially presented to her local physician with a one month history of spontaneous lateral hip pain and was treated for trochanteric bursitis for the following six months. Her treatment consisted of NSAID’s and multiple cortisone injections and physical therapy. She later took narcotics for pain control.
     After failed conservative treatment for trochanteric bursitis, the patient was evaluated and found to have no history of any medical problems or any history of predisposing conditions for tendon rupture. She also had no history of related trauma, lumbar spine disease, or contralateral hip pain. The patients lifestyle was moderately active.
     On examination, the patient weighed 150 lbs. and was 5 ft. 8 in. tall. She had symmetric spine movement, an even pelvis and no leg length discrepancy. She had an antalgic gait, a noticeable limp and a positive Trendelenburg sign. There was mild tenderness over the trochanteric bursa and severe tenderness over the insertion of the gluteus medius and minimus tendons. No palpable lesions were noted. There was full symmetric range of motion of both hips and no groin pain with provocative maneuvers. There was weakness and trochanteric pain with resisted hip abduction and flexion as well as mild tightness but no snapping of the iliotibial band. Straight leg raise was unrestricted and pain free and deep tendon reflexes were symmetrical, 2+ at the knees and ankles. Patrick’s sign to assess intraarticular hip disease was negative.
     Plain radiographs were negative for boney avulsion and for calcification adjacent to the greater trochanter or within the substance of the gluteal tendons. There was no sclerosis of the greater trochanter or degenerative disease of the hip. An MRI was obtained to rule out any pathology related to the greater trochanter and consisted of coronal T1, coronal STIR, axial T1, sagittal T2 fast spin-echo with fat saturation imaging sequences of the pelvis and small field-of-view coronal proton density fat-saturated images.  The images revealed focal edema surrounding the insertion of the gluteus medius and minimus tendons with rupture of the gluteus minimus and at least partial tear of the gluteus medius. The musculature and tendinous insertions of the left hip were within normal limits.[Figure 1]
     Surgical reattachment was offered to the patient because of her severe debilitating symptoms and failed conservative treatment. The patient agreed  and was taken to the operating room definitive treatment.
     A longitudinal incision was made over the right hip and the tensor fascia lata incised in line with its fibers. The trochanteric bursa was noted to be normal. The anterior gluteus medius tendon was partially avulsed from the greater trochanter. The gluteus medius tendon was released anteriorly to expose the gluteus minimus tendon. The majority of the gluteus minimus was found to be avulsed [Fig. 2A]. Several sutures were placed in the free end of the tendon and repaired back to the greater trochanter through interosseous drill holes. The repair was augmented using the Restore TM orthobiologic patch (DePuy Orthopedics, Warsaw, IN, USA). The patch was unwrapped, reconstituted, cut to fit the repaired area, and then sutured under slight tension to the gluteus minimus and the trochanteric remnant with 2-0 vicryl suture[Figs. 2B, 2C]. The anterior portion of the gluteus tendon was then advanced and repaired back to the cuff of tendon attached to the greater trochanter. Interosseous sutures were also used to secure the repair of the medius. The wound was closed in routine fashion.
     She was discharged home on the next day and had no postoperative complications. After two weeks she was begun on abduction exercises and graduated to one crutch. At 5 weeks her pain and limp were gone and she had full return of abduction and flexion strength. By four months she was symptom free and able to walk two miles without difficulty.
     Five years later she presented with a four month history of spontaneous progressive lateral pain and weakness of the opposite hip and no history of trauma. Her exam was the same except that the patients limp and Trendelenburg sign were not as pronounced. As before, her MRI findings revealed a rupture of the gluteus minimus tendon and possible tear of the gluteus medius tendon.[Figure 3] The right hip was found to be normal.
     Because of her previous history, conservative as well as surgical treatment was offered to the patient. The patient opted for surgical treatment. Surgical repair was performed using the same technique. The patient is currently 8 weeks from surgery and ambulating without pain, crutches or a limp. 
Discussion
     Although rupture of the gluteus medius and minimus tendons is thought to be an uncommon injury, unilateral ruptures have been recently reported in both the orthopedic and radiographic literature. However, in our literature review, we found no mention of spontaneous bilateral ruptures or description of surgical repair.      There are several findings characteristic of gluteus medius and minimus ruptures. These findings, however, often lead the orthopedist, rheumatologist, as well as the primary care physician to the wrong diagnosis. Patients are often diagnosed with trochanteric bursitis and treated for months with NSAID’s, cortisone injections, and physical therapy. Some patients get better but most often have lingering symptoms with intractable pain and hip weakness.^{12, 14-16}
     Patients usually present with chronic lateral hip pain often associated with a disabling limp without antecedent history of trauma. They may complain of a “grinding” sensation and difficulty climbing stairs. On exam, there often will be exquisite tenderness over the insertion of the gluteus medius and occasionally over the trochanteric bursa.^{8, 9, 17}  The two most reliable clinical signs are the Trendelenburg sign and pain on resisted hip abduction, both of which are reported to have greater than 70% specificity and sensitivity. Pain on resisted hip internal rotation is a helpful sign but not as reliable.¹
     Conditions such as fibromyalgia, mechanical low back pain, buttock and leg pain, lumbar spinal stenosis, lumbar radiculopathy and femoral nerve irritation, stress fracture and avascular necrosis may mimic this condition and should be considered in the differential diagnosis.^{1, 9}   A variety of systemic conditions (Table 1) may predispose to degenerative changes in the tendon and these changes may lead to eventual rupture of the tendons.^{6, 18}  The gradual attritional changes caused by these conditions may lead to eventual rupture in the same way as the rotator cuff in the shoulder.^{6, 14}   This, however, doesn’t account for patients without these conditions. It has been postulated that pelvic morphology, high valgus angle and leg length discrepancy biomechanically predispose patients to injury as the greater trochanter impinges on a tight iliotibial band. Tension within the iliotibial band may result in frictional trauma to the gluteus medius and minimus tendons, just as the acromial process causes trauma to the rotator cuff in the shoulder girdle.^{2, 8, 9, 12, 14}   An alteration in gait due to altered biomechanics is likely a predisposing factor and may play a role in causation as well.²
     Clinical diagnosis of the gluteus medius or minimus tendon ruptures alone is often difficult.  Plain radiographs are usually not helpful but may show calcification within the gluteal tendons or boney avulsion. Tendinous calcification has been reported in up to 40% of patients diagnosed with greater trochanteric bursitis, however, other studies found radiographic signs   to be less common. Shapira et.al found positive signs in only 9 of 72 patients.¹⁹  Scintigraphic findings are largely nonspecific to the lateral aspect of the greater trochanter.  However, some researchers have suggested that scan findings may indicate gluteal tendonitis and not bursitis because of the characteristic appearance of a short linear band of increased uptake confined to the superior and lateral aspects of the greater trochanter on early blood pool or delayed images.²⁰  Tendonitis, tears and ruptures of the gluteal tendons are most accurately diagnosed by MR imaging. Coronal T1 with fat saturation images and axial fast spin-echo T2 with fat saturation images were found to be the best imaging modality for identifying tears of the gluteus medius and minimus.  These techniques may reveal calcification within the tendons and edema within the muscle and adjacent compartments.²    
     Ultrasound can also be a useful aid in detecting gluteal injuries. Connell et.al. evaluated 75 consecutive patients with pain and point tenderness over the greater trochanter with ultrasonography in order to discriminate tendinosis from partial or complete tear. 53 of 75 patients showed sonographic evidence of gluteus medius tendonapathy, 16 partial tears, and 9 full-thickness tears along with 10 patients with gluteus minimus tears. Twenty-two patients required surgery.²¹
     GTPS is most commonly seen in middle-aged and elderly women. For this reason it is thought that gluteal tears would follow the same pattern. The overall incidence of injury to the gluteus medius and minimus tendons is unknown.^{4, 7}  Howell et. al.²² found degenerative tears of the gluteus medius or minimus in 20% of 176 patients undergoing total hip arthroplasty and Bunker et.al.¹³ reported a 22% incidence of tears in a prospective study of 50 consecutive patients with femoral neck fractures. The percentage of symptomatic patients in these two studies was not known.
     Gluteus tendon ruptures, if diagnosed early, can be treated conservatively by unloading the involved hip with crutches or a cane, NSAID’s, and physical therapy once acute symptoms have subsided. Surgical management may by necessary if the patient fails conservative treatment or the patient’s pain and weakness warrant it. Surgery should include conjoined tendon debridement, transosseous fixation and possibly augmentation with soft tissue graft material.  The latter could include autograft, allograft, or xenograft in the case of the Restore TM  orthobiologic patch.
     In conclusion, gluteus medius and minimus tears are often misdiagnosed, under recognized, and may be more common than previously appreciated. This diagnostic dilemma is particularly true for spontaneous ruptures in patients with no predisposing condition.  A thorough history and physical exam followed MR imaging is most important in making the correct diagnosis. Ultrasound may represent an alternate diagnostic procedure to consider. Injury to the gluteus medius and minimus should be included in the differential diagnosis of patients presenting with acute or chronic hip pain.
     The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
References
1.  Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of MRI and physical examination findings in patients with greater trochanteric pain syndrome. Artrhritis Rheum. 2001;44:2138-2145
2.  Kingzett-Taylor A, Tirman PF, Feller J, et al. Tendinosis and tears of gluteus medius and minimus muscles as a cause of hip pain: MR imaging findings. Am J Roentgenol. 1999;173:1123-1126
3.  Schuh A, Zeiler G. Rupture of the gluteus medius tendon. Zentralblatt fur Chirurgie. 2003;128(2):139-142
4.  Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanteric pain syndrome). Mayo Clin Proc. 1996;71:565-569
5.  Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI diagnosis of  Tears of the hip abductor tendons (Gluteus medius and minimus). Am J Roentgenol. 2004;182:137-143
6.  Lonner JH, Van Kleunen JP. Spontaneus rupture of the gluteus medius and minimus tendon. Am J Orthop. 2002;31:579-581
7.  Kumagai M, Shiba N, Nishimara H, Inoue A. Functional evaluation of hip abductor muscles with use of magnetic resonance imaging. J Orthop Res. 1997;15:888-893
8.  Karpinski MRK, Piggott H. Greater trochanteric pain syndrome. J Bone Joint Surg Br 1985;67-B:762-763
9.  Traycoff RB. “Pseudotrochanteric bursitis”: the differential diagnosis of lateral hip pain. J Rheumatol. 1991;18: 1810-1812
10. Uhthoff  HK, Sarkar K. Classification and definition of tendinopathies. Clin Sports Med. 1991;10:707-720
11. Liow RYL, Tavares S. Bilateral ruptures of the quadriceps tendon associated with anabolic steroids. Br J Sports Med. 1995;29:77-79
12. LaBan MM, Weir SK, Taylor RS. ‘Bald trochanter’ spontaneous rupture of the conjoined tendons of the gluteus medius and minimus presenting as a trochanteric bursitis. Am J Phys Med Rehabil. 2004;83:806-809
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17. Beck M, Sledge JB, Gautier E, Dora CF, Ganz R. The anatomy and function of the gluteus minimus muscle. J Bone Joint Surg Br. 2000;82-B:358-363
18. Jones A, Barton N, Pattrick M, Doherty M. Tophaceous  pyrophosphate deposition with extensor tendon rupture. Br J Rheumatol. 1992;31:421-423
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22. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis.  J Arthroplasty 2001;16:121-123

Purpose:  Within the last five years several variations in technique to perform a total knee replacement have been introduced.  While the procedure is touted as being highly successful in improving the quality of life for many patients, it also can be significantly painful, expensive, labor intensive, and resource consuming.  The purpose of this study is to determine what effect specific changes in technique would have on patient’s early mobility, pain control, and component alignment and sizing.
Methods:  A consecutive series of three groups of patients was studied.  These groups consisted of 25 patients before changes were implemented (A), 25 patients when the mid-vastus approach was added (B), and 25 patients after computer assisted navigation was added (C).  Patients were assessed on functionality, pain control, and blood loss during their hospital stay, as well as the limb alignment achieved.
Results:  Early function was substantially improved.  80% of patients in group C achieved greater than 90 degrees of flexion by discharge versus only 18% in group A.  92% of patients in group C went home while only 8% in group C went home.  There was trend toward less need for pain pills and a reduction in need for intravenous rescue from 64% in group A to 28% in group C. Blood loss was not substantially different. Limb alignment improved with less deviation from target parameters.  92% of tibias in group C were within one degree of the 0⁰ target while only 36% in group A achieved that target. 
Conclusion: The sum total of specific changes in this study measurably improved the functionality, pain control, and limb alignment of patients undergoing total knee arthroplasty.

Purpose:  To evaluate the long-term results of pediatric patients with high grade spondylolisthesis treated with posterior decompression, posterolateral fusion and fibular dowel strut graft. 
Study Design:  Retrospective clinical and radiographic study.
Materials:  Twenty-two patients underwent surgery and were followed an average of 8.7 years (range 3-17 years).  Average age at the time of surgery was 13.5 years (range 11-17 years).  5 patients had Meyerding grade III spondylolisthesis, 12 had grade IV, and 5 had spondyloptosis.  Each patient underwent a wide decompression with an L5 laminectomy and bilateral foraminotomies.  A fibular dowel was placed in a posterior to anterior fashion across the disc space from the sacrum into the L5 body.  A posterolateral fusion with autogenous iliac crest bone graft was performed in each case.  Pedicle screw instrumentation was employed in 12 cases.  No forceful reduction of the deformity was attempted.  Clinical assessment was with the SRS-24 instrument as well as specific queries regarding relief of pre-operative back and leg pain, improvement in quality of life, satisfaction with surgery, and willingness to retrospectively repeat surgery. Radiographic parameters evaluated were: slip grade, slip angle, sacral inclination, and lumbar lordosis.
Results:  Relief of back pain was excellent in 18 patients (82%), good in 2 patients (9%), and fair in 2 patients (9%).  Relief of leg pain was excellent in 20 patients (91%) and good in 2 patients (9%).  21 patients (95%) reported improvement in their quality of life post-operatively, at the most recent follow-up.  21 patients (95%) felt their pre-operative expectations had been met.  There was no statistical difference in SRS-24 scores between patients who had instrumented and uninstrumented fusions.  The SRS-24 was slightly lower in patients who required revision surgery though it was not significant.  20 patients (91%) had a solid fusion at 6 months postoperatively.  The 2 patients (9%) with a pseudarthrosis had uninstrumented fusions.  4 patients (18%), all of whom had uninstrumented fusions, had deformity progression of one slip grade.  Slip angle improved an average of 16 degrees in patients in with instrumented fusions compared with 2 degrees in uninstrumented cases.  Transient L5 neuropraxia occurred in 4 patients (18%), all of which resolved within 3 months post-operatively.  No focal motor deficits occurred.  3 patients (14%) required additional surgery, 2 for revision fusion and 1 for removal of prominent pedicle screw instrumentation.
Conclusion:  Posterior decompression with posterolateral fusion and fibular dowel strut placement is an effective technique to address high grade spondylolisthesis, with predictable relief of back and leg pain and improvement in quality of life. 

Background:  More than 40 fusion techniques for the ankle joint have been reported. The purpose of this retrospective study was to review our preliminary clinical and radiographic results by using an anatomically contoured anterior plate for ankle arthrodesis.
Methods:  From Sept 2004 to Oct 2006, 10 arthrodeses were performed by the senior author (LAH) using an anatomically contoured anterior plate (Synthes, Paoli, PA) through anterior approach. The patients include 6 men and 4 women with an average age of 43.6 (range from 23 to 79). All the patients were followed up from 5 months to 28 months with an average of 13 months.
     All patients had disabling ankle arthritis of variable etiology. Preoperative diagnosis consisted of three patients with primary degenerative osteoarthritis, one with avascular necrosis of talus, six with posttraumatic osteoarthritis. Among the six patients with posttraumatic osteoarthritis, five of them were complicated with infection after open ankle fracture, in which two have undergone skin graft or flap. Five of ten patients were combined with bone defects which were located at the distal end of the tibia and the fibula, talus and medial malleolus. The indications for surgery were severe pain and/or deformity which had no responded to conservative treatment. Three patients had not undergone any previous surgeries on the involved ankle, two had one operation, three had two operations, one had three operations, and one had four previous operations. Eight patients underwent primary arthrodesis by using anatomically contoured anterior plate, one patient underwent secondary arthrodesis by reapplying the same plate for distal screw loosening after primary fusion, one patient underwent the third arthrodesis for nonunion of fusion with cortical and cancellous or cannulated screws twice.
     All patients were evaluated by a reviewer who was not involved with the initial surgery. Plain radiographs of ankle 3 views were taken usually after operation immediately, 6 weeks, 12 weeks, 24 weeks postoperatively to aid in determining the stability of fixation and time of fusion. AOFAS clinical rating system for ankle-hindfoot, ¹⁰ which includes scores for both ankle and hindfoot, was utilized selectively (Table 2). Because two cases in our series were combined with subtalar fusion simultaneously, which made it impossible to evaluate the hindfoot motion by using AOFAS system. We also were unable to use AOFAS system to measure the maximum walking distance because it was dependant on estimation.
Results:  Nine of ten patients achieved solid fusion radiographically and clinically at an average of 15 weeks (range 12 to 22 weeks). Bony healing was achieved after an additional 12 weeks for the patient who underwent re-fusion. There were no postoperative wound problems or recurrent infection. All patients reported an improvement in their pain level following successful fusion.
Conclusion:   The application of anatomically contoured plate through anterior approach provides many advantages, including minimal soft tissue disruption, ease of deformity correction, early rehabilitation, and high rate of union. It is easily reproducible and can be recommended for patients with failed fusion and posttraumatic arthritis with infection and poor bone quality.

     Anatomic variation involving the median nerve and intrinsic muscles exist in the hand.  Knowledge of this is important to avoid iatrogenic injury during carpal tunnel release.  The purpose of this study is to describe a previous underreported relationship between an aberrant course of the median nerve motor branch and anomalous thenar musculature.
     Materials/Methods - This study is two part, in the clinical part 20 cases were encountered (of total 530 CTR between 1/2000-1/2007) that demonstrated an anatomic variation between the motor branch and the thenar musculature.  A cadaveric study (42 upper extremities) was performed to describe its frequency.
     Results - In the clinical study 20/530 cases (4%)of cases demonstrated an anomalous head of the flexor pollicis brevis (FPB) associated with a more ulnar take-off of the recurrent branch.  In the cadaveric study this was documented 5% of the time.  Unpaired T-Tests results confirm a p-value of .0001.  ANOVA with post-hoc analysis confirmed to a p-value of .0001 the relationship of the aberrant course with its relation to the anomalous muscle. 
     Conclusion - This muscle has a 1) triangular shape, 2) minimal fascial covering, and 3) ranges from an extension of the FPB to an additional head.  Its presence has been associated 100% of the time with an ulnar take-off of the motor branch and should alert the surgeon operating in this area.   

     Abstract:  Arthritis of the thumb carpometacarpal (CMC) joint in young active patients is an increasingly common problem faced by the hand surgeon.  Multiple reconstructive procedures ranging from simple trapeziectomy to trapeziectomy and tendon transfer for ligament reconstruction and interposition have been reported with universally good results but primarily in a more aged population.  This report reviews the early clinical results of a single surgeon’s experience with a limited trapeziectomy and bioabsorbable interpositional implant for treatment of  thumb CMC arthritis.
     Methods:  Twenty-three patients with symptomatic thumb CMC arthritis underwent arthroplasty with a limited trapeziectomy and implantation of an Artelon spacer.  All patients had failed maximal conservative measures and had clinical and radiographic evidence of CMC arthritis with no STT involvement.  The patient population (n=23) consisted of 17 females and 5 males (1 female bilateral) with an average age of 51 years (range 42-65).  The procedure was performed on 9 right hands and 14 left hands – 7 dominant and 16 nondominant.  Six patients underwent simultaneous carpal tunnel release and 2 underwent trigger thumb release.     Patients were immobilized in a thumb spica splint for 10-14 days followed by a thumb spica cast for 4 weeks.  A neoprene splint was utilized until 12 weeks post-op at which time full unrestricted activity was allowed.
     Results:  A minimum 6 month follow-up was available on 16 patients.  Average follow-up was 12 months with a range of 6 – 15 months.  There were no complications and all patients were satisfied with the results reporting good pain relief and return to function.  There was 1 revision for instability following a severe motor vehicle accident.
     Early results of CMC arthroplasty utilizing an Artelon spacer are promising with good pain relief and return to activity.  Longer term follow-up with more objective evaluations are warranted and ongoing.

Clinical and radiographic data from a consecutive series of 26 patients treated with one and two level lumbosacral interbody fusions using trans-axial fixation inserted thru a presacral approach were reviewed.
     The average age was 42 years with an age range of 20-68 years. Twenty –four of the patients had back and radicular pain. No patient had a neurologic deficit. A trans-sacral approach was used. An axial tract was reamed in the S1 body using C arm control in the A.P. and Lat. planes. Through this portal the L5-S1 intradiscal contents were removed and the end plates were prepared with special cutters.  Autogenous bone, BMP and bone filler was placed in the prepared interspace and a trans-axial screw was inserted into the sacral body and into L5 after reaming an axial channel in the L5 vertebra. Pedicle fixation was used in all cases.
     The mean Oswestry went from 50% pre-op to 33% post- op and the mean VAS from 67 mm pre –op to 41 mm post –op. Average blood loss was 150cc. There were 3 superficial infections that resolved. There were no fixation failures. There was some lysis noted around the trans-axial screw in 3 patients not achieving an interbody fusion. Two spine surgeons and a neuroradiologist reviewed the post operative reformatted CT scans. Each reviewer worked independently and submitted their data for tabulation. Fusion rate was 88 %. There was only one discrepancy regarding fusion among the 3 reviewers.
     In conclusion, the trans-sacral approach using the trans-axial screw provides interbody fusion rates consistent with more invasive anterior techniques. Complications and morbidity were rare and the clinical results showed improvement in the Oswestry and VAS scores.

Analysis of clinical outcomes is of paramount importance for the establishment of evidence-based practice guidelines in Orthopedic Surgery.  Despite its significance, collecting and analyzing clinical data with subsequent publication of scientific results is time and resource demanding.  Barriers are increased when multiple sites are required to achieve a representative patient population.  This presentation will demonstrate a series of Web applications developed by the Division of Orthopaedic Surgery at Duke University to streamline clinical research processes.  The Web applications include activities of prospective data collection, project management, online writing of scientific articles, and overall project management.  Each Web application will be demonstrated using examples of ongoing clinical projects involving Duke University and participating sites in academic and non-academic institutions.

     The primary object of open wound care is to provide closure or coverage as soon as possible.
     Two basic procedures should be in the armamentarium of the physician who deals with upper extremity injuries and reconstruction: the split thickness skin graft and the random flap either groin or abdominal pedicle.
     A split thickness skin graft .016-.018 inches thick offers qualities of a reliable “take” and good durability and sensibility. The healed graft occupies about 60 percent of the area of the original wound and during healing acts in a purse-string fashion to draw centrally normal skin and subcutaneous tissue.
     The split graft is as durable as the full thickness skin graft and has similar sensibility with a better chance for survival.  It will have the pigmentation of the donor site so occasionally it may be taken from the hypothenar area of the hand to resurface digital defects in patients with darker skin.
     The Davol battery powered dermatome may be used to obtain smaller grafts from the upper inner arm just distal to the axilla. Otherwise for larger grafts a standard dermatome harvests skin from the thigh or abdomen.
     A meshed split thickness graft provides very effective resurfacing of dirty granulation tissue and burns particularly when donor’s skin is scarce. The transudate exudates or blood escapes from the interstices of the graft and healing progresses to fill the defects from the normal skin latticework.
     Distant random pedicles either abdominal or groin provide excellent secondary and occasionally primary resurfacing from the elbow distally.  Deeper reconstruction of skeleton nerve or tendon or a combination can be carried out simultaneously with flap application or release or at a later procedure.
     The flap must be thin with appropriate fat removal since the skin of the flap is nourished by the subdermal vascular plexus. The donor area of the flap is closed primarily if possible or covered by a split thickness skin graft. The pedicle may be severed at three weeks after application with donor site revision.
     A random flap can be used to fabricate a thumb-index web after release of a severe contracture by the method of Littler.
     Two or more random flaps can be applied simultaneously.
     Seldom is it necessary to utilize a composite free graft which necessitates microvascular anastomosis of artery and veins

Background: The reverse DELTA III shoulder prosthesis can successfully relieve pain and restore function in cuff tear arthropathy. The most frequently reported radiographic complication is inferior scapular notching. The purpose of this study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence.
Methods: Seventy-seven consecutive shoulders of 76 patients of an average age of 71 years with an irreparable rotator cuff deficiency were treated with a reverse DELTA III shoulder arthroplasty and followed clinically and radiographically under fluoroscopic control for a minimum of 24 months (mean: 44, range: 24 to 96). The effect of glenoid cranial caudal component positioning and of the prosthesis ? scapular neck angle on the development of inferior scapular notching and clinical outcome was assessed.
Results: All shoulders which developed notching did so in the first fourteen months. Of the seventy-seven shoulders studied, thirty-four (44%) had inferior scapular notching, twenty-three (30%) had posterior notching and six (8%) had anterior notching. Osteophytes along the inferior scapula occurred in twenty-one (27%) of the seventy-seven shoulders. The angle between the glénosphère and the scapular neck (r=+0.677)) as well as the cranio-caudal position of the glénosphère (r=+0.654) were highly correlated with inferior notching (p<0.001). A notching index  (notching index = height of prosthesis + (prosthesis scapular neck angle x 0.13) was calculated using the height of implantation of the glénosphère and the postoperative prosthesis scapular neck angle: This allowed a prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%.   The height of implantation  of the glenosphere  had approximately an 8 times greater influence on inferior notching than the prosthesis scapular neck angle. Inferior scapular notching was associated with a significantly poorer clinical outcome than absence of inferior notching: At final follow-up, the respective average subjective shoulder values were 62% and 71% (p=0.032), relative Constant scores were 72% and 83% (p=0.028), abduction strength was 4.3 versus 8.7 kilograms (p<0.001), active abduction was 102° versus 118° (p=0.033) and flexion averaged 110°versus 127° (p=0.004).
Conclusion: Inferior scapular notching after reverse total shoulder arthroplasty adversely affects midterm clinical outcome. It can be prevented by optimal positioning of the glenoid component. 

Background data: The Darrach procedure (excision of the distal ulna) has been the gold standard for surgical treatment of DRUJ arthritis (DJD, RA, post-traumatic). Despite modifications (Bower hemiresection, matched resection, wafer procedure) failure rates remain high (7-48%). The typical cause of failure is painful radioulnar impingement and instability leading to pain and loss of grip strength. Failed distal ulna resection comprises a difficult reconstructive dilemma. Several salvage techniques have been described (tenodesis, revision resection, silicone capping, implant arthroplasty) with variable results.
Purpose of study: To evaluate a new salvage procedure for management of failed distal ulna resection.
Material and methods: Seventeen patients with incapacitating pain and weakness following distal ulna resection were treated using a new surgical technique with allograft reconstruction of the DRUJ. The distal ulnar stump and the medial aspect of the distal ulna were initially exposed through the previous incision. An Achilles tendon allograft was fashioned into a bulky spacer and interposed between the distal radius and the distal ulnar stump. The graft was stabilized with placement of bone anchors into the medial cortex of the radius and drill holes through the distal ulna. Adequate graft size was verified by rotating the forearm and applying pressure to the medial aspect of the ulna while assessing for crepitus. Postoperatively a long arm splint and cast were placed for 6 weeks, followed by physical therapy. Patients were evaluated for demographic parameters, pre- and post-operative pain (recorded on a visual analog scale), range of motion, grip strength, presence of crepitus, and radiographic parameters. Patient satisfaction with the procedure was also assessed.
Results: Mean patient age was 47 years (range 39-68). The mean elapsed time since the index procedure was 15 months (range 9-26). Mean follow-up was 46 months with a minimum of 12 months. Pain improved significantly by an mean of 6 points. Forearm rotation improved by a mean of +72° (pronation +30°, supination +42°). Grip strength improved by mean of 74%. Persistent crepitus was noted in the first patient of the series. This failure was attributed to inadequate graft size. The remaining patients graded their results as excellent (6 cases) or good (10 cases). Post-operative X-rays showed maintenance of the radioulnar space with no impingement with loading of the forearm in neutral rotation. Mild forearm swelling resolved within 2 weeks in all cases. No evidence of infection or clinically significant graft-related complications was noted.
Conclusion: Allograft reconstruction of the DRUJ effectively prevented radioulnar impingement and stabilized the distal ulna. This novel technique provides an attractive alternative to implant arthroplasty for salvage of failed distal ulna resections. Long-term follow-up is necessary to validate these promising early results.

Object:  The pathogenesis of intraneural ganglia has been controversial for more than a century.  Recently we have identified a stereotypic pattern of occurrence of peroneal and tibial intraneural ganglia and based on an understanding of their pathogenesis, provided a unifying explanation.  Atypical features occasionally observed have offered an opportunity to further verify and expand upon our proposed theory.   
Methods: Ten unusual cases are reviewed to introduce the dynamic features of peroneal and tibial intraneural ganglia.  In part I, we analyzed 2 of our own patients who shared the essential principles common to peroneal intraneural ganglia: namely a) connections to the anterior portion of the superior tibiofibular joint, and b) intraepineurial dissection of the cyst along the articular branch of the peroneal nerve and proximally. These patients also demonstrated unusual MRI findings: a) the presence of a cyst within the tibial and sural nerves in the popliteal fossa region, and b) spontaneous regression of the cysts on serial examinations performed weeks apart.  We then identified a clinical outlier that could not be understood in terms of our previously reported unified theory.  Reported 32 years ago, this patient had a tibial neuropathy and was found to have tibial, peroneal and sciatic intraneural cysts without a joint connection at operation.  Our hypothesis, based on our initial experience was that this reported patient had a primary tibial intraneural ganglion with proximal extension, sciatic cross-over and then distal descent, and that a joint connection to the posterior aspect of the superior tibiofibular joint with remnant cyst within the articular branch would be present, a finding that would help us explain the formation of the different cysts by a single mechanism.  We proved this by careful inspection of a recently obtained postoperative MRI.  In part II, we retrospectively reviewed 20 additional cases of our own and identified 7 examples with subtle unrecognized MRI features of sciatic cross-over (as well as several examples in the literature). 
Conclusions: These cases provide firm evidence for mechanisms underlying intraneural ganglia formation and allow us to expand our unified articular theory to elucidate unusual presentations of intraneural cysts.  Whereas an articular connection and fluid following the path of least resistance was pivotal, we now incorporate dynamic aspects of cyst formation due to pressure fluxes.  These principles explain new patterns of primary ascent, sciatic cross-over and terminal branch descent when cyst fills the sciatic nerve’s common epineurial sheath.  

Background:  Although its introduction was over twenty years ago, there remains continual debate and controversy regarding endoscopic approach to carpal tunnel release.  A number of meta-analyses have attempted to review the large body of literature on open versus endoscopic techniques, including both retrospective and prospective studies with varying levels of evidence.  Unfortunately no definitive conclusions can be drawn from these studies and controversy still remains in regards to the increased technical difficulty, cost, and complication rates for the endoscopic technique.  This retrospective review attempted to examine the outcomes of a single surgeon’s experience with the endoscopic technique over the last 15 years to better understand effects of a surgeon’s experience on outcomes and complication rates. 
Methods: A retrospective review was performed on a case series of 155 hands in 130 patients ages 25-89 years old.  An endoscopic carpal tunnel release was performed on all patients by a single surgeon at a Duke University over the course of 15 years.  All patients had clinical signs or symptoms and electrodiagnostic findings consistent with carpal tunnel disease and almost all had failed non operative treatment.
Results:  The average age of these patients was 55 years old with two times as many females compared to males.  The Tinel’s sign and two point discrimination test appeared to have the weakest correlation to a diagnosis of carpal tunnel syndrome.  Twenty three patients had other contributing problems in either the upper extremity or cervical spine which were evaluated prior to surgery.  There was an average of three month follow up for all patients and one postoperative complication that required return to the operating room.  Ninety six percent of patients had significant improvement in severity of nerve symptoms and pain at follow up.  The billed cost of endoscopic carpal tunnel release at our university was 9% more than standard open release and the average return to work was 3weeks.  There is a positive trend demonstrating improved outcomes for patients treated in the last 7½ years of experience compared to this single surgeons first 7½ years utilizing this technique.
Discussion:  Previous recommendations against the endoscopic carpal tunnel release have focused on increased complication rates and cost, with no reported significant differences in long term clinical outcomes or patient satisfaction. Our results demonstrate increased success and lower complication rates for this series of patients treated by a single surgeon over 15 years.  This may indicate a significant correlation between a surgeon’s expertise and outcomes for the endoscopic carpal tunnel release.

     A presentation of the current EP techniques available (EMG,SSEP,MEP) and common applications in Orthopedic surgery.  A review of recent literature and case reports presented.  Data presented from surveys of the national Piedmont Society membership.
     Recommendation made that EP be employed in combination (EMG/SSEP/MEP) to minimize the false-negative rate for clinical neurological injury detection.
     Majority consensus exists that surgical EP monitoring should be employed for selective high risk cases, mainly spinal deformity, spinal instrumentation, and myelopathy cases. However, controversy does exist on the clinical usefulness and cost effectiveness for EP monitoring in the operating room setting.

Abstracts 2006

     Investigation performed at the Bone and Joint/Sports Medicine Institute, Charette Health Sciences Center, Portsmouth, Virginia
     The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
     The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States government.
     Background: Most extra-articular metacarpal fractures can be managed nonoperatively. While the conventional wisdom is that the metacarpophalangeal joint should be immobilized in a position of flexion, alternative methods for cast immobilization have been described. The purpose of this study was to retrospectively evaluate three methods of closed treatment; specifically, we investigated whether the position of immobilization of the metacarpophalangeal joint or the absence of a range of motion of the interphalangeal joints affected the short-term outcome or fracture alignment.
     Methods: Between November 2000 and April 2004, extra-articular metacarpal fractures were immobilized for five weeks in one of three ways: with the metacarpophalangeal joints in flexion and full interphalangeal joint motion permitted (Group 1); with the metacarpophalangeal joints in extension and full interphalangeal joint motion permitted (Group 2); and with the metacarpophalangeal joints in flexion, the interphalangeal joints in extension, and no interphalangeal joint motion permitted (Group 3). Radiographs and the range of motion were evaluated at five weeks after application of the cast, and the range of motion and grip strength were assessed at nine weeks.                                    
     Results: Two hundred and sixty-three patients met the inclusion criteria. At five weeks, there was no difference among the treatment methods with regard to the range of motion or the maintenance of fracture reduction. At nine weeks, there was no significant difference with regard to the range of motion or grip strength.
     Conclusions: When immobilization was discontinued by five weeks, the position of the metacarpophalangeal joints and the absence or presence of interphalangeal joint motion during the immobilization had little effect on motion, grip strength, or fracture alignment. This finding contradicts the conventional teaching that the metacarpophalangeal joint must be immobilized in flexion to prevent long-term loss of joint extension. Patient comfort, ease of application, and the surgeon's familiarity with the technique should influence the choice of immobilization.

2006  Early radiographic results following total hip arthroplasty utilizing a tapered, proximally-coated femoral stem with immediate postoperative weight bearing, Christian P. Christensen, MD & Cale Jacobs, PhD, ATC, Lexington Clinic, Lexington, KY

2006  Results of Open Reduction and Internal Fixation of the Symptomatic Type II Accessory Navicular, Jonathan R. Saluta, MD and Mark E Easley, MD, Duke University Medical Center, Durham, NC

Introduction: Currently, the modified Kidner procedure is recommended to treat the symptomatic accessory navicular that fails nonoperative management.  Based on anecdotal evidence, some foot and ankle specialists have cautioned that excision of the accessory navicular can lead to a progressive increase in pain and loss of the longitudinal arch.  As a result, they have recommended open reduction and internal fixation (ORIF) of the symptomatic accessory navicular as a surgical alternative.  To our knowledge, the only references to this surgical alternative in the orthopedic literature are two technique papers.  To substantiate this technique, we conducted a prospective study of ORIF of the symptomatic type II accessory navicular.
     Methods: Between 1999 and 2005, the senior investigator surgically managed 17 symptomatic type II accessory naviculars that failed nonoperative measures.  The average age was 25 years, range 10-59 years; the study cohort included 8 males and 9 females.  A standard treatment algorithm was followed: (A) accessory naviculars of adequate size underwent an ORIF (10), and (B) accessory naviculars of smaller size underwent a modified Kidner procedure (7).  The determination of adequate size to support screw fixation was made intraoperatively.  Corrective osteotomies and/or soft-tissue procedures were performed concomitantly in nine patients to address pes planus.  Pre- and postoperatively, patients were assessed radiographically with three standard weightbearing x-rays of the foot and an external oblique view.  Preoperative MRI scans were available in 12/17 feet and were analyzed to see if there was any correlation between MRI findings and success of ORIF of the accessory navicular.  Patients were evaluated with the AOFAS midfoot clinical rating system (maximum 100 points).  Evaluation was by independent observer. 
     Results: In the patients treated with ORIF, average follow-up was 31 months (range 11-71).  The average AOFAS midfoot score improved from 49 (range 0-62) to 89 (range 69-100) points.  Radiographic analysis suggested an 80% union rate.  However, only one patient out of ten (10%) undergoing ORIF with subsequent nonunion was symptomatic at the accessory navicular.  Only one patient (10%) had painful hardware, and her pain resolved after screw removal.  In the patients treated with excision, average followup was 48 months (range 24-68).  The average AOFAS score improved from 45 (range 26-70) to 78 (range 26-93) points.   Three of seven feet (43%) treated with accessory navicular excision had persistent midfoot pain at last followup with clinical and radiographic signs of progressive loss of the longitudinal arch.  Twelve patients had a preoperative MRI of the foot with all showing edema suggesting an injury to the synchondrosis.  We found no correlation between MRI findings and success of ORIF of the accessory navicular. 
     Discussion:  As suggested by previous technique papers and this study, ORIF of the symptomatic type II accessory navicular may have merit.  We anticipate that this study will prompt a comprehensive multicenter evaluation of this technique.

2006  Revision Tibiotalar Arthrodesis using Ring External Fixation, Mark Easley MD, Duke University Medical Center, Durham, NC

Background: Contemporary recommendations for primary and revision ankle arthrodesis favor internal compression techniques using screw and/or plate fixation, with satisfactory outcomes being reported for the majority of patients. In select patients, revision tibiotalar arthrodesis with internal fixation may be limited or even contraindicated given insufficient bone stock to adequately support implants, an abundance of avascular bone, or a history of osteomyelitis.  Recently, comparable outcomes of primary and revision tibiotalar arthrodeses have been reported using external fixation, even in situations where limb salvage is questionable.  We report our experience with ring external fixation for complex, revision ankle arthrodesis.  
     Methods:  Twenty-two consecutive patients underwent revision tibiotalar arthrodesis using ring external fixation.  All patients had at least one prior attempt at arthrodesis using internal fixation. The average number of surgeries prior to revision arthrodesis was 2 (range, 1 to 8). External fixation was maintained for an average of 15 weeks (range, 12 to 44 weeks). Union (time to removal of external fixation) was suggested by evidence for bridging trabeculation at the arthrodesis site in three standard radiographic views of the ankle. In cases where union could not be adequately determined on radiographic views or the arthrodesis site was obscured by the external fixator, a limited CT scan was obtained to assess union. All patients were encouraged to wear a brace for the first six months following external fixator removal.  Pre-and post-operative AOFAS ankle-hindfoot scores were used to assess functional outcome.
     Results: All 22 patients were available for followup at an average of 51 months (range, 15 to 62). The average AOFAS ankle-hindfoot score improved from 26 preoperatively (range, 0 to 45) to 64 points at final followup (range, 0 to 87 points).  Tibiotalar fusion was achieved in 19/22 patients (86%). In the three patients with persistent nonunions, one had avascular necrosis of the talus and two had persistent osteomyelitis. Two of these patients underwent rerevision arthrodesis and one opted for amputation. Over the course of treatment with external fixation, 34 minor complications (pin tract infections (24), broken pins (3), cellulitis (7)) were managed effectively with local wound care, oral antibiotics, and/or pin removal in the clinic setting.  Four major complications (deep infection (2), wound dehiscence (2)) were surgically addressed while maintaining compression at the arthrodesis site by external fixation.  Three patients had symptomatic malunions:  varus (2), equinus (1).   Hindfoot motion was less than physiologic in all patients (compared to the contralateral extremity), despite the external fixator being constructed to protect the subtalar joint from concomitant compression.
     Conclusion: Ring external fixation is not a panacea for revision ankle arthrodesis. However, our study suggests that union rates and results of revision ankle arthrodesis using ring external fixation are comparable to those reported for revision arthrodesis with internal compression.  Furthermore, ring external fixation may facilitate clinically acceptable limb salvage in these complex cases when internal fixation methods are limited or even contraindicated.

2006  The Early U.S. Experience of Reverse Shoulder Arthroplasty: Indications, Technique, and Results, Spero G. Karas MD, Emory Healthcare Sports Medicine Center, Atlanta, GA, spero.karas@emoryhealthcare.org

Introduction: To date, rotator cuff arthropathy (RCA) remains a difficult clinical entity with no uniformly excellent surgical option. The recent approval of reverse prosthetic technology offers a promising treatment modality for this difficult problem. We discuss technical considerations and early results of the first 462 consecutive patients treated with the Reverse Shoulder Prosthesis (Encore Medical, Austin, TX, USA).
     Materials: From November 2002 through January 2005, 462 RSP procedures were performed for primary RCA or a failed prosthetic replacement with rotator cuff deficiency. The study was a multi-center, FDA approved Investigational Device Exemption clinical trial of the Reverse Shoulder Prosthesis. The device has since been FDA approved. Patients were assessed pre-operatively with pain and range of motion scores. Pre-operative pain as assessed on a 1-10 scale averaged 8.7 (Range= 6-10, SD= 1.41). Pre-operative forward elevation was 53.1 degrees. Patients were assessed for pain, range of motion, and by validated outcomes tools at 3, 6, 12, and 24 months post-operatively.
     Results: One year follow-up was available for 312 patients. The mean pain score decreased to 3.2 from a pre-operative value of 8.7. Average forward elevation improved to 93º from a pre-operative value of 53º. The ASES score at one year was 70, compared to a pre-operative mean of 28. There were significant improvements in the pain, function, social, and emotional arms of the SF-36. The complication rate was 14.9% (69/462) which, in addition to problems related to the component, also included infection, hematoma, and unresolved pain. The most common cause of revision was instability of the components.
     Discussion and Conclusions: The early results of reverse shoulder arthroplasty are encouraging, but not without complications. Longer follow-up is necessary to thoroughly evaluate the safety and efficacy of this procedure.

Introduction: Massive, irreparable tears of the rotator cuff present a unique set of reconstructive challenges to the orthopaedic surgeon. Numerous tendon transfers have been described for reconstruction of irreparable rotator cuff tears, including the trapezius, triceps, deltoid, and latissimus dorsi musculotendinous units. We present the indications, technique, and outcomes of latissimus dorsi transfer for the management of irreparable rotator cuff tears.
     Methods: From 1999-2004, 12 patients were treated with latissimus dorsi transfer for massive, irreparable rotator cuff tears. All patients had failed previous attempts at rotator cuff repair. Short or thin latissimus tendons were augmented with autologus fascia lata. A minimum 12 month follow-up was available for 10 patients.
     Results: Mean post-operative pain scores decreased to 3.6 from a pre-operative value of 9.1 (p< .05). The mean post-operative Constant-Murley score improved to 44 from a pre-operative value of 23 (p< .05). Forward elevation improved an average of 27 degrees across the study group. Four patients rated their results “good”, four rated themselves as “satisfactory”, and two rated their result as “poor”. There were three complications: two wound infections at the fascia lata harvest site and one infection at the rotator cuff repair site.
     Conclusions: Latissimus transfer for irreparable rotator cuff tears provides improvement in pain, function, and range of motion. Appropriate patient selection and attention to surgical technique should optimize patient outcomes while limiting complications.

Objective:  Scapular muscle control is thought to play a vital role in shoulder stability. The purpose of this study was to evaluate and compare scapular kinematic differences in patients with and without multidirectional instability (MDI) of the shoulder.
     Methods:  A group of 24 recreationally active subjects were used for this study. All subjects in the study group (n=12) were diagnosed with symptomatic MDI by a fellowship trained shoulder specialist. All subjects in the control group (n=12) had asymptomatic shoulders. Subjects were matched for age, anthropometrics, activity level, and arm dominance. An electromagnetic tracking system assessed shoulder joint kinematics while subjects raised and lowered their humerus over an arc from 0 - 120° while holding a dumbbell equal to 5% bodyweight. We assessed 3-dimensional scapular motion for upward-downward rotation (U-D), internal-external rotation (IR-ER), and anterior-posterior tipping (A-P) over 30° motion arcs as the humerus was lowered from 120° to 30°. Scapular motion was compared across 3-arcs of forward flexion (120-90°, 89°-60 and 59°-30°). Separate two-way repeated measure ANOVAs were performed to compare scapular motion between the MDI and control groups across the 3-arcs of humeral motion.
     Results:  There was a significant main effect between groups (P=.001) for scapula IR-ER motion. The MDI group moved into scapular IR while the stable group moved into scapular ER as subjects lowered their arm (Figure 1). There was a significant group-by-motion arc interaction for scapula A-P tipping (P=.028). Tukey’s post hoc procedures revealed greater scapular posterior tipping for the MDI group over the 120°- 90° motion arc in comparison to the stable group. There were no significant differences between the MDI and stable groups for scapula U-D rotation (P>.05).
     Conclusions:  Differences in scapular anterior-posterior tipping and internal-external rotation between the MDI and stable groups may represent a lack of dynamic control or a compensatory movement strategy in the MDI group. As the arm is lowered, scapular posterior tipping and internal rotation may increase bony congruency and compensate for the loss of static and dynamic glenohumeral constraints in subjects with MDI. Our observed differences in scapular kinematics help confirm clinical observations of scapular dyskinesis in patients with MDI.

2006  Surgical Treatment for the Congenital Retroflexible Thumb Deformity, Zhongyu Li, MD, PhD, L. Andrew Koman, MD, Wake Forest University School of Medicine, Winston-Salem, NC

Retroflexible thumb is an uncommon congenital anomaly. Patients often present with trigger thumb symptoms associated with a flexed thumb interphalangeal (IP) and a hyperextendible thumb metacarpophalangeal (MP) deformities. Neither the pathology of the deformity nor the treatment protocol has been well defined. The purpose of this study is to describe a single technique for treating pediatric retroflexible thumbs and report our results in a consecutive series of patients.
     Between 1994 and 2004, 7 patients seen at our institution were identified as having retroflexible thumb deformity after conducting a retrospective chart review. All patients were surgically treated with a release of the A1 pulley, proximal advancement of the MP volar plate using a pull-out button and pining of the MP joint at 10-20° of flexion for 3.5 to 4 weeks.
     There were 4 girls and 3 boys involving 3 right, 2 left and 2 bilateral thumbs. One patient had history of arthrogryposis. Five patients were noticed to have the deformity since birth. The mean age of surgery was 46 months (26 to 82 months). All patients had symptom of thumb triggering with a painless, palpable MP nodule. Thumb MP joints were able to be hyperextended to 60-90° passively. The mean follow-up was 64 months (12 month to 8 years). All thumbs were stable, there was no further triggering or recurrent hyperextension deformity. No postoperative complications were observed.
     Retroflexible thumb can be safely treated with predictable results by releasing the A1 pulley, advancing the MP volar plate with a pullout button and pinning of MP joint in slight flexion.

     This study seeks to evaluate the clinical outcomes of a second primary total knee arthroplasty (TKA), in patients whose initial (contralateral) primary TKA was complicated by stiffness.  We retrospectively compared the pre- and post-operative ROM and knee society scores (KSS) from a study group of 15 patients to an age-matched control group. Statistical analysis did not reveal a significant difference in final post-operative ROM, or KSS between the two groups.  However, there was a statistically significant higher rate of closed manipulation in the study group.  Therefore, while the study group did show a higher rate of early stiffness, eventual functional outcome was comparable to a non-stiffness control group. 
     Introduction:  Stiffness following total knee arthroplasty (TKA) can cause poor functional results.  Outcome following second primary TKA in patients whose contralateral primary arthroplasty was complicated by stiffness is evaluated in this study. 
     Methods:   Between February 1994 and February 2005, 34 of 239 revision TKA’s and 104 closed manipulations after primary TKA were performed for knee stiffness (range of motion (ROM) less or equal to 85 degrees).  From this group, 15 patients underwent contralateral primary TKA.  One-hundred nine contemporary primary TKA’s served as the control.  Analysis included statistical comparison of pre and post operative motion as well as Knee Society Scores (KSS) using unpaired student’s t-test.  Manipulation rates were compared using chi-square analysis.  Minimum follow up was 2 years (range 2 years to 5 years). 
     Results:  Four of 15 study patients developed arthrofibrosis requiring manipulation, achieving final ROM of greater or equal to 90 degrees.   With minimum 2-year follow up, the study group did not show statistically different post operative flexion (p=0.119) nor total range of motion (p=0.187) compared to the control group.  Additionally, with minimum 2-year follow up, there were no significant differences in Pain Score (p=0.383), Knee Score(p=0.42), or Functional Score (p=0.43) between the two groups. The study group had a higher rate of closed manipulation (p = <0.001). 
     Conclusion:   Therefore, while the study group did show a higher rate of early stiffness, eventual functional outcome was comparable to a non-stiffness control group. 

2006  COMPARISON OF EXTERNAL FIXATION AND VOLAR PLATE FIXATION FOR TREATMAENT OF UNSTABLE INTRA-ARTICULAR DISTAL RADIUS FRACTURES,  Marco Rizzo, M.D., Mayo Clinic, Rochester, MN

Introduction Controversy exists with respect to the optimal treatment modality for unstable distal radius fractures.  Various reports using locked volar plating have provided excellent results.  We retrospectively compared the results of open reduction and internal fixation (ORIF) through a volar approach using a locking plate with standard external fixation and percutaneous pinning for the treatment of unstable distal radius fractures.
     Methods The study included patients with similar unstable distal radius fractures treated by a single surgeon over a four year period, with a minimum two-year follow-up. The locked volar plate group included 41 patients with an average 29 months follow up. The external fixation, or control group, included 14 patients with an average follow up of 33 months.  Average age at presentation was 45 years in the external fixation group and 48 years in the ORIF group.  The male/female ratios were 16/25 among the ORIF and 6/8 in the external fixation groups.  The two groups were compared for range of motion, strength, and functional outcome measured by DASH score. Radiographic measurements were also evaluated between groups.
     Results Final ranges of motion and grip strengths were similar between the two groups.  However, at interim six week follow-up, the ORIF group had superior range-of-motion. The mean DASH score of the locked volar plate group was 12 compared to 23 for the external fixation group.  Radiographically, volar tilt and radial length were significantly better in the patients treated with ORIF.  The ORIF group required less therapy visits.  No complications occurred in the locked volar plate group while two patients had a pin tract infection and one had prolonged finger stiffness required extensive therapy in the external fixation group. 
     Discussion and Conclusion The use of the locked volar plate for the treatment unstable radius fractures resulted in earlier recovery from surgical treatment of distal radius fractures.  Improved DASH scores were noted in the ORIF group.  In addition, the ORIF group had improved radial length and volar tilt on x-rays.  Despite no significant difference between range-of-motion and grip strength long-term, locked volar plating compares favorably to external fixation and pinning for amenable fracture patterns.

     Absolute emergencies in hand surgery are those cases which must be treated immediately to maintain tissue viability, achieve the best functional result, or both.

     These situations include:

1.  Open wounds
2.  Replantation of amputated or near amputated parts
3.  Closed compartment syndrome
4.  High pressure injection injuries
5.  Human bite wounds

     Contraindicated are delayed wound care or conservative initial care.

2006  Radiofrequency Probe Applications in Wrist Arthroscopy, Sotereanos D.G., Giannoulis F.S., Darlis N.A., Weiser R.W., Allegheny General Hospital, Department of Orthopaedi