Speciality
Spotlight

 



 


Orthopaedics


 

 





  • Raikin
    SM, Landsman J.C., Alexander V.A. et al (Mount Sinai
    Med. Ctr. Cleveland, Ohio)


    Effect
    of Nicotine on the Rate and Strength of Long Bone
    Fracture Healing

    Clin. Ortho 353; 231-237, 1998

       

    This study attempts to scientifically prove that
    nicotine inhibits long bone fracture healing.

        

    Forty
    rabbits were subjected to midshaft tibial
    osteotomies and plating.
    One group was given systemic nicotine and the
    other only saline.  Radiographs were taken at 4, 6 and 8 weeks.
    At 8 weeks the rabbits were sacrificed for
    biochemical comparisons of healing.

        

    The nicotine group had significantly lag in cortical
    continuity formation.
    13% showed no clinical evidence of union,
    whereas all fractures in the control group had
    healed. In
    the biomechanical comparisons the nicotine group
    were 26% weaker in 3 point binding then the control
    groups.


          

  • EP
    Frankenburg, Goldstein SA, Bauer TW, et al (Univ of
    Michigan, Ann Arbor; Cleveland Clinic Found, Ohio)


    Biomechanical
    and Histological Evaluation of a Calcium Phosphate
    Cement

    J Bone Joint Surg Am  80-A:
    1112-1124, 1998

      

    Stable
    fixation of a comminuted fracture associated with a
    metaphysical defect is difficult.
    This study explores the use of injectable
    resorbable cement into an osseous defect to
    stabilise the fracture and maintain osseous
    integrity.

      

    72
    dogs with proximal tibial metaphysical and distal
    femoral metaphysical defects were treated with
    either cement or allograft bone.
    The dogs were assessed 24 hours to 78 weeks
    after surgery.

      

    Cement
    was shown to be osteoconductive, achieves high level
    of compressive strength rapidly.
    It is tissue compatible.
    It gradually is remodeled overtime and the
    pattern suggested gradual restoration of a
    physiologic proportion of the bone with maintenance
    of mechanical function.

         

  • Petersen
    MM, Lauritzen JB, Schwarz P, et al (Univ of
    Copenhagen)


    Effect
    of Nasal Salmon Calcitonin on Post-traumatic
    Osteopenia Following Ankle Fracture: A Randomized
    Double-blind Placebo Controlled study in 24
    Patients.

    Acta Orthop Scand 69: 347-350, 1998.

      

    Calcitonin
    inhibits bone resorption through a direct effect on
    osteoclasts and hence has been used to treat bone
    diseases characterised by increased bone turnover.
    Its effect on postfracture ostopenia has been
    studied.

       

    24
    patients with internally fixed ankle fractures were
    assigned to 3 months treatment with 200 i.u.sCT
    or placebo. Dual
    photon absorptiometry was performed after surgery
    after 1 week, 1.5 month, 3 months and 6 months to
    establish bone mineral content (BMC).

      

    It
    was found that 3 months after the fracture, BMC in
    the injured legs had declined by 14% in the placebo
    group and 2.1% in the sCT group (non-significant
    difference).  In
    the healthy legs, 6 weeks after the fracture BMC
    reduction was 4.6% in the placebo group and 7.4% in
    sCT group. Nasal
    sCT does not significantly reduce post-fracture
    osteopenia, but significantly effects the healthy
    leg.


         

  • Joakimsen
    RM, Fonnebo V, Magnus JH, et al (Univ of Tromso,
    Norway;  Natl
    Inst. of Public Health, Norway)


    The
    Tromso Study: Physical Activity and the Incidence of
    Fractures in a Middle-aged Population.

    J Bone Miner Res 13: 1149-1157, 1998

      

    The
    relationship between physical activity and bone mass
    has been demonstrated.
    This study explores the effect of physical
    activity at work, and during leisure time and change
    of this activity on the incidence of fractures.

        

    1435
    non-vertebral fractures from 1988 to 1995 from a
    single hospital were reviewed.
    The fracture incidence at all locations
    increased with age. In
    men, the fracture incidence decreased or was
    independent of age. In
    low-energetic fractures, men had incidence of 55.2%
    and women 74.4%. Gender
    differences were most notable in upper extremities.

       

    Below
    45 years there was no appreciable relationship
    between physical activity and fractures.
    Above 45 years active people had a lower
    incidence than sedentary ones in the weight bearing
    bones but not in non-weight bearing bones.

          

  • Velmahos
    GC, Arroyo H, Ramicone E, et al (Univ of Southern
    California, Los Angeles; Los Angeles County,USC Med
    Ctr)


    Timing
    of Fracture Fixation in Blunt Trauma Patients with
    Severe Head Injuries.

    Am J Surg 176: 324-330, 1998.

      

    Early
    fracture fixation is thought to reduce postoperative
    morbidity by permitting early mobilisation and
    decreasing the release of harmful inflammatory
    mediators. This
    approach is disputed in severe head trauma.

      

    A
    retrospective study of 47 consecutive patients of
    severe head injury with long bone fracture were
    reviewed. 22
    had undergone fixation within 24 hours and 25 at a
    mean of 143 hours after trauma.

      

    The
    timing of the fracture fixation did not affect
    morbidity, mortality or neurologic outcome.
    The treatment of patients with severe head
    injuries should be based on sound individual
    clinical assessment rather than mandatory policies
    on long bone fracture fixation.

        

  • Van
    der Sluis CK, Timmer HW, Eisma WH, et al (Univ Hosp
    Groningen, The Netherlands)


    Outcome
    in Elderly Injured Patients: Injury Severity Versus
    Host Factors.

    Injury 28: 588-592, 1997.

       

    The
    growing proportion of elderly in the Western world
    has led to an increase in the health care costs.
    One third of the total cost of trauma care is
    spent on elderly patients.
    There is debate now over whether treatment of
    severely injured elderly patients is worthwhile.
    A study was therefore conducted to find out
    the difference in outcomes of 42 elderly patients
    with severe trauma with 76 elderly patients with
    less severe injuries.

       

    The
    results were as follows.
    In hospital mortality was 31`% in severe
    trauma as against 3% in less severe trauma.
    34% of severe trauma patients were sent home,
    while 65% of less severe trauma were sent to a
    nursing home. The
    functional outcome at the end of 1 year was better
    in severe trauma. Host
    factors were better determinants of long term
    survival than injury severity. 
    “Active” persons had a better
    prognosis than “inactive” persons.

       

    Age,
    preinjury medical status, and sex were the most
    reliable predictors of long term survival in the
    elderly patients. Young
    active females had the best chance of survival.


         

  • Lang
    GJ, Richardson M, Bosse MJ, et al (Univ of
    Wisconsin, Madisonp Carolinas Med Ctr, Charlotte,
    NC)


    Efficacy
    of Surgical Wound Drainage in Orthopaedic Trauma
    Patients: A Randomized Prospective Trial.

    J. Orthop Trauma  12:
    348-350, 1998.

       

    The
    use of drains in contaminated or purulent wounds is
    widely accepted. Their
    use in clean surgical wounds is not well documented.

       

    202
    patients in a level I orthopaedic trauma service
    were randomized in a prospective trial. 100 patients received a drain and 102 did not.

       

    The
    two groups were comparable in injury severity,
    systemic disease, age, bodyweight, physical status
    and estimated blood loss.
    They did not differ greatly in wound
    drainage, edema, haematoma, erythema, dehiscence,
    infection or the need for repeat surgery or
    hospitalisation.

        

    The
    use of drains has no apparent benefits in clean
    wounds.

          

  • Palmer
    S, Fairbank AC, Bircher M (Queen Mary’s Univ,
    Roehampton, England; Orthopaedic Training Scheme,
    London; St. George’s Hosp, London)


    Surgical
    Complications and Implications of External Fixation
    of Pelvic Fractures

    Injury 28: 649-653, 1997.

        

    External
    fixation of severe pelvic fractures is an accepted
    modality of treatment if it is applied quickly and
    safely. This
    study examines the complications following this
    treatment and the methods of minimising them.

       

    It
    is a prospective of study of 23 patients. 
    The results were evaluated from patient
    records, radiographs and CT scans.

       

    The
    complication rate was 47%.
    This high rate increases mortality, morbidity
    and interferes with the management of the severely
    ill patients. The
    majority of these complications were related to pin
    placement and pin bone interfaces. Accurate placement of the fixators is likely to reduce the
    complication rate.

          

  • Dujardin
    FH, Hossenbaccus M, Duparc F, et al (Univ of Rouen
    Hosp, France)


    Long-term
    Functional Prognosis of Posterior Injuries in
    High-energy Pelvic Disruption

    J Orthop Trauma  12 :
    145-151, 1998.

        

    High
    energy pelvic disruption with posterior lesions have
    poor long term results.
    This study examines functional result in a
    retrospective study of 88 patients over a period of
    10 years.

         

    28
    patients with anteroposterior compression fractures,
    an external fixation was done immediately to control
    bleeding or later on as definitive treatment.
    6 patients had anterior internal fixation
    with a plate to repair symphyseal disruption.
    Vertical shear injuries were stabilised with
    tibial traction.

        

    Radiographs
    of the pelvic ring were taken for evaluation of
    treatment.

         

    The
    best prognosis were seen in iliac wing fractures
    with sacroiliac dislocation.
    Conservative methods produced unsatisfactory
    results, as also pure SI lesions.

        

    They
    conclude that the functional result depends on the
    injury pattern and quality of reduction.

         

  • Blundell
    CM, Parker MJ, Pryor GA, et al (Peterborough
    District Hosp, England)


    Assessment
    of the AO Classification of Intracapsular Fractures
    of the Proximal Femur.

    J Bone Joint Surg Br 80-B: 679-683, 1998.

       

    This study assesses the intraobserver and the
    interobserver reproducibility and predictive
    accuracy of the AO system of the classifying
    intracapsular fractures of the proximal femur.

       

    Five
    clinicians independently and blindly evaluated
    radiographs of 68 fractures as per the AO system. This process was repeated after 8-10 weeks.
    The results were compared with the method of
    treatment and the incidence of nonunion to estimate
    prognostic value.

        

    Both
    the interobserver and the intraobserver reliability
    were excellent.

          

  • Pandey
    R, McNally E, Ali A,e t al (John Radcliffe Hosp,
    Oxford, England)


    The
    Role of MRI in the Diagnosis of Occult Hip Fractures

    Injury 29: 61-63, 1998.

       

    The
    diagnosis of a hip fracture is not always easy.
    Misdiagnosis affects the prognosis
    unfavourably. This
    study assesses the usefulness of MRI in clinically
    suspect but radiologically negative cases.

        

    33
    of 770 such patients had an MRI done within 48 hours
    of admission. 39%
    had a fractured neck of femur, 15% had
    intertrochanteric fractures and 11% had other
    fractures around the hip.
    One patient had a tumour. 10 patients (33%)
    had no fracture.

        

    It
    is recommended that all patients with significant
    hip pain after injury and negative radiographs
    should undergo MRI.

          

  • Nikolajsen
    L, Ilkjaer S, Jensen TS (Univ Hosp of Aarhus,
    Denmark)

    Effect of Preoperative Extradural Bupivacaine and Morphine on Stump
    Sensation in Lower Limb Amputees.

    Br. J Anaesth 81: 348-354, 1998.

        

    This is a randomized double blind study to
    determine if postoperative pain can be prevented by
    the use of preoperative use of extradural
    bupivacaine and morphine.

       

    The
    pressure pain threshold, touch and pain detection
    thresholds, thermal sensibility, allodynia and
    windup like pain were evaluated before amputation
    and 1 week and 6 months after amputation.

        

    The
    results indicate that preoperative extradural
    anaesthesia did not prevent postoperative
    hyperexcitability in the stump and had no effect on
    long term hyperalgesia, allodynia or wind-up like
    pain in amputees.

          

  • Larsson
    J, Agardh C-D, Apelqvist 
    J, et al (Univ Hosp, Lund, Sweden)

    Long Term Prognosis After Healed Amputation in Patients with Diabetes.

    Clin Orthop 350: 149-158, 1998.

        

    This
    is a prospective study of 220 patients with diabetes
    with foot ulcers subjected to amputation after
    primary treatment. 136
    had a below knee (BK) and 84 patients had an above
    knee (AK) amputation.
    Of these 29 patients died before healing, 5
    patients with BK amputation underwent after knee
    amputation. 2
    patients did not heal and were excluded.
    The remaining 189 patients were followed up
    for 6.3 years (range, 1-10.8 years).

       

    The
    time for healing was an average of 29 weeks for BK
    amputations and 8 weeks for AK amputations.

       

    The
    mortality at 1, 3 and 5 years was 15%, 38% and 68%
    respectively. The
    rate of new amputations were required at 1, 3 and 5
    years was 14%, 30% and 49% respectively.

        

    It
    is concluded that diabetics who underwent an AK
    amputation had a higher mortality rate of new above
    knee amputation and a lower rehabilitation potential
    than those undergoing BK amputations.

          

  • Legro
    MW, Reiber GD, Smith DG, et al (VA Puget Sound
    Health Care System, Seattle; Univ of Washington,
    Seattle; Prosthetics Research Study, Seattle).


    Prosthesis
    Evaluation Questionnaire for Persons with Lower Limb
    Amputations: Assessing
    Prosthesis-related Quality of Life.

    Arch Phys Med Rehabil 79: 931-938, 1998.

       

    A
    self administered questionnaire was developed for
    the evaluation of prosthetic care by quantifying the
    evaluation of individuals with amputations with
    regard to their prosthesis and their quality of life
    (PEQ- Prosthesis evaluation questionnaire).
    It consisted of 10 scales regarding
    prosthesis function mobility, psychosocial
    experience and wellbeing.

       

    92
    patients completed the questionnaire.
    The internal consistency was high for all
    scales except “transfers”.
    Scores were stable over time.

        

    The
    scales showed good psychometric properties.
    It is a good tool for evaluation of
    prosthetic care.

          

  • TM
    Best, B Loitz-Ramage, DT Corr, et al (Univ of
    Wisconsin, Madison)


    Hyperbaric
    Oxygen in the Treatment of Acute Muscle Stretch
    Injuries: Results in an Animal Model.

    Am J Sports Med 26:367-372, 1998.

        

    The effect of Hyperbaric Oxygen (HBO) therapy
    were studied in a rabbit model of acute muscle
    stretch injury.

       

    Method
    : A standardised partial stretch injury of tibialis
    anterior muscle-tendon unit was created in 18
    rabbits. The
    opposite limb was used as control starting 24 hours
    after the injury, one group of animals received HBO
    therapy (oxygen levels >95% at 2.5atm, 60 min/day
    for 5 days). The
    other group received no treatment.
    Tissue healing, functional and morphological
    indicators of recovery were assessed after 7 days.

        

    Results:
    The functional deficit was significantly reduced in
    the HBO treated group. 
    The percentage of ankle isometric torque on
    the injured side was 15% in the treated group versus
    48% in the uninjured group.
    Surgical wound healing was quicker and on
    histology the HBO treated group showed reduced
    cellularity and fiber damage.

       

    Conclusion:
    HBO therapy may help to hasten recovery after muscle
    stretch injury.

          

  • JM
    Beiner, P Jokl, J Cholewicki, et al (Yale Univ, New
    Haven, Conn)


    The
    Effect of Anabolic Steroids and Corticosteroids on
    Healing of Muscle Contusion Injury.

    Am J Sports Med  27: 2-9,
    1999.

       

    The
    effects of nandrolone, an anabolic steroid and
    methylprednisolone acetate (a corticosteroid) on
    muscle healing were studied in a rat model.

        

    Methods: 
    The muscle was injured using a drop-mass
    technique. Active
    contractile tension was measured in each muscle and
    histologic analysis was performed to determine
    healing.

        

    Findings: 
    With corticosteroids on day 2, there was
    significant improvement in the twitch and tetanic
    strength, but by day 7, this effect was reversed and
    on day 14, total degeneration was observed in the
    muscle.  There
    was no significant effect in the anabolic steroid
    group.

       

    Conclusion:
    Corticosteroids may be beneficial in the short term
    but results in irreversible damage in the long term.
    Anabolic steroids may facilitate healing of
    muscle contusion injury.

          

  • JE
    Houglum (South Dakota State Univ, Brookings)


    Pharmacologic
    Considerations In the Treatment of Injured Athletes
    with Non-Steroidal Anti-inflammatory Drugs.

    J.Athletic Train  33;
    259-263. 1998

       

    A
    thorough understanding of the pharmacodynamics of
    NSAIDs is essential to optimise the use of these
    drugs in the treatment of sports injuries.

       

    The
    primary mechanism of action is through the
    inhibition of arachidonic acid metabolism.
    This has implications for potential adverse
    effects and drug interactions particularly those
    associated with clotting pathway, kidney function
    and gastrointestinal side effects.
    The extent of injury, drug dosing and
    duration of therapy and the specific agent used can
    affect the rate of healing and in relief from pain
    and inflammation.

       

    It
    is recommended that only one NSAID should be used.
    It should be taken with food.
    It should be stopped as soon as the desired
    therapeutic effect is obtained.
    The use of 2 or more NSAIDs provide no
    increased benefit and may increase toxic effects.

         

  • KA
    Hildebrand, SL-Y Woo, DW Smith, et al (Univ of
    Pittsburgh, Pa)


    The
    Effects of Platelet-derived Growth Factor-BB on
    Healing of the Rabbit Medial Collateral Ligament: An
    In Vivo Study.

    Am J Sports Med 26: 549-554, 1998.

       

    In a previous in-vitro study the authors have
    shown that platelet derived growth factor-BB
    promoted fibroblast proliferation and that
    transforming growth factor B1 promoted matrix
    synthesis. These
    factors were now used in-vivo studies.

       

    Methods:
    37 rabbits were divided into 5 groups.
    2 groups were given high or low dose growth
    factor-BB, 2 groups were given in addition a high or
    low dose of growth factor B1 and one group was given
    fibrin sealant only (used as a delivery system).
    The rabbits were sacrificed at 6 weeks and
    biomechanical and histologic analysis of healing was
    performed.

       

    Results:
    The values for ultimate load, energy absorbed to
    failure and ultimate elongation were 1.6, 2.4 and
    1.6 times higher in higher doses of growth factor
    BB. The
    addition of growth factor-B1 did not increase the
    structural properties of the complex.

        

  • KA
    Karlson (Univ of Michigan, Ann Arbor)


    Rib
    Stress Fractures in Elite Rowers: A Case Series and
    Proposed Mechanism.

    Am J Sports Med  26:
    516-519, 1998.

       

    Ten
    elite rowers with 14 stress fractures were
    interviewed (3 males, 7 females).
    Sex, date of injury, side rowed, weight
    class, fracture location, training phase and method
    of diagnosis evaluated.

      

    Results
    : Fractures occurred on the anterior to
    posterolateral aspect of ribs 5-9. 
    11 were diagnosed by bone scan, 2 by plain
    radiographs and 1 by clinical observation.
    The onset was slow with several days or weeks
    of discomfort followed by sharp pain that worsened
    at the end of the arm pull through phase.

       

    Conclusion:
    Rib stress fractures appear to be the result of the
    pull of the serratus anterior and external oblique
    muscles on the rib which causes repetitive bending
    of the rib. Therefore,
    the incidence can be reduced by decreasing the force
    of pull on the rib by the serratus anterior and the
    external oblique muscle or both.

         

  • BP
    Boden, DT Kirkendall, Jr Garrett WE (Duke Univ,
    Durham,NC)


    Concussion
    Incidence in Elite College Soccer Players

    Am J Sports Med 26: 238-241, 1998.

       

    The potential for head injuries among soccer
    players and its relation to neuropsychological
    deficits have long been debated.
    The incidence of concussion in elite college
    soccer players has been assessed.

      

    Methods:
    Seven men’s and 8 women’s soccer teams were studied
    for 2 seasons, and results documented.

       

    Findings:
    29 concussions were diagnosed in 26 athletes (17men
    and 12 women). Concussions
    occurred from contact with :

      

    1)                
    an opponent’s head in 28%

    2)                
    an elbow in 14%

    3)                
    a knee in 3%

    4)                
    a foot in 3%

    5)                
    a ball in 24%

    6)                
    ground in 10%

    7)                
    concrete side lines 3%

    8)                
    goal post in 3%

    9)                
    combination in 10%

      

    69%
    occurred during games.
    None of them occurred during intentional
    heading of the ball 72% of concussions were grade 1
    and 28% were grade 2.

       


    Conclusions:
    Concussion occurs more commonly in soccer than has
    been believed. Such injuries may result in long term neuropsychological changes.

         

  • JA 
    Gastel, MA Palumbo, MJ Hulstyn, et al (Brown
    Univ, Providence, Rl)


    Emergency
    Removal of Football Equipment: A Cadaveric Cervical
    Spine Injury Model.

    Ann Emerg Med 32: 411-417, 1998.

      

    Purpose: The proper early management of
    suspected cervical spine injuries in football
    players is critical.
    EMT’s are trained to remove the helmet to
    avoid hyperflexion of the neck but sports medicine
    experts recommend against this practice.
    A cadaver study was conducted to analyse the
    effects of a football helmet or shoulder pads on
    alignment of the unstable cervical spine.

       

    Methods:
    The study included 8 cadavers of average age 73
    years. A
    simulated bilateral facet dislocation was created at
    C5-C6 motion segment.
    Lateral x-rays were taken before and after
    injury with cadaver wearing (1) no equipment (2) a
    helmet only (3) shoulder pads only and (4) a helmet
    and shoulder pads. The
    effect of the alignment of the cervical spine was
    studied.

      

    Results:
    Lordosis was decreased by 9.6 degrees with helmet
    only and increased 13.6 degrees with shoulder pads
    only.

       

    After
    destabilisation of the cervical spine, C5-C6 forward
    angulation was increased by 16.5 degrees with helmet
    only and the posterior disc space height was
    increased by 3.8mm and dorsal element distraction by
    8.3 mm. In
    the other 3 indications there were no significant
    differences.

      

    Conclusions:
    The results suggest that the helmet and shoulder
    pads should be left in place until the patient
    reaches a hospital unless CPR is required.

         

  • WF
    Donaldson III, WC Lauerman, B Heil, et al (Univ of
    Pittsburgh, Pa)


    Helmet
    and Shoulder Pad Removal From a Player With
    Suspected Cervical Spine Injury: A Cadaveric Model.

    Spine 23: 1729-1733, 1998.

      

    Objective: Cervical spine injuries can result in
    quadriplegia. The
    problem of removing the helmet and shoulder pads of
    an injured football player has been debated.
    A cadaver model was used to study how much
    motion occurs with 2 types of injuries when a helmet
    and shoulder pads are removed.

      

    Methods:
    Transoral osteotomy at waist of odontoid process was
    done to render C1-C2 unstable in 3 cadavers and in
    another 3 cadavers, the interspinous ligaments, the
    facet capsules, posterior longitudinal ligaments and
    posterior one third of the disc were sectioned at
    C5-C6. Under
    fluoroscopic visualization, 4 people removed the
    helmets by first removing the facemask, then the
    chinstrap and then the ear-pieces.
    The shoulder pads were then removed. 
    Maximum displacements were recorded and
    analysed.

       

    Results:
    Instability at C2 resulted in a change in angulation
    of 5.47 degrees distraction of 2.98 mm and a change
    in space available for the cord by 3.91 mm when the
    helmet was removed. With
    removal of shoulder pads, the change in angulation
    was 2.9 degrees distraction 1.76mm and the change in
    the space available for the cord 2.64 mm.

      

    Conclusions:
    A significant amount of movement can occur in an
    unstable cervical spine when the helmet and shoulder
    pads are removed. Therefore,
    it would be unwise to try to remove the helmet and
    shoulder pads before transportation to hospital.

        

  • MJ
    Wetzler, T Akpata, W Laughlin, et al (American
    Orthopaedic Rugby Football Assoc, Washington
    Crossing, Pa; South Jersey Orthopedic Associates,
    Voorhees, NJ: Rugby Magazine, 
    New York; et al )


    Occurrence
    of Cervical Spine Injuries During the Rugby Scrum

    Am J Sports Med 26: 177-180, 1998.

      

    Methods:
    Data on 62 injured players was compiled from oral
    and written reports and from medical records.

       

    Results: 
    Between 1970 and 1996, 36 (58%) players
    sustaining a cervical spine injury were injured
    during a scrum with 23(64%) occurring during the
    engagement and 13 (36%) during the collapse of the
    scrum.

        

    Conclusion:
    Cervical spine injuries to rugby players occur more
    frequently during the engagement phase of the scrum,
    to hookers, and to lower level players.

      

  • WAA
    Swen, JWG Jacobs, PR Algra, et al (Medisch Centrum Alkmaar, The Netherlands, niv Med Ctr, Utrecht, The Netherlands)


    Sonography and Magnetic Resonance Imaging Equivalent for the Assessment of Full-Thickness Rotator Cuff Tears



    Arthritis Rheum 42:2231-2238, 1999


      


    The common causative factor in frozen shoulder is the diagnosis by the Orthopaedic surgeons of Rotator Cuff Tear. There does not seem to be any good confirmatory test for Rotator cuff tear. After various investigative procedures, the two most useful tests were sonography and MRI. Of these two, sonography is much cheaper and is quite satisfactory.

       

  • Chung
    CB, Robertson JE, Cho GJ, et al [Univ of California,
    San Diego; Scripps Clinic Med Group, La Jolla, Calif]


    Gluteus Medius Tendon Tears and Avulsive
    Injuries in Elderly Women: Imaging Findings in Six
    Patients


    AJR
    173:351-353,1999


     

    Although
    common, lateral hip pain can be a difficult
    to-diagnose problem. Common causes include
    arthritis, tendinitis, and bursitis; less common are
    syndromes such as abductor muscle strain and
    myofascial pain syndromes.

     

    Surgical
    repair provides improvement but not complete relief
    of the patient’s symptoms 
    in most instances.

       

  • Kannus
    P, Natri A, Paakkala T, et al [UKK Inst, Tampere,
    Finland; Tampere Univ, Finland]


    An Outcome Study of Chronic Patellofemoral
    Pain Syndrome : Seven Year Follow-up of Patients in
    a Randomized, Controlled Trial


    J
    Bone Joint Surg Am 81-A:355-363, 1999


     

    The
    etiology, pathogenesis, and outcome of
    patellofemoral pain syndrome are not well understood.

     

    For
    6 weeks, 53 patients [28 women], with an average age
    of 27 years, with unilateral patellofemoral pain
    syndrome received intensive 3 
    isometric quadiceps exercises once daily and
    oral nonsteroidal anti-in-flammatory medication for
    20 days [group A], the same nonoperative treatment
    plus 5 intra-articular injections of lidocaine
    [group B], or the same nonoperative treatment plus 5
    intra-articular injections of glycosaminoglycan
    polysulfate [ group C].

     

    Nonoperative
    treatment was successful in maintaining function and
    dealing with pain in most patients with chronic
    patellofemoral pain syndrome.

      

  • Harwin
    SF {Beth Israel Med Ctr, New York]


    Arthroscopic Debridement for
    Osteoarthritis of the Knee: Predictors of Patient
    Satisfaction


    Arthroscopy
    15: 142-146, 1999

     

    Arthroscopic
    debridement is now commonly performed in patients
    with degenerative knees. There is no evidence that
    debridement affects the pathologic process; however,
    some patients appear to benefit in terms of pain
    relief and functional gains, possibly delaying or
    avoiding more extensive surgery.

     

    The
    results are best in younger patients with no
    previous surgery and an angular deformity of less 50. 
    Approximately 85% of procedures are
    satisfactory when the axial alignment approaches
    normal and only 25% when there is a greater than 50
    deviation from the normal mechanical axis.

       

  • Cheng
    JCY, Tang N [ Prince of Wales Hosp, Hong Kong]


    Decompression and Stable Internal Fixation
    of Femoral Neck Fractures in Children Can Affect the
    Outcome


    J
    Pediatr Orthop 19: 338-343, 1999


     

    The
    incidence of AVN decreases with early aggressive
    decompression or internal fixation of the fracture,
    or both.

     

    Prevention
    of any cases of AVN by treating the fracture a bit
    more quickly than we may be used to will save a
    teenager from a lifetime of hip disability.

        

  • Infection


    Kocher
    MS, Zurakowski D, Kasser JR [Harvard Med School,
    Boston]

    Differentiating Between Septic Arthritis
    and Transient Synovitis of the Hip in Children: An
    Evidence-Based Clinical Prediction Algorithm


    J
    Bone Joint Surg Am 81-A: 1662-1670, 1999


     

    Differentiating
    between septic arthritis and transient synovitis of
    the hip in children can be difficult, because they
    have similar signs and symptoms.

     

    An
    infection of the hip in a child is an orthopedic
    emergency, requiring a quick workup during a period
    of hours, not days.

       

  • Miscellaneous


    Isogai
    N, Landis W, Kim TH, et al [Harvard Med School,
    Boston]

    Formation of Phalanges and Small Joints by
    Tissue-Engineering


    J
    Bone Joint Surg Am 81-A:306-316, 1999


     

    Children
    with severely traumatized or congenitally abnormal
    joints may require multiple replacement joints as
    they grow.  The
    engineering of new tissue by cell transplantation,
    where cells are placed on biodegradable polymer
    matrices, provides a novel approach to tissue in
    growth. Once the polymer is degraded, it leaves
    behind only naturally regenerated tissue.

     

    Growth
    of cell types derived from bovine periosteum,
    cartilage, and tendon used to from a joint.

     

    Fresh
    bovine periosteum was wrapped around a copolymer of
    polyglycolic and poly-L-lactic acid. Calf shoulder
    chondrocytes and tenocytes were used as sources of
    other cells.

     

    The
    composite structure was sutured in vitro to form
    constructs that created models of a human distal
    phalanx and a distal interphalangeal joint.

     

    The
    tissues were implanted subcutaneously in athymic
    mice.

     

    Twenty
    weeks after implantation of the construct into
    athymic mice, new human phalangeal jointed tissue
    had formed.

     

    None
    of the implants showed signs of inflammation.

     

    Well
    –defined whole-joint structures can be grown on
    biodegradable polymeric vehicles by using
    polyglycolic acid alone or with poly-L-lactic acid
    copolymer.

     

    The
    use of an absorbable carrier for the cell lines has
    worked well, and the carrier used by these authors
    can be shaped readily into an accurate anatomic
    representation of the part[s] needed.

     

  • Hagino
    T, Hamada Y [ Yamanashi Med Univ, Japan]


    Accelerating Bone Formation and Earlier
    Healing After Using Demineralized Bone Matrix for
    Limb Lengthening in Rabbits


    J
    Orthop Res 17: 232-237, 1999


     

    Prolonged
    fixation during distraction osteogenesis and callus
    distraction can lead to clinical problems.
    Accleration of callus formation may alleviate
    the problem of delayed bone formation.

     

    Use
    of the demineralized bone matrix shortened the
    latency period, prevented delay in bone formation,
    and shortened the fixator-wearing period. 
    Complete healing was observed at 1 year.

     

  • White
    RE Jr, Allman JK, Trauger JA, et al [New Mexico
    Orthopaedic Associates, Albuquerque; Advantage
    Orthopedics & Sports Medicine, Portland, Ore]


    Clinical Comparison of the Midvastus and
    Medial Parapatellar Surgical Approaches


    Clin
    Orthop 367: 117-122, 1999


     

    The
    most common surgical approach for TKA is the medial
    parapatellar. More
    recently, the midvastus-splitting approach has come
    into use. The
    advantage of the midvastus approach is that it does
    not violate the quadriceps, tendon proximal to its
    insertion into the patella.

     

    The
    knees which were operated on by the midvastus
    approach required fewer lateral retinacular
    releases, were less painful at 8 days and at 6
    weeks, and had a higher ability to straight leg
    raise at 8 days.

      

  • Matsuda
    S, Miura H, Nagamine R, et al [ Kyushu Univ,
    Fukuoka, Japan]


    Changes in Knee Alignment After Total Knee
    Arthroplasty


    J
    Arthroplasty 14: 566-570, 1999


     

    Accurate
    alignment is an important key to the success of TKA.

     

    This
    contribution does underscore the absolute necessity
    of restoring and maintaining the mechanical axis at
    the time of the joint replacement to gain a higher
    likelihood of long-term success.

      

  • Shelbourne
    KD, Davis TJ, Patel DV [ Methodist Sports Medicine
    Ctr, Indianapolis, Ind]


    The Natural History of Acute, Isolated,
    Nonoperatively Treated Posterior Cruciate Ligament
    Injuries: A Prospective Study


    Am
    J Sports Med 27: 276-283, 1999


     

    The
    authors’ experiences suggest that the results
    achieved with surgical repair are similar to those
    of nonoperative treatment.

     

    The
    likelihood of returning to a sport was unrelated to
    the amount of posterior laxity.

     

    This
    prospective study suggests that isolated,
    nonoperatively treated PCL injuries generally heal
    with some degree of residual knee laxity; which does
    not increase over follow-up.

       

  • Taranow
    WS, Bisignani GA, Towers JD, et al [ Univ of
    Pittsburgh, Pa]



    Retrograde
    Drilling of Osteochondral Lesions of the Medial
    Talar Dome


    Foot
    Ankle Int 20: 474-480, 1999


     

    When
    ankle pain caused by osteochondritis dissecans [OCD]
    of the talar dome fails to respond to nonoperative
    treatment, surgery is indicated.


     

    A
    new arthroscopic retrograde drilling technique for
    the treatment of medial osteochondral lesions was
    reported.


     

    Unlike
    traditional surgical techniques for management of
    OCD of the talar dome, this operation preserves
    intact articular cartilage.


     

    This
    pathology can be very difficult to expose and in the
    past required osteotomy of the medial malleolus when
    involving the medial talus.


     

    The
    attractiveness of addressing this arthoscopically
    is, therefore obvious.

        

  • Baker
    CL Jr, Morales RW [Hughston Clinic, PC, Columbus, Ga]



    Arthroscopic
    Treatment of Transchondral Talar Dome Fractures : A
    Long-term Follow-up Study


    Arthroscopy
    15: 197-202, 1999


     

    With
    arthroscopic treatment of transchondral talar dome
    fractures, lesions can be visualized accurately and
    debrided with less postoperative morbidity and
    earlier mobilization than arthrotomy.


     

    Transchondral
    talar dome fracture treatment with arthroscopic
    debridement and curettage yields a predictably high
    percentage of successful outcomes.


     

    Morbidity
    associated with this procedure is low.


     

    Both
    medial and lateral lesions were readily addressed,
    so the value of avoiding medial malleolar osteotomy
    associated with the medial lesions is particularly
    attractive.

     

  • Huang
    P-J, Fu Y-C, Cheng Y-M, et al [Kaohsiung Med
    College, Taiwan, Republic of China]



    Subtalar
    Arthrodesis for Late Sequelae of Calcaneal
    Fractures: Fusion in Situ Versus Fusion With Sliding
    Corrective Osteotomy


    Foot
    Ankle Int 20: 166-170, 1999


     

    Subtalar
    arthritis most occurs as a late sequela of intra-articular
    calcaneal fractures. Subtalar arthrodesis is used to treat not
    only acute calcaneal fractures but also the residual
    subtalar joint pain.


     

    Calcaneal
    fractures are also associated with loss of heel
    height and widening of the heel, which suggests that
    calcaneal corrective osteotomy could be pSubtalar
    arthritis most occurs as a late sequela of intra-articular
    calcaneal fractures. Subtalar arthrodesis is used to treat not
    only acute calcaneal fractures but also the residual
    subtalar joint pain.


     

    Calcaneal
    fractures are also associated with loss of heel
    height and widening of the heel, which suggests that
    calcaneal corrective osteotomy could be performed
    along with subtalar arthrodesis.

      

    Good
    results are reported from subtalar fusion combined
    with sliding corrective osteotomy.


     

    The
    corrective osteotomy does appear appropriate for
    pients with a – banana – shaped calcaneal malunion.


     

    Distraction
    subtalar arthrodesis might be a better choice for
    patients with tibiotalar impingement causing ankle
    pain.

     

  • Wolfe
    SW, Pike L, Slade JF III, et al [Yale Univ, New
    Haven, Conn]



    Augmentation
    of Distal Radius Fracture Fixation with Coralline 
    Hydroxyapatite Bone Graft Substitute


    J
    Hand Surg [Am] 24A:816-827, 1999


     

    Corralline
    hydroxyapatite [CHA], an alternative to bone graft,
    has a pore structure and biomechanical properties
    similar to human cancellous bone.


     

    Distal
    radius fractures treated with external fixation and
    Kirschner [K] wires were implanted with CHA bone
    graft as a substitute for autogenous bone graft.


     

    CHA
    effectively maintained articular surface reduction
    in combination with external fixation and K wires.
    The safety profile of CHA was comparable to that of
    other forms of treatment.


     

    These
    methods combine limited open reduction and internal
    fixation [using small plates, K wires, or both] with
    bone grafting of the metaphyseal defects to support
    the articular surface and external fixation. Autogenous iliac 
    crest bone grafting has been considered the
    gold standard for such procedures, but, no doubt, is
    associated with increased morbidity.


     

    The
    interest in borne graft substitutes for such
    procedures has proportionally increased along with
    advocates of hybrid fixation as a treatment
    alternative.

      

  • Garcia-Elias
    M, Lluch AL, Farreres, A, et al [ Institut Kaplan
    and the Hosp Clinic I Provincial, Barcelona; Hosp
    Gen de Catalunya, Sant Cugat del Valles, Spain;
    Institut Francias de Chirurgie de la Main, Paris]


    Resection
    of the Distal Scaphoid for Scaphotrapeziotrapezoid
    Osteo-arthritis

    J Hand Surg [Br] 24B:448-452,
    1999

     
    Osteoarthritis of the
    scaphotrapeziotrapeziod [STT] joint is more common in
    older women, because treatment by STT fusion can lead
    to painful nonunion and
    radioscaphoid impingement, Linschied et al,
    recommended minimal resection of the distal scaphoid
    and interposition of tendon tissue, a modified
    excisional arthroplasty.
     
    No
    patients had pain or functional discomfort after
    surgery.  the grip and pinch
    strength improved.
     
    Excision of the distal scaphoid
    in patients with STT osteoarthritis results in relief
    of pain and functional disability.
     

  • Surgical
    Techniques

    Cortet B, Cotton A, Boutry N, et
    al [Univ Hosp of Lille, France]
    Percutaneous Vertebroplasty in
    the Treatment of Osteoporotic Vertebral Compression
    Fractures: An Open Prospective Study

    J Rheumatol 26: 2222-2228,
    1999

     
    Polymethylmethacrylate [PMMA]
    vertebroplasty is a new percutaneous procedure that
    can relieve pain and strengthen weakened vertebral
    bodies. It might also be useful for the treatment of
    painful osteoporotic compression fractures.
     
    All patients underwent
    vertebroplasty, consisting of posterolateral or
    transpedicular injection of PMMA under fluoroscopic
    guidance.
     
    Vertebroplasty is a useful
    treatment for patients with severe and persistent pain
    resulting from osteoporotic vertebral fractures. 
    The procedure offers prompt pain relief with no
    adverse effects.
     
    The mechanism of action of
    vertebroplasty is unknown. Mechanical, thermal,
    vascular, and chemical theories have been
    postulated.
     
    Other investigators have
    assessed the mechanical properties of various cements
    and found significantly less stiffness with
    Cranioplastic than with Simplex P and Osteobond.
     
    Vertebroplasty has shown
    promising early results for treating other painful
    lesions of the vertebral body including osteolytic
    metastases and multiple myeloma.
     
    There were no clinically
    significant adverse effects, but there was leakage of
    cement outside of the vertebral body in 65% of the
    vertebrae.
      

  • Hurlbert RJ, Theodore N, Drabier
    JB, et al [Univ of Calgary, Alta; St Joseph’s Hosp,
    Phoenix, Ariz]
    A
    Prospective Randomized Double- Blind Controlled Trial
    to Evaluate the Efficacy of an Analgesic Epidural
    Paste Following Lumbar Decompressive Surgery

    J Neurosurg : Spine 90: 191-197,
    1999

     
    Pain management after lumbar
    surgery currently relies on systemic narcotics, which
    carry significant side effects and can delay, return
    to activities.
     
    An
    analgesic paste containing morphine and
    methylprednisolone was evaluated for its ability to
    control postoperative pain after lumbar spine
    decompression.
     
    Applied directly to the dura just
    before wound closure, an analgesic epidural paste can
    significantly improve pain control after lumbar spine
    decompressive surgery.

     
    Analgesic paste is a safe and
    effective treatment that may become a new standard of
    care for patients undergoing lumbar decompression and
    other surgical procedures.
     
    Surgeons frequently underestimate
    and undertreat postoperative pain.
     
    A
    safe and effective local agent capable of providing
    sustained analgesia for 6 weeks or more is highly
    desirable, and may well influence hospital stay,
    return to work, and, certainly, patient
    satisfaction.
     
    The originator of the paste has
    cautioned that the agent has the potential to act as a
    hyperosmolar agent, producing a sometimes painful but
    sterile and self-limiting subcutaneous fluid
    collection.
     
    More research is needed before
    analgesic epidural paste can be recommended.
      

  • Spinner RJ, Goldner RD [ Duke
    Univ, Durham, NC]
    Snapping of the Medial Head of
    the Triceps and Recurrent Dislocation of the Ulnar
    Nerve: Anatomical and Dynamic Factors
    J Bone Joint Surg Am 80 – A:
    239-247, 1998

     
    Snapping of the medial head of
    triceps may often go unrecognised. Failure to
    recognise that this lesion and concurrent dislocation
    of the ulnar nerve can lead to persist symptoms after
    an otherwise successful transposition of the ulnar
    nerve.
     
    17 patients [ average age 25
    years] were studied. The diagnosis was suspected on
    clinical grounds, and confirmed with MRI, CT or both.
    Operative findings were confirmatory in 3 cases. 
    Two patients were seen for painless snapping, 4
    had painful snapping in the medial aspect of the
    elbow. 3 had symptoms related to ulnar nerve only. 6
    had snapping and ulnar nerve involvement. Four
    patients were asymptomatic and were incidentally
    detected.
     
    Five of these were treated by
    transposition of ulnar nerve and lateral transposition
    or excision of medial head of triceps with excellent
    results. Among those managed conservatively control of
    pain was achieved.
     
    They conclude that persistent snapping after a successful transposition of the ulnar
    nerve can result from failure to recognise concurrent
    dislocation of the medial head of triceps. This
    snapping could be asymptomatic also. 
    The results of non operative treatment are also
    good.
       

  • Ellenbecker TS, Mattalino AJ,
    Elam EA, et al [ Scottsdale Sports Clinic, Ariz;
    Clinical Diagnostic Radiology Ltd, Phoenix, Ariz;
    Milwaukee Brewers Baseball Club, Milwaukee, Wis]
    Medial
    Elbow Joint Laxity in Professional Baseball Pitchers:
    A Bilateral Comparison Using Stress Radiography


    Am J Sports Med 26: 420-424, 1998

     
    Baseball pitching and other
    throwing activities place repetitive valgus stress on
    the elbow leading to ulnar collateral ligament injury.
    This study compared medial elbow laxity in the
    throwing and non-throwing arms of 40 professional
    baseball pitchers.
     
    The
    clinical range of motion of the elbows and
    wrist and bilateral stress radiography was done and
    the laxity was calculated by measuring joint space
    width between the trochlea and the coronoid process on
    anteroposterior radiographs.
     
    The dominant arm showed greater
    medial joint width and reduced range of movement
    [particularly extension] than the non dominant arm.
     
    They
    conclude that professional baseball pitchers show
    increased medial elbow laxity in the throwing arm than
    the other arm. Stress radiography is a reliable test
    to demonstrate this.

       

  • Lee
    GA, Katz SD, Lazarus MD [Albert Einstein Med Ctr,
    Philadelphia]

    Elbow Valgus Stress Radiography in an Uninjured
    Population


    Am
    J Sports Med 26: 425-427, 1998


      

    Valgus instability of the elbow is usually
    diagnosed clinically, though some have used gravity
    valgus stress radiography to aid in diagnosis. The
    amount of ulnahumeral gapping was measured in normal
    elbows by this method.

     

    40
    asymptomatic people [ 20 men and 20 women] mean age
    [ 27 years] were studied. Both elbows were
    radiographed with the elbows in extension and in 300
    flexion. Medial ulnahumeral distance was measured in
    3 situations. [a] No stress [b] gravity valgus
    stress [c] applied valgus stress.

         

    The
    ulnahumeral distance increased significantly with
    increasing stress.

       

    They
    conclude that even in normal elbows valgus stress
    causes significant increase in 
    ulnahumeral distance. This test could be used
    for diagnosis of valgus instability in injured
    patients but is of no value in
    uninjured elbows.

       

  • Zeman
    C, Hunter RE, Freeman JR, et al [Orthopaedic
    Associates of Asper, Colo; Aspen Found for Sports
    Medicine, Education and Research, Colo]
    Acute Skier’s Thumb Repaired with
    a Proximal Phalanx Suture Anchor
    Am J Sports Med 26: 644-650,
    1998

     
    58 patients with grade III
    sprains of the UCL [Ulnar Collateral Ligament] were
    repaired using a suture anchor for fixation of thumb
    to the proximal phalanx. 
    After a year a 14 point questionnaire was
    administered to determine functional outcomes.
     
    98% of the interviewed patients
    were satisfied with the result and had a stable repair
    with good range of movements and no hindrance in their
    activities. 17% reported mild discomfort and 7%
    experienced pain in the activities.
     
    This is a good method of
    repair.
     

  • Mont MA, LaPorte DM, Mullick T,
    et al [ Johns Hopkins Univ, Baltimore, Md]
    Tennis
    After Total Hip Arthroplasty


    Am J Sports Med 27: 60-64, 1999

       

    Many active patients wish to
    continue playing tennis after hip arthroplasty. Only
    14% of surgeons had approved of their playing tennis.
    34% recommended only doubles.
     
    A
    survey was conducted on such patients. 50 men and 8
    women aged 47 to 89 years were identified. The survey
    was meant to assess the functional abilities and
    degree of satisfaction in this group.
     
    All were very satisfied with
    their surgeries and their increased ability to play
    tennis. After a mean of 8
    years 3 patients needed revision surgery.
     
    Physicians should advise caution
    in restarting the game of tennis after hip
    arthroplasty and they should be followed annually for
    local  changes in the
    bones.
      

  • Clanton TO, Coupe KJ [Univ of
    Texas, Houston]
    Hamstring Strains in Athletes :
    Diagnosis and Treatment
    J Am Acad Orthop Surg 6: 237-248,
    1998
     
    Hamstring injuries are common,
    well-defined athletic injuries.
    Their diagnosis is discussed.
     
    The hamstrings act during the
    early stance phase of gait for knee support, during
    the late stance phase for propulsion, and during
    midswing to control leg momentum. Injuries occurs at
    musculotendinous junction where forces are
    concentrated and results from hamstring strength
    imbalances and lack of adequate flexibility.
     
    Most injuries are acute. The
    entire length of muscle should be palpated and the
    injury should be classified as Mild [pulled],
    moderate [ partial tear] or
    severe [ complete rupture]. CT scan, MRI and USG are
    diagnostic.
     
    Treatment consists of
    immobilization rest, ice; compression and elevation to
    control hemorrhage, pain and edema.
     
    Administration of NSAID is
    controversial.
     
    The symptoms subside quickly.
    Careful mobilization and pain-free stretching or
    strengthening exercises help to regain morbidity.
     

  • Temple HT, Kuklo TR, Sweet
    DE, et al [ Walter Reed Army Med Ctr, Washington,
    DC]
    Rectus Femoris Muscle Tear
    Appearing as a Pseudotumor
    Am J Sports Med 26: 544-548,
    1998
     
    Quadriceps femoris muscle
    injuries are very common in athletes. Sometimes this
    tear may present as a soft tissue mass on the anterior
    thigh, with or without a history of significant
    trauma.
     
    Seven patients with
    unexplained soft tissue mass of the thigh were seen at
    a army medical centre [males between 15 and 73 years,
    3 were active duty personnel, 3 were military
    dependents and 1, a  retired serviceman.
    Laboratory X-rays were unremarkable. MRI showed an
    obvious but ill-defined mass at the musculotendinous
    junction of rectus. Biopsy was done in 4 patients to
    exclude a soft tissue sarcoma. Histologically it
    showed fibrosis, degeneration of muscle fibers and
    chronic inflammatory reaction.
     
    These injuries could have obvious
    traumatic origin or possibly repeated microtrauma. The
    diagnosis should be suspected and selective
    radiologic  examination
    performed.  Full functional
    recovery can be expected.
       

  • Bernicker JP, Hadded JL, Lintner
    DM, et al [Baylor college of Medicine, Houston]
    Patellar Tendon Defect During the
    First Year After Anterior Cruciate Ligament
    Reconstruction: Appearance on Serial Magnetic
    Resonance Imaging
    Arthroscopy 14: 804-809, 1998
     
    ACL rupture is commonly repaired
    using the central third of the patellar tendon. The
    healing process of the patellar tendon has been
    chronicled with the aid of MRI.
      
    MRI scanning was done on
    12 consecutive patients [ 15 to 48 years] who
    underwent arthroscopic ACL repair at 3 weeks, 3
    months, 6 months and one year after surgery. The tendon defect
    was not closed, only the peritenon was sutured. The
    tendon gap and the patellar bone harvest site were
    evaluated.
     
    Although the patellar tendon
    defect had decreased by an average of 62% at one year,
    only 2 persons had healed completely and some had not
    healed at all. Tendon width and length decreased. The
    greatest change occurred between 3 and 6
    months after surgery thereafter healing showed
    down.
       

  • Natri A, Kannus P, Jarvinen
    M  [UKK Inst, Tampere,
    Finland; Univ of Tampere, Finland; Univ of Vermont,
    Burlington]
    Which Factors Predict the
    Long-term Outcome in Chronic Patellofemoral Pain
    Syndrome? A 7-Year Prospective Follow-up Study
    Med Sci Sports Exerc 30:
    1572-1577, 1998
     
    Patellofemoral pain syndrome
    [PFPS] is a common sports injury that often becomes
    chronic. Neither conservative
    or operative management has yielded consistent
    results. A prospective study
    of conservative treatment has been done.
     
    49
    consecutive cases of PFPS with an average age of 27
    years were given 6 weeks of conservative treatment and
    evaluated. The effect of 19 variables like age, sex,
    duration athletic activity, etc. were studied. 10 patients had
    surgery during the follow-up.

      

    They conclude that systemic
    rehabilitation of quadriceps with a period of
    restriction is the treatment of choice for chronic
    PFPS.
       

  • Jee W-H, Choe B-Y, Kim J-M, et al
    [Catholic Univ, Seoul, Korea]
    The Plica Syndrome : Diagnostic
    Value of MRI with Arthroscopic Co-relation
    J Comput Assist Tomogr 22:
    814-818, 1998
     
    This is a study of the efficacy
    of MRI in diagnosing plica syndrome.
     
    The MR images of 55 patients with
    arthroscopically confirmed pathologic mediopatellar
    plicae were compared with those of 100 patients
    without plicae.
     
    The sensitivity and
    specificity of axial multiplanar gradient-recalled
    [MPGR] images for diagnosing plica syndrome were 73%
    and 83% respectively and for the combination of these
    images they were 95% and
    72% respectively. With the criterion
    of extension beyond the medial end of the patella on
    axial MPGR images, the incidence of pathologic medial
    plica increased.
     
    MRI is a useful non invasive
    screening tool for diagnosing plica syndrome before
    arthrography.
         

  • Rubin DA, Kettering JM, Towers JD, et al [Univ of
    Pittsburgh, Pa; West moreland Regional Hosp,
    Greensburg, Pa]

    MR Imaging of Knees having Isolated and Combined
    Ligament Injuries


    AJR 170: 1207-1213, 1998

      

    MRI is more sensitive than physical examination in
    detecting meniscal tears in patients with torn ACLs.

      

    The sensitivity of MRI in the diagnosis of ACL tears
    was 93%, with a specificity of 93% to 96%. 

      

    MRI offered a sensitivity of 93% for isolated ACL
    tears, 83% for ACL tears when both the ACL and
    posterior cruciate ligament [PCL] were torn, 100% for
    isolated PCL tears.

      

    The incidence of medial meniscus tears was 49% in
    knees with all ligaments intact.

      

    MRI scanning continues to be a valuable diagnostic
    procedure, particularly if the physical examination is
    difficult or incomplete.

      

  • LaPorte DM<, Mont MA, Mohan V,
    et al [Johns Hopkins Univ, Baltimore, Md]
    Multifocal Osteonecrosis
    J Rheumatol 25: 1968-1974,
    1998
     


    Osteonecrosis is debilitating
    when confined to 1 joint [most typically the hips,
    knees, or shoulders], but when it spreads to multiple
    sites, its effects can be devastating.
     
    Plain radiographs and MRI were used to determine
    where the lesions were and their presenting stage.



    Patients [94%] had used or were using corticosteroids. 



    Each of patients had bilateral lesions at the femoral
    head. All patients had bilateral knee lesions.



    Most patients had multiple joint or hip symptoms when
    first seen. Symptoms were present in all the knees
    involved.



    Radiographs showed that most of the joints [77%] were
    at pre-collapse stage.



    The high use of corticosteroids in these patients
    suggests that these durgs are strongly associated with
    multifocal osteonecrosis.



    The vast majority [94%] of patients with multifocal
    osteonecrosis were o steroids.

        


  • Ebraheim NA, Lu J, Skie M, et al
    (Med College of Ohio, Toledo)
    Vulnerability of the Recurrent
    Laryngeal Nerve in the Anterior Approach to the Lower
    Cervical Spine.
    Spine 22:
    2664-2667, 1997.

        
    This is cadaveric study. Anatomy
    demonstrated suggest danger of injury to recurrent
    laryngeal nerve more on right side because the nerve
    courses outside esophagotracheal groove and runs in
    oblique direction relative to the sagittal plane.
    Inferior thyroid vessel should be ligated as laterally
    as possible and the retractor should be blunt tipped
    to retract the longus colli muscle to provide
    intermittent retraction of the midline structures.
       
    This article highlights the
    rationale of using left sided approach to the spine
    when possible. If right sided approach is used then
    above precautions are necessary to prevent injury to
    recurrent laryngeal nerve.
        

  • Dubernard
    J-M, Owen E, Herzberg G, et al [ Hopital Edouard
    Herriot, Lyon, France; Microsearch Found of Australia
    and Outer Sydney Hand and Micro-Surgery Unit; St
    Mary’s Hosp, London; et al]

    Human Hand Allograft Report on First 6 Months

    Lancer
    353: 1315-1320, 1999

         

    The
    results of transplantation of 
    the right forearm and hand of a brain-dead male
    donor to a male recipient who had a traumatic
    midforearm amputation are discussed.

     

    The
    technique has been described. There were no surgical
    complications. At 8 weeks there was a rejection
    episode which was treated successfully. Passive
    mobilization was started on day one and continued till
    week six. At 100 days, no stiffness was noted, but
    sensation was lacking. There was good callus formation
    at 3 months and advanced healing at 6 months. 
    At 80 days, the patient had some sensation.

      

    They
    conclude that hand transplants can be successfully
    done but sensation and functional analysis are not
    complete.

       

  • Smutz
    WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic
    and Found, Rochester, Minn]

    Mechanical
    Advantage of the Thumb Muscles

    J
    Biomech 31: 565-570, 1998

      

    The
    moment arms of the thumb muscles at the
    interphalangeal, metacarpophalangeal, and
    carpometacarpal joints were measured
    throughout the range of motion of each joint.

      

    The
    technique is described and the results show that :-

      


    1.  
    At metacarpophalangeal joint


     

    FPL, FPB, ADPt and ADPo and OPP were the major
    flexors.

     

    2.  
    At carpometacarpal joint


     

    FPL, FPB, ADPt, ADPo and OPP were the major
    flexors.

     

    EDL, EPB and APL were the major extensors.

     

    ADPt, ADPo, and EPL were the only abductors.

     

    APB, APL and FPB were the main abductors.

      

    This
    knowledge can aid in planning rehabilitation.

      

  • Lyons
    RP, Kozin SH, Failla JM [ US Air Force, Aviano, Air
    Force Base, Italy; Temple Univ, Philadelphia; Henry
    Ford Hosp, Detroit]

    The Anatomy of the Radial Side of the Thumb:
    Static Restraints in Preventing Subluxation and
    Rotation After Injury


    Am
    J Orthop 27: 759-763, 1998

      

    A
    cadaver study was performed to delineate the
    anatomic variations of the radial side of the thumb
    MP joint and to assess the relative contributions of
    the volar plate, radial collateral ligament, dorsal
    capsule and the extensor pollicis brevis in
    preventing rotation and volar subluxation.

      

    The
    methodology has been described. The results: The
    extensor pollicis brevis insertion was variable [
    61% inserted into the base of the proximal phalanx,
    26% continue as a distal slip to the distal phalanx
    with no discrete insertion, and blending into the
    capsule with no discrete insertion in 10%. Volar
    subluxation varied from 0% to 35% and rotation from
    12% to 35%. Volar subluxation increased to 26%, and
    rotation increased 20% when the radial collateral
    ligament was sectioned.

     

    Corresponding
    increases after incision of the extensor pollicis
    brevis/dorsal capsule were 12% and 12
    %,
    and were 21% and 24
    %
    after volar plate section. When the extensor
    pollicis brevis/dorsal capsule was sectioned first,
    followed by sectioning of the radial collateral
    ligament and the volar plate, results were 32% and
    14
    %,
    9% and 12
    %,
    and 18
    %
    and 24
    %
    respectively.

      

    They
    conclude that the radial collateral ligament and
    extensor pollicis brevis/ capsule help stabilize the
    joint against rotation and volar subluxation. An
    X-ray after volar displacement is more helpful than
    after pronation for revealing MP instability.

        

  • Romain
    M, Allieu Y [Hopital Lapeyronie, Montepellier,
    France]

    Overview of the Function of Flexor and Extensor
    Tendons of the Hand [French]


    Ann
    Chir Main 17: 259-265, 1998

        

    The
    authors describe 4 commonly used methods plus their
    own, of evaluating the flexor tendons of the hands
    and extrapolate their personal method to the
    evaluation of the extensor tendons.

     

    The
    four commonly used methods are –

     

    1.    
    Total active movement [TAM]

     

    2.    
    Buck-Gramcko Method

     

    3.    
    Kleinert method and

     

    4.    
    Strickland method

     

    Each
    of these methods has drawbacks of their own. Their
    own method takes into account MP flexion, eliminates
    the action of the intrinsic muscles, and can be used
    in every zone. First, the hand is straightened. The
    MP joints are stabilized at 900 of
    flexion. The patient is asked to flex the digits,
    and the DPPPD is measured. Then the hand is placed
    in 450 of extension and the extension
    deficits of the MP, PIP and DIP 
    joints are measured. This method was compared
    with the other four methods [ 165 patients]. The
    greatest number of excellent and good results was
    found with the Buck-Gramcko method [76%] followed in
    descending order by the authors method [ 66.6%], the
    Kleinert method [ 54.5%] and the Strickland’s
    method [53%].

     

    Extrapolation
    to Evaluation of the Extensor Tendons – First, the
    hand is placed in 450 of extension and
    the angle of extension deficit is measured. Then the
    hand is straightened. The MP joints are maintained
    at 900 and the DPPPD is measured in
    passive flexions. [ A twist on the method for
    measuring flexor function].

     

    The
    method is simple and offers a reliable and
    reproducible means of measuring the function of the
    tendons of hands.

        

  • Bouchlis
    G, Bhatia A, Asfazadourian H, et al [Athenes,
    Greece; Pune, India; Institut d’Antomie de Paris;
    et al]

    Distal Insertions of Abductor
    Pollicis Longus Muscle and Arthritis of the First
    Carpometacarpal Joint in 104 Dissections [ French
    ]

    Ann
    Chir Main 16: 326-338, 1997

     

    This
    study examines the varying types of distal
    insertions of the APL tendons and their possible
    impact on the evolution of arthritis of the CMC
    joint of the thumb.

     

    104
    cadavers were dissected at the level of the CMC
    joint of the thumb. The appearance of the joint
    surface was noted and the distal insertions of the
    tendons to the level of the CMC joint was observed.
    The type of arthritis was correlated with the
    type of distal insertion of APL tendon.

     

    The
    APL had multiple insertion in 95% of cases.
    There was always an insertion at the base of
    the 1st metacarpal. 70% had an insertion
    into the trapezium as well 42% had an accessory
    tendon to the thenar eminence. 97% showed
    rhizarthrosis. 71% had lateral compartment of the
    joint surface involvement and was probably the
    starting point of the arthritis. The degree of
    arthritis did not reveal any correlation with the
    type of insertion of APL.

     

    The
    findings suggest that arthritis of the first CMC
    joint is extremely common and appears to start in
    the lateral compartments. 
    There is no correlation with the insertion of
    the APL tendon. The
    finding do not support the practice of early
    prophylactic tenotomy for arthritis of the first CMC
    joint.

       

  • Gajisin
    S, Bednarkiewicz 
    M, Zbrodowski A [ Centre Medical
    Universitaire, Geneve; Hopital Cantonal
    Universitaire, Geneve]

    Blood Supply of the Digital Sheath

    Ann
    Chir Main 17: 147-153, 1998

     

    This study identifies the sources and
    describes the network  distributing the arterial blood supply of the digital sheath.

     

    A
    mixture containing india ink and gelatin or colored
    latex was injected into the brachial artery of 100
    fresh human cadavers. After formalin fixation,
    dissection was performed under the
    stereo-microscope.

     

    The
    digital sheaths of index, middle and ring fingers
    were studied. There
    are two main sources of supply [1] digitopalmar
    arches and [2] palmer digital arteries. Many
    anastomoses  are
    formed between these branches to create a fine
    arterial network on the inner surface of the digital
    sheath. The floor of the sheath is the most
    vascularized area, next the side wall and lastly the
    palmar side. The proximal dead end of the sheath is
    directly supplied by branches from the arcus
    palmaris  superficials.

       

  • Clarke
    MT, Lyall HA, Grant JW, et al [Addenbrooke’s Hosp,
    Cambridge, England]

    The
    Histopathology of de Quevain’s Disease

    J
    Hand Surg [Br] 23B:732-734, 1998

     

    De
    Quervain’s disease is considered to be a stenosing
    tenovaginitis of either acute or chronic
    inflammatory etiology. This was re-examined using a
    staining technique that reveals the accumulation of
    connective tissue mucopolysaccharide suggesting
    myxoid degeneration.
    This was performed on 23 consecutive patients
    undergoing treatment for Dequevain’s disease.
    There was no sign of active inflammation.  The terms ‘ stenosing tenovaginitis’ and ‘
    tenosynovitis’ are misnomers.

      

  • Sbernardori
    MC, Montella A, De Santis E [Universita degli Studi
    di Sassari]

    Histo-morphological Findings on
    the Flexor Digitorum Tendons in Human Embryos Hand
    at the End of First Trimester of Gestation [Italian
    ]

    Riv
    Chir Riab Mano Arto Sup 34: 229-233, 1997
     
    +
    Sbernardori
    MC [Universita Degli Studi di Sassari]


    Ultrastructural Aspects of the Palmar Aponeurosis
    of Fetal Hand [Italian]


    Riv
    Chir Riab Mano Arto Sup 34: 187-191, 1997

     

    These two articles are well documented and
    original studies on the development of the human
    hand.

     

    Histomorphology
    of the flexor tendons and palmar aponeurosis was
    studied under light and electron microscopy in a
    series of 1
    mm
    thick cross sections of the finger.

     

    The
    palmar aponeurosis [12th week], is easily
    seen under the derma with its typical double layer
    structure with a double oriented perpendicular
    pattern. Strict relationship is shown with
    intertendinous septa.

      

  • Griffiths
    GP, Selesnick FH [Miami Sports Medicine Fellowship,
    Coral Gables, Fla]

    Operative Treatment and Arthroscopic Findings in
    Chronic Patellar Tendinitis


    Arthroscopy
    14: 836-839, 1998

     

    Though
    conservative treatment is usually effective in
    chronic patellar tendinitis some patients continue
    to have symptoms, these patients may require
    surgery.

     

    The
    authors conclude that chronic patellar tendinitis
    that does not respond to conservative surgery,
    respond to surgery.

       

  • Risberg
    MA, Holm I, Steen H, et al [ Univ of Oslo, Norway;
    Martina Hansens Hosp, Baerum , Norway]

    The
    Effect of Knee Bracing After Anterior Cruciate
    Ligament Reconstruction : A Prospective, Randomized
    Study With Two Year’s Follow-up

    Am
    J Sports Med 27: 76-83, 1999

      

    This
    study investigates the effects of knee bracing after
    ACL reconstruction on knee joint laxity, lower limb
    function, the cross-sectional area of the the thigh
    and the incidence of further intra-articular injury.

        

  • Matava
    MJ, Evans TA, Wright RW, et al [Washington Univ, St
    Louis; Slippery Rock Univ, Pa]

    Septic
    Arthritis of the Knee Following Anterior Cruciate
    Ligament Reconstruction: Results of a Survey of
    Sports Medicine Fellowship Directors

    Arthroscopy
    14: 717-725, 1998

     

    This
    is a review of literature regarding the incidence of
    septic arthritis as a
    complication following ACL reconstruction and its
    prevention and treatment.

     

    A
    questionnaire was mailed to 74 surgeons listed in
    the Sports Medicine Fellowship Program regarding
    their experience and practices in performing ACL
    surgery, number of years in practice, number of ACL
    reconstructions performed annually, graft choice,
    surgical technique, use of postoperative drains,
    prophylactic antibiotics and postoperative
    complications in the past 2 and 5 years.

     

    82%
    of responders had been in practice for an average of
    17.3 years and performed an average of 98 ACL
    repairs annually.

     

    77%
    chose the patellar tendon graft, followed by
    hamstring graft [23%]. Endoscopic reconstruction was
    the method of choice [72%] whereas 16% used
    arthroscopically assisted surgery. 98% used
    postoperative prophylactic antibiotics 51% used a
    drain. 30% had treated an ACL infection within the
    past 2 years, and 26% within the past 5 years.
    Culture-specific IV antibiotics and irrigation of
    the joint was the treatment of choice for 85% of
    responders. Graft removal was chosen by 31%.
    Revision after graft removal was done after 6-9
    months by 49% of responders.

     

    In
    conclusion, septic arthritis is a rare complication
    following ACL repair and treatment consists of
    culture specific IV antibiotics and joint irrigation
    with graft retention; with graft removal reserved
    for resistant infection.

  • Barber-Westin
    SD, Noyes FR, Heckmann TP, et al [Deaconess Hosp,
    Cincinati, Ohio; HealthSouth Rehabilitation Corp,
    Cincinnati, Ohio]

    The
    Effect of Exercise and Rehabilitation on
    Anterior-Posterior Knee Displacements After Anterior
    Cruciate Ligament Autograft Reconstruction

    Am
    J Sports Med 27: 84-93, 1999

     

    Current
    trends in rehabilitation after ACL reconstruction
    focus on aggressive or accelerated exercise
    protocols with early return to full weight bearing
    and high levels of at athletic activity. This study
    analyses the results of such protocols.

     

    Individual
    evaluation based rehabilitation is needed after ACL
    reconstruction.

      

  • Fischer
    DA, Tewes DP, Boyd JL, et al [Minneapolis Sports
    Medicine Ctr]

    Home-based
    Rehabilitation for Anterior Cruciate Ligament
    Reconstruction

    Clin
    Orthop 347: 194-199, 1998

     

    The
    results of a postoperative home based rehabilitation
    program after ACL reconstruction were compared with
    the results of a traditional clinic-based program.

     

    The
    home based rehabilitation program after ACL
    reconstruction provides good, cost-effective
    results.

        

  • Dye
    SF, Wojtys EM, Fu FH, et al [Univ of California, San
    Francisco; Univ of Michigan, Ann Arbor; Univ of
    Pittsburgh, Pa et al]

    Factors
    Contributing to Function of the Knee Joint After
    Injury or Reconstruction of the Anterior Cruciate
    Ligament

    J
    Bone Joint Surg Am 80-A: 1380-1393, 1998

        

    The
    factors that govern restoration of knee function
    after injury or ACL reconstruction
    are discussed in terms of musculoskeletal 
    function.

        

    This
    concept encompasses the capacity to generate,
    transmit, absorb and dissipate loads and to maintain
    homeostasis.

       

    Several
    factors contribute to the functional capacity of a
    joint. These include [1] anatomical factors, like
    macromorphology and micromorphology, structural
    integrity, and biomechanical characteristics. [2]
    Kinematic factors, such as pattern of sequential
    tightening  of 
    the ACL fibers and the dynamics of all the
    complex neuromuscular control mechanisms [3]
    Physiologic factors, such as the biochemical and
    metabolic processes that maintain homeostasis in the
    joint and musculoskeletal components. And [ 4] Non
    operative or operative treatments.

        

    Absence
    of pain, warmth, swelling and functional instability
    indicate that a joint is not being overloaded.

         

  • Tieschky
    M, Faber S, Haubner M, et al [ Ludwig-Mximilians -
    Universitat Munchen, Germany; Klinikum Gro
    bhadern,
    Munich,  Germany;
    Institut for Medizinische Informatik und
    Systemforschung, Neuherberg, Germany; et al]

    Repeatability
    of Patellar Cartilage Thickness Patterns in the
    Living, Using a Fat-suppressed Magnetic Resonance
    Imaging Sequence With Short Acquisition Time and
    Three-Dimensional Data Processing

    J
    Orthop Res 15: 808-813, 1997

     

    The
    right knees
    of 8 healthy volunteers were examined by transverse
    MRI with a T1-weighted, fat-suppressed, flash-3D
    sequence. The
    entire transverse data set was acquired in 4 min. 10
    sec. 6 different positions were used to determine
    the replicability of cartilage thickness.

       

    A
    fat suppressed, FLASH-3D MRI sequence with 3D
    reconstruction and digital data processing reliably
    determines the thickness of the articular cartilage
    in a non-invasive fast and reproducible manner.

        

  • Potter
    HG, Linklater JM, Allen AA, et al [ Hosp for Special
    Surgery, New York City ]

    Magnetic
    Resonance Imaging of Articular Cartilage in the Knee
    : An Evaluation With Use of Fast-Spin-Echo Imaging

    J
    Bone Joint Surg Am 80-A: 1276-1284, 1998

     

    The
    best MRI sequence for detection of chondral
    abnormalities remains unclear. This study evaluates
    a specialized proton density weighted high
    resolution fast spin echo sequence for evaluation of
    chondral pathology.

     

    This
    method provides a valuable approach for evaluation
    of chondral pathology.

       

  • Saal
    JS, Saal JA [SOAR, Menlo Park, Calif]

    Management of Chronic Discogenic Low Back
    Pain With a Thermal Intradiscal Catheter : A
    Preliminary Report


    Spine
    25: 382-388, 2000

     

    New
    alternatives for the treatment of chronic diskogenic
    low back pain are needed. Previous studies have
    suggested that intradiskal heating can shrink
    collagen fibrils, cauterize granulation tissue, and
    coagulate nerve endings. To take advantage of these effects, a catheter and thermal
    treatment protocol for intradiskal electrothermal
    annuloplasty and nuclectomy [IDET] was developed.

     

    Patients
    were back to work within 
    5 days of the procedure and there were no
    complications.

      

  • Weiner
    BK, Walker M, Brower RS, et al [ College of
    Medicine, Akron, Ohio]


    Microdecompression
    for Lumbar Spinal Canal Stenosis


    Spine
    24: 2268-2272, 1999

     

    Surgical
    management of lumbar degenerative spinal canal
    stenosis can result in significant destruction of
    uninvolved tissues.

     

    The
    technique is technically demanding, has a steep
    learning curve, and is advisable only in selected
    cases and only by surgeons very comfortable with the
    technique.

      

  • Blackley
    HR, Wunder JS, Davis AM, et al [ Mount Sinai Hosp,
    Toronto]


    Treatment
    of Giant-Cell Tumors of Long Bones With Curettage
    and Bone-grafting


    J
    Bone Joint Surg Am 81-A : 811-820, 1999

     

    Most experts recommend treating
    giant-cell tumors of long bones with curettage,
    adjuvants [such as phenol] to destroy any remaining
    tumor cells, and filling of the defect with
    methylmethacrylate cement.
    However, evidence is insufficient to prove
    that this approach is significantly superior to
    curettage with long bone drafting.

     

    The
    recurrence rates with curettage by means of a high
    speed burr and autogenous bone grafting [with or
    without allograft bone] reported here compare
    favorably with those associated with the use of
    curettage, adjutants, and cement.

     

    This
    supports the belief that the major reason for
    improvements  in
    local control of giant cell is because of surgical
    technique and not because o reconstructive
    techniques.

          

  • Robicsek
    F., Cook JW, Rizzoni W [Carolina Med Ctr, Charlotte,
    NC]

    Sternoplasty for Incomplete Sternum Separation

    J
    Thorac Cardiovasc Surg 116: 361-362, 1998


     

    The
    authors have previously reported a technique for
    surgical repair of poststernotomy separation. In the
    sternum weaving technique, persistent bilateral
    double-row sutures are placed, and transverse
    sutures are used to reunite the sternum halves,
    buttressed by the double axial suture lines. This
    technique is highly useful for patients with
    separation along the complete length of the
    sternum,but some patients have separation only of
    the lower portion of the sternum.
    In these cases the full sternum may sometimes
    be divided just to reapproximate the lower portion.
    A modified technique for reapproximation of
    the separated lower portion of the sternum has been
    described.

     

    This
    modified sternoplasty technique can be used in cases
    of partial postoperative sternum separation.
    This approach was successful in several
    patients with chronic, noninfected partial sternum
    separations. All
    patients showed good results, with early discharge
    from the hospital.

       

  • Reconstruction


    Kawai
    A, Muschler GF, Lane JM, et al [Mem Sloan-Kettering
    Cancer Ctr, New York; Cleveland Clinic Found, Ohio;
    Hosp for Special Surgery, New York]

    Prosthetic
    Knee Replacement After Resection of a Malignant
    Tumor of the Distal Part of the Femur : Medium to
    Long-term Results


    J
    Bone Joint Surg Am 80-A :636-647, 1998


     

    This
    study is a medium to long term follow up [5-17
    years] of a custom prosthetic knee replacement after
    wide resection of a primary malignant tumor of the
    distal femur.

     

    The
    results were encouraging. None of the 40 patients
    had a local recurrence.
    However the prosthetic survival rates at 5
    and 10 years were only 67% and 48% respectively. The rate of prosthetic survival was significantly lower for males,
    in those who had a 40% resection of the femur and a
    total resection of the quadriceps and for patients
    in whom a straight femoral stem had been used and
    fixed with cement. Functional
    recovery was 80%.

      

Next

 


 

         

Speciality Spotlight

 

 

  • Raikin SM, Landsman J.C., Alexander V.A. et al (Mount Sinai Med. Ctr. Cleveland, Ohio)
    Effect of Nicotine on the Rate and Strength of Long Bone Fracture Healing
    Clin. Ortho 353; 231-237, 1998
       
    This study attempts to scientifically prove that nicotine inhibits long bone fracture healing.
        
    Forty rabbits were subjected to midshaft tibial osteotomies and plating. One group was given systemic nicotine and the other only saline.  Radiographs were taken at 4, 6 and 8 weeks. At 8 weeks the rabbits were sacrificed for biochemical comparisons of healing.
        
    The nicotine group had significantly lag in cortical continuity formation. 13% showed no clinical evidence of union, whereas all fractures in the control group had healed. In the biomechanical comparisons the nicotine group were 26% weaker in 3 point binding then the control groups.
          

  • EP Frankenburg, Goldstein SA, Bauer TW, et al (Univ of Michigan, Ann Arbor; Cleveland Clinic Found, Ohio)
    Biomechanical and Histological Evaluation of a Calcium Phosphate Cement
    J Bone Joint Surg Am  80-A: 1112-1124, 1998
      
    Stable fixation of a comminuted fracture associated with a metaphysical defect is difficult. This study explores the use of injectable resorbable cement into an osseous defect to stabilise the fracture and maintain osseous integrity.
      
    72 dogs with proximal tibial metaphysical and distal femoral metaphysical defects were treated with either cement or allograft bone. The dogs were assessed 24 hours to 78 weeks after surgery.
      
    Cement was shown to be osteoconductive, achieves high level of compressive strength rapidly. It is tissue compatible. It gradually is remodeled overtime and the pattern suggested gradual restoration of a physiologic proportion of the bone with maintenance of mechanical function.
         

  • Petersen MM, Lauritzen JB, Schwarz P, et al (Univ of Copenhagen)
    Effect of Nasal Salmon Calcitonin on Post-traumatic Osteopenia Following Ankle Fracture: A Randomized Double-blind Placebo Controlled study in 24 Patients.
    Acta Orthop Scand 69: 347-350, 1998.
      
    Calcitonin inhibits bone resorption through a direct effect on osteoclasts and hence has been used to treat bone diseases characterised by increased bone turnover. Its effect on postfracture ostopenia has been studied.
       
    24 patients with internally fixed ankle fractures were assigned to 3 months treatment with 200 i.u.sCT or placebo. Dual photon absorptiometry was performed after surgery after 1 week, 1.5 month, 3 months and 6 months to establish bone mineral content (BMC).
      
    It was found that 3 months after the fracture, BMC in the injured legs had declined by 14% in the placebo group and 2.1% in the sCT group (non-significant difference).  In the healthy legs, 6 weeks after the fracture BMC reduction was 4.6% in the placebo group and 7.4% in sCT group. Nasal sCT does not significantly reduce post-fracture osteopenia, but significantly effects the healthy leg.
         

  • Joakimsen RM, Fonnebo V, Magnus JH, et al (Univ of Tromso, Norway;  Natl Inst. of Public Health, Norway)
    The Tromso Study: Physical Activity and the Incidence of Fractures in a Middle-aged Population.
    J Bone Miner Res 13: 1149-1157, 1998
      
    The relationship between physical activity and bone mass has been demonstrated. This study explores the effect of physical activity at work, and during leisure time and change of this activity on the incidence of fractures.
        
    1435 non-vertebral fractures from 1988 to 1995 from a single hospital were reviewed. The fracture incidence at all locations increased with age. In men, the fracture incidence decreased or was independent of age. In low-energetic fractures, men had incidence of 55.2% and women 74.4%. Gender differences were most notable in upper extremities.
       
    Below 45 years there was no appreciable relationship between physical activity and fractures. Above 45 years active people had a lower incidence than sedentary ones in the weight bearing bones but not in non-weight bearing bones.
          

  • Velmahos GC, Arroyo H, Ramicone E, et al (Univ of Southern California, Los Angeles; Los Angeles County,USC Med Ctr)
    Timing of Fracture Fixation in Blunt Trauma Patients with Severe Head Injuries.
    Am J Surg 176: 324-330, 1998.
      
    Early fracture fixation is thought to reduce postoperative morbidity by permitting early mobilisation and decreasing the release of harmful inflammatory mediators. This approach is disputed in severe head trauma.
      
    A retrospective study of 47 consecutive patients of severe head injury with long bone fracture were reviewed. 22 had undergone fixation within 24 hours and 25 at a mean of 143 hours after trauma.
      
    The timing of the fracture fixation did not affect morbidity, mortality or neurologic outcome. The treatment of patients with severe head injuries should be based on sound individual clinical assessment rather than mandatory policies on long bone fracture fixation.
        

  • Van der Sluis CK, Timmer HW, Eisma WH, et al (Univ Hosp Groningen, The Netherlands)
    Outcome in Elderly Injured Patients: Injury Severity Versus Host Factors.
    Injury 28: 588-592, 1997.
       
    The growing proportion of elderly in the Western world has led to an increase in the health care costs. One third of the total cost of trauma care is spent on elderly patients. There is debate now over whether treatment of severely injured elderly patients is worthwhile. A study was therefore conducted to find out the difference in outcomes of 42 elderly patients with severe trauma with 76 elderly patients with less severe injuries.
       
    The results were as follows. In hospital mortality was 31`% in severe trauma as against 3% in less severe trauma. 34% of severe trauma patients were sent home, while 65% of less severe trauma were sent to a nursing home. The functional outcome at the end of 1 year was better in severe trauma. Host factors were better determinants of long term survival than injury severity.  “Active” persons had a better prognosis than “inactive” persons.
       
    Age, preinjury medical status, and sex were the most reliable predictors of long term survival in the elderly patients. Young active females had the best chance of survival.
         

  • Lang GJ, Richardson M, Bosse MJ, et al (Univ of Wisconsin, Madisonp Carolinas Med Ctr, Charlotte, NC)
    Efficacy of Surgical Wound Drainage in Orthopaedic Trauma Patients: A Randomized Prospective Trial.
    J. Orthop Trauma  12: 348-350, 1998.
       
    The use of drains in contaminated or purulent wounds is widely accepted. Their use in clean surgical wounds is not well documented.
       
    202 patients in a level I orthopaedic trauma service were randomized in a prospective trial. 100 patients received a drain and 102 did not.
       
    The two groups were comparable in injury severity, systemic disease, age, bodyweight, physical status and estimated blood loss. They did not differ greatly in wound drainage, edema, haematoma, erythema, dehiscence, infection or the need for repeat surgery or hospitalisation.
        
    The use of drains has no apparent benefits in clean wounds.
          

  • Palmer S, Fairbank AC, Bircher M (Queen Mary’s Univ, Roehampton, England; Orthopaedic Training Scheme, London; St. George’s Hosp, London)
    Surgical Complications and Implications of External Fixation of Pelvic Fractures
    Injury 28: 649-653, 1997.
        
    External fixation of severe pelvic fractures is an accepted modality of treatment if it is applied quickly and safely. This study examines the complications following this treatment and the methods of minimising them.
       
    It is a prospective of study of 23 patients.  The results were evaluated from patient records, radiographs and CT scans.
       
    The complication rate was 47%. This high rate increases mortality, morbidity and interferes with the management of the severely ill patients. The majority of these complications were related to pin placement and pin bone interfaces. Accurate placement of the fixators is likely to reduce the complication rate.
          

  • Dujardin FH, Hossenbaccus M, Duparc F, et al (Univ of Rouen Hosp, France)
    Long-term Functional Prognosis of Posterior Injuries in High-energy Pelvic Disruption
    J Orthop Trauma  12 : 145-151, 1998.
        
    High energy pelvic disruption with posterior lesions have poor long term results. This study examines functional result in a retrospective study of 88 patients over a period of 10 years.
         
    28 patients with anteroposterior compression fractures, an external fixation was done immediately to control bleeding or later on as definitive treatment. 6 patients had anterior internal fixation with a plate to repair symphyseal disruption. Vertical shear injuries were stabilised with tibial traction.
        
    Radiographs of the pelvic ring were taken for evaluation of treatment.
         
    The best prognosis were seen in iliac wing fractures with sacroiliac dislocation. Conservative methods produced unsatisfactory results, as also pure SI lesions.
        
    They conclude that the functional result depends on the injury pattern and quality of reduction.
         

  • Blundell CM, Parker MJ, Pryor GA, et al (Peterborough District Hosp, England)
    Assessment of the AO Classification of Intracapsular Fractures of the Proximal Femur.
    J Bone Joint Surg Br 80-B: 679-683, 1998.
       
    This study assesses the intraobserver and the interobserver reproducibility and predictive accuracy of the AO system of the classifying intracapsular fractures of the proximal femur.
       
    Five clinicians independently and blindly evaluated radiographs of 68 fractures as per the AO system. This process was repeated after 8-10 weeks. The results were compared with the method of treatment and the incidence of nonunion to estimate prognostic value.
        
    Both the interobserver and the intraobserver reliability were excellent.
          

  • Pandey R, McNally E, Ali A,e t al (John Radcliffe Hosp, Oxford, England)
    The Role of MRI in the Diagnosis of Occult Hip Fractures
    Injury 29: 61-63, 1998.
       
    The diagnosis of a hip fracture is not always easy. Misdiagnosis affects the prognosis unfavourably. This study assesses the usefulness of MRI in clinically suspect but radiologically negative cases.
        
    33 of 770 such patients had an MRI done within 48 hours of admission. 39% had a fractured neck of femur, 15% had intertrochanteric fractures and 11% had other fractures around the hip. One patient had a tumour. 10 patients (33%) had no fracture.
        
    It is recommended that all patients with significant hip pain after injury and negative radiographs should undergo MRI.
          

  • Nikolajsen L, Ilkjaer S, Jensen TS (Univ Hosp of Aarhus, Denmark)
    Effect of Preoperative Extradural Bupivacaine and Morphine on Stump Sensation in Lower Limb Amputees.
    Br. J Anaesth 81: 348-354, 1998.
        
    This is a randomized double blind study to determine if postoperative pain can be prevented by the use of preoperative use of extradural bupivacaine and morphine.
       
    The pressure pain threshold, touch and pain detection thresholds, thermal sensibility, allodynia and windup like pain were evaluated before amputation and 1 week and 6 months after amputation.
        
    The results indicate that preoperative extradural anaesthesia did not prevent postoperative hyperexcitability in the stump and had no effect on long term hyperalgesia, allodynia or wind-up like pain in amputees.
          

  • Larsson J, Agardh C-D, Apelqvist  J, et al (Univ Hosp, Lund, Sweden)
    Long Term Prognosis After Healed Amputation in Patients with Diabetes.
    Clin Orthop 350: 149-158, 1998.
        
    This is a prospective study of 220 patients with diabetes with foot ulcers subjected to amputation after primary treatment. 136 had a below knee (BK) and 84 patients had an above knee (AK) amputation. Of these 29 patients died before healing, 5 patients with BK amputation underwent after knee amputation. 2 patients did not heal and were excluded. The remaining 189 patients were followed up for 6.3 years (range, 1-10.8 years).
       
    The time for healing was an average of 29 weeks for BK amputations and 8 weeks for AK amputations.
       
    The mortality at 1, 3 and 5 years was 15%, 38% and 68% respectively. The rate of new amputations were required at 1, 3 and 5 years was 14%, 30% and 49% respectively.
        
    It is concluded that diabetics who underwent an AK amputation had a higher mortality rate of new above knee amputation and a lower rehabilitation potential than those undergoing BK amputations.
          

  • Legro MW, Reiber GD, Smith DG, et al (VA Puget Sound Health Care System, Seattle; Univ of Washington, Seattle; Prosthetics Research Study, Seattle).
    Prosthesis Evaluation Questionnaire for Persons with Lower Limb Amputations: Assessing Prosthesis-related Quality of Life.
    Arch Phys Med Rehabil 79: 931-938, 1998.
       
    A self administered questionnaire was developed for the evaluation of prosthetic care by quantifying the evaluation of individuals with amputations with regard to their prosthesis and their quality of life (PEQ- Prosthesis evaluation questionnaire). It consisted of 10 scales regarding prosthesis function mobility, psychosocial experience and wellbeing.
       
    92 patients completed the questionnaire. The internal consistency was high for all scales except “transfers”. Scores were stable over time.
        
    The scales showed good psychometric properties. It is a good tool for evaluation of prosthetic care.
          

  • TM Best, B Loitz-Ramage, DT Corr, et al (Univ of Wisconsin, Madison)
    Hyperbaric Oxygen in the Treatment of Acute Muscle Stretch Injuries: Results in an Animal Model.
    Am J Sports Med 26:367-372, 1998.
        
    The effect of Hyperbaric Oxygen (HBO) therapy were studied in a rabbit model of acute muscle stretch injury.
       
    Method : A standardised partial stretch injury of tibialis anterior muscle-tendon unit was created in 18 rabbits. The opposite limb was used as control starting 24 hours after the injury, one group of animals received HBO therapy (oxygen levels >95% at 2.5atm, 60 min/day for 5 days). The other group received no treatment. Tissue healing, functional and morphological indicators of recovery were assessed after 7 days.
        
    Results: The functional deficit was significantly reduced in the HBO treated group.  The percentage of ankle isometric torque on the injured side was 15% in the treated group versus 48% in the uninjured group. Surgical wound healing was quicker and on histology the HBO treated group showed reduced cellularity and fiber damage.
       
    Conclusion: HBO therapy may help to hasten recovery after muscle stretch injury.
          

  • JM Beiner, P Jokl, J Cholewicki, et al (Yale Univ, New Haven, Conn)
    The Effect of Anabolic Steroids and Corticosteroids on Healing of Muscle Contusion Injury.
    Am J Sports Med  27: 2-9, 1999.
       
    The effects of nandrolone, an anabolic steroid and methylprednisolone acetate (a corticosteroid) on muscle healing were studied in a rat model.
        
    Methods:  The muscle was injured using a drop-mass technique. Active contractile tension was measured in each muscle and histologic analysis was performed to determine healing.
        
    Findings:  With corticosteroids on day 2, there was significant improvement in the twitch and tetanic strength, but by day 7, this effect was reversed and on day 14, total degeneration was observed in the muscle.  There was no significant effect in the anabolic steroid group.
       
    Conclusion: Corticosteroids may be beneficial in the short term but results in irreversible damage in the long term. Anabolic steroids may facilitate healing of muscle contusion injury.
          

  • JE Houglum (South Dakota State Univ, Brookings)
    Pharmacologic Considerations In the Treatment of Injured Athletes with Non-Steroidal Anti-inflammatory Drugs.
    J.Athletic Train  33; 259-263. 1998
       
    A thorough understanding of the pharmacodynamics of NSAIDs is essential to optimise the use of these drugs in the treatment of sports injuries.
       
    The primary mechanism of action is through the inhibition of arachidonic acid metabolism. This has implications for potential adverse effects and drug interactions particularly those associated with clotting pathway, kidney function and gastrointestinal side effects. The extent of injury, drug dosing and duration of therapy and the specific agent used can affect the rate of healing and in relief from pain and inflammation.
       
    It is recommended that only one NSAID should be used. It should be taken with food. It should be stopped as soon as the desired therapeutic effect is obtained. The use of 2 or more NSAIDs provide no increased benefit and may increase toxic effects.
         

  • KA Hildebrand, SL-Y Woo, DW Smith, et al (Univ of Pittsburgh, Pa)
    The Effects of Platelet-derived Growth Factor-BB on Healing of the Rabbit Medial Collateral Ligament: An In Vivo Study.
    Am J Sports Med 26: 549-554, 1998.
       
    In a previous in-vitro study the authors have shown that platelet derived growth factor-BB promoted fibroblast proliferation and that transforming growth factor B1 promoted matrix synthesis. These factors were now used in-vivo studies.
       
    Methods: 37 rabbits were divided into 5 groups. 2 groups were given high or low dose growth factor-BB, 2 groups were given in addition a high or low dose of growth factor B1 and one group was given fibrin sealant only (used as a delivery system). The rabbits were sacrificed at 6 weeks and biomechanical and histologic analysis of healing was performed.
       
    Results: The values for ultimate load, energy absorbed to failure and ultimate elongation were 1.6, 2.4 and 1.6 times higher in higher doses of growth factor BB. The addition of growth factor-B1 did not increase the structural properties of the complex.
        

  • KA Karlson (Univ of Michigan, Ann Arbor)
    Rib Stress Fractures in Elite Rowers: A Case Series and Proposed Mechanism.
    Am J Sports Med  26: 516-519, 1998.
       
    Ten elite rowers with 14 stress fractures were interviewed (3 males, 7 females). Sex, date of injury, side rowed, weight class, fracture location, training phase and method of diagnosis evaluated.
      
    Results : Fractures occurred on the anterior to posterolateral aspect of ribs 5-9.  11 were diagnosed by bone scan, 2 by plain radiographs and 1 by clinical observation. The onset was slow with several days or weeks of discomfort followed by sharp pain that worsened at the end of the arm pull through phase.
       
    Conclusion: Rib stress fractures appear to be the result of the pull of the serratus anterior and external oblique muscles on the rib which causes repetitive bending of the rib. Therefore, the incidence can be reduced by decreasing the force of pull on the rib by the serratus anterior and the external oblique muscle or both.
         

  • BP Boden, DT Kirkendall, Jr Garrett WE (Duke Univ, Durham,NC)
    Concussion Incidence in Elite College Soccer Players
    Am J Sports Med 26: 238-241, 1998.
       
    The potential for head injuries among soccer players and its relation to neuropsychological deficits have long been debated. The incidence of concussion in elite college soccer players has been assessed.
      
    Methods: Seven men’s and 8 women’s soccer teams were studied for 2 seasons, and results documented.
       
    Findings: 29 concussions were diagnosed in 26 athletes (17men and 12 women). Concussions occurred from contact with :
      
    1)                 an opponent’s head in 28%

    2)                 an elbow in 14%

    3)                 a knee in 3%

    4)                 a foot in 3%

    5)                 a ball in 24%

    6)                 ground in 10%

    7)                 concrete side lines 3%

    8)                 goal post in 3%

    9)                 combination in 10%
      
    69% occurred during games. None of them occurred during intentional heading of the ball 72% of concussions were grade 1 and 28% were grade 2.
       
    Conclusions: Concussion occurs more commonly in soccer than has been believed. Such injuries may result in long term neuropsychological changes.
         

  • JA  Gastel, MA Palumbo, MJ Hulstyn, et al (Brown Univ, Providence, Rl)
    Emergency Removal of Football Equipment: A Cadaveric Cervical Spine Injury Model.
    Ann Emerg Med 32: 411-417, 1998.
      
    Purpose: The proper early management of suspected cervical spine injuries in football players is critical. EMT’s are trained to remove the helmet to avoid hyperflexion of the neck but sports medicine experts recommend against this practice. A cadaver study was conducted to analyse the effects of a football helmet or shoulder pads on alignment of the unstable cervical spine.
       
    Methods: The study included 8 cadavers of average age 73 years. A simulated bilateral facet dislocation was created at C5-C6 motion segment. Lateral x-rays were taken before and after injury with cadaver wearing (1) no equipment (2) a helmet only (3) shoulder pads only and (4) a helmet and shoulder pads. The effect of the alignment of the cervical spine was studied.
      
    Results: Lordosis was decreased by 9.6 degrees with helmet only and increased 13.6 degrees with shoulder pads only.
       
    After destabilisation of the cervical spine, C5-C6 forward angulation was increased by 16.5 degrees with helmet only and the posterior disc space height was increased by 3.8mm and dorsal element distraction by 8.3 mm. In the other 3 indications there were no significant differences.
      
    Conclusions: The results suggest that the helmet and shoulder pads should be left in place until the patient reaches a hospital unless CPR is required.
         

  • WF Donaldson III, WC Lauerman, B Heil, et al (Univ of Pittsburgh, Pa)
    Helmet and Shoulder Pad Removal From a Player With Suspected Cervical Spine Injury: A Cadaveric Model.
    Spine 23: 1729-1733, 1998.
      
    Objective: Cervical spine injuries can result in quadriplegia. The problem of removing the helmet and shoulder pads of an injured football player has been debated. A cadaver model was used to study how much motion occurs with 2 types of injuries when a helmet and shoulder pads are removed.
      
    Methods: Transoral osteotomy at waist of odontoid process was done to render C1-C2 unstable in 3 cadavers and in another 3 cadavers, the interspinous ligaments, the facet capsules, posterior longitudinal ligaments and posterior one third of the disc were sectioned at C5-C6. Under fluoroscopic visualization, 4 people removed the helmets by first removing the facemask, then the chinstrap and then the ear-pieces. The shoulder pads were then removed.  Maximum displacements were recorded and analysed.
       
    Results: Instability at C2 resulted in a change in angulation of 5.47 degrees distraction of 2.98 mm and a change in space available for the cord by 3.91 mm when the helmet was removed. With removal of shoulder pads, the change in angulation was 2.9 degrees distraction 1.76mm and the change in the space available for the cord 2.64 mm.
      
    Conclusions: A significant amount of movement can occur in an unstable cervical spine when the helmet and shoulder pads are removed. Therefore, it would be unwise to try to remove the helmet and shoulder pads before transportation to hospital.
        

  • MJ Wetzler, T Akpata, W Laughlin, et al (American Orthopaedic Rugby Football Assoc, Washington Crossing, Pa; South Jersey Orthopedic Associates, Voorhees, NJ: Rugby Magazine,  New York; et al )
    Occurrence of Cervical Spine Injuries During the Rugby Scrum
    Am J Sports Med 26: 177-180, 1998.
      
    Methods: Data on 62 injured players was compiled from oral and written reports and from medical records.
       
    Results:  Between 1970 and 1996, 36 (58%) players sustaining a cervical spine injury were injured during a scrum with 23(64%) occurring during the engagement and 13 (36%) during the collapse of the scrum.
        
    Conclusion: Cervical spine injuries to rugby players occur more frequently during the engagement phase of the scrum, to hookers, and to lower level players.
      

  • WAA Swen, JWG Jacobs, PR Algra, et al (Medisch Centrum Alkmaar, The Netherlands, niv Med Ctr, Utrecht, The Netherlands)
    Sonography and Magnetic Resonance Imaging Equivalent for the Assessment of Full-Thickness Rotator Cuff Tears
    Arthritis Rheum 42:2231-2238, 1999
      
    The common causative factor in frozen shoulder is the diagnosis by the Orthopaedic surgeons of Rotator Cuff Tear. There does not seem to be any good confirmatory test for Rotator cuff tear. After various investigative procedures, the two most useful tests were sonography and MRI. Of these two, sonography is much cheaper and is quite satisfactory.
       

  • Chung CB, Robertson JE, Cho GJ, et al [Univ of California, San Diego; Scripps Clinic Med Group, La Jolla, Calif]
    Gluteus Medius Tendon Tears and Avulsive Injuries in Elderly Women: Imaging Findings in Six Patients
    AJR 173:351-353,1999
     
    Although common, lateral hip pain can be a difficult to-diagnose problem. Common causes include arthritis, tendinitis, and bursitis; less common are syndromes such as abductor muscle strain and myofascial pain syndromes.
     
    Surgical repair provides improvement but not complete relief of the patient’s symptoms  in most instances.
       

  • Kannus P, Natri A, Paakkala T, et al [UKK Inst, Tampere, Finland; Tampere Univ, Finland]
    An Outcome Study of Chronic Patellofemoral Pain Syndrome : Seven Year Follow-up of Patients in a Randomized, Controlled Trial
    J Bone Joint Surg Am 81-A:355-363, 1999
     
    The etiology, pathogenesis, and outcome of patellofemoral pain syndrome are not well understood.
     
    For 6 weeks, 53 patients [28 women], with an average age of 27 years, with unilateral patellofemoral pain syndrome received intensive 3  isometric quadiceps exercises once daily and oral nonsteroidal anti-in-flammatory medication for 20 days [group A], the same nonoperative treatment plus 5 intra-articular injections of lidocaine [group B], or the same nonoperative treatment plus 5 intra-articular injections of glycosaminoglycan polysulfate [ group C].
     
    Nonoperative treatment was successful in maintaining function and dealing with pain in most patients with chronic patellofemoral pain syndrome.
      

  • Harwin SF {Beth Israel Med Ctr, New York]
    Arthroscopic Debridement for Osteoarthritis of the Knee: Predictors of Patient Satisfaction
    Arthroscopy 15: 142-146, 1999
     
    Arthroscopic debridement is now commonly performed in patients with degenerative knees. There is no evidence that debridement affects the pathologic process; however, some patients appear to benefit in terms of pain relief and functional gains, possibly delaying or avoiding more extensive surgery.
     
    The results are best in younger patients with no previous surgery and an angular deformity of less 50.  Approximately 85% of procedures are satisfactory when the axial alignment approaches normal and only 25% when there is a greater than 50 deviation from the normal mechanical axis.
       

  • Cheng JCY, Tang N [ Prince of Wales Hosp, Hong Kong]
    Decompression and Stable Internal Fixation of Femoral Neck Fractures in Children Can Affect the Outcome
    J Pediatr Orthop 19: 338-343, 1999
     
    The incidence of AVN decreases with early aggressive decompression or internal fixation of the fracture, or both.
     
    Prevention of any cases of AVN by treating the fracture a bit more quickly than we may be used to will save a teenager from a lifetime of hip disability.
        

  • Infection
    Kocher MS, Zurakowski D, Kasser JR [Harvard Med School, Boston]
    Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm
    J Bone Joint Surg Am 81-A: 1662-1670, 1999
     
    Differentiating between septic arthritis and transient synovitis of the hip in children can be difficult, because they have similar signs and symptoms.
     
    An infection of the hip in a child is an orthopedic emergency, requiring a quick workup during a period of hours, not days.
       

  • Miscellaneous
    Isogai N, Landis W, Kim TH, et al [Harvard Med School, Boston]
    Formation of Phalanges and Small Joints by Tissue-Engineering
    J Bone Joint Surg Am 81-A:306-316, 1999
     
    Children with severely traumatized or congenitally abnormal joints may require multiple replacement joints as they grow.  The engineering of new tissue by cell transplantation, where cells are placed on biodegradable polymer matrices, provides a novel approach to tissue in growth. Once the polymer is degraded, it leaves behind only naturally regenerated tissue.
     
    Growth of cell types derived from bovine periosteum, cartilage, and tendon used to from a joint.
     
    Fresh bovine periosteum was wrapped around a copolymer of polyglycolic and poly-L-lactic acid. Calf shoulder chondrocytes and tenocytes were used as sources of other cells.
     
    The composite structure was sutured in vitro to form constructs that created models of a human distal phalanx and a distal interphalangeal joint.
     
    The tissues were implanted subcutaneously in athymic mice.
     
    Twenty weeks after implantation of the construct into athymic mice, new human phalangeal jointed tissue had formed.
     
    None of the implants showed signs of inflammation.
     
    Well –defined whole-joint structures can be grown on biodegradable polymeric vehicles by using polyglycolic acid alone or with poly-L-lactic acid copolymer.
     
    The use of an absorbable carrier for the cell lines has worked well, and the carrier used by these authors can be shaped readily into an accurate anatomic representation of the part[s] needed.
     

  • Hagino T, Hamada Y [ Yamanashi Med Univ, Japan]
    Accelerating Bone Formation and Earlier Healing After Using Demineralized Bone Matrix for Limb Lengthening in Rabbits
    J Orthop Res 17: 232-237, 1999
     
    Prolonged fixation during distraction osteogenesis and callus distraction can lead to clinical problems. Accleration of callus formation may alleviate the problem of delayed bone formation.
     
    Use of the demineralized bone matrix shortened the latency period, prevented delay in bone formation, and shortened the fixator-wearing period.  Complete healing was observed at 1 year.
     

  • White RE Jr, Allman JK, Trauger JA, et al [New Mexico Orthopaedic Associates, Albuquerque; Advantage Orthopedics & Sports Medicine, Portland, Ore]
    Clinical Comparison of the Midvastus and Medial Parapatellar Surgical Approaches
    Clin Orthop 367: 117-122, 1999
     
    The most common surgical approach for TKA is the medial parapatellar. More recently, the midvastus-splitting approach has come into use. The advantage of the midvastus approach is that it does not violate the quadriceps, tendon proximal to its insertion into the patella.
     
    The knees which were operated on by the midvastus approach required fewer lateral retinacular releases, were less painful at 8 days and at 6 weeks, and had a higher ability to straight leg raise at 8 days.
      

  • Matsuda S, Miura H, Nagamine R, et al [ Kyushu Univ, Fukuoka, Japan]
    Changes in Knee Alignment After Total Knee Arthroplasty
    J Arthroplasty 14: 566-570, 1999
     
    Accurate alignment is an important key to the success of TKA.
     
    This contribution does underscore the absolute necessity of restoring and maintaining the mechanical axis at the time of the joint replacement to gain a higher likelihood of long-term success.
      

  • Shelbourne KD, Davis TJ, Patel DV [ Methodist Sports Medicine Ctr, Indianapolis, Ind]
    The Natural History of Acute, Isolated, Nonoperatively Treated Posterior Cruciate Ligament Injuries: A Prospective Study
    Am J Sports Med 27: 276-283, 1999
     
    The authors’ experiences suggest that the results achieved with surgical repair are similar to those of nonoperative treatment.
     
    The likelihood of returning to a sport was unrelated to the amount of posterior laxity.
     
    This prospective study suggests that isolated, nonoperatively treated PCL injuries generally heal with some degree of residual knee laxity; which does not increase over follow-up.
       

  • Taranow WS, Bisignani GA, Towers JD, et al [ Univ of Pittsburgh, Pa]
    Retrograde Drilling of Osteochondral Lesions of the Medial Talar Dome
    Foot Ankle Int 20: 474-480, 1999
     
    When ankle pain caused by osteochondritis dissecans [OCD] of the talar dome fails to respond to nonoperative treatment, surgery is indicated.
     
    A new arthroscopic retrograde drilling technique for the treatment of medial osteochondral lesions was reported.
     
    Unlike traditional surgical techniques for management of OCD of the talar dome, this operation preserves intact articular cartilage.
     
    This pathology can be very difficult to expose and in the past required osteotomy of the medial malleolus when involving the medial talus.
     
    The attractiveness of addressing this arthoscopically is, therefore obvious.
        

  • Baker CL Jr, Morales RW [Hughston Clinic, PC, Columbus, Ga]
    Arthroscopic Treatment of Transchondral Talar Dome Fractures : A Long-term Follow-up Study
    Arthroscopy 15: 197-202, 1999
     
    With arthroscopic treatment of transchondral talar dome fractures, lesions can be visualized accurately and debrided with less postoperative morbidity and earlier mobilization than arthrotomy.
     
    Transchondral talar dome fracture treatment with arthroscopic debridement and curettage yields a predictably high percentage of successful outcomes.
     
    Morbidity associated with this procedure is low.
     
    Both medial and lateral lesions were readily addressed, so the value of avoiding medial malleolar osteotomy associated with the medial lesions is particularly attractive.
     

  • Huang P-J, Fu Y-C, Cheng Y-M, et al [Kaohsiung Med College, Taiwan, Republic of China]
    Subtalar Arthrodesis for Late Sequelae of Calcaneal Fractures: Fusion in Situ Versus Fusion With Sliding Corrective Osteotomy
    Foot Ankle Int 20: 166-170, 1999
     
    Subtalar arthritis most occurs as a late sequela of intra-articular calcaneal fractures. Subtalar arthrodesis is used to treat not only acute calcaneal fractures but also the residual subtalar joint pain.
     
    Calcaneal fractures are also associated with loss of heel height and widening of the heel, which suggests that calcaneal corrective osteotomy could be pSubtalar arthritis most occurs as a late sequela of intra-articular calcaneal fractures. Subtalar arthrodesis is used to treat not only acute calcaneal fractures but also the residual subtalar joint pain.
     
    Calcaneal fractures are also associated with loss of heel height and widening of the heel, which suggests that calcaneal corrective osteotomy could be performed along with subtalar arthrodesis.
      
    Good results are reported from subtalar fusion combined with sliding corrective osteotomy.
     
    The corrective osteotomy does appear appropriate for pients with a – banana – shaped calcaneal malunion.
     
    Distraction subtalar arthrodesis might be a better choice for patients with tibiotalar impingement causing ankle pain.
     

  • Wolfe SW, Pike L, Slade JF III, et al [Yale Univ, New Haven, Conn]
    Augmentation of Distal Radius Fracture Fixation with Coralline  Hydroxyapatite Bone Graft Substitute
    J Hand Surg [Am] 24A:816-827, 1999
     
    Corralline hydroxyapatite [CHA], an alternative to bone graft, has a pore structure and biomechanical properties similar to human cancellous bone.
     
    Distal radius fractures treated with external fixation and Kirschner [K] wires were implanted with CHA bone graft as a substitute for autogenous bone graft.
     
    CHA effectively maintained articular surface reduction in combination with external fixation and K wires. The safety profile of CHA was comparable to that of other forms of treatment.
     
    These methods combine limited open reduction and internal fixation [using small plates, K wires, or both] with bone grafting of the metaphyseal defects to support the articular surface and external fixation. Autogenous iliac  crest bone grafting has been considered the gold standard for such procedures, but, no doubt, is associated with increased morbidity.
     
    The interest in borne graft substitutes for such procedures has proportionally increased along with advocates of hybrid fixation as a treatment alternative.
      

  • Garcia-Elias M, Lluch AL, Farreres, A, et al [ Institut Kaplan and the Hosp Clinic I Provincial, Barcelona; Hosp Gen de Catalunya, Sant Cugat del Valles, Spain; Institut Francias de Chirurgie de la Main, Paris]
    Resection of the Distal Scaphoid for Scaphotrapeziotrapezoid Osteo-arthritis
    J Hand Surg [Br] 24B:448-452, 1999
     
    Osteoarthritis of the scaphotrapeziotrapeziod [STT] joint is more common in older women, because treatment by STT fusion can lead to painful nonunion and radioscaphoid impingement, Linschied et al, recommended minimal resection of the distal scaphoid and interposition of tendon tissue, a modified excisional arthroplasty.
     
    No patients had pain or functional discomfort after surgery.  the grip and pinch strength improved.
     
    Excision of the distal scaphoid in patients with STT osteoarthritis results in relief of pain and functional disability.
     

  • Surgical Techniques
    Cortet B, Cotton A, Boutry N, et al [Univ Hosp of Lille, France]
    Percutaneous Vertebroplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: An Open Prospective Study
    J Rheumatol 26: 2222-2228, 1999
     
    Polymethylmethacrylate [PMMA] vertebroplasty is a new percutaneous procedure that can relieve pain and strengthen weakened vertebral bodies. It might also be useful for the treatment of painful osteoporotic compression fractures.
     
    All patients underwent vertebroplasty, consisting of posterolateral or transpedicular injection of PMMA under fluoroscopic guidance.
     
    Vertebroplasty is a useful treatment for patients with severe and persistent pain resulting from osteoporotic vertebral fractures.  The procedure offers prompt pain relief with no adverse effects.
     
    The mechanism of action of vertebroplasty is unknown. Mechanical, thermal, vascular, and chemical theories have been postulated.
     
    Other investigators have assessed the mechanical properties of various cements and found significantly less stiffness with Cranioplastic than with Simplex P and Osteobond.
     
    Vertebroplasty has shown promising early results for treating other painful lesions of the vertebral body including osteolytic metastases and multiple myeloma.
     
    There were no clinically significant adverse effects, but there was leakage of cement outside of the vertebral body in 65% of the vertebrae.
      

  • Hurlbert RJ, Theodore N, Drabier JB, et al [Univ of Calgary, Alta; St Joseph’s Hosp, Phoenix, Ariz]
    A Prospective Randomized Double- Blind Controlled Trial to Evaluate the Efficacy of an Analgesic Epidural Paste Following Lumbar Decompressive Surgery
    J Neurosurg : Spine 90: 191-197, 1999
     
    Pain management after lumbar surgery currently relies on systemic narcotics, which carry significant side effects and can delay, return to activities.
     
    An analgesic paste containing morphine and methylprednisolone was evaluated for its ability to control postoperative pain after lumbar spine decompression.
     
    Applied directly to the dura just before wound closure, an analgesic epidural paste can significantly improve pain control after lumbar spine decompressive surgery.
     
    Analgesic paste is a safe and effective treatment that may become a new standard of care for patients undergoing lumbar decompression and other surgical procedures.
     
    Surgeons frequently underestimate and undertreat postoperative pain.
     
    A safe and effective local agent capable of providing sustained analgesia for 6 weeks or more is highly desirable, and may well influence hospital stay, return to work, and, certainly, patient satisfaction.
     
    The originator of the paste has cautioned that the agent has the potential to act as a hyperosmolar agent, producing a sometimes painful but sterile and self-limiting subcutaneous fluid collection.
     
    More research is needed before analgesic epidural paste can be recommended.
      

  • Spinner RJ, Goldner RD [ Duke Univ, Durham, NC]
    Snapping of the Medial Head of the Triceps and Recurrent Dislocation of the Ulnar Nerve: Anatomical and Dynamic Factors
    J Bone Joint Surg Am 80 – A: 239-247, 1998
     
    Snapping of the medial head of triceps may often go unrecognised. Failure to recognise that this lesion and concurrent dislocation of the ulnar nerve can lead to persist symptoms after an otherwise successful transposition of the ulnar nerve.
     
    17 patients [ average age 25 years] were studied. The diagnosis was suspected on clinical grounds, and confirmed with MRI, CT or both. Operative findings were confirmatory in 3 cases.  Two patients were seen for painless snapping, 4 had painful snapping in the medial aspect of the elbow. 3 had symptoms related to ulnar nerve only. 6 had snapping and ulnar nerve involvement. Four patients were asymptomatic and were incidentally detected.
     
    Five of these were treated by transposition of ulnar nerve and lateral transposition or excision of medial head of triceps with excellent results. Among those managed conservatively control of pain was achieved.
     
    They conclude that persistent snapping after a successful transposition of the ulnar nerve can result from failure to recognise concurrent dislocation of the medial head of triceps. This snapping could be asymptomatic also.  The results of non operative treatment are also good.
       

  • Ellenbecker TS, Mattalino AJ, Elam EA, et al [ Scottsdale Sports Clinic, Ariz; Clinical Diagnostic Radiology Ltd, Phoenix, Ariz; Milwaukee Brewers Baseball Club, Milwaukee, Wis]
    Medial Elbow Joint Laxity in Professional Baseball Pitchers: A Bilateral Comparison Using Stress Radiography
    Am J Sports Med 26: 420-424, 1998

     
    Baseball pitching and other throwing activities place repetitive valgus stress on the elbow leading to ulnar collateral ligament injury. This study compared medial elbow laxity in the throwing and non-throwing arms of 40 professional baseball pitchers.
     
    The clinical range of motion of the elbows and wrist and bilateral stress radiography was done and the laxity was calculated by measuring joint space width between the trochlea and the coronoid process on anteroposterior radiographs.
     
    The dominant arm showed greater medial joint width and reduced range of movement [particularly extension] than the non dominant arm.
     
    They conclude that professional baseball pitchers show increased medial elbow laxity in the throwing arm than the other arm. Stress radiography is a reliable test to demonstrate this.
       

  • Lee GA, Katz SD, Lazarus MD [Albert Einstein Med Ctr, Philadelphia]
    Elbow Valgus Stress Radiography in an Uninjured Population
    Am J Sports Med 26: 425-427, 1998
      
    Valgus instability of the elbow is usually diagnosed clinically, though some have used gravity valgus stress radiography to aid in diagnosis. The amount of ulnahumeral gapping was measured in normal elbows by this method.
     
    40 asymptomatic people [ 20 men and 20 women] mean age [ 27 years] were studied. Both elbows were radiographed with the elbows in extension and in 300 flexion. Medial ulnahumeral distance was measured in 3 situations. [a] No stress [b] gravity valgus stress [c] applied valgus stress.
         
    The ulnahumeral distance increased significantly with increasing stress.
       
    They conclude that even in normal elbows valgus stress causes significant increase in  ulnahumeral distance. This test could be used for diagnosis of valgus instability in injured patients but is of no value in uninjured elbows.
       

  • Zeman C, Hunter RE, Freeman JR, et al [Orthopaedic Associates of Asper, Colo; Aspen Found for Sports Medicine, Education and Research, Colo]
    Acute Skier’s Thumb Repaired with a Proximal Phalanx Suture Anchor
    Am J Sports Med 26: 644-650, 1998
     
    58 patients with grade III sprains of the UCL [Ulnar Collateral Ligament] were repaired using a suture anchor for fixation of thumb to the proximal phalanx.  After a year a 14 point questionnaire was administered to determine functional outcomes.
     
    98% of the interviewed patients were satisfied with the result and had a stable repair with good range of movements and no hindrance in their activities. 17% reported mild discomfort and 7% experienced pain in the activities.
     
    This is a good method of repair.
     

  • Mont MA, LaPorte DM, Mullick T, et al [ Johns Hopkins Univ, Baltimore, Md]
    Tennis After Total Hip Arthroplasty
    Am J Sports Med 27: 60-64, 1999
       
    Many active patients wish to continue playing tennis after hip arthroplasty. Only 14% of surgeons had approved of their playing tennis. 34% recommended only doubles.
     
    A survey was conducted on such patients. 50 men and 8 women aged 47 to 89 years were identified. The survey was meant to assess the functional abilities and degree of satisfaction in this group.
     
    All were very satisfied with their surgeries and their increased ability to play tennis. After a mean of 8 years 3 patients needed revision surgery.
     
    Physicians should advise caution in restarting the game of tennis after hip arthroplasty and they should be followed annually for local  changes in the bones.
      

  • Clanton TO, Coupe KJ [Univ of Texas, Houston]
    Hamstring Strains in Athletes : Diagnosis and Treatment
    J Am Acad Orthop Surg 6: 237-248, 1998
     
    Hamstring injuries are common, well-defined athletic injuries. Their diagnosis is discussed.
     
    The hamstrings act during the early stance phase of gait for knee support, during the late stance phase for propulsion, and during midswing to control leg momentum. Injuries occurs at musculotendinous junction where forces are concentrated and results from hamstring strength imbalances and lack of adequate flexibility.
     
    Most injuries are acute. The entire length of muscle should be palpated and the injury should be classified as Mild [pulled], moderate [ partial tear] or severe [ complete rupture]. CT scan, MRI and USG are diagnostic.
     
    Treatment consists of immobilization rest, ice; compression and elevation to control hemorrhage, pain and edema.
     
    Administration of NSAID is controversial.
     
    The symptoms subside quickly. Careful mobilization and pain-free stretching or strengthening exercises help to regain morbidity.
     

  • Temple HT, Kuklo TR, Sweet DE, et al [ Walter Reed Army Med Ctr, Washington, DC]
    Rectus Femoris Muscle Tear Appearing as a Pseudotumor
    Am J Sports Med 26: 544-548, 1998
     
    Quadriceps femoris muscle injuries are very common in athletes. Sometimes this tear may present as a soft tissue mass on the anterior thigh, with or without a history of significant trauma.
     
    Seven patients with unexplained soft tissue mass of the thigh were seen at a army medical centre [males between 15 and 73 years, 3 were active duty personnel, 3 were military dependents and 1, a  retired serviceman. Laboratory X-rays were unremarkable. MRI showed an obvious but ill-defined mass at the musculotendinous junction of rectus. Biopsy was done in 4 patients to exclude a soft tissue sarcoma. Histologically it showed fibrosis, degeneration of muscle fibers and chronic inflammatory reaction.
     
    These injuries could have obvious traumatic origin or possibly repeated microtrauma. The diagnosis should be suspected and selective radiologic  examination performed.  Full functional recovery can be expected.
       

  • Bernicker JP, Hadded JL, Lintner DM, et al [Baylor college of Medicine, Houston]
    Patellar Tendon Defect During the First Year After Anterior Cruciate Ligament Reconstruction: Appearance on Serial Magnetic Resonance Imaging
    Arthroscopy 14: 804-809, 1998
     
    ACL rupture is commonly repaired using the central third of the patellar tendon. The healing process of the patellar tendon has been chronicled with the aid of MRI.
      
    MRI scanning was done on 12 consecutive patients [ 15 to 48 years] who underwent arthroscopic ACL repair at 3 weeks, 3 months, 6 months and one year after surgery. The tendon defect was not closed, only the peritenon was sutured. The tendon gap and the patellar bone harvest site were evaluated.
     
    Although the patellar tendon defect had decreased by an average of 62% at one year, only 2 persons had healed completely and some had not healed at all. Tendon width and length decreased. The greatest change occurred between 3 and 6 months after surgery thereafter healing showed down.
       

  • Natri A, Kannus P, Jarvinen M  [UKK Inst, Tampere, Finland; Univ of Tampere, Finland; Univ of Vermont, Burlington]
    Which Factors Predict the Long-term Outcome in Chronic Patellofemoral Pain Syndrome? A 7-Year Prospective Follow-up Study
    Med Sci Sports Exerc 30: 1572-1577, 1998
     
    Patellofemoral pain syndrome [PFPS] is a common sports injury that often becomes chronic. Neither conservative or operative management has yielded consistent results. A prospective study of conservative treatment has been done.
     
    49 consecutive cases of PFPS with an average age of 27 years were given 6 weeks of conservative treatment and evaluated. The effect of 19 variables like age, sex, duration athletic activity, etc. were studied. 10 patients had surgery during the follow-up.
      
    They conclude that systemic rehabilitation of quadriceps with a period of restriction is the treatment of choice for chronic PFPS.
       

  • Jee W-H, Choe B-Y, Kim J-M, et al [Catholic Univ, Seoul, Korea]
    The Plica Syndrome : Diagnostic Value of MRI with Arthroscopic Co-relation
    J Comput Assist Tomogr 22: 814-818, 1998
     
    This is a study of the efficacy of MRI in diagnosing plica syndrome.
     
    The MR images of 55 patients with arthroscopically confirmed pathologic mediopatellar plicae were compared with those of 100 patients without plicae.
     
    The sensitivity and specificity of axial multiplanar gradient-recalled [MPGR] images for diagnosing plica syndrome were 73% and 83% respectively and for the combination of these images they were 95% and 72% respectively. With the criterion of extension beyond the medial end of the patella on axial MPGR images, the incidence of pathologic medial plica increased.
     
    MRI is a useful non invasive screening tool for diagnosing plica syndrome before arthrography.
         

  • Rubin DA, Kettering JM, Towers JD, et al [Univ of Pittsburgh, Pa; West moreland Regional Hosp, Greensburg, Pa]
    MR Imaging of Knees having Isolated and Combined Ligament Injuries
    AJR 170: 1207-1213, 1998
      
    MRI is more sensitive than physical examination in detecting meniscal tears in patients with torn ACLs.
      
    The sensitivity of MRI in the diagnosis of ACL tears was 93%, with a specificity of 93% to 96%. 
      
    MRI offered a sensitivity of 93% for isolated ACL tears, 83% for ACL tears when both the ACL and posterior cruciate ligament [PCL] were torn, 100% for isolated PCL tears.
      
    The incidence of medial meniscus tears was 49% in knees with all ligaments intact.
      
    MRI scanning continues to be a valuable diagnostic procedure, particularly if the physical examination is difficult or incomplete.
      

  • LaPorte DM<, Mont MA, Mohan V, et al [Johns Hopkins Univ, Baltimore, Md]
    Multifocal Osteonecrosis
    J Rheumatol 25: 1968-1974, 1998
     
    Osteonecrosis is debilitating when confined to 1 joint [most typically the hips, knees, or shoulders], but when it spreads to multiple sites, its effects can be devastating.
     
    Plain radiographs and MRI were used to determine where the lesions were and their presenting stage.

    Patients [94%] had used or were using corticosteroids. 

    Each of patients had bilateral lesions at the femoral head. All patients had bilateral knee lesions.

    Most patients had multiple joint or hip symptoms when first seen. Symptoms were present in all the knees involved.

    Radiographs showed that most of the joints [77%] were at pre-collapse stage.

    The high use of corticosteroids in these patients suggests that these durgs are strongly associated with multifocal osteonecrosis.

    The vast majority [94%] of patients with multifocal osteonecrosis were o steroids.
        

  • Ebraheim NA, Lu J, Skie M, et al (Med College of Ohio, Toledo)
    Vulnerability of the Recurrent Laryngeal Nerve in the Anterior Approach to the Lower Cervical Spine.
    Spine 22: 2664-2667, 1997.
        
    This is cadaveric study. Anatomy demonstrated suggest danger of injury to recurrent laryngeal nerve more on right side because the nerve courses outside esophagotracheal groove and runs in oblique direction relative to the sagittal plane. Inferior thyroid vessel should be ligated as laterally as possible and the retractor should be blunt tipped to retract the longus colli muscle to provide intermittent retraction of the midline structures.
       
    This article highlights the rationale of using left sided approach to the spine when possible. If right sided approach is used then above precautions are necessary to prevent injury to recurrent laryngeal nerve.
        

  • Dubernard J-M, Owen E, Herzberg G, et al [ Hopital Edouard Herriot, Lyon, France; Microsearch Found of Australia and Outer Sydney Hand and Micro-Surgery Unit; St Mary’s Hosp, London; et al]
    Human Hand Allograft Report on First 6 Months
    Lancer 353: 1315-1320, 1999
         
    The results of transplantation of  the right forearm and hand of a brain-dead male donor to a male recipient who had a traumatic midforearm amputation are discussed.
     
    The technique has been described. There were no surgical complications. At 8 weeks there was a rejection episode which was treated successfully. Passive mobilization was started on day one and continued till week six. At 100 days, no stiffness was noted, but sensation was lacking. There was good callus formation at 3 months and advanced healing at 6 months.  At 80 days, the patient had some sensation.
      
    They conclude that hand transplants can be successfully done but sensation and functional analysis are not complete.
       

  • Smutz WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic and Found, Rochester, Minn]
    Mechanical Advantage of the Thumb Muscles
    J Biomech 31: 565-570, 1998
      
    The moment arms of the thumb muscles at the interphalangeal, metacarpophalangeal, and carpometacarpal joints were measured throughout the range of motion of each joint.
      
    The technique is described and the results show that :-
      
    1.   At metacarpophalangeal joint
     
    FPL, FPB, ADPt and ADPo and OPP were the major flexors.
     
    2.   At carpometacarpal joint
     
    FPL, FPB, ADPt, ADPo and OPP were the major flexors.
     
    EDL, EPB and APL were the major extensors.
     
    ADPt, ADPo, and EPL were the only abductors.
     
    APB, APL and FPB were the main abductors.
      
    This knowledge can aid in planning rehabilitation.
      

  • Lyons RP, Kozin SH, Failla JM [ US Air Force, Aviano, Air Force Base, Italy; Temple Univ, Philadelphia; Henry Ford Hosp, Detroit]
    The Anatomy of the Radial Side of the Thumb: Static Restraints in Preventing Subluxation and Rotation After Injury
    Am J Orthop 27: 759-763, 1998
      
    A cadaver study was performed to delineate the anatomic variations of the radial side of the thumb MP joint and to assess the relative contributions of the volar plate, radial collateral ligament, dorsal capsule and the extensor pollicis brevis in preventing rotation and volar subluxation.
      
    The methodology has been described. The results: The extensor pollicis brevis insertion was variable [ 61% inserted into the base of the proximal phalanx, 26% continue as a distal slip to the distal phalanx with no discrete insertion, and blending into the capsule with no discrete insertion in 10%. Volar subluxation varied from 0% to 35% and rotation from 12% to 35%. Volar subluxation increased to 26%, and rotation increased 20% when the radial collateral ligament was sectioned.
     
    Corresponding increases after incision of the extensor pollicis brevis/dorsal capsule were 12% and 12%, and were 21% and 24% after volar plate section. When the extensor pollicis brevis/dorsal capsule was sectioned first, followed by sectioning of the radial collateral ligament and the volar plate, results were 32% and 14%, 9% and 12%, and 18% and 24% respectively.
      
    They conclude that the radial collateral ligament and extensor pollicis brevis/ capsule help stabilize the joint against rotation and volar subluxation. An X-ray after volar displacement is more helpful than after pronation for revealing MP instability.
        

  • Romain M, Allieu Y [Hopital Lapeyronie, Montepellier, France]
    Overview of the Function of Flexor and Extensor Tendons of the Hand [French]
    Ann Chir Main 17: 259-265, 1998
        
    The authors describe 4 commonly used methods plus their own, of evaluating the flexor tendons of the hands and extrapolate their personal method to the evaluation of the extensor tendons.
     
    The four commonly used methods are –
     
    1.     Total active movement [TAM]
     
    2.     Buck-Gramcko Method
     
    3.     Kleinert method and
     
    4.     Strickland method
     
    Each of these methods has drawbacks of their own. Their own method takes into account MP flexion, eliminates the action of the intrinsic muscles, and can be used in every zone. First, the hand is straightened. The MP joints are stabilized at 900 of flexion. The patient is asked to flex the digits, and the DPPPD is measured. Then the hand is placed in 450 of extension and the extension deficits of the MP, PIP and DIP  joints are measured. This method was compared with the other four methods [ 165 patients]. The greatest number of excellent and good results was found with the Buck-Gramcko method [76%] followed in descending order by the authors method [ 66.6%], the Kleinert method [ 54.5%] and the Strickland’s method [53%].
     
    Extrapolation to Evaluation of the Extensor Tendons – First, the hand is placed in 450 of extension and the angle of extension deficit is measured. Then the hand is straightened. The MP joints are maintained at 900 and the DPPPD is measured in passive flexions. [ A twist on the method for measuring flexor function].
     
    The method is simple and offers a reliable and reproducible means of measuring the function of the tendons of hands.
        

  • Bouchlis G, Bhatia A, Asfazadourian H, et al [Athenes, Greece; Pune, India; Institut d’Antomie de Paris; et al]
    Distal Insertions of Abductor Pollicis Longus Muscle and Arthritis of the First Carpometacarpal Joint in 104 Dissections [ French]
    Ann Chir Main 16: 326-338, 1997
     
    This study examines the varying types of distal insertions of the APL tendons and their possible impact on the evolution of arthritis of the CMC joint of the thumb.
     
    104 cadavers were dissected at the level of the CMC joint of the thumb. The appearance of the joint surface was noted and the distal insertions of the tendons to the level of the CMC joint was observed. The type of arthritis was correlated with the type of distal insertion of APL tendon.
     
    The APL had multiple insertion in 95% of cases. There was always an insertion at the base of the 1st metacarpal. 70% had an insertion into the trapezium as well 42% had an accessory tendon to the thenar eminence. 97% showed rhizarthrosis. 71% had lateral compartment of the joint surface involvement and was probably the starting point of the arthritis. The degree of arthritis did not reveal any correlation with the type of insertion of APL.
     
    The findings suggest that arthritis of the first CMC joint is extremely common and appears to start in the lateral compartments.  There is no correlation with the insertion of the APL tendon. The finding do not support the practice of early prophylactic tenotomy for arthritis of the first CMC joint.
       

  • Gajisin S, Bednarkiewicz  M, Zbrodowski A [ Centre Medical Universitaire, Geneve; Hopital Cantonal Universitaire, Geneve]
    Blood Supply of the Digital Sheath
    Ann Chir Main 17: 147-153, 1998
     
    This study identifies the sources and describes the network  distributing the arterial blood supply of the digital sheath.
     
    A mixture containing india ink and gelatin or colored latex was injected into the brachial artery of 100 fresh human cadavers. After formalin fixation, dissection was performed under the stereo-microscope.
     
    The digital sheaths of index, middle and ring fingers were studied. There are two main sources of supply [1] digitopalmar arches and [2] palmer digital arteries. Many anastomoses  are formed between these branches to create a fine arterial network on the inner surface of the digital sheath. The floor of the sheath is the most vascularized area, next the side wall and lastly the palmar side. The proximal dead end of the sheath is directly supplied by branches from the arcus palmaris  superficials.
       

  • Clarke MT, Lyall HA, Grant JW, et al [Addenbrooke’s Hosp, Cambridge, England]
    The Histopathology of de Quevain’s Disease
    J Hand Surg [Br] 23B:732-734, 1998
     
    De Quervain’s disease is considered to be a stenosing tenovaginitis of either acute or chronic inflammatory etiology. This was re-examined using a staining technique that reveals the accumulation of connective tissue mucopolysaccharide suggesting myxoid degeneration. This was performed on 23 consecutive patients undergoing treatment for Dequevain’s disease. There was no sign of active inflammation.  The terms ‘ stenosing tenovaginitis’ and ‘ tenosynovitis’ are misnomers.
      

  • Sbernardori MC, Montella A, De Santis E [Universita degli Studi di Sassari]
    Histo-morphological Findings on the Flexor Digitorum Tendons in Human Embryos Hand at the End of First Trimester of Gestation [Italian]
    Riv Chir Riab Mano Arto Sup 34: 229-233, 1997  + Sbernardori MC [Universita Degli Studi di Sassari]
    Ultrastructural Aspects of the Palmar Aponeurosis of Fetal Hand [Italian]
    Riv Chir Riab Mano Arto Sup 34: 187-191, 1997
     
    These two articles are well documented and original studies on the development of the human hand.
     
    Histomorphology of the flexor tendons and palmar aponeurosis was studied under light and electron microscopy in a series of 1 mm thick cross sections of the finger.
     
    The palmar aponeurosis [12th week], is easily seen under the derma with its typical double layer structure with a double oriented perpendicular pattern. Strict relationship is shown with intertendinous septa.
      

  • Griffiths GP, Selesnick FH [Miami Sports Medicine Fellowship, Coral Gables, Fla]
    Operative Treatment and Arthroscopic Findings in Chronic Patellar Tendinitis
    Arthroscopy 14: 836-839, 1998
     
    Though conservative treatment is usually effective in chronic patellar tendinitis some patients continue to have symptoms, these patients may require surgery.
     
    The authors conclude that chronic patellar tendinitis that does not respond to conservative surgery, respond to surgery.
       

  • Risberg MA, Holm I, Steen H, et al [ Univ of Oslo, Norway; Martina Hansens Hosp, Baerum , Norway]
    The Effect of Knee Bracing After Anterior Cruciate Ligament Reconstruction : A Prospective, Randomized Study With Two Year’s Follow-up
    Am J Sports Med 27: 76-83, 1999
      
    This study investigates the effects of knee bracing after ACL reconstruction on knee joint laxity, lower limb function, the cross-sectional area of the the thigh and the incidence of further intra-articular injury.
        

  • Matava MJ, Evans TA, Wright RW, et al [Washington Univ, St Louis; Slippery Rock Univ, Pa]
    Septic Arthritis of the Knee Following Anterior Cruciate Ligament Reconstruction: Results of a Survey of Sports Medicine Fellowship Directors
    Arthroscopy 14: 717-725, 1998
     
    This is a review of literature regarding the incidence of septic arthritis as a complication following ACL reconstruction and its prevention and treatment.
     
    A questionnaire was mailed to 74 surgeons listed in the Sports Medicine Fellowship Program regarding their experience and practices in performing ACL surgery, number of years in practice, number of ACL reconstructions performed annually, graft choice, surgical technique, use of postoperative drains, prophylactic antibiotics and postoperative complications in the past 2 and 5 years.
     
    82% of responders had been in practice for an average of 17.3 years and performed an average of 98 ACL repairs annually.
     
    77% chose the patellar tendon graft, followed by hamstring graft [23%]. Endoscopic reconstruction was the method of choice [72%] whereas 16% used arthroscopically assisted surgery. 98% used postoperative prophylactic antibiotics 51% used a drain. 30% had treated an ACL infection within the past 2 years, and 26% within the past 5 years. Culture-specific IV antibiotics and irrigation of the joint was the treatment of choice for 85% of responders. Graft removal was chosen by 31%. Revision after graft removal was done after 6-9 months by 49% of responders.
     
    In conclusion, septic arthritis is a rare complication following ACL repair and treatment consists of culture specific IV antibiotics and joint irrigation with graft retention; with graft removal reserved for resistant infection.

  • Barber-Westin SD, Noyes FR, Heckmann TP, et al [Deaconess Hosp, Cincinati, Ohio; HealthSouth Rehabilitation Corp, Cincinnati, Ohio]
    The Effect of Exercise and Rehabilitation on Anterior-Posterior Knee Displacements After Anterior Cruciate Ligament Autograft Reconstruction
    Am J Sports Med 27: 84-93, 1999
     
    Current trends in rehabilitation after ACL reconstruction focus on aggressive or accelerated exercise protocols with early return to full weight bearing and high levels of at athletic activity. This study analyses the results of such protocols.
     
    Individual evaluation based rehabilitation is needed after ACL reconstruction.
      

  • Fischer DA, Tewes DP, Boyd JL, et al [Minneapolis Sports Medicine Ctr]
    Home-based Rehabilitation for Anterior Cruciate Ligament Reconstruction
    Clin Orthop 347: 194-199, 1998
     
    The results of a postoperative home based rehabilitation program after ACL reconstruction were compared with the results of a traditional clinic-based program.
     
    The home based rehabilitation program after ACL reconstruction provides good, cost-effective results.
        

  • Dye SF, Wojtys EM, Fu FH, et al [Univ of California, San Francisco; Univ of Michigan, Ann Arbor; Univ of Pittsburgh, Pa et al]
    Factors Contributing to Function of the Knee Joint After Injury or Reconstruction of the Anterior Cruciate Ligament
    J Bone Joint Surg Am 80-A: 1380-1393, 1998
        
    The factors that govern restoration of knee function after injury or ACL reconstruction are discussed in terms of musculoskeletal  function.
        
    This concept encompasses the capacity to generate, transmit, absorb and dissipate loads and to maintain homeostasis.
       
    Several factors contribute to the functional capacity of a joint. These include [1] anatomical factors, like macromorphology and micromorphology, structural integrity, and biomechanical characteristics. [2] Kinematic factors, such as pattern of sequential tightening  of  the ACL fibers and the dynamics of all the complex neuromuscular control mechanisms [3] Physiologic factors, such as the biochemical and metabolic processes that maintain homeostasis in the joint and musculoskeletal components. And [ 4] Non operative or operative treatments.
        
    Absence of pain, warmth, swelling and functional instability indicate that a joint is not being overloaded.
         

  • Tieschky M, Faber S, Haubner M, et al [ Ludwig-Mximilians - Universitat Munchen, Germany; Klinikum Grobhadern, Munich,  Germany; Institut for Medizinische Informatik und Systemforschung, Neuherberg, Germany; et al]
    Repeatability of Patellar Cartilage Thickness Patterns in the Living, Using a Fat-suppressed Magnetic Resonance Imaging Sequence With Short Acquisition Time and Three-Dimensional Data Processing
    J Orthop Res 15: 808-813, 1997
     
    The right knees of 8 healthy volunteers were examined by transverse MRI with a T1-weighted, fat-suppressed, flash-3D sequence. The entire transverse data set was acquired in 4 min. 10 sec. 6 different positions were used to determine the replicability of cartilage thickness.
       
    A fat suppressed, FLASH-3D MRI sequence with 3D reconstruction and digital data processing reliably determines the thickness of the articular cartilage in a non-invasive fast and reproducible manner.
        

  • Potter HG, Linklater JM, Allen AA, et al [ Hosp for Special Surgery, New York City ]
    Magnetic Resonance Imaging of Articular Cartilage in the Knee : An Evaluation With Use of Fast-Spin-Echo Imaging
    J Bone Joint Surg Am 80-A: 1276-1284, 1998
     
    The best MRI sequence for detection of chondral abnormalities remains unclear. This study evaluates a specialized proton density weighted high resolution fast spin echo sequence for evaluation of chondral pathology.
     
    This method provides a valuable approach for evaluation of chondral pathology.
       

  • Saal JS, Saal JA [SOAR, Menlo Park, Calif]
    Management of Chronic Discogenic Low Back Pain With a Thermal Intradiscal Catheter : A Preliminary Report
    Spine 25: 382-388, 2000
     
    New alternatives for the treatment of chronic diskogenic low back pain are needed. Previous studies have suggested that intradiskal heating can shrink collagen fibrils, cauterize granulation tissue, and coagulate nerve endings. To take advantage of these effects, a catheter and thermal treatment protocol for intradiskal electrothermal annuloplasty and nuclectomy [IDET] was developed.
     
    Patients were back to work within  5 days of the procedure and there were no complications.
      

  • Weiner BK, Walker M, Brower RS, et al [ College of Medicine, Akron, Ohio]
    Microdecompression for Lumbar Spinal Canal Stenosis
    Spine 24: 2268-2272, 1999
     
    Surgical management of lumbar degenerative spinal canal stenosis can result in significant destruction of uninvolved tissues.
     
    The technique is technically demanding, has a steep learning curve, and is advisable only in selected cases and only by surgeons very comfortable with the technique.
      

  • Blackley HR, Wunder JS, Davis AM, et al [ Mount Sinai Hosp, Toronto]
    Treatment of Giant-Cell Tumors of Long Bones With Curettage and Bone-grafting
    J Bone Joint Surg Am 81-A : 811-820, 1999
     
    Most experts recommend treating giant-cell tumors of long bones with curettage, adjuvants [such as phenol] to destroy any remaining tumor cells, and filling of the defect with methylmethacrylate cement. However, evidence is insufficient to prove that this approach is significantly superior to curettage with long bone drafting.
     
    The recurrence rates with curettage by means of a high speed burr and autogenous bone grafting [with or without allograft bone] reported here compare favorably with those associated with the use of curettage, adjutants, and cement.
     
    This supports the belief that the major reason for improvements  in local control of giant cell is because of surgical technique and not because o reconstructive techniques.
          

  • Robicsek F., Cook JW, Rizzoni W [Carolina Med Ctr, Charlotte, NC]
    Sternoplasty for Incomplete Sternum Separation
    J Thorac Cardiovasc Surg 116: 361-362, 1998
     
    The authors have previously reported a technique for surgical repair of poststernotomy separation. In the sternum weaving technique, persistent bilateral double-row sutures are placed, and transverse sutures are used to reunite the sternum halves, buttressed by the double axial suture lines. This technique is highly useful for patients with separation along the complete length of the sternum,but some patients have separation only of the lower portion of the sternum. In these cases the full sternum may sometimes be divided just to reapproximate the lower portion. A modified technique for reapproximation of the separated lower portion of the sternum has been described.
     
    This modified sternoplasty technique can be used in cases of partial postoperative sternum separation. This approach was successful in several patients with chronic, noninfected partial sternum separations. All patients showed good results, with early discharge from the hospital.
       

  • Reconstruction
    Kawai A, Muschler GF, Lane JM, et al [Mem Sloan-Kettering Cancer Ctr, New York; Cleveland Clinic Found, Ohio; Hosp for Special Surgery, New York]
    Prosthetic Knee Replacement After Resection of a Malignant Tumor of the Distal Part of the Femur : Medium to Long-term Results
    J Bone Joint Surg Am 80-A :636-647, 1998
     
    This study is a medium to long term follow up [5-17 years] of a custom prosthetic knee replacement after wide resection of a primary malignant tumor of the distal femur.
     
    The results were encouraging. None of the 40 patients had a local recurrence. However the prosthetic survival rates at 5 and 10 years were only 67% and 48% respectively. The rate of prosthetic survival was significantly lower for males, in those who had a 40% resection of the femur and a total resection of the quadriceps and for patients in whom a straight femoral stem had been used and fixed with cement. Functional recovery was 80%.
      

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