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 Orthopaedics, Pittsburgh, PA

Purpose:  The use of electrosurgical (radiofrequency) devices in arthroscopic surgery has gained increasing popularity in recent years as a tool for resection, ablation, coagulation and soft tissue thermal shrinkage.  Recently, the availability of radiofrequency (RF) probes for small joint arthroscopy has extended its use in the wrist joint.  We present the initial results of triangular fibrocartilage complex (TFCC) tear debridement and scapholunate (SL) ligament thermal shrinkage using RF probes.
     Methods:  The results of 36 patients on which RF probes were used during wrist arthroscopy are presented.  Sixteen patients (mean age 34 years) were treated for partial (Geissler grade 1 and II) SL interosseous ligament tears and 20 patients (mean age 44 years) had TFCC tear debridement.  In the SL group no patient demonstrated radiologic signs of dissociation preoperatively (SL interval under 3.5mm, mean SL angle 49^o).  Fourteen partial tears and two redundant SL ligaments were treated with thermal shrinkage.  In the TFCC group 18 central and two radial tears were debrided to a stable rim using the probe.
     Results:  All patients had a follow-up of at least 9 months (mean 19 months for the SL group and 22 months for the TFCC group).  Fourteen of the 16 patients with partial SL tears experienced substantial pain relief whereas in two the pain remained unchanged.  No patient exhibited radiologic signs of arthritis or static or dynamic instability postoperatively (SL interval remained under 3.5mm, mean SL angle 53^o).  In the modified Mayo wrist score here were 8 excellent, 6 good, 1 fair and 1 poor result.  In the TFCC group seventeen patients experienced substantial pain relief whereas in three the pain was unchanged.  Ten excellent, 7 good and 3 fair results were achieved.  No complications were noted from the use of radiofrequency probes in either group.
     Conclusions:  The results of the two individual procedures that were studied compare favorably with the results using standard mechanized resectors.  RF probes are small in size, easy to handle, precise and provide coagulation and a thermal shrinkage effect in treated tissues.  No complications were noted from their use.  Concerns over creep and reduced elasticity of tissues after thermal shrinkage have not been proven to be clinically significant in the wrist joint.  Compared to lasers that have also been used in wrist arthroscopy, the risk of accidental damage to the hyaline cartilage is minimal and the overall cost is lower.

Object.  Unlike the more commonly noted paralabral cysts (extraneural ganglia) which are well known to result in suprascapular nerve compression, only four cases of suprascapular intraneural ganglia have been reported.  Because of their rarity, the pathogenesis of suprascapular intraneural ganglia has been poorly understood and a pathoanatomical explanation has not been provided.  In view of the growing literature demonstrating strong associations between paralabral cysts and labral (capsular) pathology, joint connections and joint communications, the authors retrospectively reviewed the magnetic resonance (MR) imaging studies and postoperative results in the two featured patients to test a hypothesis that suprascapular intraneural ganglia would have analogous findings.
     Methods. Two patients who presented with suprascapular neuropathy were found to have intraneural ganglia.  Connections to the glenohumeral joint could be established in both patients through posterior labrocapsular complex tears.  In neither patient was the joint connection identified preoperatively or intraoperatively, and cyst decompression was performed by itself without attention to the labral tear.  The suprascapular intraneural ganglia extended from the glenohumeral joint as far proximally to the level of the nerves’ origin from the upper trunk in the supraclavicular fossa.  Although both patients experienced symptomatic improvement after operation, neurologic recovery was incomplete.  In both cases, postoperative MR images revealed cyst persistence.  In addition, unrecognized SLAP II lesions (tears of the superior labrum extending anterior to posterior and involving the biceps anchor at the labrum without actual extension into the tendon) were visualized.  In one patient with a persistent cyst, MR arthrography was obtained and demonstrated a communication between the joint and the cyst. 
     Conclusions.  The findings in these two patients would support the synovial theory for intraneural ganglia.  Based on their experience with intraneural ganglia at other sites, the authors believe that suprascapular intraneural ganglia arise from the glenohumeral joint, egress through a superior (posterior) labral tear and dissect within the epineurium along an articular branch into the main nerve, following the path of least resistance.  Furthermore, these two cases of intraneural ganglia with SLAP lesions are directly analogous to the many cases of paralabral cysts associated with these types of labral tears.  By better understanding the origin of this unusual type of ganglia and drawing analogies to the more common extraneural cysts, surgical strategies can be formulated to  address the underlying pathoanatomy, improve operative outcomes, and prevent recurrences.  (J Neurosurg 104:551-557, 2006)

     Abstract:  Distal radius fractures are among the most common fractures treated by orthopaedic surgeons.  Numerous techniques have been devised to address these fractures and the factors associated with these injuries.  The T-Pin ® (Union Surgical, LLC, Philadelphia, Pennsylvania) is a novel instrumentation designed to utilize standard percutaneous techniques in the treatment of extra-articular distal radius fractures. The T-Pin® allows for early active range of motion, as well as, earlier return to functional activities.  This article discusses the instrumentation, the techniques of insertion and extraction, and post-operative care.
     Indications/Contraindications:  The indications for use of the T-Pin® include extraarticular dorsally displaced distal radius fractures (Fig. 2).  This technique can be used in active patients because it is a relatively short procedure and allows for a quick return of function following a short immobilization period.  The short nature of the procedure, especially the limited incisions for insertion of the pins, makes this procedure useful in the elderly and medically unstable populations because it can be performed under local anesthesia with intravenous sedation.
     The contraindications to this procedure include intraarticular fractures having displacement and/or severe comminution.  Low-demand patients who have fractures amenable to immobilization would also not be considered candidates for this procedure.
     Technique:  Patients are placed supine on the operating table.  Typical anesthesia used for the case is conscious sedation with a local field block.  We use bupivicaine 0.5% without epinephrine. A tourniquet is then applied to the operative extremity and the extremity is prepped and draped in a sterile fashion.  The limb is exsanguinated, and the tourniquet is inflated to 250 mm Hg.  Typical tourniquet time is approximately 20 minutes.
     Under fluoroscopic guidance, closed reduction of the fracture is performed.  Two 0.5 cm  longitudinal incisions are made: 1 at the distal aspect of the radial styloid between the first and second dorsal extensor compartment, dorsal to the abductor pollicis longus / extensor pollicis brevis tendons and the second at Lister’s tubercle between the third and fourth dorsal extensor compartment.  The soft tissues are bluntly dissected to bone for adequate placement of guide wires.  Dissection is carried down to visualize the pin insertion site, and adjacent extensor tendons are protected by retraction or the use of the tissue protection guide.  The fracture is initially stabilized with smooth 1 mm  guide wires at the aforementioned insertional sites and placement is adjusted under fluoroscopic guidance (Fig. 3).  A technical point to note is that the guide wire will deflect off the inner cortices and bend whereas the more rigid T-Pin® will not.  Therefore, the guide wire insertion must stop when cortical contact is made (Fig. 4).  A measuring guide is then applied along each guide wire indicating the length of the T-Pin® required (Fig. 5).  The pin tray supplies pin lengths from 40 mm to 70 mm in 5 mm increments. 
     The cannulated T-Pin® and its tissue protector are loaded onto the power driver and inserted over the guide wire (Fig. 6).  The T-Pin® is driven along the guide wire until the trailing threads are nearly flush to the bone.  The tissue protector provided on the tray has the feature of opening up to allow removal for final seating of the pin without having to disengage the driver.  The surgeon removes the power driver and guide wire, leaving only the T-Pin® in place.  The break-off driving mechanism of the pin is easily removed by bending in hand. 
     Stability of the fixation is checked under fluoroscopy (Fig. 7).  The tourniquet is deflated and the skin closed with nylon sutures (Fig. 8).  The post-operative dressing includes sterile gauze and a volar splint.

Abstracts 2005

     2005  Proximal Femoral Fracture During THA:Risk Factors, Treatment and Outcome, Michael E. Berend, M.D., Orthopaedic Indianapolis Center for Hip and Knee, Mooresville, Indiana

Proximal femoral fracture is a relatively common occurrence during THA.  Treatment with protected weight bearing, cerclage wires, or long stem prostheses has been described.  Less is known about risk factors for fracture and clinical outcome of treatment options.  The purpose of this study was to identify risk factors associated with proximal femoral fracture during THA examining surgical approach, patient demographics including age, sex, and body mass index, type of femoral component fixation, treatment options, and outcome of the arthroplasty.  3084 hips were examined.  The incidence of fracture was 3% for all THA’s.  Uncemented stem insertion had a significantly higher fracture rate at 8.2% compared to cemented stems at 1.2% (p<0.0001).  Risk factors for proximal femoral fractures include anterolateral approach, uncemented femoral component fixation, and female gender (p=0.0018).  Treatment with cerclage wiring was the most common treatment and maintained femoral component stability.  This study identifies an “at risk” population based on surgical approach, gender, and the use of uncemented components for proximal femoral fracture during THA.  Treatment with cerclage wiring in combination with tapered titanium proximally circumferentially coated implants yielded excellent clinical and radiographic results.

     2005  Comparison of Patterns of Arthritis Between Rheumatoid Arthritis and Osteoarthritis In Patients Undergoing Total Knee Arthroplasty, Michael E. Berend, M.D., Orthopaedic Indianapolis Center for Hip and Knee, Mooresville, Indiana

Knees with endstage rheumatoid arthritis (RA), and osteoarthritis (OA) have unique radiographic features.  The comparative intraoperative patterns of arthrosis, preoperative clinical variables, and outcome of TKA are less well understood.  The purpose of this study was to compare these features in knees with RA and OA undergoing TKA.  7036 knees with OA were compared with 179 knees with RA.  Intraoperative patterns of arthrosis demonstrate that knees with RA have more symmetric involvement of the medial, lateral, and patellofemoral articulations.  ACL and meniscal degeneration was more advanced and involved both menisci in knees with RA (p<0.0001).  Osteophytic changes were significantly more advanced in patients with OA in all three compartments and on both sides of the articulation (p<0.02).  Preoperative range of motion was less and preoperative alignment was in significantly more valgus in knees with RA:  4.4° vs. OA:  0.1°(p<0.0001).  TKA survival for both PCL retaining and PCL substituting implants was no different comparing knees with RA and OA out to 12 years.  Mean age at arthroplasty was significantly younger in patients with RA: 61.8 yrs vs. OA:  70.1 yrs.  We conclude that the intraoperative pattern of OA including surface arthrosis, meniscal and ACL degeneration, and asymmetry is significantly different than the more symmetric and less osteophytic appearance of RA.  Preoperative alignment and range of motion are significantly affected by preoperative diagnosis.  Interestingly, the long-term survival of both PCL retaining and PCL substituting implants is not different for knees with RA vs. OA.

     2005  Effect of Intraoperative Anterior Cruciate Ligament Integrity on Surgical Technique and Outcome of Total Knee Arthroplasty, Michael E. Berend, M.D., Orthopaedic Indianapolis Center for Hip and Knee, Mooresville, Indiana

The aim in this study was to determine the effect of intraoperative anterior cruciate ligament (ACL) integrity on total knee arthroplasty (TKA) surgical technique and functional and radiographic TKA outcome.  6524 primary total knee arthroplasties in 4393 patients were performed for osteoarthritis had the intraoperative appearance of the anterior cruciate ligament graded as normal, present but damaged, or absent.  Patients were followed for a minimum of 2 years.  Preoperative deformity, intraoperative variables of ligament balancing requirements and implant features, clinical outcomes, and implant survival were compared based on ACL status.  The ACL was graded as normal - 43%, present but damaged – 38%, and absent in 19% of knees.  Male gender was associated with more advanced ACL degeneration (p<0.0001).  An absent ACL was associated with the need for more significant medial, lateral, and posterior soft tissue releases, decreased preoperative range of motion, and insertion of a thicker tibial polyethylene implant (p<0.05).  There was no difference with respect to implant survival at ten years, knee scores, function scores, or late instability between ACL groups.  We conclude that an absent ACL is associated with greater preoperative deformity, increased intraoperative balancing requirements, and thicker polyethylene inserts but does not affect clinical outcome of the TKA or implant survival.

     2005  A Ten to Thirty-One Year Survival ANALYSIS OF Total Elbow Arthroplasty With the Coonrad/Coonrad-Morrey Prosthesis,  J. Mack Aldridge III, M.D.†, Nina R. Lightdale, M.D, William J. Mallon, M.D, Ralph W. Coonrad, M.D., Durham, North Carolina

There have been few long term survivability reports of total elbow arthroplasty beyond 10 to 15 years. In a series of 65 consecutive elbow arthroplasties carried out by a single surgeon between 1974 and 2002, using the Coonrad/Morrey prosthesis, 41 elbows in 40 patients with an average age of 56 years (range 19 yrs – 83 yrs) identified with a minimum survival of 10 years were assessed by functional survival analysis, using permanent implant removal and revision as the failure endpoints. The varied pathology consisted of intermediate stage rheumatoid to extensive traumatic conditions, often with multiple failed previous procedures. Thirty-one of the 40 patients were 60 years of age or older at the time of arthroplasty. Surgical selection excluded prior elbow infection or patient refusal to adopt a sedentary elbow activity level for life of the implant. Objective data was collected from charts, radiographs, clinical photographs, supplemented by referring orthopedists’ records and radiographs if health or distance prevented final clinic return. Subjective outcome was defined by patient satisfaction. There were 14 complications, no acute infections or peri-operative fractures. Thirteen elbows had from one to four revisions and all were still functional until the time of death or final evaluation (9 patients were deceased). Bushing wear requiring revision occurred in five elbows and was associated with overuse and preoperative deformity in all. Of the 41 elbows at final assessment, 33 were rated excellent (80%), 7 good (17%) and 1 fair (2%) using the MEPS system. All patients would have repeated their operation. For survival analysis with removal and revision as the sole end points for failure, there were no permanent removals, 13 revisions were classified as failures although at the time of final assessment, 40 of 41 elbows were satisfactory objective outcomes (97%) at a mean of 18 years after surgery (10 to 31 years). The authors considered sedentary activity compliance an important but unproven factor in outcome. Total elbow arthroplasty using the Coonrad/Coonrad-Morrey prosthesis is a durable and effective option in alleviating pain and restoring motion in the salvage elbow.

     2005  Tibiotalocalcaneal Arthrodesis, Mark Easley, M.D., Duke University Medical Center, Durham, North Carolina

Introduction:  Prospective evaluation of tibiotalocalcaneal arthrodesis with standardized algorithm:  (1) intramedullary nail when residual talar body present and (2) lateral blade plate with talar collapse/AVN.Methods:  Thirty-six tibiotalocalcaneal arthrodeses were performed by a single surgeon in 35 patients (Average age: 46 years, (range, 22-71), 17 males, 18 females) for limb salvage.  A standardized algorithm was followed:  (A) retrograde IM nail with residual talar body (TTC arthrodesis) (24) and (B) lateral blade plate/crossed lag screws with talar body collapse/AVN (TC arthrodesis) (12).   Indications included:  Post-traumatic DJD of ankle/subtalar joint (20), Charcot neuroarthropathy (10), talar AVN (6).  Associated problems included:  Failed prior surgery to hindfoot or ankle (22) and history of osteomyelitis/sepsis of hindfoot/ ankle (6).  Evaluation was by independent observer.

Results:  Average followup of 22 months (range, 12-58) was available for 34 patients.  The average AOFAS hindfoot/ankle score improved from 34 to 71 points (maximum AOFAS score possible postop: 86 points.) Leg length discrepancy averaged 1.4 cm in the TTC group and 2.9 cm in the TC group.  Standard weightbearing foot and ankle radiographs suggested an 82% union rate at most recent followup, based on bridging trabeculation at the arthrodesis sites. Three patients lacked bridging trabeculation but remained asymptomatic.  Complications included: Symptomatic nonunion (no bridging trabeculation and pain/deformity) (3), deep infection (3), fracture above the hindfoot/ankle (2). Further surgeries included: Hardware removal (5), Irrigation and debridement (4), Revision arthrodesis (4), ORIF of tibia fracture (1), transtibial amputation (3).

Discussion:  This simple treatment algorithm allows for limb salvage in a majority of cases.  The nonunion and complication rates are concerning, but anticipated given the complex hindfoot pathology.

     2005  The Modified Ludloff Proximal First Metatarsal Osteotomy for Surgical Correction of Hallux Valgus Deformity, Mark Easley, M.D., Duke University Medical Center, Durham, North Carolina

Introduction:  Prospective Analysis of the modified Ludloff osteotomy for surgical correction of hallux valgus deformity.

Methods:  One-hundred nine feet in 99 patients (average age 53 years (range, 16-77), 89 females, 10 males) underwent modified Ludloff osteotomies with DSTP at two institutions. Evaluation was prospective using the AOFAS forefoot-metatarsophalangeal-interphalangeal scoring system preoperatively and at latest followup.   Weightbearing foot radiographs were analyzed according to AOFAS guidelines.

Results:  Eighty-eight patients (97 feet) (89%) were available at an average followup of 36 months (range, 24-56 months).  The average AOFAS score improved from 53 points to 87 points.  Preoperatively, all patients complained of pain; at most recent followup 79 patients (90%) were asymptomatic.  Radiographic evaluation suggested all osteotomies healed, but 17 cases (16%) demonstrated callus formation at the osteotomy site.  Average age of patients with callus formation was 67 years.  No cases of dorsiflexion malunion were observed.  Average IMAs preoperatively and at latest followup were 17.8 degrees and 7.8 degrees, respectively; average HVAs were 41 degrees and 15 degrees, respectively.  Tibial sesamoid position improved an average of 1.5 grades. Hallux varus was observed in 12 feet (11%).  Three feet developed hallux rigidus (3%).  Recurrence of hallux valgus was observed in 3 feet (3%).  One deep infection and one cellulitis were managed effectively with satisfactory outcome.

Discussion:  To our knowledge, this prospective, multicenter investigation comprises the largest cohort of patients undergoing a modified Ludloff osteotomy.  At intermediate followup, currently available outcome measures suggest that the results of this proximal first metatarsal osteotomy are at least equal to those reported for other proximal first metatarsal osteotomies utilized in correcting hallux valgus.

     2005  Percutaneous achilles tendon Repair, Lamar L. Fleming, MD and Sanda L. Tomak, M.D., Emory University School of Medicine, Atlanta, Georgia

     Since 1980 the senior author has used the percutaneous technique for repairs of Achilles tendon in those individuals who normally would have a closed technique of treatment. We have treated them in this manner with an accelerated rehabilitation program.  The technique is to use 1% xylocaine with epinephrine injected in eight places along the sides of the Achilles tendon.  We then make stab wounds on each side of the tendon, four on each side. Using a Bunnell type suture technique with a No. 0# monofilament polydioaxone suture and two Keith needles we suture the tendon with two weaves above the rupture and two below the rupture.  This suture is tied on the lateral aspect of the ankle. It must close down the rupture gap.  Any puckering of the skin is released subcutaneous with a hemostat. The wounds are closed with staples and the patient is put in an equinus padded splint.

     At ten days the patient is brought back to the clinic where he is put into adjustable plantar flexion brace at 15° of plantar flexion for two weeks then raised to neutral degree at one-month post- op. He is able to walk and to ambulate weight bearing while in his brace.  Therapy is started at four weeks with concentric strengthening and range of motion. At two month eccentric exercises are begun. None of them are allowed to go back to sports for six months.  We were able to get ten of our cases who were at two years or more post-op and found their AOFAS ankle hind foot score was 94 out of a possible 100,all were satisfied with the treatment, no complications, and no re-ruptures. One patient stated that he was still weak when playing basketball. The Cybex 11 dynamometry studies show that they all had mean decrease in total work capacity compared to the uninvolved leg by 21% less strength.  The circumferences of their involved calves were smaller by a means of 1.6 cm. They were all satisfied with the results their treatment.

This technique can be done in the emergency room or in a minor surgical room where the cost is remarkably less than compared to an operation room setting where the operation room cost itself is 4 to 5 times as much. 

     We have found this to be an acceptable, economical, and reproducible technique for semi-closed treatment of Achilles tendon ruptures.

REFERENCES

1. Tomak, MD, S.L. and Fleming, MD, L.L.: Achilles Tendon Rupture:  An alternative Treatment. AJO: 2004;9-12.

     2005  LAMINOPLASTY VERSUS ANTERIOR CORPECTOMY IN THE TREATMENT OF CERVICAL SPONDYLYTIC MYELOPATHY, Christopher G. Furey, M.D., Assistant Professor, Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, Ohio

OBJECTIVE:  To identify perioperative experience, neurologic improvement, clinical outcome, and patient satisfaction in patients undergoing either anterior cervical corpectomy and fusion or posterior cervical laminoplasty for the treatment of cervical spondylytic myelopathy.

MATERIALS & METHODS:  2 cohorts, each with 20 patients, with comparable demographics and similar degree of neurologic dysfunction underwent surgical treatment for cervical spondylytic myelopathy.

Choice of surgery was non-random and was primarily based on the degree of cervical lordosis and the magnitude of axial neck pain.  Patients with relative maintenance of cervical lordosis and minimal complaints of neck pain underwent multi-level laminoplasty.  Patients with advanced degenerative spondylosis and loss of cervical lordosis, with any significant component of axial neck pain, underwent multi-level anterior cervical corpectomy and fusion.

Patients were evaluated with Nurick disability scale of cervical myelopathy, a SF-36 score, and a specialty questionnaire relating personal satisfaction, resumption of prior lifestyle, and willingness to repeat the operation.  Radiographs were obtained at 6 weeks, 3,6,and 12 months post-operatively.

Minimum follow-up was 2 years with an average of 4.6 years. 

RESULTS:  Operative time, surgical blood loss, and hospital stay were significantly lower in the laminoplasty cohort.  Post-operative dyphagia, need for narcotic pain medication, and persistence of axial neck pain were also significantly less common in the laminoplasty cohort.  SF-36 scores and change in Nurick grade post-operatively, as well as satisfaction with the procedure and willingness to repeat the specific surgery were not significantly different. 

3 patients in the corpectomy cohort required additional surgery, two for the removal of prominent anterior plate and one to address a pseudarthrosis with a posterior fusion.  No patient in the laminoplasty cohort required further surgery.

CONCLUSION:  Anterior cervical corpectomy and laminoplasty  are both effective techniques to treat the neurologic sequelae of cervical spondylytic myelopathy.  While indications for laminoplasty are limited by the need for preserved cervical lordosis and minimal axial neck pain, it is a surgery of less magnitude and more tolerable in the immediate post-operative period.

     2005  Use of a Humeral Nail with Spiral Blade for Proximal Humerus Fractures, Wildstein MS, Valentine B, An YH, Horan M, Kmiec S, and Hartsock, LA, Medical University of South Carolina, Charleston, South Carolina

     Purpose: The purpose of this study was to test the strength of the spiral blade intramedullary nail system (SBIN, Synthes, Paoli, PA) when augmented with the bone cement, Norian (Norian Co, Cupertino, CA) and report on preliminary clinical results.

     Biomechanical Materials and Methods: Twelve pairs of sawbones and twelve pairs of fresh frozen cadaveric humeral bones (range 55 – 82 years, average 69 years) were obtained. X-rays showed significant osteopenic changes in the cadaveric bones.

     An osteotomy was made in each bone to reproduce a Neer two part humeral fracture. The fracture was reduced and the SBIN construct was inserted into the proximal humerus. In augmented specimens, the spiral blade was then removed and 10 ml of Norian was injected into the void in the humeral head created by the spiral blade. The blade was then reinserted, the bones wrapped in moist towels and placed in an incubator at 37°C overnight. Each bone/SBIN construct underwent either torsional or cantilever testing using a hydraulic mechanical testing system (MiniBionix 858; MTS, Eden Prairie, MN). The ultimate load to failure for each humerus was determined, with the machine run under displacement control at a rate of 25 mm/min. An identical procedure was followed for all humeri.  Data were evaluated using paired students t-test.

Biomechanical Results: The ultimate load to failure of the Norian augmented and non-Norian augmented humeri were compared. In the 6 pairs of sawbones, the difference was statistically significant (Cemented: 1035±338 N, non-cemented: 454±249 N, p = 0.00056). In the cadaveric humeri, there was an obvious trend of increased ultimate load sustained by the Norian augmented specimens (Cemented: 527±103 N, non-cemented: 342±126 N, p = 0.07).

Clinical Materials and Methods: Twenty-five patients were treated from 2002-2005. Patients were treated with a humeral nail and spiral blade. Norian was used to fill metaphyseal voids. Early full range of motion was initiated immediately after surgery. Results were collected retrospectively and outcomes scores were obtained using the DSAH, oxford and SST.

Clinical Results: Outcome data are available for 11 patients. There were seven 2 part fractures and four 3 part fractures. Seven patients were female and four were male. The average age was 55, average ISS was 12 and average follow up was 17 months. There were no deep infections and no nonunions. The average DASH Score was 36.7(1-82), oxford score was 30 (14-47), and SST was 4 (1-12).

Discussion: The SBIN system is an effective method for fixation of Neer two part fractures of the proximal humerus. Norian augmentation shows a clear trend in increasing load to failure.

The addition of the spiral blade to the intramedullary construct yields an increase in surface area contact in the proximal humerus When combined with the void filling bone cement, Norian, this study demonstrates increased strength in the fixation of proximal humerus fractures.

Preliminary clinical results are encouraging and warrant continued use of this technique for two part and selected three part fractures.  

 * This research was supported by a grant from the AO foundation.

     2005  The Role of a Geared Multiplanar External Fixator in the Correction of Soft Tissue and Boney Deformity, Jian Shen, MD, PhD, Beth Paterson Smith, PhD, L. Andrew Koman, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina

Acute correction of joint deformity with or without associated soft tissue contractures is a difficult problem that requires radical release of the joint, osseous resection, or staged correction using pins and a cast or thin wire multiplanar ring fixation.  Pins and cast and multiplanar fixation techniques often are tedious and complicated.  In order to simplify the correction process, a multiplanar-geared minirail device was designed to allow incremental longitudinal distraction, flexion-extension, and radial-ulnar correction.  The hypothesis of the study was that the availability of a device that permits staged correction of complex joint deformities and non-surgical lengthening of musculotendinous contractures will improve patient outcomes and will aid in the management of complex upper extremity deformities.  The specific aims were: 1) to present techniques for the use of this device, 2) to review clinical indications, contraindications, and complications associated with its use, and 3) to present preliminary results of our clinical experience.

Methods:  The multiplanar geared minirail (M3J; patent pending; Orthofix, Inc., McKinney, Texas) was envisioned by LAK and developed by Orthofix engineers.  The device consists of linked monorails connected by paired worm gears.  It allows the positioning of the radial-ulnar or palmar-dorsal gears over the center rotation of the joint in order to permit distraction and/or compression of either railed segment.

The geared multiplanar fixator was used in 7 patients (8 extremities).  All the patients were males with an average age of 10 years (range:  3-18 years).  Clinical indications for use of the fixator included longitudinal deficiency of the radius (radial club hand n=5 extremities) and wrist flexion contracture and spasticity (n=3 extremities).

Results:  After application of the fixator followed by incremental correction of the joint deformity, patients experienced improved wrist range of motion, improved range of dorsiflexion and improvements in grasp, release, and activities of daily living.  There were no pin tract infections, device failures, and all patients achieved their desired goals.

Conclusions:  Multiplanar-geared fixation is a useful adjunct for the management of complex upper extremity deformities in pediatric patients.  The use of the fixator is simple, allows correction in the palmar-dorsal and radial-ulnar planes, and permits distraction, if it is required.

     2005  KIKUYU KENYA, James A. Pressly, Charlotte Orthopaedic Specialists, Matthews, North Carolina

     Kenya, a country of 30 million people in Africa, was formerly a part of British East Africa. It is bordered by Ethiopia and Sudan on the north; Uganda and Lake Victoria on the west; Tanzania on the south; and Somalia and the Indian Ocean on the east.

     Our church and OrthoCarolina, the orthopaedic group I am affiliated with in Charlotte, NC, has supported Kikuyu Orthopaedic Rehabilitation Hospital for the past 9 years. The hospital was constructed in 1997 as a combined project of USAID and the Presbyterian Church USA with 15 acres of land donated for the project by the Presbyterian Church of East Africa. It borders the general hospital complex originally established by Scottish Presbyterians as a mission station in 1898.  

     Kenya is about the size of Texas. It was granted independence in 1962 after the Mau Mau “emergency”. Most of the population is Christian with a growing Muslim minority mostly along the coast around Mombasa. Access to orthopaedic care is not good. Education is valued and the literacy rate is about 75 per cent.

     In Kikuyu, there is a general hospital, an eye unit, a dental facility and the orthopaedic rehab hospital. The orthopaedic hospital is well-known and may be one of the best places to receive orthopaedic care in sub-saharan Africa. It is a 36 bed unit with male, female and children’s wards. It has an outpatient clinic, an x-ray department, lab, physical therapy and a pharmacy. There are two well-equipped operating rooms.

     The hospital had over 10,000 outpatient visits in 2004 and over 900 operative cases were done. The physical therapy and orthotics department were very active. The hospital is self sustaining. A clinic visit is $3 or 225 shillings; a total joint is $700 or 50,000 shillings.

     On the orthopedic hospital grounds, small duplexes have been built to house doctors, administrators and nurses. Since housing is limited and so expensive in Kenya, this allows the hospital to compete with hospitals in Nairobi that can pay high salaries but do not offer housing. There is also a hostel for visiting doctors and mission teams. The hospital is staffed permanently by Dr. Johnson Murila, who attended the Alliance School and the University of Nairobi. He received his orthopaedic training in Great Britain. He is an excellent clinician and technician and a dynamic leader.

     Patients come from all over Kenya and as far away as Somalia. Dr. Murila treats many different orthopaedic problems including club feet and other congenital deformities, burn scar contractures, old mal-united fractures, unreduced dislocations, and much acute trauma. He is adept at tibial and femoral nailings, total hip and knee arthroplasty and arthroscopy.

     Generally, the groups going to Kikuyu include an orthopaedist, a scrub nurse and an anesthetist.  Most trips also include a construction group to work on various projects around the hospital or at local churches, schools and orphanage. Each person on the team takes a 70 pound container of medical equipment donated by local hospitals and representatives of Dupuy and Zimmer. Visits are usually for 2-3 weeks in length and serve to supplement other volunteers from the USA and Europe who assist Dr. Murila.

Each volunteer doctor from my practice has found the experience unforgettable, from hospital work and contact with the Kenyan people, to the amazing beauty of the scenery and animals.

     We believe that the integration of advanced imaging is an important component of a multidisciplinary surgical team approach in the comprehensive evaluation and treatment of patients with sciatic notch dumbbell tumors.  This imaging technique allows distinction between tumor and nerve and can help predict a tumor's resectability.   It appears that in patients with extensive unilateral sciatic notch dumbbell tumors, safe and complete resection may be achievable and may be predicted.  Furthermore, even when these tumors are of neural origin, they seem to arise from small branches rather than the main sciatic nerve along which they track more frequently than previously thought.

     2005  Reconstruction Options for Massive Bone Loss of the Elbow, James R. Urbaniak, M.D., Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

     The author discussed the management of massive bone loss of the elbow (the entire elbow joint is completely lost).  Some type of external support such as a brace is usually inadequate because to get good function of the elbow the brace compresses the area of nerves in the upper arm and forearm because of lack of any buttressing of the brace with the elbow joint being absent. 
     Bridge plating can be used in a child with elbow fixed about 90 degrees and then the plates subsequently removed and oftentimes good elbow function with essentially full range of motion can be achieved when the child reaches maturity.     
     Allografts are extremely useful, however after two to four years there is usually cartilage degeneration on both sides of the joint although painless function may persist with some instability.  The allograft may be revised by:
     a.  re-allograft
     b.  prosthetic implant.
     A custom-made implant of the Coonrad-Morrey type of elbow is reserved when the above fail or in the older patient (over 60 years of age). 
     Patient videos demonstrating the function of all of these methods were included in the presentation.

     2005  Advances in regional anesthesia for hip surgery, Thomas Parker Vail, MD, Duke Medical Center, Durham, North Carolina

Universal interest in less invasive surgical techniques, quicker rehabilitation, and improved pain management has led to innovation and improvement in regional anesthetic options for major lower extremity reconstruction.  Regional anesthetic techniques hold the potential to meet the demand for improved pain management, decreased postoperative nausea and vomiting, and early return to function.  While advances in the field of anesthesia have made the wider use of regional technique possible, surgeons retain a strong influence on patient choice in anesthetic options.  Historically, regional anesthesia has been associated with unpredictable outcome and longer operative turnover times.  Surgeons without experience in the use of regional anesthesia are hesitant to adopt the technique because of perceived inefficiency and prolonged room turnover, while also indicating great satisfaction with the pain relief provided by continuous peripheral nerve blockade.  A focus on safety and effectiveness combined with newly developed catheters for continuous medication delivery, specialized infusion pumps, and a growth in the subspecialty of regional anesthesia have made this option more attractive to patients and surgeons.  Regional anesthesia for major lower extremity reconstruction includes the use of single shot and continuous epidural injection, single shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves.  Success with these techniques has led to the application of regional anesthetic technique in conjunction with major lower extremity reconstructive procedures such as multi-ligament knee reconstruction, tibial osteotomy, unicompartmental replacement, ankle fusion, and ankle replacement, as well as hip and knee replacement.  Recent evidence indicates a high degree of reliability, safety, effectiveness, and patient satisfaction with regional anesthesia.  Shorter stays in the recovery room area contributes to the cost effectiveness of these techniques.  Widespread adoption of regional anesthesia will require an increase in the number of anesthesiologists trained in regional techniques, continued demonstration of safety, the possibility of early mobilization with weight-bearing, the early return of proprioceptive function, and system efficiency.

     2005  CHARITÉ ARTIFICIAL DISK REPLACEMENT, Kenneth E. Wood, MD, Samuel J. Chewning, MD, H. Lee Gooch, MD, Jonathan Garrett, PA-C, Piedmont Health Care, Statesville, North Carolina

OBJECTIVE:  To present a brief review of the pertinent literature and data on a small series.

SUMMARY OF BACKGROUND DATA:  Pathologic changes of degenerative disk disease include diminished H2O binding, annular fissures, loss of mechanical competence and subsequent narrowing and osteophyte formation.

The rationale for artificial disk replacement is based on maintaining motion at the operative segment and restoring disk height while maintaining segmental lordosis. 

The first Charité disk replacement was developed in East Berlin at the Charité Clinic (1982) by Dr. Kurt Schellnach and Dr. Karin Buttner-Janz.  The components of this device include two endplates made of high quality cobalt, chromium, alloy and a sliding conforming convex ultrahigh molecular weight polyethylene core insert. 

   Indications approved by the FDA:

1. Single level disk disease.
2. Age greater than 60 years.
3. No more than 3 mm of spondylolisthesis.
4. Failure of six months treatment.

   The Charité disk replacement is implanted through an anterior retroperitoneal approach.  Implantation requires complete diskectomy and proper alignment under bipolar imaging. 

The US and European literature include several hundred patients and still promising results.

   RESULTS:  To date we have performed fourteen (14) artificial disk replacements in twelve (12) patients since December 2004.  The short-term data show outstanding results with minimal complications. 

     DISCUSSION:  Early results appear promising for the Charité disk replacement device.  Concerns remain significant and include such things as possible loosening and infection.

     2005  BANDA ACEH, Lewis G. Zirkle, Jr., M.D., SIGN, Richland, Washington, www.sign-post.org

SIGN was founded in 1999 to design and manufacture IM nil interlocking screw systems that could be used in developing countries where no C-arm is available.  Nine-hundred (900) SIGN surgeons in 37 countries have performed 13,000 surgeries on fractured femurs, tibias and humeri using the donated SIGN systems.  Six-thousand two-hundred (6,200) SIGN surgeries have been recorded on our surgical database within the last 18 months.  These include pre and post operative x-rays.
     When the tsunami struck Aceh, Indonesia and the surrounding areas many SIGN surgeons volunteered to help. These include surgeons from Vietnam, Nepal, India, Bangladesh and the US.  I traveled with the executive director of SIGN to Banda Aceh in January 2005 to help and to assess the situation for future help.  We were met in Jakarta and accompanied to Aceh by Dr. Azharuddin.  He was the only orthopedic surgeon in Aceh with a population of 4.5 million people.      
     Dr. Azharuddin’s hospital was destroyed so we worked in a Danish mobile surgery hospital.  We then traveled back to Jakarta where we demonstrated the SIGN system to Dr. Azharuddin and to the Fatmawati Hospital residents.  Dr. Azharuddin then returned to Aceh after the hospital had been cleaned.  The first elective orthopedic surgery was a SIGN nailing of a fractured femur.  Since then many tsunami victims have shown up for treatment.  These patients had been previously treated by bone setters and malunions and nonunions resulted.
     I showed an interview of Dr. Azharuddin and his hospital. The hospital lost all of the surgical equipment including Dr. Azharuddin’s personal equipment and the hospital had eight inches of mud on the floor.  Dr. Azharuddin lost his house and all of his possessions including his library and teaching materials.  Fortunately his family was unharmed.  We showed the destruction of the tsunami in Banda Aceh and the people attempting to return to the activities of their daily living. 
     We hope this video will show Dr. Azharuddin’s sadness yet determination to continue caring for his people.

2005 RING REMOVAL FROM A SWOLLEN FINGER – A REFINED TECHNIQUE, Wayne B. Venters, M.D., Spokane, Washington

     Removing a ring or other circular object (wide steel band) from a swollen finger can be most difficult if not almost impossible.
     The usual method of removing rings made of soft or precious metal is by lubricating or soaping the finger well, wrapping with a string, using the standard circular blade ring cutter or using a pneumatic saw or diamond burr on steel bands. These methods mutilate the ring, often held very precious by the wearer, may lacerate or burn the finger, leave micrometal shavings in an open wound which have caused foreign body granulomata and may not be feasible with a massive object, such as a large threaded nut from a lug bolt.  J.D. Nancarrow in 1973 recognized that vascular inflow to the finger had to be stopped before venous and lymph drainage outflow could shrink the finger.¹  He used a blood pressure cuff briefly.
     C.R. Cresap also used a blood pressure cuff only before unwrapping the elastic tape from a finger but did not prevent inflow to the palm while trying to compress the edema out of the finger.²
     The following technique was developed while I was removing a 12 mm wide threaded lug nut from a 2½ year-old child’s finger some hours after it had become impaled.  The following refined method has been used extensively in our office, emergency department, and preoperative area.
     Apply a padded pneumatic tourniquet, or blood pressure cuff, on the upper arm, wrap the digit with a small Penrose drain or elastic tape (Coban®), wrap the entire extremity with an Esmarch or Ace bandage and inflate the tourniquet above systolic blood pressure. Re-wrap the finger with the elastic tape several times to compress the blood and lymph out of the swollen digit into an empty palm, because the tourniquet is still inflated, and the palm has been emptied with the Esmarch or Ace.  Remove the ring or object using a mechanical method desired, such as a string, rubber band or piece of glove as described previously in the literature. The equipment for removal is readily available in all medical offices and emergency departments and this method provides a simple solution to a common and often difficult problem.  This technique may not work to remove rings from large arthritic knuckles often seen in the preoperative area.  However, it is worth a try and the technique is recommended. 
     I am not aware of any complications using this technique.
References:
1.  Nancarrow, J.D.: “A Simple Technique for Removing Stubborn Rings Prior to Hand Surgery”, J.HANDSBURG (BR) 1993, 18B:544.
2.  Cresap, C.R.: “Removal of a Hardened Steel Ring from an Extremity”, AM J EMERG MED, 1995 May; 13(3): 0318-20.
 

Abstracts 2004

     2004  TOM BROKAW, ORTHOPAEDICS, AND THE PIEDMONT ORTHOPEDIC SOCIETY, James P. Aplington, M.D., Greensboro, North Carolina

When I received a letter from Dr. Goldner last July, I suspected this was either a statement that I owed the Piedmont some money or it was a refund from last years meeting.  I was totally surprised to learn that the Executive Committee had asked me to be one of the two guest speakers at the years Piedmont meeting. When I look at the distinguished list of Piedmont members and those that have been up here at the podium in the past years, I am indeed deeply honored to be speaking to you today.
     To pick a topic of interest to such a diverse audience required some thought.  Many of you are probably wondering about the unusual title of my speech today; I hope you will find it interesting and pertinent.
     Four years ago, one of my patients gave me as a present Tom Brokaw’s book, The Greatest Generation.  The stimulus for this book was two visits he made to Normandy in commemoration of the fortieth and fiftieth anniversaries of D-Day and talking to American veterans who had been there.  To paraphrase Mr. Brokaw, this generation was united not only by a common purpose but also by common values -- duty, honor, economy, service, and responsibility for ones self.  He termed these veterans “the greatest generation any society has produced”.  He proceeds to profile lives of ordinary people – men and women – as well as some well-known individuals such as George Bus, Joe Foss (B29 pilot, Congressional Metal of Honor winner, first president of the old American Football Conference), Ben Bradley, Mark Hatfield, and Bob Dole.  By in large, this generation was content simply to have a roof over their heads, food on the table, and a job.  If they were lucky, they obtained an education after high school.  Everyone worked hard for the war effort. Especially revered were the midwestern farm boys who worked from daylight to darkness without complaint (Dr. Goldner, does that sound familiar?).  The individuals profiled were successful at many levels after the war, through hard work and character.  This often led to problems with their children, however, who frequently did not share their work ethic and sense of values.  Families become estranged when parents could not or would not accept the attitudes of this new generation.
     When my wife heard about Mr. Brokaw’s subsequent book, A Long Way From Home, she gave it to me as a gift.  This book deals with his ancestors and describes his growing up in his semi-rural environment in South Dakota.  I was struck by the similarities in his early life and mine.  We were born four months apart in 1940, which put us at the tail end of the greatest generation.  I also grew up in a small town but in Maine. There was a lot of love in both of our households but there were no material extras. We both learned early on that most of the time, if we wanted something, we would have to work for it.  No effort, no reward.  We both played varsity sports in high school.  He subsequently married a physician’s daughter.  I went to medical school and married a nurse.
     My Orthopaedic years at Duke, I feel embodied much of the greatest generation philosophy. We took pride in a job well done; we were very economic in that we performed many job functions that ancillary staff such as cast techs, IV teams, and PAs perform today.  It did not matter how smart you were, you still had to work. You could not complain because Dr. Goldner was right there in the trenches with you.
     Now, the winds of change are upon us.  It is a different era. We have mandated 80-hour resident workweeks.  Private practice may prove to be quite a shock to some of the physicians trained under this system.  I only hope the surgeon fixing my fractured hip will not leave in the middle of my case because he has worked too many hours that day.  Women now comprise up to 50% of medical school classes.  However, many of these women are opting to work part-time with no nights, weekends, or holidays.  Is it possible we will be working shifts some time in the future? 
     With all of our technological advances, patient expectations often are unrealistic.  Patient self-responsibility is on the wane.  Most of my Workman’s Compensation patients now seem to have a rehabilitation nurse accompanying them to monitor and expedite their care.  It seems harder to get them well and returned to work; frequently, they have secured the services of an attorney.
     In our present economic climate frugality is often a forgotten word. Instead of writing a prescription for what the patient might need with refills, if necessary, with co-payments the patient does not want to have to pay more than one co-payment and expects to have a prescription large enough to more than cover their needs and frequently much of it will go unused.
     Where are we headed? - - -  I do not know.  Change is inevitable.  Like “The Greatest Generation” we need to adapt and most of us have, I think.  The principals of The Greatest Generation seem to be eroding but not lost completely.
     This brings me to the Piedmont Orthopedic Society.  This has always been my favorite medical and social meeting. We have a distinguished group of men and women who have shared the same rigors of residency and cherish values of hard work and quality.  The BS factor is usually negligible.  I would hope we would be able to maintain these ideals for years to come.
     In closing, I once again would like to thank Dr. Goldner and the Executive Committee for making me one of the two honored guests this year.  It has been a pleasure being able to share some of my observations and ideas with you.  I look forward to attending many more Piedmont Orthopedic Society meetings in the future.

2004   Ileus Following Total Hip or Knee Arthroplasty is Associated with Increased Risk of Deep Venous Thrombosis and Pulmonary Embolism, Keith R. Berend, MD, Adolph V. Lombardi, Jr., MD, FACS, Thomas H. Mallory, MD, FACS, Kathleen L. Dodds, BS, RN, Joanne B. Adams, BFA, Joint Implant Surgeons, Inc., 720 East Broad Street, Columbus, Ohio

Venous thromboembolic disease (VTD) occurs following THA and TKA.  Ileus occurs up to 4.0%.  3364 Primary and revision THA and TKA over 2-years were reviewed to examine a relationship between ileus and VTD.  Prophylaxis was aspirin and intermittent pulse boots for most. High risk patients received chemical prophylaxis and boots. 62 Patients had ileus (2.1%) and symptomatic DVT in 51 (1.7%).  With ileus, the incidence of DVT was 8.1%: odds ratio 5.5 (p=0.0036).  Symptomatic PE occurred in 7 (0.24%); with ileus the incidence was 3.2%: odds ratio 19.6 (p=0.0082).  A significant increase in rates of VTD with ileus was seen.

Factors that helped to cause the increase in Medical Liability insurance premiums were reviewed.  The sharp increase in premiums did not affect all specialties equally.  Those physicians performing procedures such as those delivering babies had a larger increase than primary care physicians. 
     Organized medicine proposed a bipartisan effort to achieve a legislative fix to the Medical Liability insurance crisis.  Partisan politics assumed control of the issue at both the national and state levels, in most cases resulting in lack of meaningful legislation.
     To achieve the Medical Liability reforms needed to stabilize Medical Liability insurance premiums and preserve access to medical care, doctors will need to get involved.

     Persistent instability or redislocation is uncommon but of significant concerning treating elbow dislocations. Following reduction, the finding of an objective, static, radiographic sign that might correlate with the presence of instability was the purpose of this study. Pre and post-reduction radiographs of ten consecutive simple and complete adult elbow dislocations (from an institutional series of 183 complex and simple dislocations) were compared with radiographs of twenty consecutive adult elbows without trauma history. A statistically significant measured increase in static ulnohumeral distance was noted on the routine unstressed post-reduction lateral radiographs of patients sustaining dislocation. We have termed this increased distance the “drop sign”. It differs from the radiographic ulnohumeral separation noted during O’Driscoll’s test for posterolateral rotary instability which is present only with axial compression. The  “drop sign” becomes concerning only if persistent or recurrent after the first reduction radiograph and may be a warning sign of the presence of instability.

 Magnetic resonance imaging (MRI) of twenty-two patients with pygenic vertebral osteomyelitis were reviewed to determine whether MRI predicted failure of nonoperative treatment.  Nine patients failed non-operative treatment and required surgical intervention.  Patients treated successfully by non-operative means had an average of 57% +/- 19% involvement of the affected motion segment, whereas those failing conservative treatment had an average of 89% +/- 18% involvement of the affected motion segment.
     Patients with Pyogenic Vertebral Osteomyelitis that have ninety percent or greater involvement of an affected motion segment should be considered for early operative management.

2004  Correction of Joint and Soft Tissue Contractures in Children:  The Role of a Multiplanar-Geared Correction Device, L. Andrew Koman, MD*, Beth Paterson Smith, PhD, Greg Mohler, BS, Richard Bryant BS, Wake Forest University School of Medicine, Winston-Salem, North Carolina 

  14 patients with RCL injuries to the index MCP joint were reviewed. Age, mechanism of injury, delay to treatment, and grade of injury were correlated with pain, change in function, stability, motion, strength, degenerative changes, and satisfaction.
     Grade 1-2 early treated with casting had excellent results. There were no stable injuries late. All grade 3 early were treated surgically with good to excellent results. Of grade 3 late all had poor results. MCP joint fusion was an effective salvage procedure for stability and pain. Four late grade 3 patients opted for non-operative and have instability.
     The significance of this injury remains underestimated and the diagnosis requires a high index of suspicion.

Introduction:  Distal radius fractures are very common and often require surgical intervention.  This study is a retrospective review of results using a locked volar plating technique.
     Materials:  Sixty-eight patients were treated with Synthes’ volar locking plate for distal radius fractures over an 18-month period. 
     Results:  All of the fractures healed with the volar locking plate technique.  There were no cases of hardware failure.  Post-operative range of motion averaged approximately 80% of unaffected.
     Discussion:  Locked volar plating for the management of some distal radius fractures has been effective with encouraging early results 

Introduction:  Distal radius fractures are very common and often require surgical intervention.  This study is a retrospective review of results using a locked volar plating technique.

Materials:  Sixty-eight patients were treated with Synthes’ volar locking plate for distal radius fractures over an 18-month period. 

Results:  All of the fractures healed with the volar locking plate technique.  There were no cases of hardware failure.  Post-operative range of motion averaged approximately 80% of unaffected.

Discussion:  Locked volar plating for the management of some distal radius fractures has been effective with encouraging early result

     Introduction:  Dorsal carpal ganglions are common causes of pain and limited function.  The purpose of this paper is to review the results of arthroscopic resection of dorsal wrist ganglions.
     Methods:  Forty-one patients with dorsal wrist ganglions underwent arthroscopic resection.  There were 24 females and 17 males.  The average patient age was 29.8 years. 
     Results:  The average follow-up to date is 35.2 months (range 6 to 84).  In all patients post-operative range of motion was equal to or better than pre-operative motion. Thirty-nine of 41 (95.2%) patients had no recurrence.
     Discussion:  Based on these results, arthroscopic ganglionectomy is a safe and reliable alternative to open resection.

     Introduction. The diagnosis of many proximal lower limb mononeuropathies or lumbosacral plexopathies remains elusive despite thorough evaluation, including routine MRI and even, sural nerve biopsy.  Empiric medical or surgical treatment is typically attempted with limited success for neurologic recovery.
     Materials and Methods.  Ten patients (average age 42 years) with non-compressive peroneal, tibial, sciatic neuropathies or lumbosacral plexopathies affecting 14 limbs were evaluated.  Localization was established by physical examination and confirmed with electrodiagnostic studies.  High resolution MR neurograms were performed in all cases.  Six patients had previous non-diagnostic distal cutaneous nerve biopsy (sural in 5 and superficial peroneal in 1).  Fascicular biopsy was performed of the peroneal (1), tibial (2) or sciatic nerve (7).  The biopsy location was selected by considering percussion tenderness, surgical accessibility, imaging and operative abnormalities.    
     Results.  In all patients, percussion of the affected nerve revealed an area of irritation with radiating paresthesias.  This area correlated with signal abnormality and/or enlargement of the nerves demonstrated on MRI.  These imaging abnormalities were often subtle.  In all cases, the fascicular biopsy was informative for a specific pathologic alteration: lymphoma (1), sarcoidosis (1), perineurioma (2), inflammatory/immune suggestive of vasculitis (2) and inflammatory demyelinating (4).  No complication resulted from the fascicular biopsy.
     Conclusions. Targeted fascicular biopsy, when performed at a center specializing in peripheral nerve diseases, can be accomplished safely.  It can lead to diagnoses of lower limb neuropathies that have therapeutic implications.  MR neurograms can localize focal or multifocal proximal limb nerve lesions, but are not by themselves diagnostic of the pathologic process.

Pyarthrosis of the pediatric hip can lead to osteonecrosis of the femoral head. When symptomatic, treatment options for this condition are limited. We have hypothesized that free vascularized fibula autografting (FVFG) is an effective treatment for symptomatic osteonecrosis of the pediatric femoral head secondary to pyarthrosis. Our study evaluated seven patients who presented with Stages IV and V osteonecrosis of the femoral head. All patients were treated with free vascularized fibular autografting to the femoral head. Postoperative evaluations of pain symptoms, hip range of motion, and Harris Hip Scores showed improvements in all patients. Hip range of motion was noted to be significantly improved in the arcs of flexion (+23 degrees; p=0.002) and external rotation (+22 degrees; p=0.014). Harris Hip Scores increased significantly from an average preoperative score of 68 to an average postoperative score of 96 (p=0.002). No patients were revised to hip arthrodesis or arthroplasty within the average three year follow-up period. In conclusion, free vascularized fibular autografting is a reasonable option in the treatment of osteonecrosis of the pediatric hip secondary to pyarthrosis.

Presented is a summary of the 2004 legislative effort in the Virginia General Assembly, concerning tort reform and relief for physicians and hospitals struggling with medical malpractice issues.
    These included SB 601, creating a state-run malpractice insurance program; HB 1127 providing venue limits for malpractice trials; HB 627 requiring plaintiffs to cover all defense costs in cases of nonsuit; SB 385 creating protection for peer-review activities by physicians.
     A summary of legislative activity in nine other states was provided to the committee by the national Piedmont Society membership, and presented.
     A series of recommendations was made encouraging physician involvement in the legislative process, goals for future legislation including caps on economic and non-economic damages.  However, it was concluded that in the current political climate that only marginal prospects exist for meaningful and comprehensive tort reform and relief for physicians with high insurance premiums until legislators and the public perceive a crisis situation over “access to care” issues in their home states.   

Abstracts 2003

     Healthcare is under continued pressure to shorten inpatient admission time. Adjusting the surgical approach for Total Knee Arthroplasty to an incision medial to the Quadriceps tendon does shorten the recovery of straight leg raising (SLR) ability. In 75 patients undergoing total knee arthroplasty (TKA) SLR was reached on average in less than 3 days [range 1-7].

     This incision compared to a traditional Quadriceps splitting surgical approach has shortened our patients’ recovery of motor control in the operated extremity without affecting outcome. This allows for earlier discharge of the patient from the hospital.

Edward J Harvey MD MSc, McGill University Health Center, Department of Orthopaedic Surgery, Montreal General Hospital, Room B5.159.5, 1650 Cedar Ave  Montreal Quebec Canada H3G 1A4, Phone(514) 937-6011 x42734, Fax (514) 934-8493, ejharvey@hotmail.com

     Purpose:  Frozen shoulder or adhesive capsulitis is a painful and progressive loss of both active and passive range of motion without any known intrinsic cause.  The natural history and histological stages have been described to help explain the pathogenesis.  There have been conflicting reports evaluating the effects of intra-articular corticosteroid injections in the treatment to improve the natural history.  We report our non-operative experience with the use of glenohumeral corticosteroid injections in patients diagnosed with adhesive capsulitis of the shoulder.                                                         
     Methods:  129 consecutive patients with a diagnosis of frozen shoulder were followed from 1997-2002.  A detailed physical examination in both the erect and supine position documented range of motion.  A visual analogue scale (VAS) was used to document pain.  All patients underwent a glenohumeral injection with 40 mg DepoMedrol and 9 cc 1% plain lidocaine at the time of initial presentation and at monthly follow-up with the following criteria:                                                                           
         1.  No improvement in pain of 2 VAS levels

2.  No improvement in erect abduction or forward flexion of 20º

or

3.  No improvement in erect or supine IR or ER of 10º. 

     A maximum of 3 injections was used.  Patients were followed until complete resolution of symptoms or if surgical intervention was needed.  Successful treatment was considered if there was complete resolution of pain, full function, and patient satisfaction.  Initial and follow-up ASES and HSS L’Insalata scores were recorded.
     Results:  Thirty-one patients were lost to follow-up leaving 98 patients to be evaluated.  There were 69 females with average age of 40.7 years and 29 males with average age of 53.2 years.  Overall success was 71.4% (71% females, 72.4% males).  Successful treatment occurred at 4.15 months in females and 4.5 months in males.  85.7% of both female and male patients recovered with 1 or 2 injections.  Poor prognostic indicators were Diabetes Mellitus, absent physiotherapy, workman’s compensation, post-operative stiffness cases, dominant arm, and stage 3 cases.  Average ASES scores were 41.8 at presentation and 92.7 at resolution and HSS L’Insalata scores were 52.5 at presentation and 91.0 at resolution.  There were no complications with our technique.
     Conclusions:  Glenohumeral corticosteroid injections for the patient with adhesive capsulitis are considered to be safe and an effective method of treatment for resolution of pain and improvement in functional range of motion.  We recommend glenohumeral corticosteroid injections at the time of presentation and with close follow-up for frozen shoulder as part of the initial treatment regime.  We have suggested an algorithm for the timing of intra-articular injections based on pain and objective range of motion.

     Context- Motor vehicle collision (MVC) related cervical spine injury is a severe and often permanently disabling injury.  Although advances in automobile crashworthiness have reduced both fatalities and some severe injuries, the impact of varying occupant restraint systems (seatbelts and airbags) on cervical spine injury is unknown. 
     Objective- To investigate the relationship between the occurrence of cervical spine injury and occupant restraint systems among front seat occupants involved in frontal MVCs.
     Design, Setting, and Patients- A case-control study among subjects obtained from the 1995 to 2001 National Automotive Sampling System (NASS).  Cases were identified based on having sustained a cervical spine injury of > 2 on the Abbreviated Injury Scale, 1990 Revision.
     Results- Approximately half (44.7%) of 8,412 cases of cervical spine injury were unrestrained occupants while belted only, airbag only and both restraint systems represented 38.2%, 8.8% and 8.4% of cases respectively.  Overall, the combined use of airbag and seatbelt had the greatest protective effect, relative to unrestrained occupants, with an odds ratio (OR) of 0.19 and a 95% confidence interval (CI) of 0.12 to 0.30.  Use of a seatbelt only also had a protective effect (OR=0.40, 95% CI=0.23 to 0.70).  Occupant use of an airbag only neither increased nor decreased the risk of cervical spine injuries relative to unrestrained occupants (OR=1.02, 95% CI=0.57 to 2.13).
     Conclusions- The results of this study suggest that there is an increase in overall protection against cervical spine injury by combining airbag and seatbelt restraint systems relative to seatbelt alone.

     Purpose: Study aims were to evaluate the impact of complex regional pain syndrome after distal radius fracture (DRF) on function and health-related quality of life (HRQL) and to correlate outcome after therapeutic interventions.

     Materials and methods: A retrospective review was conducted on 28 patients (24 women and 4 men) diagnosed with complex regional pain syndrome following distal radius fracture between 1991 and 2000 as diagnosed by a hand surgeon. Mean age at injury was 52.9 (Range: 29-74). Initial fracture management included closed reduction (n=24), open reduction (n=4), external fixation (n=6), open reduction and internal fixation (n=1), and percutaneous pinning (n=5). Sixteen patients had casts. After initial management, 21 patients underwent subsequent surgeries which included wrist fusion, ulna resection, iliac crest bone graft, wrist arthroscope, plate ORIF, repeat external fixation, Darrach procedure, shoulder arthroscope, and intrinsics release. The average time from injury to CRPS diagnosis was 186 days.Treatment of CRPS included autonomic nerve blocks [stellate block (n=5), epidural block (n=2), axillary block (n=1), and infraclavicular brachial plexus block (n=2)]; hand therapy with active and passive range of motion (n=28) and contrast baths (n=28); median nerve decompression (n=7), and oral medications (n=28). Three outcome measures (clinical assessment, standardized validated HRQL instruments, and thermoregulatory testing) were compared between initial diagnosis and after five years of treatment. Statistical analysis included one and two-way analysis of variance (ANOVA).

     Results: Health-related quality of life instruments: The Levine symptom and functional status scales showed a statistically significant improvement at the 5-year follow up examination when compared to initial examination for both symptom (p=0.003) and function status (p=0.001). The McCabe cold sensitivity severity scale showed no statistically significant improvement at follow up exam. The McGill pain questionnaire showed a statistically significant difference between the initial exam & follow up exam (p=0.048). The Wake Forest University symptom rating scale showed a statistically significant difference between initial exam and follow up exam in pain (p=0.014), weakness (p=0.001), and stiffness (p=0.001) with no statistically significant difference in numbness and cold intolerance  between the initial exam and follow up exam. At follow-up exam, when study population’s DASH scores were compared to DASH scores of 36 control subjects (individuals with history of distal radius fractures without CRPS diagnosis), a statistically significant difference between our study group and the control group was found (p=0.002).

     Thermoregulatory testing: There was no statistically significant difference (p>0.05) in laser Doppler fluxmetry, or digital temperatures between initial exam and follow up exam. This indicates no significant improvement in these parameters.

     Clinical examination findings at CRPS diagnosis and follow-up exam correlated well with the other outcome measures.

     Conclusions: At a mean follow up of five years after initial exam (mean 6.6 years post-injury), Compared with uncomplicated DRF, patients with CRPS treated with current protocols demonstrate a significantly diminished function and HRQL and may be impacted positively by active intervention with diminished pain, improved strength, and decreased stiffness; however, numbness and cold intolerance may persist resulting in residual disability in spite of active and vigorous intervention.

      MATERIALS AND METHODS:  Seven patients with clinical evidence of septic flexor tenosynovitis were treated with a limited incision for open irrigation and drainage of the flexor tendon sheath.  The sheath was exposed using a limited technique, employing 4 volar-midline skin incisions over the distal palm, proximal phalanx, mid-phalanx, and distal phalanx taking care not to cross the digital creases. Through these incisions the sheath is exposed protecting the A2 and A4 pulleys.  A pediatric feeding tube is threaded through each incision into the sheath where vigorous irrigation with bacitracin solution is performed.  Once the sheath is adequately drained, the wounds were packed open with bacitracin solution-soaked gauze and the hand splinted in the functional position.

Postoperatively on day one, daily whirlpool therapy is instituted with repacking of the wounds, institution of range of motion, and functional splint wear.  This was continued for 10-14 days with intravenous antibiotics continued on average of 2-3 weeks followed by p.o. antibiotics.

     In the cadaveric part of the study, a limited open incision technique was performed on 8 digits from 2 cadaveric hands.  Longitudinal volar midline incisions x4 were made over the tendon sheath avoiding the digital creases.  The tendon was exposed by longitudinally opening the sheath at the A1, C1, A3, C2, C3 and A5 pulleys leaving the A2 and A4 annular pulleys intact. After exposure, the skin was completely removed to allow inspection of the tendon sheath.

RESULTS:  All seven patients were followed for approximately 1 year.  6 of 7 patients revealed complete closure of wounds within 3 weeks after surgical drainage.  6 of 7 patients gained full composite flexion being able to flex to the distal palmar crease of the involved digit by time of wound closure, approximately 3 weeks, range 18 to 27 days.  The 7^th patient demonstrated continued limited motion lacking approximately 3.5 cm. of flexion to the distal palmar crease, but did have preexisting degenerative arthritis involving both the PIP and DIP joint.  No complications were noted in the previous 6 patients; specifically no contracture, neurovascular injury, bowstringing, or prolonged healing.  None of the patients have required additional procedures up to this point.

Dissection of the cadaveric digits revealed that the A2 and A4 pulleys were preserved with complete exposure. Exposure of the remaining tendon sheath was complete in all digits with the limited open incision.  In 2 of the digits, approximately 25% of A4 had been incised proximally.  The A2 pulley was preserved in all of the cadaveric digits.

     CONCLUSION: Pyogenic flexor tenosynovitis can lead to devastating hand morbidity.  While surgical debridement is recommended, no single technique has gained universal support.  The cadaveric study conforms that adequate debridement can be successfully achieved with 4 limited longitudinal incisions. Care must be taken not to cross the digital creases.  Further, the incision of the tendon sheath in the distal half of the middle phalangeal wound can violate the 4^th proximal annular pulley and requires careful attention.  The clinical cases demonstrate adequate debridement achieved without violating the A2 and A4 pulley with expedient wound closure, regaining of full range of motion, and a few soft tissue complications. This limited open incision technique allows successful debridement of the sheath while maintaining the benefits of the limited incision technique without the difficulties inherent to their catheter systems.

     Radial ulnar synostosis is the most common complication of the two-incision biceps repair.  Thus far, only one study in the literature has described this complication and treatment.  Between 1992 and 2000, 8 patients with radioulnar synostosis after a two-incision biceps repair were evaluated and treated with a mean age of 38 (range 29-47) years old.  The mean time between tendon repair and resection of the synostosis was 8 (6-18) months.  The average follow-up was a 27 (range 13-36) months.  An average pronation-supination arc of 27 ^o (range 0 ^o – 70 ^o) was noted preoperatively. Postoperatively all patients underwent post-operative radiotherapy in two divided doses for a total of 700 rads.  At an average follow-up of 27 months, it was noted that the rotation arc of the forearm improved to 155 ^o (range 140 ^o - 170 ^o) with an average gain of 128 degrees.  The strength of supination was 80% (range 70% - 90%) of the contralateral limb.  Seven of the eight patients had no pain after activities of daily living or work.  One had mild pain after prolonged activity.  No radiographic or clinical evidence of synostosis recurrence was noted at final follow-up. 

     The posterolateral incision was extended and the interval between the extensor digitorum communis and the extensor carpi radialis brevis is developed to expose the supinator muscle.  The posterior interosseous nerve is identified and protected.  The synostosis is subperiosteally exposed through a separate interval, from the ulna to the radius.  After resection, bone wax is applied over bleeding surfaces, the wound is irrigated and the tourniquet is released to obtain excellent hemostasis.  A drain is placed for 24 hours.

     Musculoskeletal manifestations of tuberculosis include arthritis, osteomyelitis, and spondylitis. With adequate compliance, current chemotherapeutic protocols should successfully eradicate more than 90% of cases of osteoarticular tuberculosis. Surgery serves as an adjunct to chemotherapy.  Articular involvement begins with a proliferation of synovial granulation tissue, which is followed by marginal erosions, and ultimately destruction of the joint. Early diagnosis is essential as outcome depends upon the degree of involvement at presentation. In addition to chemotherapy, splinting and early motion help prevent contractures.  Surgical indications include biopsy for diagnosis, synovectomy/debridement (controversial), and salvage procedures including resection arthroplasty (hip), arthrodesis, osteotomy, and total joint arthroplasty. 

     Skeletal tuberculosis most commonly presents as a lytic lesion with a sclerotic rim, but may also have an aggressive appearance (periosteal reaction, small sequestra).  Uncommon forms include cystic (no sclerotic rim, children, diverse sites, may be multicystic), disseminated (compromised host, appendicular in children, skull/axial in adults), closed multiple tubercular diaphysitis (very rare, children, swelling in forearms and legs with diaphyseal thickening and sclerosis), and tubercular rheumatism (Poncet’s disease, multiple effusions).  Skeletal lesions may invade neighboring joints, and may cross the physis.  Sinuses are common, and up to 50% of these may be superinfected by bacteria.

     The disease focus in tuberculous spondylitis (Pott’s disease) is usually within the vertebral bodies, and chemotherapy is the mainstay of treatment. Neurologic deficits may occur during the active phase (abscess, granulation tissue, sequestra) or the healed phase (transverse ridge of bone at the apex, dural fibrosis). A subset of patients will develop a significant kyphosis (» 5% > 60°) despite treatment, and risk factors include age (children), thoracic involvement, multiple levels of involvement, and greater initial loss of vertebral height.  The indications for surgery remain controversial, and include establishing the diagnosis, decompressing the neural elements, preventing the development of significant deformities in those at risk, and shortening the duration of symptoms. Surgical approaches include anterior (most common), posterior (laminectomy for isolated posterior or intradural disease), and anterior and posterior (significant kyphosis, high risk of significant kyphosis).  In patients unable to tolerate an anterior approach to the spine, costotransversectomy allows drainage of abscesses, while the lateral extrapleural approach allows decompression of the spinal cord and grafting. Instrumentation is not contraindicated in mycobacterial infections.

     When the costs associated with complications are accounted for, the potential cost benefit of simultaneous bilateral TKA may be less than previously estimated.

   METHODS: This is a retrospective, observational study.  All patients had isolated MCL injuries and underwent an operation for complaints of pain and/or instability.  The operations included anatomic repair of the superficial and deep portions of the MCL and of the posterior oblique ligament.  Additionally, the semitendinosis tendon was used to reinforce and protect the repair.  The study group includes nine patients operated on between 1997 and 2002. Eight were male. Average age was 25 (18-40).  The average time from injury to operation was 18months. Eight patients had follow-up evaluations at an average of 36 months (6-56); one patient was only one month postop.  Patients’ follow-up evaluations included physical examination measures, radiographs, and isokinetic strength testing.  We used the Lysholm and SANE outcome measures, and assessed activity level on the Tegner scale.

   RESULTS: All patients were able to return to their preoperative level of activity.  Postoperative surveys and physical examinations were performed.  All eight patients demonstrated less valgus laxity at follow-up with five Grade I and three Grade 0. The average Single Assessment Numeric Evaluation (SANE) rating was 87 (range 70-100), average Lysholm score was 87 (range 81-95), and average Tegner activity score was 7 (range 4-9).  The IKDC results were 2 normal, 5 nearly normal, and 1 slightly abnormal. All individuals regained their preoperative range of motion and had a negative Swain Test.  One individual developed stiffness and underwent a manipulation under anesthesia without further sequelae.  Three of four individuals who had the double limb grafts developed problems with the screw and spiked washer on the femoral epicondyle and requested hardware removal.

   DISCUSSION: This is a preliminary report of our experience in surgically treating isolated chronic MCL injuries.  The study should bring out two interesting points for discussion: (1) Do some isolated MCL sprains need surgical treatment acutely, and if so, which ones?, and (2) What is the best treatment for persistent symptoms following an MCL sprain?  Nonoperative? Repair/reconstruction? Trephination of the ligament from inside the joint? “Microperforation” from outside the joint?

     Two individual surveys were available to Society members through direct mailings and through official website.  These results were summarized and presented to the membership.

     Survey 1 : Sports Recommendations for Total Knee Patients, and Cervical Fusion Patients. (50 respondents) 

#1 Unilateral TKA :  100% for biking, swimming, fishing, golf.

                      82% for hunting

                      49% for hiking, tennis

                      31% for skiing

                      11% jogging

#2 Bilateral TKA :   100% for biking, swimming, fishing

                      95% for golf

                      80% for hunting

                      37% for tennis, hiking

                      24% for skiing

                       7% for racquetball, jogging

#3 Cervical Fusion (single level ACDF):

                      50% of respondents approved of contact

                      sports. 

     Survey 2 : Emergency Room Coverage for Unassigned Orthopaedic Surgeons (63 Respondents)

     90% of MD's under age of 56 still taking Call.

     19% of respondents anticipating retirement prior to age 60.

     Vast majority of surgeons in academic practices rarely went to ER's themselves to see patients.

     A trend toward full-time Orthopaedic Tramatologists, but mainly at the major academic medical centers, rarely at private hospital.

     A trend toward private hospitals paying daily cash stipends for Orthopaedic coverage of their ER's.

     Purpose: The authors developed a case-based, interactive computerized program to teach and assess the musculoskeletal pathology knowledge of orthopaedic surgeons, pathologists and radiologists. Cases were chosen to illustrate basic entities, with emphasis on the clinical presentation, image interpretation, histology interpretation, diagnosis establishment and treatment knowledge.  Evolving technology allowed creation of a CME ready, commercially viable educational program particularly aimed at orthopaedic surgeons.

     Introduction: This clinical-radiological-histological interactive training program was developed as an outgrowth from a regional musculoskeletal pathology course that was taught by the combined faculties of Duke University, Wake Forest University School of Medicine, University of North Carolina School of Medicine, the Charlotte Orthopaedic training program, Medical University of South Carolina, and Emory University faculty.  This clinical radiologic histologic interactive training activity evolved from a case based program utilizing 5 x 7 black and white radiographic image copies and actual glass slide histology microscopic examinations, into a highly sophisticated, yet easy to use interactive program that allows the learner to view 200 cases of musculoskeletal tumors and tumor-like conditions that require correlation of clinical, radiographic and histologic material to illustrate basic teaching points of musculoskeletal pathology and musculoskeletal tumor management.  The activity was designed to allow the reader to perform his own interpretations with annotated interpretations provided that can be viewed or hidden from view depending on the viewer's preference.  These cases may be selected randomly or they may be selected on the base of diagnosis, anatomic area, imaging modality, patient age grouping, tissue type (bone versus soft tissue) and benign versus malignant.  The learner objectives are as follows:

1. The learner should be better able to recognize and describe the clinical presentation, the laboratory findings and the radiographic findings of basic musculoskeletal ongoing and related disease processes.
2. The learner should be able to discuss the basic evaluation and proper management of patients presenting with problems suggestive of a bone or soft tissue tumor, including the appropriate clinical, laboratory and radiographic work-up.
3. The learner should be able to understand the pathophysiology as a more common encounter bone and soft tissue tumors. This knowledge will enable him/her to properly classify these patients and their problems, properly interpret and analyze the clinical/radiographic and pathologic findings and formulate a diagnostic work-up and treatment plan.
4. The learner should be better able to select and prescribe the appropriate therapies of both benign and malignant bone and soft tissue tumors including chemotherapy, radiation therapy and limb salvage surgical techniques.
5. The learner should be able to judge or measure his/her knowledge by the built in, self evaluation quiz mechanism in a clinical based context that simulates clinical practice.

    References are provided, but not all inclusive, but include references utilized by the authors during their preparation of the program and/or references utilized by the authors during their training and references believed by the authors to be useful to students. The content also reflects the input of the many mentors the authors had over the years, whose teaching are reflected in this work, but whom may not be formally acknowledged.

     Method:  From over 2000 cases performed by the primary surgeon, 200 classic cases were selected.  Each case presented at least one unique teaching point that the senior author felt was quite instructive for the orthopaedic learner as well as the pathology and radiology learner.  The images were captured with state-of-the-art imaging technology.  Each case presents with a brief clinical history followed by thumbnails of the radiographic and histologic images allowing the user to complete the interactive quiz for the radiologic and the final clinical radiologic histologic diagnosis.

     Treatment Discussion:  This is provided along with an interpretation of each of the studies, allowing the user to fully assess their knowledge.

     Results:  The CD-ROM has been utilized by the author at his own institution and residents who have used the program have raved about its ability to prepare them for both clinical practice and for board examinations. It was well received at the Piedmont Orthopaedic Society and presented in his interactive format as well as at other venues.

     Conclusion:  This interactive educational activity is designed to meet the need of busy practitioners allowing them to review these topics in a concise case based format facilitates retention as opposed to the rather dry encyclopedic format of most musculoskeletal pathology. Interactive nature maintains the clinician's interest.  The educational activity is eligible for a maximum of 16.5 hours of Category 1 CME credit as defined on the author's website, Innovativecognition.com from which additional descriptive information as well as potential ordering information is available.

     From 1946 to 1952 I used the Kite method for management of idiopathic clubfeet.  During that time, clubfeet were separated into idiopathic and teratologic based on both severity and the presence of other systemic deficiencies.  The method included:  (1) pre-treatment attempts to rate severity; (2) frequent change of above knee plaster casts attempting to diminish forefoot adduction, cavus, hindfoot internal rotation and inversion; malposition of the talus in the ankle mortise, and equinus related to triceps surae contracture and contracture of the posterior tibiotalar calcaneal capsule.
     Other pathologic lesions treated were contracture of the posterior tibial, flexor digitorum longus, and flexor hallucis longus muscles.  The toe extensors were usually physiologic, the peroneal muscles were frequently weak, and the contracted anterior tibial muscle supinated and adducted the forefoot and secondarily the hindfoot. Lateral up and down radiographs established the degree of static equinus. Social, economic, and logistical reasons, resulted in cast changes every two to four weeks.  Maximum improvement from cast treatment was attempted for 6 to 12 months. 
     A large number of patients were incompletely corrected and better management was necessary.  With cast treatment and/or Denis-Browne splints, “rocker bottom” was seen frequently.  Those patients who improved temporarily with cast treatment were in the minimal to mild category of severity.  About 25% of the entire group of clubfeet that I treated from 1950 through 1955 maintained correction for two years.  Half of those patients, however, recurred and required surgery eventually.  Approximately 85% of the referred patients from 1950 through 1960 required progressive surgical treatment to maintain painless weightbearing feet.  As progressive surgical management was being developed, the procedures done included heelcord lengthening, posterior release of tibiotalar capsule, lengthening of the posterior tibial, flexor hallucis longus, and flexor digitorum longus tendons as well as arthrotomy of the talonavicular joint.  By 1960, the approach was to the posterior, medial, plantar, and lateral aspects of the foot and the four-quadrant release, excluding the subtalar joint and including transfer of the anterior tibial tendon to the dorsum of the first metatarsal, had been developed.  In this prospective study, at least 90% of the moderate-severe and severe feet were aligned by removing a wedge from the cuboid bone and adding that to an open osteotomy of the first cuneiform.
     During this same period, a severity classification was established: 1-5/60 positional; 5-10/60 minimal; 10-20/60 mild; 20-40/60 moderate; 40/60 severe; 60/60 very severe (teratologic).  Of the newborn infants referred, approximately 50% responded to monthly cast changes for six months.  These feet were classified as positional or minimal.  They occasionally required a heelcord lengthening and posterior tibiotalar capsulotomy. 
     The remaining feet showed progressive severity and the surgical procedure done was based on severity.  In 1968, a prospective study of four-quadrant release was initiated after the feet had been classified according to severity.  Those prospective patients (1968-1984) with a 20-35 year outcome (1968-2003) are currently being analyzed.  The preliminary results show that patients in the mild and moderate categories, who had progressive surgery, had satisfactory functional and relatively painless feet until they were, at least, 25 years old.  Those with severe and very severe feet had intermittent pain during adolescence and subsequently, based on incongruity of articular surfaces between talus and navicular and other tarsal defects with or without musculotendinous imbalance.
     We have concluded that surgical treatment, per se, was not the cause of foot pain.  Asymmetrical incongruity of talonavicular and tarsometatarsal joints accounted for some degree of discomfort.  A “ball and socket” ankle joint occurred in several patients but these feet were not always painful.  “Ball and socket” ankle joints frequently developed when the range of talocalcaneal motion was severely limited.  The outcomes of similar cohorts were measured.  Patients that required triple arthrodesis by the time they were 20 years old were all in the severe and very severe categories. Five percent of the severe cohorts required triple arthrodesis. 
     Until feet in similar cohorts of severity are compared with each other, the current statistical information related to clubfeet outcome studies are invalid.  It is inappropriate to compare the outcome of a mild foot with that of a severe foot.

            Introduction: Acetabulum fractures (AF) are uncommon injuries.  This study documents a single surgeon's experience in a single institution.
     Materials and Methods:  All AF operative cases of the author from October 1997 to April 2000 were included in this retrospective review of charts, radiographs, and outpatient records. All patients had pre-operative AP pelvis and Judet radiographs and a CT scan of the pelvis. Fractures were classified according to Letournel. Surgery was performed under general anesthesia with skeletal traction, cell saver, C-arm, and radiolucent table. Fractures were repaired with 3.5mm screws and reconstruction plates. All fractures were treated through Kocher-Langenbeck, ilioinguinal, extended iliofemoral, or combined Kocher-Langenbeck and iliofemoral approaches. Only the extended iliofemoral approach received prophylaxis against heterotopic bone (HO). Post-operatively patients were allowed full range of motion, but stayed touch down weight bearing (WB) for six weeks followed by partial WB for another six weeks. All patients had AP pelvis and Judet radiographs at the end of the procedure, and AP pelvis x-ray and follow-up exam at 6 weeks, 12 weeks, 6 mos, 1 year and 2 years post op.
     Results:  There were 69 male and 34 female patients (total of 103). The average age was 37 (range 13-85). MVCs were the cause of 65 fractures; 38 occurred from motorcycle accidents, falls, industrial accidents, bicycle and pedestrian accidents. There were 42 elementary fractures and 54 associated fractures. Seven fractures were unclassified. In the elementary group there were 21 posterior wall, 12 transverse, 5 posterior column, and 4 anterior column fractures. In the associated group there were 14 both column fractures, 20 transverse with posterior wall, 11 T-type, 7 posterior column/posterior wall and 2 anterior column/posterior hemitransverse fractures.  There were 61 Kocher-Langenbeck approaches, 14 ilioinguinal approaches, 14 combined approaches, and 4 extended iliofemoral approaches. Follow-up on all patients was challenging with 69% at 6 weeks, 52% at 12 weeks, 39% at 6 mos, 20% at 1 year and 12% at 2 years.  There were two acute revisions: one for an intraarticular screw and one for a loose bone fragment. There were 5 post-op nerve palsies involving the peroneal nerve. There were no deep infections and 2 superficial infections which required treatment in the OR. There were 2 documented PEs. Four patients had Grade 4 HO and all underwent excision. There were no nonunions and one case of AVN. By 2002, 5.8% of cases had been converted to total hip. The average conversion occurred at 14 mos post op. These included 3 transverse fractures, 1 both column, and 2 posterior wall fractures.
     Discussion:  The demographics of this series are similar to others reported in the literature. Our series differs from Matta by having more elementary types, fewer extended approaches and more combined approaches. There was a low conversion to THA by 2002. Acetabulum fractures can be successfully treated after careful analysis of the fracture by radiography and CT, expert use of a variety of surgical approaches and reduction strategies, and careful postoperative care.

     The goal of HTO in instabilities, arthrosis and cartilage and meniscal saving procedures is to correct or overcorrect the mechanical axis.   Pre-operative radiographs include standing hip-to-ankle views to target the weight-bearing axis and lateral views to assess posterior tibial slope.  It is important to keep in mind that increasing the posterior tibial slope will aggravate an ACL deficit, but help a PCL deficit.   As well, the location of erosions and wear patterns will vary depending on the knee’s stability, whether it is ACL or PCL deficient and on the status of the meniscii.   With an intact ACL there is anteromedial arthrosis, while in ACL deficiency posteromedial arthrosis is frequently seen.   It is important to tailor the osteotomy to the pathology.

     The author’s preferred technique of HTO is opening wedge with Puddu 
plate fixation.  The advantages of opening over closing wedge osteotomy are that the proximal tibio-fibular joint and the peroneal nerve are avoided; a two plane (sagittal/ coronal) osteotomy is easier to create and requires one cut only; the osteotomy is made most often at the site of the deformity; it is easier to do small corrections; the anterior compartment of leg not violated; the collateral structures are tensioned and finally, the osteotomy is a stable construct.  The main disadvantage is that most often a graft and a longer period of rehabilitation are required.

     A clinical and radiographic review of 22 opening wedge high tibial osteotomies in 20 patients with chronic posterior or posterolateral instability was carried out at our centre.   Knee stability was significantly improved in 60% of cases, somewhat improved in 35% and unchanged in 5%.  All 20 patients would undergo the procedure again.  Alignment was altered a mean of 4° valgus and posterior tibial slope was increased a mean of 7°.    We concluded that good functional and radiographic results can be achieved with biplanar corrections.

     Osteotomy may be combined with soft tissue surgery.  However, correction of alignment should be the first order of business and may be the only surgical intervention required.  If deemed necessary, soft tissue procedures can be done at a later date.  Overcorrection of alignment should not be the goal in patients with instability alone.   Osteotomies about the knee can be either femoral or tibial and opening or closing, depending on surgeon preference and experience.

Abstracts 2002

     2002 MY RECOLLECTIONS OF THE EARLY DUKE EDUCATIONAL PROGRAM IN ORTHOPAEDICS,  John Adams, M.D.*, M.P.H.,  804 Bay Avenue, Lewes, DE

This meeting is a 50/50 meeting for me, as I was  Chief Resident at Duke 50 years ago.

My awareness of the Duke Orthopaedic Program began when Lenox D. Baker visited the 49^th General Hospital in Tokyo where I was stationed as a medical officer on the orthopaedic service in the United States Army.  After Dr. Baker had been there for a few days, he offered me a position on the Duke Residency Program to begin July 1, 1949.  Prior to my entering the program, I learned even more about Duke from Dean Wilburt Davison when he visited the 49^th General Hospital as a Pediatric consultant.

In 1949, J. Leonard Goldner was the Chief resident, six residents of the total program were assigned to Duke.  There were two residents on the public service, one on the private service, and one at Lincoln Hospital which was in Durham but away from Duke.  One resident was assigned to basic science, which was a six month rotation on either Anatomy or Pathology. At that time, Dr. Baker was the only full time faculty on orthopaedics and Dr. Beverly Raney was half time.  Dr. Everett Bugg who had a private practice in Durham was part time faculty as other residents were assigned to the city hospital Watts and to Lincoln Hospital. 

At Duke, we did surgery three days a week, running two rooms simultaneously.  There were outpatient clinics every day, we were on call every other night, and we had patient rounds each morning at 6:00 a.m. and teaching rounds three times a week including Sunday.  All clinic notes had to be written or dictated before the resident left the hospital. 

Other residents during this period were E. E. Bleck, Don Eyler, Ralph Coonrad, Paul Thompson, Les Meyer, Rick Wrenn, Jim Funk, and Gary Hough.  My second six month rotation was on General Pathology under Dr. Wiley Forbus, a master in General Pathology.  This rotation was unique and valuable to my education. I completed my year rotation at the Private Diagnostic Clinic and Lincoln Hospital and on January 1, 1950 began a twelve month rotation away from Duke at the North Carolina Orthopaedic Hospital (NCOH) in Gastonia, North Carolina, which is twenty miles from Charlotte.  Dr. William Roberts was the Chief Surgeon, there were approximately 150 patients, and the common diagnoses at that time were osteomyelitis, poliomyelitis, tuberculosis, acute and chronic burns, and congenital anomalies.  At that time, streptomycin had not yet been introduced for the treatment of tuberculosis and the Salk vaccine had not been completely developed.  In 1950, practically all patients who had scoliosis in North Carolina were treated through NCOH.  Most patients treated for scoliosis remained in the hospital for a year and required inpatient schooling and special nursing care.  There was one operating day each week with several patients being completed.  Large outpatient clinics were held each day.  An outlying clinic was attended once each month in Goldsboro, North Carolina, which was approximately 200 miles from Gastonia, 80 miles from Durham, and 80 miles from the Eastern Coast of North Carolina.  At this clinic, approximately 100 patients, new and follow-up, would be seen in order to provide follow-up for patients from Eastern North Carolina.  At that clinic, Dr. Goldner would attend from Duke and treat the patients with clubfeet.  The average clinic had about twenty patients with cast changes.  This is where he was introduced to the complex problem of clubfeet from which he developed his practical approach. 

Operative treatment of patients at Gastonia was an “eye opener”.  All anesthesia was given by a nurse anesthetist.  Several hundred scoliosis patients had been operated upon by Dr. Roberts during the several years that he had been there, and there had been no intubation and no blood transfusions.  The mortality rate was zero.  Operative cases seldom lasted more then one hour.  A triple arthrodesis, for example, took approximately twenty minutes, there was no internal fixation, and the foot was molded and held in a long leg cast.  Dr. Roberts was an expert surgeon, worked rapidly in the operating room, and made all of his decisions before the operation began. 

I was Chief Resident at Duke beginning July 1, 1951.  This was the same year that the North Carolina Cerebral Palsy Hospital opened.  Lenox Baker was the Medical Director and he had been working toward developing this unit for several years.  Duke gave the land and the State built the hospital.  During that first year, there was a meeting of the American Academy for Cerebral Palsy.  The topics on the program were classification of cerebral palsy; diagnosis and treatment, which included discussions about bracing, surgery, physical therapy, and combinations of these modalities. 

Len Goldner had joined the full time faculty as of July 1, 1950 and at the Cerebral Palsy meeting, he presented several patients who had upper extremity problems that he had treated surgically.  Winthrop Phelps, the national authority on the subject, was there and he expressed his surprise at the “aggressive approach to children with cerebral palsy who had upper extremity problems”.  It was his policy to wait until they were full grown to even consider surgical treatment.  New energy, new ideas, and new results were evident during that meeting.

During my year as Chief Resident, I was introduced to our first full time anesthesiologist and observed the formation of a residency training program by Dr. Ronald Stephens who was Chief of the Division of Anesthesiology.  The time interval between cases elongated, but the clinical and research information improved. 

There were many incidents that punctuated my Duke experience such as: (1) when the orthopaedic service acquired its first Chick Fracture Table.  Dr. Baker was attached to the old Hawley Table.  More than one time he would kick the new Chick Table as he walked by it. 

Sub-capital fractures of the hip in elderly patients were treated in the sub-basement Radiology room where the portable x-rays could be taken quickly.  There was no fluoroscope in the operating room.  In the Radiology Department, at that time, the resuscitation equipment was minimal.  The set up for holding the patient was limited by the way the AP and the lateral x-ray was taken.  We usually positioned the fractured extremity in such a way that the first year resident would put traction on the extremity and sit under the drapes while the procedure was being done.  Dr. Goldner was instrumental in eliminating that undesirable location for this procedure.

Our clinical experiences and our basic science rotation were augmented by outreach clinics held in county health departments throughout the State.  On a regular basis, each resident would attend outlying clinics where children and adults could be seen in follow-up and in consultation.  Local referring physicians and public health nurses directed patients to the “orthopaedic clinics” for advice and treatment by the orthopaedic consultant from Duke.  In this way, the residents experienced graduated responsibility and learned how to communicate with referring individuals.  Also, the experience of talking to a patient from a rural community surrounded by several members of the family was somewhat different than the protected environment of Duke Hospital. 

All in all, during my Duke residency, I was associated with enthusiastic colleagues and a teaching staff that had no equal.  The faculty members gave the necessary time and effort to encourage residents, to work with them on clinical and laboratory projects, and to provide them with useful role models.  Duke was one of the stellar teaching programs even at that time.  Education for the residents has increased both clinically and in the research laboratory and the current residents are outstanding.  There is great pride in knowing that I was part of and associated with the Duke Orthopaedic Residency Program during its formative years. 

*  Professor and Chairman Emeritus, Department of Orthopaedic Surgery, Washington Medical Center

     2002 Revision Anterior Cruciate Ligament Reconstruction Using a Reharvested Ipsilateral Patella Tendon, Colosimo, AJ; Heidt, R.S. Jr.; Traub, JA; Carlonas, RL; University Sports Medicine Center, Cincinnati, Ohio

      2002 A RETROSPECTIVE STUDY OF PERCUTANEOUS HEEL CORD REPAIRS, Andrew Bullington,  John Xerogeanes, M.D., Lamar Fleming, M.D., Emory University School of Medicine, Atlanta, Georgia

     ·     The outcome of the first 10 patients operated by a single surgeon by a  new instrumentation with KASS (Kaneda Anterior Spine System) was assessed.

·    The average follow-up was 4.0 years (mean 3.6) following the operative correction. There was follow-up on every patient.

·    Average preoperative curve was 52º.

·    Average correction was 37.9º (73% correction).

·    The sagittal plane was corrected toward normal in every patient.

·    No interbody spacers or grafts were used in any patient.

·    Bone-on-bone interbody apposition was achieved during each patient’s surgery.

·    The average number of vertebrae instrumented was 4.7 (mean4.5), which was half the levels of standard posterior instrumentation.

·    Average operative time was 4 ½ hours and average blood loss was 850 cc.

·    There were no serious complications.

·    All patients wore a postoperative TLSO until radiographic interbody healing was evident.

Fusion occurred at an average of 2 ½ months.

     2002 SYMPOSIUM ABOUT THE 50th ANNIVERSARY (PHASE I) OF THE PIEDMONT ORTHOPEDIC SOCIETY, J. Leonard Goldner, M.D., James B. Duke Professor and Chairman Emeritus, Orthopaedic Surgery, Duke University Medical Center; Executive Secretary Piedmont Orthopedic Society

        The Piedmont Orthopedic Society had its 50^th Anniversary (Phase I) in Durham, North Carolina at Duke University Medical Center on May 14, 2002.  The meeting was split between Durham and Bermuda.  During the initial segment of the meeting in Durham, several individuals were recognized as contributors to the Piedmont Orthopedic Society; foremost among them was Mrs. J. Leonard Goldner who was awarded an Honorary Professorship in the organization.  Her dedication to the members and to the development of the Society during the past fifty years was recognized by the membership as being a critical aspect of the interest that the members maintained not only in each other but in the Society as a whole. 

         During the first segment of the Duke meeting on May 14, there was an orthopaedic symposium that included information about the history of the Piedmont Orthopedic Society, the early educational program of Duke residents, and the contributions by several members of the Society who had been involved for as long as fifty years and as short a time as two years. 

VIGNETTE OF THE HISTORY OF THE PIEDMONT ORTHOPEDIC SOCIETY  

         In 1950, J. Leonard Goldner, Walter Hoyt, Jr., Jack C. Hughston, and Ned Shutkin agreed that the members of the Duke Orthopaedic and Affiliated Training Program should continue to correspond, communicate as a group, and to establish cooperative orthopaedic studies among institutions beginning then and in the future.  Furthermore, from the Society would originate a Piedmont Orthopedic Foundation sponsored by the members with the interest from the endowment being returned to residents in training at Duke for pilot orthopaedic research projects.  The Society was incorporated in 1951 in Tennessee by Don Eyler; the Foundation was incorporated in Charlotte, North Carolina by Wayne Lee.  The requirement for membership by physicians or scientists was to spend at least one year on the Duke Orthopaedic Educational Program and to continue to be active in clinical or research orthopaedics.  The initial number of members was approximately forty and the current membership is approximately 500.  The first meeting was held in Durham at Duke in 1953, the second meeting was in Nashville, Tennessee in 1954 with Don Eyler as Chairman, the third meeting was in Winston-Salem, North Carolina in 1955 with Cabell Young as Chairman, and the fourth meeting at Sea Island, Georgia with Jack Hughston as Chairman. Every other year, from that time on, the meeting was held at Sea Island, Georgia with new Chairmen being selected each year and an elected Executive Committee.  The Piedmont Orthopedic Foundation also had an Executive Committee and a Secretary/Treasurer.  The first research grant from the Foundation was awarded to Donald Ferlic in 1963.

        The Piedmont Orthopedic Foundation has awarded approximately 107 grants since the Foundation was formed.  The average amount of each grant was $5,000.  Numerous publications, exhibits, presentations, and additional projects resulted from these awards.

       The structure of the Piedmont Orthopedic Society and the Foundation have enlarged and changed in keeping with changing times since the origin of each organization.  The Annual meeting each May continues with new Chairmen for each meeting; there is a Mid-Year meeting held at the same time as the meeting of the American Academy of Orthopaedic Surgeons.  The Foundation meets during the Annual meeting in May.  The business of the Foundation is carried on during the year by mail, telephone conference, and by the officers of the Foundation who have changed approximately every five years.

       When you begin a project, establish an organization, or formulate a society with common goals you never know where the end will be.  Several things happened during the past fifty years as the organization matured.

1.     Organizational memory was kept alive.

2.      Personal friendships grew, developed, and became more meaningful and mature as time passed.

3.      The role model was passed to the younger members of the organization.  As the young become mature, the requirements of the older members diminish.  The energy and enthusiasm of the younger members results in new goals, ideas, and accomplishments.

       The Piedmont was selected as the name of the Society and the Foundation because it represented the location of Duke and the Affiliated Programs at the foothills at the base of the mountain, which describes Central North Carolina, which is geographically a Piedmont area.

    2002 Type III Odontoid Fractures with Distraction:  An Unstable Injury, John Kirkpatrick, M.D., Todd Sheils, M.D., and Steven Theiss, M.D., Division of Orthopaedic Surgery, Spine Surgery, The University of Alabama at Birmingham

Introduction: Type III odontoid fractures are typically felt to be stable injuries and heal without surgical intervention.  Type III injuries presenting with distraction have vertical instability and represent a specific injury requiring aggressive surgical intervention.  The purpose of this study was to review three cases and raise awareness of this unusual injury.

            Methods: Three patients with acute traumatic Type III odontoid fractures and associated vertical instability were treated between 1998 and 2000. All three patients presented with vertical displacement of the odontoid on initial radiograph. Clinical records and imaging studies were reviewed. 

             Results: Upon presentation, each Type III odontoid fracture extended into one or both facet joint and had at least 5 mm of vertical displacement on CT scan and/ or radiographs. Each was initially treated with halo vest immobilization without traction.  Reduction was lost in each case due to continued vertical instability.  Two cases were noted to have dynamic instability with respiration when the fracture was viewed under fluoroscopy.  All cases were noted to have posterior C1-C2 capsule and ligament disruption.  One patient presented with a dense brachial plexus palsy and one had incomplete quadriplegia with cranial nerve VI palsy. The third patient was initially neurologically intact but became quadriplegic after reduction was lost in the halo vest.  Hemodynamic and hematologic instability prevented acute surgical management in the face of progressive deficit.  Definitive treatment consisted of Brooks C1-C2 sublaminar wiring with halo immobilization, C1-C2 transarticular screws with halo, and staged C1-C2 transarticular screws with wiring and halo.

             Discussion: Skeletal traction for reduction and halo immobilization is standard treatment for Type III odontoid fractures. In a vertically unstable Type III odontoid fracture, this treatment is likely to have unfavorable results. Obvious vertical displacement should alert one to vertical instability. Vertically unstable Type III odontoid fractures should be suspected when any distraction of the odontoid fragment or posterior elements is noted in high energy trauma.  When present, early surgical stabilization with internal fixation should be performed. We favor transarticular screws to assist in and maintain reduction of the fracture.

Cerebral palsy affects 700,000 to 800,000 children and adults in the United  States, with 80% of hemiplegic and quadriplegic limbs being significantly  affected. Patients may be compromised by spasticity, movement disorders, and  problems with sensibility. Movement disorders are a relative contraindication to  soft tissue procedures. Although the predominant pattern of deformity is one of  shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion,  finger flexion and thumb-in-palm, variant patterns exist and produce  difficulties.

 Patients can be assessed by a variety of methods including classic  classifications (eg, Green & Banks; Hoffer). In addition, tests which assess  a function such as the Melbourn or the Quest, are available. Tests of dexterity  include the Jebson Pickup. Assessment should include all of these aspects as  well as electromyography in selected patients. Using these guidelines, a variety  of soft tissue and bony procedures can improve 10 to 20 percent of patients with  upper extremity involvement.

    2002 Animated 3D Carpal Motion, Michael Sandow, Sam Papas, Michael Kerylidis Royal Adelaide Hospital and Wakefield Orthopaedic Clinic Adelaide

         The dorsal percutaneous technique for repair of scaphoid fractures and selected nonunions with cannulated headless compression screw allows the early return of hand function with a high union rate. A 10-year review of papers (meta-analysis) reporting on percutaneous fixation of "stable" scaphoid fractures using headless compression screws identified 214 acute fractures treated percutaneously that  resulted in a 100% healing rate.  There were 39 fractures with either fibrous unions or with late presentation treated percutaneously with rigid fixation. All 39 fractures healed without open bone graft. The only complications reported in these papers was the implantation of 4 screws that were too long (complication rate of 1.5%).

        The key to this procedure is accurate placement of a guide wire in a reduced scaphoid fracture along its central axis.  0.045 inch guide wire which is introduced percutaneously into the proximal pole of the scaphoid and driven from dorsal to volar.   0.062 inch K-wires joysticks are used to reduce the fracture.  A hand-held Standard Acutrak cannulated reamer is placed over the guide wire and the scaphoid is reamed to within the distal cortex.  The correct screw length is obtained by subtracting 4mm from the actual scaphoid length. Two parallel guidewires are used to obtain scaphoid length. At the conclusion of surgery, a removable splint is applied and a strengthening program is started. Heavy lifting and contact sports are restricted until CT confirms healing by bridging callous and clinically the patients are non-tender. We have treated over 50 scaphoid fractures with 100% union as confirmed with CT scan. These include stable, unstable and displaced scaphoid fractures rigidly repaired using this dorsal percutaneous method without complication.  In addition we have treated fibrous unions and scaphoid fractures which have presented with percutaneous rigid fixation alone without bone graft.  These have all also healed, but slower than those fractures treated acutely.

2002 CONGENITAL LONGITUDINAL DEFICIENCY OF THE TIBIA, David A. Spiegel, M.D., Randall T. Loder, M.D., and Robin C. Crandall, M.D., Shriner’s Hospital for Children/Twin Cities, Minneapolis, MN

Purpose:  Brachial plexus and severe upper extremity injuries have a devastating effect on the patient’s function.  Reconstruction of the upper extremity remains a challenging problem and microneurovascular muscle transfer has been utilized to restore upper extremity function.  Several muscles have been used including the rectus femoris and the latissimus dorsi.  We present our experience with transfer of the free gracilis muscle flap.

Material and methods:  Reconstruction of the upper extremity with the gracilis free muscle flap was undertaken in 12 patients.  Loss of function was secondary to brachial plexus injury in 6 patients, traumatic muscle loss in 5 patients, and tumor excision in one patient.  The free gracilis flap was used for restoration of elbow flexion in 6 patients, finger flexion in 4, and finger extension in 2 patients.  Follow-up ranged from 1 to 15 years (mean 5 years).  Muscle power grade 4 or greater was considered excellent, grade 3 to 4 was considered good, and less than 3 poor.

Results:  All flaps survived (100%).  The free gracilis flap resulted in good or excellent finger flexion or extension in all 6 patients.  Five of 6 patients had an excellent and one had a good outcome. Elbow flexion was achieved in 5 cases with grade 4 power in 2 cases and grade 3 in 3 cases.  No function was restored in one case.  Overall functional outcome was considered excellent in 5 of 12 cases (42%), good in 6 of 12 cases (50%), and poor in one case (8%).

             Conclusions:  Microneurovascular transfer of the gracilis is useful for reconstruction of the upper extremity, particularly for restoration of finger flexion and extension.  It is a challenging problem to restore thumb flexion separately with a single muscle transfer.  Excellent finger motion can be accomplished and good restoration of elbow flexion can be achieved.  Optimal muscle resting length, and strong and appropriately located origin and insertion are factors of paramount importance for an excellent functional outcome.

      Factors associated with the morbidity and mortality of total knee arthroplasty (TKA) were studied.  Outcome data was obtained for 479 consecutive patients who underwent 618 procedures from 1998 to 2001.  114 patients underwent simultaneous bilateral TKA, 25 patients underwent staged bilateral TKA, and 340 patients underwent unilateral TKA.

     All of the significant differences between the groups occurred within the first few post-operative weeks.  No significant differences between any of the groups were found in those patients with fewer than three medical comorbidities.  In patients with three or more comorbidities, those undergoing simultaneous bilateral TKA were more likely to sustain complications with potential long term consequences compared to those undergoing two unilateral total knee replacements.  Age over 70, independent of comorbidites, was associated with an increased risk of severe complication and death only in the bilateral TKA group.

     Body mass index, the surgeon’s experience with TKA, the sex of the patient, the type of anesthesia, and the type of comorbidity, were not found to influence the outcomes between groups.

    When the costs associated with complications are accounted for, the potential cost benefit of simultaneous bilateral TKA may be less than previously estimated.

Over 25 years ago Feagin and Curl reported on the diagnosis and treatment of isolated ACL tears.  The purpose of this study is to provide long-term follow-up of this group of patients.

METHODS:  This is a retrospective, observational study of arthrotomies performed between 1964 and 1970 for isolated ACL tears.  The original 64 patients studied were identified and thirty-four patients were contacted for follow-up.  Two patients are deceased.  The average age at the time of the ACL repair was 20 years, and the average time to follow-up from the index procedure was 34 years.  Outcome measures included subsequent operations, Lysholm scores, KOOS scores, IKDC scores and SANE ratings. 

RESULTS:  Twenty patients (59%) had subsequent operations to the same knee, and 8 of 34 had operations to address persistent instability of the knee. The average Lysholm score was 70.1, average SANE score 68.9, and average KOOS score 68.8. IKDC subjective ratings were 6 normal, 12 near normal, 7 abnormal and 9 severely abnormal. IKDC symptoms ratings were 8 normal, 9 near normal, 10 abnormal and 7 severely abnormal. The average Tegner Activity Score was 3.8.

            DISCUSSION:  In this group of patients, surgical treatment of isolated ACL tears, consisting of primary repair in most cases, resulted in good functional results at two years; however, the results deteriorated by 5 years.  The data, with more than 30-year follow-up, demonstrate that even with decreased activity demands, the majority of these patients continue to have significant knee symptoms; however, a significant number of patients have had good long-term results.

Introduction:  The purpose of this study is to describe a unique application of the radial forearm free flap for coverage of lateral heel wounds frequently seen complicating open reduction and internal fixation (ORIF) of the calcaneus.

Methods:  Seven lateral heel wounds status-post ORIF of calcaneal fractures were covered with radial forearm free flaps using a technique involving passage of the pedicle of the laterally placed flap anterior to the achilles tendon to the posterior tibial artery for end to side anastomosis.

Results:  All flaps survived with good functional and cosmetic results.

Conclusions:  Flap application using this technique provides quick, reliable coverage of heel wounds with several advantages. 

     Methods:  We retrospectively reviewed the outcomes of 106 patients who had anterior elbow release for flexion and extension contractures due to several different causes from July 1975 through June 2001.  Post-operatively, 62 of the 87 patients were treated with continuous passive motion, while the other 25 were treated with splinting in extension.  The average duration of follow-up was 23 months (range 6-120months).  The average patient age was 34 years (range 13-66years).  We evaluated the outcomes using pre and postoperative radiographs, and pre and post-operative active elbow range of motion.  This measurement was recorded by the same surgeon (JRU) using the same large goniometer (47cm.)

     Results:  The mean preoperative extension was 52 degrees, which improved to 21 degrees post-operatively.  Mean flexion increased from 111 degrees to 117 degrees. The mean total arc of motion for the group increased 38 degrees (from 59 to 97 degrees).  The total arc of motion for the patients treated with CPM increased 41 degrees while the total arc of motion for those treated with extension splinting increased 27 degrees.  There were 15 complications in 14 patients (16%). The majority of these were related to temporary traction neuropathies (ulnar nerve 5, radial nerve 3, superficial radial nerve 2, posterior interosseous nerve 1, lateral antebrachial cutaneous nerve 1).  There were two infections (one superficial, one deep) both of which resolved with oral antibiotics, irrigation, and debridement.

     Conclusion:  We concluded that release of pathologically thickened anterior elbow capsule through an anterior incision for correction of diminished elbow range of motion is a safe and effective technique.  Furthermore, the utilization of continuous passive motion during the postoperative period increases total arc of motion when compared to splinting alone.

      Survey forms were mailed to all active physician members of the Duke Orthopaedic Piedmont Society, recording their collective experience with the diagnosis and treatment of acute bacterial (non-T.B.) sepsis in selected major joints in adults and children.  Experience with arthroscopy reviewed.  Experience with percutaneous pigtail catheters reviewed.

A total of 37 surgeons responded.  The survey contained General Practice Data, and Clinical Examples.  The Data was as follows:

1.  Referral to Radiology for diagnostic procedures on suspected joint infections: Never – 35%  Rarely -  30%   
     Occas -  30%     Freq.- 5%.

2.  Referral to Radiology for therapeutic procedures on suspected joint infections :  Yes -  22%    No -  78%.

3.  Preferred treatment for:

       Knee (adult): Arthroscopic I&D (94% of respondents)

       Hip (adult): Open Arthrotomy (84%)

       Hip (peds):  Open Arthrotomy (94%)

       Ankle (adult): Arthroscopic (68%), Arthrotomy (26%)  

       Shoulder (adult):  Arthroscopic (58%), Arthrotomy (39%)

       GC:  Antibiotics alone (51%), Open arthrotomy (49%)

            General Observations and Conclusions:

1.  Referral to Radiology for diagnostic and/or therapeutic procedures was not the norm for this group of surgeons.

2.  Arthroscopic drainage procedures widespread for multiple joints, except in adult and pediatric hip cases.

3.  Very limited experience with percutaneous catheters in this group, and not recommended for pediatric hip patients.

4.  Multiple aspiration technique for treatment not recommended.

5.  Principles of early diagnosis and aggressive surgical treatment supported.

      2002 STRUT/CAGE GRAFTING AFTER CERVICAL CORPECTOMY, Kenneth E. Wood, MD, Sam Chewning, MD, Jennifer Gannon, PA-C, Piedmont Healthcare, Statesville, North Carolina

      This study is a preliminary report of a new technique for interbody fusion and fixation following corpectomy of the cervical spine.  It is a retrospective review of eleven (11) cases of severe cervical disk disease.

     The objectives are to show the efficacy and safety of the use of a titanium mesh cage filled with local autograft bone taken from the corpectomy as a strut to bridge the appropriate end-plates.  The strut grafting is followed by anterior cervical plate and screws.

     Studies have shown that the use of a fibular or iliac strut graft accompanied by anterior plate and screw fixation is an appropriate fixation technique following cervical corpectomy.  In addition it has been recognized there are potential donor site problems with the use of very large iliac crest bone grafts, and there are some contouring challenges with the use of large structural allografts.  In favor of titanium cage use, Clemme and Polly as well as Brantigan and Lowery have shown that osteosynthesis and bone remodeling occur within titanium cages.

     Eleven patients with an average age of 54.5 years underwent corpectomy and strut/cage grafting.  The average follow up is 8.1 months.  Diagnoses include multi-level spondylosis, myelopathy, subluxation and stenosis.  It is stressed that the use of strut/cage grafting is not recommended for the routine disk herniation or single-level spondylosis.

     Indications include severe multi-level cervical disk disease, cervical deformity, cervicovertebral tumors and cervical myelopathy requiring corpectomy.  Several illustrative cases are shown with pre- and post-op studies.  Results include excellent – eight (8); improved – three (3); poor – zero (0).  Complications:  Arrhythmias – One (1).  Infections – Zero (0).  Hematoma – Zero (0).  Deaths – Zero (0).

     In conclusion, titanium strut/cage grafting after cervical corpectomy accompanied by anterior plate and screws in this preliminary study is shown to be a safe procedure which is successful in a small group of patients with early follow up of 8.1 months.  This procedure reflects a safe way to use allograft and avoid bone grafting and contouring problems associated with very large iliac crest grafts and allografts.  This procedure is not recommended for routine disk herniations and single-level spondylosis.