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2007
Minimally
Invasive Unicompartmental Knee Arthroplasty: A Comparison of
All-polyethylene and Metal-backed Tibial Components,
Jeff D. Almand, M.D.,
Mississippi Orthopaedics and Sports Medicine, Jackson, MS |
|
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.
|
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2007
Operative Repair of Bilateral Spontaneous Gluteus Medius and Minimus Tendon
Ruptures: A Case Report,
David
A. Fisher, M.D.1, Jeff D. Almand, M.D.2,
Melanie Watts, ATC/L, CSCS1 , Mississippi Orthopaedics and Sports
Medicine, Jackson, MS |
|
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
13. Bunker TD, Esler CAN, Leach WJ. Rotator cuff tear of the hip.
J Bone Joint Surg Br.
1997;79:618-620
14. Kagan A. Rotator-cuff tear of the hip.
J Bone Joint Surg Br.
1998;80:182-183
15. Chung CB, Robertson JE, Cho GJ, Vaughn LM, Copp SN, Resnick D. Gluteus
medius tendon tears and avulsive injuries in elderly women: imaging findings
in six patients. Am J Roentgenol. 1999;173:351-353
16. Hardcastle P, Nade S. The significance of Trendelenburg test.
J Bone Joint Surg Br.
1985;67:741-746
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
19. Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical
problem. Arch Phys Med Rehabil. 1986;67:815-817
20. Allwright SJ, Cooper RA, Nash P. Trochanteric bursitis: bone scan
appearance. Clin Nucl Med. 1998;13: 561-564
21. Connell DA, Bass C, Sykes CA, Young D, Edwards E. Sonographi evaluation
of gluteus medius and minimus tendinopathy. European Radiology.
2003;13(6):1339-1347
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
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2007
Medical Malpractice Crisis- Fact or Myth?,
David E. Attarian, M.D., F.A.C.S., Duke Medical Center, Durham, NC |
|
The medical
malpractice crisis inevitably produces a contentious discussion among the
various stakeholders, i.e. physicians, attorneys, patients, consumer groups,
insurance companies, and government officials. The crisis has been defined
as a medicolegal environment of increasing claims and lawsuits, increasing
settlements and awards, increasing insurance premiums, physicians and
hospitals limiting access to high risk services to reduce liability,
unnecessary higher healthcare costs (defensive medicine), adversarial
relationships between physicians and patients, and a dysfunctional legal
system that consumes healthcare dollars that should ultimately be directed
to injured patients or improving the overall quality of care. Many argue
that the crisis is a myth. On average, medical malpractice premiums only
represent 4% of physician revenues; and the vast majority of cases that go
to court are found in favor of the defendant doctor. Others add that the
real crisis is the prevalence of negligent care, the failure of the medical
profession to police its own, and poor economic decisions by the insurance
companies that lead to higher malpractice premiums. Attorneys believe that
every patient has the right to a jury trial; and that the threat of such
legal action functions as an incentive for physicians and hospitals to
improve the quality of service. Key points that favor the reality of the
crisis include: physicians have a 1:6 chance of being sued in any given year
(higher for some specialties), more than 80% of claims are without merit or
frivolous, defensive medicine costs the U.S. more than $120 billion per year
and adds more than 3 million people to the list of “uninsured”, and more
than 50% of the dollars spent on medical malpractice actions are consumed by
the legal system. Given the ongoing escalating costs of the healthcare
economy (> 15% GDP), the current situation will be unsustainable. Some short
term solutions are: tort reform to limit non-economic damages, clear
definition of medical experts combined with a “certificate of merit” when a
lawsuit is filed, and more rapid acknowledgement and treatment of injuries
from medical errors. Long term strategies may include: specialized
healthcare courts for timely, unbiased, evidence based resolution of
disputes and provision of fair compensation to the injured patient,
transparent quality assurance programs and sharing of information within the
healthcare system to reduce mistakes, and more stringent oversight by the
medical profession of its members. All physicians should be politically
active by articulating the problems and potential solutions cited to their
patients and government representatives. By advocating for cost effective
and fair medical malpractice dispute resolution, the described crisis can be
reduced or eliminated. |
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2007
MOBILE BEARING UNICOMPARTMENTAL KNEE ARTHROPLASTY: INDICATIONS AND OUTCOMES,
Keith R. Berend, MD, Adloph V. Lombardi, Jr., MD, FACS,
New Albany, OH |
|
Unicompartmental
knee arthroplasty (UKA) has seen an increasing level of interest in recent
years built upon better implant design, minimally invasive techniques, and
improved outcomes. Into the second decade, the reports of the Oxford UKA
appear to rival that of traditional total knee arthroplasty, despite
somewhat more liberal indications commonly referred to as the Oxford
Indications. These indications for UKA continue to be debated. The purpose
of this study is to report the early outcomes and revisions in a consecutive
series of UKA implanted for anteromedial osteoarthritis. Between July 2004
and December 2005 316 medial, Oxford Mobile Bearing UKA (Biomet, Inc.,
Warsaw, IN) were implanted by 2 surgeons utilizing an exacting surgical
technique. The
indications
in each knee were: complete bone-on-bone disease medially on a weight
bearing radiograph, functionally intact ACL and MCL, and correctible varus
deformity. Correctability of the deformity is examined using a
valgus-stress radiograph in each UKA candidate. Using these criteria, the
indications for UKA can be as high as 30-35% of osteoarthritic knees. The
demographics and patient characteristics were reviewed to examine the
indications and their potential influences on outcomes. 40% of patients had
a BMI greater than 32 and 25% had a BMI greater than 35. Despite this
increased BMI, no increase in failure was noted. 54% of patients were
younger than 60 at index surgery, and 15% younger than 50. Again no
increase in failure was noted in these younger, active patients. Only 68%
of patients reported isolated medial sided pain pre-operatively, with 21%
reporting global knee pain, and 6.1% reporting anterior knee pain. No
difference in knee scores or post-operative pain was noted between patients
with and without pre-operative anterior knee pain or isolated medial sided
pain. 43% of knees had pre-operative radiographic evidence of
patellofemoral DJD. Despite this, no difference in pain or outcomes was
noted between those with and those without radiographic evidence of
patellofemoral DJD. In this initial series there were 5 failures (1.6%).
No relationship could be established between any outcome measure, including
failure, and any of the patient demographics examined. We would therefore
conclude that the so-called Oxford indications for UKA appear to be a safe
and accurate measure of candidacy for UKA. Excellent early results are seen
with liberal indications using this mobile bearing partial knee replacement.
|
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2007
Peri-articular
Injections Containing a Corticosteroid during TKA: Preliminary Results, Christian P. Christensen, MD, Cale A. Jacobs,
PhD, Lexington Clinic Sports Medicine Clinic, Lexington, KY |
|
Multimodal pain
control protocols that include intra-operative, peri-articular injections
have been reported to decrease pain and improve early outcomes following
TKA. While injections containing a corticosteroid have been demonstrated to
be safe and effective, to our knowledge no randomized trials have been
performed to evaluate the specific role of the corticosteroid in early
postoperative outcomes. The purpose of this study was to compare pain, range
of motion, narcotic consumption, length of hospital stay, as well as Knee
Society Scores between 40 patients randomly assigned to receive peri-articular
injections consisting of bupivacaine HCl (80 mg), morphine (4 mg),
epinephrine (300 mcg), clonidine (100 mcg), cefuroxime (750 mg), and normal
saline either with or without the inclusion of methylprednisolone acetate
(40 mg). During the hospital stay, there were no differences in pain,
narcotic consumption, or range of motion; however, the length of hospital
stay was significantly reduced for patients that received the corticosteroid
(2.6 days) compared to the group of patients that did not received the
corticosteroid (3.2 days, p=.04). There were no differences in Knee Society
Score or range of motion between the two groups preoperatively, or at the 6-
and 12-week follow-ups. Furthermore, 82% of the patients that received the
corticosteroid were discharged home compared to 72% of the group of patients
that did not receive the corticosteroid. There were also no differences in
complication rates between groups, with one patient that did not receive the
corticosteroid being readmitted to rule out infection, and one patient that
did receive the corticosteroid undergoing manipulation under anesthesia. Our
preliminary results indicate that the inclusion of corticosteroid resulted
in a slight decrease in length of hospital stay; no improvements in pain,
range of motion, or early clinical outcomes; and no increased risk of
infection or other complication. We conclude that peri-articular injections
containing a corticosteroid appear to be safe; however, our preliminary
results question the use of this medication as part of a multimodal pain
control protocol as it does not appear to provide a measurable benefit. |
|
2007
The Effect of Evolving Technique on Outcome and Limb Alignment in Total Knee
Arthoplasty,
Robert Friedman, M.D., Orthopaedic Associates of the Greater Lehigh Valley,
Easton, PA |
|
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.
|
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2007
Long-Term
Outcomes of High-Grade Spondylolisthesis Managed with Posterior
Decompression, Posterolateral Fusion and Fibular Dowel Strut Graft,
Christopher G. Furey, M.D., George H. Thompson, M.D., Henry H.
Bohlman, M.D., Department of Orthopedic Surgery, Case Western Reserve
University, Cleveland, Ohio |
|
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.
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|
2007
Ankle Arthrodedsis with an Anatomically Contoured Anterior Plate,
Changan
Guo, William R Barfield, Langdon A. Hartsock, Medical University of
South Carolina, Charleston, SC |
|
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.
|
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2007 Anomalous Thenar Musculature Associated With Aberrant Median
Nerve Motor Branch Take-off, An Anatomic and Clinical Study,
Gary M. Lourie M.D., Atlanta, GA |
|
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.
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2007
CMC Arthroplasty Utilizing a Artelon Bioabsorbable Spacer Early Clinical
Experience,
Richard
S. Moore, Jr., M.D., Wilmington Orthopaedic Group, Wilmington, NC |
|
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.
|
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2007
LUMBOSACRAL FUSIONS USING TRANS-AXIAL FIXATION,
Richard J. Nasca M.D., Wilmington, NC |
|
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.
|
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2007
Streamlining Outcomes Research in Orthopedic Surgery,
Pietrobon R, Olson S, Richardson WJ, Moorman CT, Nunley J, Vail TP, Duke
Medical Center, Durham, NC |
|
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.
|
|
2007
SKIN COVERAGE/RESURFACING OF THE HAND,
Sigurd Sandzen, M.D., Vero Beach, FL |
|
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
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2007
RADIOGRAPHIC AND ANATOMIC PREDICTORS OF SCAPULAR NOTCHING IN THE DELTA III
REVERSE TOTAL SHOULDER REPLACEMENT,
Ryan W. Simovitch, M.D., Palm Beach Orthopaedic Institute, Palm Beach
Gardens, FL |
|
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.
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2007 Failed Darrach Procedure: Allograft Reconstruction,
Sotereanos D.G.1,
Giannoulis F.S.1, Payatakes A.H.1, Greenberg J.A.2,
Weiser R.W.1 1Allegheny General Hospital, Pittsburgh,
PA; 2Indiana Hand Center, Indianapolis, IN |
|
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.
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2007 The dynamic phases
of peroneal and tibial intraneural ganglion formation: A new dimension added
to the unifying articular theory, Robert J. SPINNER,
Kimberly K. AMRAMI, Huan WANG, Bernd W. SCHEITHAUER, and Stephen W.
CARMICHAEL, Mayo Clinic School of Medicine, Departments of Neurologic
Surgery, Orthopedics, Anatomy, Radiology and Laboratory Medicine, Rochester,
MN. |
|
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.
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2007 Carpal Tunnel Release: An Evidence Based Review of a Single
Surgeon’s Experience with Endoscopic Carpal Tunnel Release,
James R. Urbaniak, M.D., Vani Sebesan, M.D., J. Mack Aldridge, M.D.,
Duke Medical Center, Durham, NC |
|
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.
|
|
2007 Surgical Electrophysiological Monitoring. A Survey and Summary
of the Piedmont Orthopedic Society Membership,
David C.
Urquia, M.D., West End Orthopaedic Clinic, Richmond, VA |
|
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.
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|
Abstracts 2006 |
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2006
Three Cast Techniques for the Treatment of Extra-Articular Metacarpal
Fractures - Comparison of Short-Term Outcomes and Final Fracture Alignments,
Lieutenant Commander Jeff
Tavassoli, DO1, Commander Robert T. Ruland, MD, Lieutenant Commander
Christopher J. Hogan, MD1 and Commander David L. Cannon, MD,
Bone and Joint/Sports Medicine Institute, Charette Health Sciences Center,
620 John Paul Jones Circle, Portsmouth, VA 23708. E-mail address for C.J.
Hogan:
cjhogan@mar.med.navy.mil |
|
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 |
|
Immediate weight-bearing following primary THA has become widely used to
improve early function, and as part of DVT prophylactic protocols. Previous
investigations of several implant designs have reported that early
weight-bearing does not result in altered fixation of the femoral component.
The purpose of this study was to evaluate early subsidence of a proximally-hydroxyapatite
coated femoral component in patients allowed immediate postoperative
weight-bearing. Over a two year period, a single surgeon performed primary
THA on 138 patients (158 hips) with a femoral component with these design
characteristics. Patients were, on average, 61.4 ± 11.5 years old at the
time of surgery with an average BMI of 30.2 ± 7.1. Implants with these
design characteristics were used on all patients during the study period
that were not wheelchair bound prior to surgery or on chronic oral
prednisone > 5 mg/day. Patients undergoing THA for displaced femoral neck
fractures were also excluded. Preoperatively, 138 of the 158 hips were
diagnosed with osteoarthritis, 16 with avascular necrosis, and four with
posttraumatic arthritis. Approximately two to six hours after surgery,
patients began weight bearing as tolerated. Once discharged from the
hospital, patients were allowed to progress from a walker to a cane to using
no assistive devices as soon as they were comfortable. Radiographs were
taken immediately post-operative and at the 6-week follow-up. Mean
subsidence was 0.8±2.3 mm and 6 of the 158 hips (3.8%) demonstrated
subsidence > 3 mm. One patient underwent revision THA after presenting with
23 mm of subsidence at the 6-week follow-up. It appears that the use of an
uncemented, tapered femoral stem with a proximal hydroxyapatite coating may
not result in improved early subsidence when used in combination with
immediate weight bearing protocols.
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2006
INTRA-ARTICULAR INJECTIONS CONTAINING A CORTICOSTEROID DURING TOTAL KNEE
ARTHROPLASTY,
Christian P. Christensen, MD & Cale Jacobs, PhD, ATC, Lexington Clinic,
Lexington, KY |
|
The principles of
minimally invasive surgery have had lead to changes in not only surgical
technique, but perhaps more importantly, to perioperative pain control. A
multimodal approach to pain control including intra-articular injections of
bupivacaine, morphine, and epinephrine has been demonstrated to be very
effective during primary total knee arthroplasty. The purpose of this
retrospective study was to compare pain, range of motion, narcotic
consumption, and manipulation rates for patients receiving peri-articular
injections either with or without the inclusion of a corticosteroid and
antibiotic. Over a six month period, 50 primary, PCL-retaining TKAs (44
patients) were performed by a single surgeon. A retrospective chart review
was performed to compare a group that received an peri-articular injection
consisting of 80 mg marcaine, 4 mg morphine, 300 µg epinephrine, and 100 µg
clonidine (NS, n = 30); and a group receiving the same injection with the
addition of a corticosteroid (40 mg methylprednisolone or kenalog) and an
antibiotic (750 mg Zinacef; S, n = 20). Patients were excluded from further
analysis if they had documented preoperative narcotic use. The two groups
were created as the surgeon gradually changed his practice from giving
injections without a steroid, and then to the current practice of using a
peri-articular injection with a steroid. The groups were not purely
consecutive, with some mixing of the two groups. Pain scores were higher for
the group that did not received the steroid on postoperative day 1 and on
the day of discharge; however, these differences did not reach statistical
significance (p = 0.13). The length of hospital stay for the steroid
group was significantly lower than the group that did not receive the
steroid (p = 0.03). The amount of narcotic pain medication consumed
did not differ between groups (p = 0.89). Three of 30 knees (10%) in
the group that did not receive the steroid required manipulation under
anesthesia, compared to 1 of 20 (5%) in the steroid group. At 6 week
follow-up, no patients in either group suffered a postoperative infection or
DVT. From these results, we conclude that the inclusion of a corticosteroid
and antibiotic with a peri-articular injection of marcaine, epinephrine,
clonidine, and morphine may improve early outcomes following primary total
knee arthroplasty. Large prospective clinical trials are necessary to
confirm improved early outcomes to determine if this treatment results in
reduced health care costs associated with this procedure. |
|
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 |
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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.
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2006
Revision Tibiotalar Arthrodesis using Ring External Fixation,
Mark Easley MD, Duke
University Medical Center, Durham, NC |
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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.
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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 |
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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.
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2006
Latissimus Dorsi Transfer for the Management of Irreparable Rotator Cuff
Tears,
Spero G
Karas MD+, AW Pearsall MD*, Sudhakar Madanogopal MD*, +Emory Healthcare
Sports Medicine Center, Atlanta, GA USA, *University of South Alabama Dept.
of Orthopaedics, Mobile, AL |
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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.
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2006 A Three Dimensional Analysis of Scapular Kinematics in Patients
with Multidirectional Shoulder Instability,
Spero G. Karas MD+*, Charles A. Thigpen MS*, Darin A Padua PhD*, +Emory
Healthcare Sports Medicine Center Atlanta, GA, *University of North Carolina
Department of Exercise and Sports Science |
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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.
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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 |
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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.
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2006 OUTCOMES
IN PATIENTS WITH A HISTORY OF KNEE STIFFNESS UNDERGOING CONTRALATERAL
PRIMARY TOTAL KNEE ARTHROPLASTY,
Jason E. Lang, M.D., Duke University Medical Center, Durham, NC |
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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.
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2006 Pisotriquetral Arthritis Following Wrist and Intercarpal
Arthrodesis,
Gary M.
Lourie, MD, The Hand and Upper Extremity Center of Georgia, Atlanta, GA |
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A retrospective
review identified nine patients with pisotriquetral arthritis requiring
pisiform excision following wrist and intercarpal arthrodesis. The second
part of the study utilized six cadaver wrists to assess the alteration in
pressure and kinematics of the pisotriquetral joint following four-corner
and wrist fusion. Nine patients (seven male, two female) with average age of
41.7, none with pre-operative pisotriquetral arthrosis, underwent four
corner (six patients) or wrist fusion (three patients). At an average of
fifteen months postoperative, patients presented with volar-ulnar wrist
pain, which was resolved with pisiform excision. Cadaveric studies revealed
maximum pisotriquetral joint pressure in full extension with progressive
pressure decrease throughout flexion. The pressure across the pisotriquetral
joint did not change with simulated fusion but fluoroscopy revealed
diminished excursion of the pisiform across a smaller area following fusion.
It is our premise that this constant loading of the joint contributes to the
development of arthrosis. Patients undergoing intercarpal and/or wrist
fusion should have the pisotriquetral joint assessed.
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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 |
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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.
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2006
ABSOLUTE EMERGENCIES IN HAND SURGERY,
Sigurd
Sandzen, Vero Beach, FL |
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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.
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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 |