Speciality
Spotlight

 



 


Orthopaedics


 

 





  • Hanlon
    M, Krajbich JI [ Saint Heliens, Auckland, New
    Zealand; Shriners Hosp for Children, Portland, Ore]


    Rotationplasty
    in Skeletally Immature Patients : Long Term
    Follow-up Results


    Clin
    Orthop 358 : 75-82, 1999

      

    Lower
    extremity sarcomas are usually treated by
    amputations. There
    are a few viable alternatives like rotationplasty,
    resection arthrodesis, allograft 
    replacement and endoprosthetic replacement.
    In immature skeletons these procedures may
    not be satisfactory.
    Rotationplasty offers a biologic functional
    joint at the level of the knee, prosthetic tolerance
    secondary to loading of normal weightbearing tissue,
    maintenance of growth and the ability to tailor the
    procedures and prosthesis to obtain limb length
    equality at maturity.

      

    Six
    of twenty one patients died and one was lost to
    follow up. The
    follow up [ 5 – 10.5 years] had good or excellent
    results functionally.

       

  • Shih
    H-N, Wen-Wei Hsu R, Sim FH [Chang Gung Mem Hosp,
    Kweishan, Taoyuan, Taiwan, China]


    Excision
    Curettage and Allografting of Gaint Cell Tumor


    World
    J Surg 22: 432-437, 1998

      

    Gaint
    cell tumor [GCT] of bone is a benign, aggressive
    lesion of long bones. The results of wide excision,
    phenol cautery therapy and bone grafting have been
    reviewed.

      

    22 patients were followed up for at least 2 years. The tumor size of about 60 ml and grade II to grade III lesions. No
    patient received chemotherapy.

      

    The
    results of this treatment show that it can be safe
    and effective.

          

  • Kochar
    MS, Gebhardt MC, Mankin HJ [Massachusetts Gen Hosp,
    Boston; Harvard Med School, Boston; Children Hosp,
    Boston]

    Reconstruction
    of the Distal Aspect of the Radius with Use of an
    Osteoarticular Allograft After Excision of a Skeletal Tumor

    J
    Bone Joint Surg Am 80-A: 407-419, 1998

     

    The
    authors repeat them experience with the use of
    osteoarticular allograft to reconstruct the distal
    aspect of the radius after excision of skeletal
    neoplasms.

     

    24
    cadaveric osteoarticular allografts were implanted
    in 24 patients [13 women and 11 men] who had
    undergone distal radius surgery for giant-cell
    tumor. The
    radiocarpal ligaments were also reconstructed and
    internal fixation was used.
    The average follow up was 10-9 years.

     

    In
    2 patients, there was local recurrence [primary
    giant cell tumor and desmoplastic fibroma ].
    8 patients required revision because of a
    fracture wrist pain and local recurrence or volar
    dislocation of carpus.

     

    They
    conclude that the rate of local recurrence was low,
    function was restored in these wrists with a
    moderate range of motion and little pain during the
    performance of moderate activation.
    However 33% needed revision.
    Nonetheless this operation is a good option
    for reconstruction of the distal aspect of the
    radius after skeletal tumor excision.

        

  • Hornicek
    FJ Jr, Mnaymneh W, Lackman RD, et al [Univ of Miami/
    Jackson Mem Med Ctr, Fla; Thomas Jefferson Univ,
    Philadelphia; Univ of Zurich, Switzerland]

    Limb
    Salvage with Osteoarticular Allografts After
    Resection of Proximal Tibia Bone Tumors


    Clin
    Orthop 352: 179-186, 1998

     

    The
    clinical behavior of proximal tibial osteoarticular
    allografts after bone tumor resection was
    investigated and long term outcomes for patients
    receiving chemotherapy were compared with those not
    receiving chemotherapy.

     

    38
    patients receiving proximal tibial allografts after
    wide resection of benign and malignant tumors were
    studied. 55% of patients experienced one or more
    complications of the allograft.
    Patients receiving chemotherapy had a higher
    incidence of fractures [58%] than those not
    receiving chemotherapy [ 50%]. However with proper
    management of the complications, allograft is still
    a viable option for reconstruction of defects after
    wide resection of tibial tumors.

      

  • Jeon
    D-G, Kawai A, Boland P, et al [Korea Cancer Ctr
    Hosp, Seoul; Okayama Univ, Japan; Mem Sloan – Kettering Cancer
    Ctr, New York]

    Algorithm
    for the Surgical Treatment of Malignant Lesions of
    the Proximal Tibia




    Clin Orthop 358: 15-26, 1999


     

    A
    retrospective study of 40 cases who had total knee
    replacements after proximal tibial resection was
    conducted. Various
    reconstructive methods were used to fix the
    prosthesis re-establish the extensor mechanism and
    provide soft tissue cover.

     

    They
    conclude that aggressive multistage management of
    infection is necessary. Those requiring chemotherapy
    or who have short potential survival should undergo
    prosthetic replacement. Failure may be caused by
    weakness of the extensor mechanism.
    Primary reconstruction with an uncemented
    rotating hinge knee replacement is the most suitable
    prosthesis.

         

  • Outcome

    Felder-Puig
    R, Formann AK, Mildner A, et al [ St Anna
    Children’s Hosp, Vienna; Univ of Vienna]

    Quality
    of Life and Psychosocial Adjustment of Young
    Patients After Treatment of Bone Cancer

    Cancer
    83: 69-75, 1998

      

  • Serletti
    JM, Carras AJ, O’Keefe RJ, et al [ The cancer Ctr,
    Rochester, NY; Univ of Rochester Med Ctr, NY]

    Functional
    Outcome After Soft-Tissue Reconstruction for Limb
    Salvage After Sarcoma Surgery

    Plast
    Reconstr Surg 102: 1576-1585, 1998

     

    Significant
    soft tissue defects occur in patients treated for
    soft tissue sarcoma. These need reconstructive
    procedure. The
    functional outcome of such cases has been
    investigated.

     

  • Kawai
    A, Backus SI, Otis JC, et al [Mem Sloan-Kettering
    Cancer Ctr, New York; Hosp for Special Surgery, New
    York]

    Interrelationships
    of Clinical Outcome, Length of Resection, and Energy
    Cost of Walking After Prosthetic Knee Replacement
    Following Resection of a Malignant Tumor of the
    Distal Aspect of the Femur

    J
    Bone Joint Surg Am 80-A: 822-831, 1998

     

    ISOLS
    [International Society of Limb Salvage] system is
    now commonly used to report functional outcome after
    prosthetic replacement. The relationship between
    ISOLS scores and objective
    measures of function after resection of malignant
    musculoskeletal tumors followed by total knee
    replacement was investigated.

     

    Surgeons
    are non encouraged to do more radical tumor
    excisions because muscle mass can be functionally
    compensated for by the innervated free muscle
    transfer.

      

  • Wedin
    R, Bauer HCF, Wersall P [ Karolinksa Hosp,
    Stockholm]

    Failures After Operation for Skeletal Metastatic
    Lesions of long Bones


    Clin
    Orthop 358: 128-139, 1999

      

    Skeletal
    metastases with patholigic fracture have a high risk
    of failure after surgery, particularly in the femur.
    A long survival time is an important risk
    factor for local failure.
    The failure rate may be reduced by rigid
    internal fixation and filling of bone defects with
    acrylic cement. A retrospective study identifies the
    other causes of fracture. The study includes [ 92
    patients with 228 metastatic lesions. Surgical
    treatment consisted of intralesional curettage [ 133
    patients] resection and reconstruction [ 18 patients
    ] and stabilization only [ 77 patients]. An endoprosthesis was used for 54 patients having reconstruction.
    An osteosynthetic device was used for 162
    patients and cement only in 10 patients.

     

    They
    conclude that endoprostheses reconstruction is
    better than osteosynthetic devices.
    Surgery is safe even in seriously ill
    patients.

        

  • Wang
    PTH, Bonavita JA, DeLone FX Jr, et al
    [Crozer-Chester Med Ctr, Upland,Pa]

    Ultrasonic Assistance in the Diagnosis of Hand Flexor Tendon Injuries

    Ann Plast Surg 42: 403-407, 1999

       

    This study examines the contribution of ultrasonography to the diagnosis of flexor tendon injuries.

      

    Eight patients were studied, clinically there was inability to flex the finger. Evaluation was performed using an ATL-HDI-3000 US unit with a high -resolution 5- to -9 MHz hockey stick linear probe. Real-time flexor tendon manipulation was performed to stimulate the patient’s symptoms. These findings were compared with the operative findings.

       

    3 cases of flexor digitorum profundus tendon rupture were diagnosed by USG. These injuries resulted from forceful extension, penetrating injury, delayed rupture 3 weeks after previous repair respectively. In all 3 cases the US findings were confirmed at surgery. In the remaining 5 cases [forceful extension, penetrating trauma, phalangeal fracture and crush injury]. The US showed the tendons to be intact; at operation, in 3 cases these findings were confirmed. 

       

    The authors conclude that US is a useful diagnostic tool for clinically equivocal flexor tendon injuries.

          

  • Drape J-L, Tardif-Chastenet de Gery S,
    Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital
    Bichat, Paris]

    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation

    Skeletal Radiol 27: 617-624, 1998

      

    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.

      

    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the
    FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.

      

    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP
    +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 

       

    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.


           

  • Failla
    JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]

    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations

    J Hand Surg [Am] 24A: 257-266, 1999

       

    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.

        

    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1
    Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is an useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.

        

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp,
    Wollongong, Australia]

    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation

    Injury 30: 59-63, 1999

      

    Complex fractures of the elbow can be difficult to diagnose – thus
    “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging
    is an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.

        

  • Wolf
    JM, Weiss A-PC [Brown Univ, Providence, RI]

    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery

    J Hand Surg [Am] 24A: 182-184, 1999

      

    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.

       

    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or
    inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.

      

    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the
    in-situ 4 corner fusion.

      

    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.

          

  • Turgeon
    TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health
    Centre, London, Ont]

    J Hand Ther 12: 7-15, 1999

      

    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.

      

    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.

      

    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion
    intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.

      

    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.

      

    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.

          

  • Marx
    RG, Bombardier C, Wright JG [Univ of Toronto]

    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?

    J Hand Surg [Am] 24A: 185-193, 1999

      

    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.

     

    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.

     

    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.

     

    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.

        

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]

    Transthecal Digital Nerve Block: An Anatomical Appraisal

    J Hand Surg [Br] 23B: 490-493, 1998

     

    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.

     

    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.

       

    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.

     

    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the
    p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.

     

    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.

     

    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.

        

  • Lundborg G, Rosen B, Lindberg S
    [Malmo Univ, Sweden]

    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility

    J Hand Surg [Am] 24A: 219-224, 1999

      

    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.

      

    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.

      

    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.

      

    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.

           

  • Wright
    JG, Hawker GA, Bombardier C, et al [Univ of Toronto; Sunnybrook & Women’s College Hosp, North York,
    Ont; Vanderbilt Univ, Nashville, Tenn; et al]

    Physician Enthusiasm as an Explanation for /area Variation in the Utilization of Knee Replacement Surgery

    Med Care 37: 946-956, 1999

       

    This study examines the variation in the utilization of knee replacement surgery by county in the Canadian province of Ontario. The factors evaluated included the characteristics and opinions of the physicians and specialists, severity of disease, access to the procedure, use of alternative surgery and population factors.

       

    Knee replacement was more frequently used in older patients and in medical school affiliated hospitals. The referring physicians were usually males, trained outside North America. Orthopedic surgeons had a higher propensity for performing knee replacements and better perceptions of the outcomes. 

       

    The authors conclude that the local orthopedic surgeons have a major influence on the rate of knee replacement in a given geographic area. Efforts to reduce variation in surgeon opinion might reduce although not eliminate, geographic variation.

        

  • Coyte PC, Hawker G, Croxford R, et al
    [Univ o Toronto; Women’s College Hosp, Toronto; Hosp for Sick Children, Toronto]

    Rates of Revision Knee Replacement In Ontario, Canada

    J Bone Joint Surg Am 81-A: 773-782, 1992

       

    This analysis includes 18,520 knee replacements performed in Ontario from 1984 to 1991. One study algorithm was used to identify primary versus revision 

    knee replacements and another was used to link revision to primary knee replacements.

       

    The survival of the primary knee replacements was assessed using the Kaplan Meier method and factors affecting survival were identified using a proportional – hazards regression model. 

       

    Overall 7% of the total number of knee replacements were revisions. Osteoarthritis was the commonest indication for primary knee replacement. The time to revision surgery was significantly longer for patients older than 55 years, rural population and in those with rheumatoid arthritis revision.

       

    Revision replacement surgery was done earlier in teaching or speciality hospitals. Long term revision rates were low. The estimated rate of revision within 7 years varied significantly according to the algorithm used from 4.3% to 9%.

       

    They conclude that revision knee replacement is a rare event. Many factors affect thus likelihood like age, sex, area of residence and type of hospital.

        

  • Robertsson O, Borgquist L, Knutspm K, et al
    [Univ Hosp, Lund, Sweden; Linkoping Univ, Sweden]

    Use of Unicompartmental Instead of Tricompartmental Prostheses for Unicompartmental Arthrosis in the Knee is a Cost-effective Alternative : 15,437 Primary Tricompartmental Prostheses Were Compared With 10,624 Primary Medial or Lateral Unicompartmental Prostheses 

    Acta Orthop Scand 70: 170-175, 1999

       

    This study evaluates the cost of UKA [Unicompartmental] and TKA [Tricompartmental] procedures including implant cost. Length of hospital stay and the difference in the number of expected revisions. 

       

    The analysis included 15,437 primary TKAs and 10,624 primary medial or lateral UKAs over an 11 year period. Registry data was used to compare length of hospital stay in the 2 groups. Survival data was used to calculate the cumulative revision rate [CRR] and relative risk of revision. The risk of second revision and infection were calculated as well. 

       

    The proportion of patients undergoing UKA implantation declined during the period of study. ‘The average age at primary operation was 73 years [TKA] and 71 years [UKA]. The postoperative stay averaged 12.3 days [TKA] and 10.7 days [UKA]. The 10 year CRR was 12% [TKA] AND 16% [UKA]. The rate of serious complications was significantly lower in UKA group. The cost of a UKA was 57% that of TKA procedure.

       

    The conclusion is that the cost of UKA implantation is lower than TKA implantation [inclusive of higher revision rate]. It also has a shorter hospital stay. The costs may be further reduced by proper selection of patients.

       

  • Parentis MA, Rumi MN, Deol GS, et al [Pennsylvania State Univ, Hershey] 

    A Comparison of the Vastus Splitting and Median Parapatellar Approaches in Total Knee Arthroplasty

    Clin Orthop 367 : 107-116, 1999

        

    This is a controlled prospective study [randomized] comparing the two approaches.

       

    42 consecutive patients [51 knees] with degenerative disease of the knee were subjected to TKA.

       

    The median parapatellar approach used a standard midline incision. In the vastus medialis splitting approach the same incision was used; however at the level of the supero medial corner of the patella, the vastus medialis fascia was incised along the margin of the quadriceps tendon and elevated medially. The muscle was then split bluntly. 

       

    Electromyography performed pre and postoperatively was used to evaluate the two approaches relative to their effect on the innervation of the quadriceps mechanism. 

       

    The two randomized groups were similar in age, weight and other clinical parameters. Postoperatively, no significant differences were noted during the hospital stay at 2, 6 and 12 weeks in terms of straight leg raise, ROM and hospital for special surgery scores, short arc quadriceps strength or tourniquet time. Blood loss was significantly greater in the standard approach [ 200 vs 129.6 ml]. 9 patients [43%] who had vastus splitting approach had abnormal postoperative electromyograms.

       

    The two approaches are similar when compared clinically. Longer tern studies, however, are needed to determine the clinical significance of denervation of the vastus medialis muscle by the vastus splitting approach.

           

  • Aglietti P, Buzzi R, De Felice R, et al [Univ of Florence, Italy]

    The Insall-Burstein Total Knee Replacement in Osteoarthritis : A 10-Year Minimum Follow-up

    J Arthroplasty 14: 560-565, 1999

       

    The Insall-Burstein posterior stabilized [IBPS] TKA was designed to improve maximal flexion and function. Previous studies have presented midterm results with this prosthesis. This study presents a ten year follow up result using the IBPS in patients with osteoarthritis. 

      

    99 IBPs TKAs in 86 patients [76 women and 10 men average age 69 years] with osteoarthritis were followed up. Follow up evaluation consisted of annual clinic visits, including the knee Society Score and radiographs. 10-15 years follow up data were available on 60 knees.

       

    58% had excellent results [Knee Society Scores ], 25% had good results, 7% had fair results and poor results in 10%. The knees had an average of 1060 of flexion. 9% had moderate patellofemoral crepitation. 8% showed osteolysis around the tibial and femoral components whereas 12% showed polyethylene wear. The 10% failure rate included 4 knees with aseptic loosening, 1 with deep infection and 1 with recurrent patellar dislocation. The 10 year cumulative success rate with revision as the end point was 92%.

       

    The IBPS TKA replacement achieves good results on a long term basis.

        

  • Cloutier J-M, Sabouret P, Deghrar A [Universite de Montreal]

    Total Knee Arthroplasty with Retention of Both Cruciate Ligaments : A Nine to Eleven -year Follow-up Study

    J Bone Joint Surg Am 81-A: 697-702, 1999

        

    Most current knee replacement systems retain the posterior or both the ACL and PCL. Despite arguments that ACL retention complicates the knee replacements procedure, the authors routinely seek to retain both ligaments when possible. A prospective study of 163 TKAs with retention of both cruciate ligaments.

       

    Of 204 TKAs performed from 1986-1988 both cruciate ligaments were retained in 163. Follow-up results were available on 107 knees of 89 patients: 96 women and 34 men with an average age of 67 years at index arthroplasty. [75% had osteoarthritis 25% had rheumatoid arthritis]. Varus deformity was present in 67% valgus in 16%. At operation ACL appeared normal in 96 knees and partially degenerated in 67. 

       

    At 10 year follow up, 97% had good to excellent results. 91% had good pain relief with an average range of flexion of 107. AP stability was normal in 89% with movement of less than 5 mm. The remaining 11% had 5-10 mm of movement. Mediolateral stability was normal in 90% whereas 10% had 5-10 mm of movement. Varus alignment was between 50 to 100 in 88%. The average knee score was 91 points, with an average functional score of 82. 10 year revision free survival was 95%. The revision rate was 4% with no revisions for patellar problems or aseptic loosening of the tibial component.

       

    The ten year follow up shows good results.

        

  • Gill GS, Joshi AB, Mills DM [ Lubbock, Tex]

    Total Condylar Knee Arthroplasty : 16- to 21-Year Results

    Clin Orthop 367: 210-215, 1999

       

    This study reports the long-term results of posterior cruciate retention total condylar knee arthroplasty performed by a single surgeon in private practice.

    159 knee arthroplasties were performed [139 patients] using total condylar knee prostheses between 1976-1982. A 16 year follow-up was available on 72 knees of 63 patients [42 men, 21 women] average age 61 years]. The main indication was osteoarthrosis. Follow up included clinical evaluation based on knee society clinical rating systems and radiographs.

       

    5 knees experienced delayed complications [ 3 had patellar stress fracture; 1 each of delayed supracondylar fracture and patellar tendon rupture]. Revision surgery was performed on 1 knee. 2 more cases were advised revision surgery but declined on medical risk grounds. There were no cases of aseptic loosening. The mean knee score improved from 40.3 points preoperatively to 88.4 points at follow up.

       

    86% had excellent results, 7% had good to fair result and poor in 7%. Among patients undergoing revision surgery, 20 year prosthesis survivorship was 98.6%. 

       

    Total Condylar Knee arthroplasty with posterior cruciate ligament retention gives excellent results in private practice.

      

  • Li PLS, Zamora J, Bentley G [King’s College Hosp, London; Southend Gen Hosp, Essex, England; Royal Natl Orthopaedic Hosp, Stanmore, England]

    The Results at Ten Years of the Insall-Burstein II total Knee Replacement: Clinical, Radiological and Survivorship Studies

    J Bone Joint Surg Br 81-B:647-653, 1999

       

    The 10 year results of the use of Insall-Burstein II prosthesis in a general orthopaedic unit are discussed. 

        

    146 total knee replacements [IB-II prosthesis] were performed on 121 patients [ 39 men, 82 women aged 46-86 years]. At ten years, 78 patients [94 knees] were available for follow-up. The hospital for special surgery [HSS] scoring system and the knee society rating system were used to evaluate outcome.

    79% had good to excellent result, 14% had a fair result and 9% had a poor result. The average knee society score was 87 [ at 10 years] and the average functional score was 56 [advanced age and infirmity]. The average knee society pain score increased significantly from 4 [pre-operatively] to 45 at 10 years. The mean ROM improved from 88% to 100%, walking distance improved from less than 500 m. to 500-1000 m. There were 9 revisions because of infection [n=5] aseptic loosening [n=4] for a cumulative survival rate at 92.3% at 10 years. Secondary patellar resurfacing was necessary in 8 patients with severe anterior knee pain. 3 had to undergo knee lateral release for patellar maltracking. 1 had a patellar tendon rupture repair, 6 had postoperative infection, one had a nonfatal pulmonary embolus. 4 had deep vein thrombosis. 1 had a stroke and 1 had a fracture of the posterolateral cortex of tibia. 7 patients had to be manipulated under anesthesia. 

       

    Radiographs of 104 knees were available for follow up. 10 tibial components showed radiolucent lines but none required revision. 

      

    The long term results of Insall-Burstein II total knee replacement orthroplasty are good with 90% , 10 year survival.

        

  • Osep E. Armagan, MD, and Michael J. Shereff, MD [ From the Section of Foot and Ankle Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois [OEA]; the Division of Orthopaedic Surgery, Department of Surgery, University of South Carolina; and the Foot and Ankle Center, Orthopaedic Specialties of Charleston, Charleston, South Carolina [MJS]

    Injuries to the Toes and Metatarsals 

    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos. 1-9


       


    Studies on force distribution of the forefoot during the stance phase of gait indicate that each of the lesser metatarsals supports an equal load [1/6 of body weight].

       

    Athletic, inversion-type injuries are a common cause of fractures of the fifth metatarsal, which is injured the most frequently. 

       

    Stress fractures, as described in military recruits, runners, and dancers, are the next most common and occur in the second and third metatarsals. Fractures of the first metatarsal are less common because of its relative size and mobility.

       

    Acute direct forces occur most commonly as a result of crushing-type injuries, such as a heavy object falling onto the dorsum of the foot, producing transverse or comminuted fracture patterns, often of adjacent metatarsals, with varying degrees of skin injury. In these cases, a compartment syndrome of the foot must be suspected and treated with early fasciotomy if indicated.

       

    There is less risk of displacement of fractures of the base of the metatarsals because of the retraining effect of the capsular attachments, interosseous ligaments, and balanced tendinous insertions of the tibialis posterior and peroneus longus muscles.

       

    Injuries to the metatarsal shaft are relatively more common than injuries to the base.

      

    The strong flexor tendons usually force the distal fragment of the metatarsal fracture in a plantar and proximal direction. More distal the fracture of the metatarsal, the more significant plantar flexion, which in turn, increased the plantar prominence of the metatarsal head, and the more likely that distal fractures will require open reduction. 

        

    To minimize the postoperative stiffness of the metatarsophalangeal joint. 

       

    Myerson advocates placing the anterograde Kirschner -wire through the distal metatarsal with the toes only slightly dorsiflexed, such that the Kirscher-wire engages the plantar aspect of the base of the proximal phalanx, avoiding scarring to the plantar plate.

       

    Regarding surgical incisions, dorsal longitudinal incisions are recommended, centered over the affected shaft or the web space between adjacent fractures. 

       

    Fractures of the fifth metatarsal deserve special attention their prevalence and their because of historical incidence of delayed union.

       

    These injuries can occur without direct trauma. The bone anatomy consists of the common articulation between the cuboid and the fourth and fifth metatarsals, which is the anatomic basis for the classification of the fractures of the fifth metatarsal.

       

    Fractures proximal to the articulation of the fourth and fifth metatarsal are referred to as tuberosity fractures, fractures involving this articulation are referred to as Jones fractures, and fractures distal to this articulation are refined to as diaphyseal stress fractures.

        

    Tuberosity fractures are avulsion-type injuries caused by an indirect force, causing tension on the lateral band of the plantar fascia. They are commonly referred to as pseudo-jones fractures and are treated symptomatically with rigid soled shoes and activities as tolerated, with an excellent prognosis for healing in 4 to 6 weeks.

        

  • Paul Juliano, MD, and Hoan-Vu Nguyen, MD [ From Department of Orthopedic Surgery, Hershey Medical Center, Hershey, Pennsylvania]

    Fractures of the Calcaneus

    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001,Pg.Nos.35- 51 

        

    Fractures o the calcaneous [os calcis] are the most common of tarsal bone fractures. 

        

    There is considerable debate regarding their treatment and overall management.

        

    Conservative management through rest and elevation remained the mainstay of treatment until the 1990s. In 1908, Cotton and Wilson described their closed reduction technique in an attempt to restore normal anatomy.

       

    In 1931, Bohler modified this technique using pin traction and clamps in an attempt to restore normal anatomy.

       

    He emphasized the need to restore the tuber angle [Bohler’s angle]. Operative fixation of calcaneal fractures in the United States focused on primary subtalar arthrodesis alone or triple arthrodesis. 

       

    In 1943, Gallie first described primary subtalar arthrodesis. These four treatment options conservative management, closed reduction, open reduction and primary arthrodesis- continue to be viable treatment alternatives today.

       

    The calcaneus has a thin cortical shell and is composed mostly of cancellous bone. The exceptions include the cortical thickening that supports the posterior facet [known as the thalamic portion], the dense cortical bone in the sustentaculum tali, and the thick cortex in the angle of Gissane.

       

    The first widely accepted classification system was proposed by Essex-Lopresti in 1952. 

       

    Essex-Lopresti Classification –

    I. Not involving subtaloid joint

    A. Tuberosity fractures

         1. Beak type

         2. Avulsion medial border

         3. Vertical

         4. Horizontal

    B. Involving calcaneocuboid joint

    A. Without displacement

    B. With displacement

         1. Tongue type, with displacement

         2. Centrolateral depression of joint

         3. Sustentaculum tali fracture along

         4. With comminution from below

             
    [including severe tongue and joint depression type]

         5. From behind forward with
    Dislocation subtaloid joint

        

    With the advent of the CT scan, new classification systems were developed to assist in the diagnosis of calcaneus fractures.

       

    The cause of these fractures is a fall from a height. The most common signs of a fracture include tenderness, swelling, ecchymosis, and distortion of the normal anatomy around the heel. Although not pahognomonic for calcaneal fractures, plantar ecchymosis is specific for these fractures. The skin blistering that commonly is seen usually occurs within the first 36 hours after injury.

        

    At the time of initial presentation, the patient’s foot should be placed in a Jones dressing and foot pump to reduce the amount of swelling. A posterior splint should be applied and the leg elevated to minimize swelling and prevent blister formation or excessive swelling until the wounds epithelialize and the skin passes the wrinkle test. The skin on the lateral surface of the heel should wrinkle along the normal skin creases on dorsiflexion and eversion of the foot. It may take 2 to 3 weeks for the skin to wrinkle.

        

    Most physicians have agreed on the treatment of extra-articular fractures, which generally have a more favorable result than
    treatment of intra-articular fractures. 

        

    The options for treatment of avulsion fractures are various, but most clinicians agree that optimal treatment is nonoperative. Recommendations include a woven elastic [Ace] bandage and crutches for 2 weeks, non-weight bearing and short leg cast for 4 weeks, and non-weight bearing for 8 weeks. 

        

    These fractures may take 1 year to become asymptomatic. Fragments greater than 2 cm generally require operative treatment.

       

    The treatment of intra-articular fractures is controversial. Nonoperative treatment continues to be the preferred method for undisplaced fractures.

       

    Displaced and comminuted fractures can be treated conservatively without reduction and early range of motion, with closed reduction, with primary arthrodesis – subtalar or triple – or with open reduction and internal fixation.

       

    The overall result was better, however, in the operative fractures if the posterior facet was anatomically reduced.

       

    Complications after calcaneus fractures can be divided into two categories – early and late. Early complications include fracture blisters and compartment syndrome. Fracture blisters should be debrided and allowed to epithelialize before surgical intervention. Compartment syndrome or suspicion thereof should be followed with immediate fasciotomy. The clinical consequences of an untreated compartment syndrome include clawing of the lesser toes, stiffness, aching, weakness, sensory changes, atrophy, and fixed deformities of the forefoot. 

       

    Late complications include wound dehiscence, wound infection, subtalar arthritis, lateral impingement syndrome, and sural neuritis.

       

    Subtalar arthritis should be treated conservatively initially through activity change, shoe modifications, and anti-inflammatory medications. Subtalar or triple arthrodesis should be considered if these means fail.

       

    The technique for primary subtalar fusion is identical to open reduction and internal fixation of the calcaneus. 

       

    The advantages of this approach is that the geometry of the foot is restored [i.e. length, width, height, and valgus alignment]. This advantage precludes the need to wait 6 or 9 months to see if the patient will improve, be out of work, or be in pain with a fracture that has a high probability of future fusion. This is a judgement call- but why keep a laborer out of work when the probability is high hat a fusion ultimately will be needed?

       

  • Gregory C. Berlet, MD, FRCS[C], Thomas H. Lee, MD, and Eric G. Massa, DPM [ From the Orthopedic Foot and Ankle Center [GCB, THL, EGM]; and the Division of Foot and Ankle Surgery [THL], Department of Orthopaedic Surgery [GCB, THL], The Ohio State University [THL], Columbus, Ohio

    Talar Neck Fractures 

    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.53-64

       

    Immediate reduction and use of compression screws in displaced talar neck fractures – a recommendation that prevails today. Methods of surgical approaches and fixation may differ, but the evolved theme remains early open reduction and internal fixation, with awareness of the major complications of varus malunion and a vascular necrosis [AVN] of the talus.

       

    In Roman times, the heel bone of a horse was used as dice and called taxillus. This word evolved into talus. The talus is the second largest bone in the tarsus. It has no muscular origins, and 70% of its surface is covered with cartilage. The talus is the torque converter of the lower extremity, allowing for foot flexibility to adapt to uneven ground but providing a rigid lever for propulsion. 

       

    In cases of talar injury, restoration of the complex spatial relationship of its three parts – the head, neck, and body – is imperative to achieve good functional results.

       

    The neck of the talus projects anteromedially and downward from the body. Its average length is 17 mm, and angle of the medial deviation is 150 to 20o in adults. Plantar deviation of the neck is approximately 240. 

       

    Although there are no muscular origins, te talus is bound tightly to the ankle mortise, calcaneus, and navicular bone by multiple ligamentous and capsular soft tissues. This extensive soft tissue complex about the talus allows for stability and motion and provides the conduit for blood supply to the bone itself.

       

    The talar blood supply has been shown to be rich through a vast but fragile network of extraosseous blood supply comes from the three arteries- the posterior tibial artery, anterior tibial artery, and perforating peroneal artery. These arteries anastomose to form a vascular sling around the talus. 

       

    The main artery supplying blood to the body of the talus is the artery of the tarsal canal. Most blood supplied to the head and neck of the talus arises from the dorsalis pedis artery.

       

    The intraosseous blood supply is a network of three or four anastomoses throughout the body of the talus. The branches of these anastomoses originate mainly from the artery of the tarsal canal.

       

    The portion of the talus most vulnerable to vascular compromise is the body because of the lack of true nutrient artery. 

      

    A vascular plexus rich with anastomoses may provide vascularity to the talar body when a major vascular source is disrupted.

      

    Although the medial neurovasculature is at risk in severe talar neck fracture-dislocations, it usually is protected by the flexor hallucis longus tendon and the fact that the talar body rotates away from the vital structures.

       

    CT scanning can be used to assess displacement and comminution of the fracture as well as to evaluate the joints associated with the fracture. 

       

    Treatment of the talar neck fracture is difficult. Any fracture that involves a joint complicates treatment and outcome. Most of the talus is covered with cartilage and because of its intricate structure and function, exact anatomic reduction is needed to prevent long term arthritis and mechanical dysfunction resulting from varus malunion.

       

    Although risk of AVN may be determined at the time of injury, prompt and accurate anatomic reduction can decrease its likelihood.

       

    Hansen believes that no talar neck fracture should be treated by casting alone because it precludes early motion and that internal fixation should be performed instead. These fractures carry a favorable prognosis with no cases of nonunion, and minimal risk of AVN of the body.

       

    Surgical exposure of the talus is difficult secondary to its anatomy and the anatomy of the surrounding tissues and structures. Because talar neck fractures with dislocation have been reported to have 3 times greater incidence of nonunion associated with a twofold delay in return to work, the authors believe open reduction and internal fixation should be performed.

       

    The medial approach is used most frequently for open reduction and internal fixation of talar neck fractures. 

       

    The medial approach is mandatory for reduction and grafting in the case of medial comminution to prevent varus malalignment of the talar head.

       

    The authors often augment the medial approach with an anterolateral approach to visualize the subtalar joint and to assist with placement of fixation.

       

    Screws are placed from anterolateral to posteromedial into dense talar bone. This approach achieves compression and reduces the tendency for the fracture to collapse into varus malalignment.

       

    The anterolateral approach avoids damage to the deltoid artery and permits easy access to the talus.

       

    The posterolateral approach to the talus is excellent for fixation placement and avoidance of the body’s blood supply, but visualization of the subtalar joint and the body of the talus is difficult.

       

    Posterior-lateral -to -anterior -medial screw placement into the talar head has been found to be biomechanically superior to anterior-to posterior fixation. 

       

    Two-screw fixation placed perpendicular to the fracture line should be a goal in surgery because it can allow for early motion, prevent axial rotation, and guard against shear forces. Titanium fixation allows for postoperative MR imaging when staging for AVN.

       

    The basic tenet in treating severe talar neck fractures is to achieve a prompt, anatomic, stable reduction 

       

    The current trend is to treat these fractures using careful open reduction and internal fixation and to reserve arthrodesis for limb salvage.

      

  • Mark D, Perry, MD, and Arthur Manoli II, MD [ From the Foot and Ankle Service, Department of Orthooedic Surgery, University of South Alabama College of Medicine, Mobile Alabama
    [MDP]; and the Michigan International Foot & Ankle Center, Pontiac, Michigan


    Foot Compartment Syndrome


    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.103-111

        

    Foot compartment syndrome [FCS] has undergone increased refinement over the past decade, resulting in improved understanding of the anatomic structure, clinical presentation, treatment, and clinical outcome. 

        

    The pathophysiology of FCS is similar to the mechanism of acute, posttraumatic compartment syndrome of the lower extremity.

       

    The traumatic event usually causes an initial increase in the interstitial fluid ressure secondary to edema or hemorrhage within the foot compartment.

       

    Secondary to a rise in interstitial compartment pressure [greater than the capillary filling pressures], decreased capillary blood flow and local muscle ischemia occur gradually.

       

    This ischemic process promotes vasodilation and increased capillary permeability. The influx of fluid into an already compromised space leads to additional intracompartmental edema and increased tissue pressure.

       

    This rising compartment pressure finally results in a tamponade phenomenon and sustained muscle
    ischemia. 

    Consequently the ischemic muscle undergoes necrosis, fibrosis, and
    contracture.

       

    Nerves can sustain compression for longer periods than muscles and show some reversibility. 

         

    The modern compartment concept of the foot is one of a multicompartmentalized structure with three of the compartments running along the entire length of the foot [medial, lateral, and superficial] and 6 localized compartments.

        

    Calcaneal compartment contains the quadratus plantae muscle and the lateral plantar nerve. In addition, a communication was shown between the calcaneal compartment and the deep posterior compartment of the leg through the flexor
    retinaculum, which originates from the medical
    malleolus. 

        

    Claw toe deformity, following a calcaneus fracture, appears to be secondary to a late contracture of the quandratus plantae muscle in the calcaneal compartment.

        

    As the pressure rises, the quadratus plantae muscle becomes ischemic within the calcaneal compartment. If untreated, the quadratus plantae [ with its insertion into the flexum digitorum longus tendon] contracts, and fibrosis secondary to the ischemic process occurs. 

       

    Two unusual circumstances causing FCS are blood dyscrasia and inappropriate prolonged positioning. 

       

    The consistent message is that constant vigilance by the treating physician is crucial, especially in light of the significant morbidity of a missed
    FCS. FCS can develop slowly or quickly, depending on the energy expended at the time injury. Sometimes, FCS can occur as late as 36 hours after time of injury. 

       

    The clinical signs of FCS are vague and ill defined compared with the clasic presentations of compartment syndrome of the lower extremity.

       

    Patients with calcaneal fractures and subsequently proven FCS describe clinical symptoms of a severe, relentless, burning pain involving the entire foot.

       

    Pain on passive dorsiflexion of the toes loss of two-point discrimination, decreased light touch, and loss of pinprick sensation. Objective motor deficit was difficult to document and was considered unreliable. 

        

    The most consistent finding was presence of tense swelling, with only half of the conscious patients, having increased plain with passive range of motion of the toe or sensory deficits to the foot.

       

    The only way of diagnosing compartment syndrome reliably is direct tissue pressure measurement. 

       

    Phillips et al described the clinical finding of decreased vibratory perception of 256 Hz as the earliest and most reliable modality change when a 35 to 40 mm Hg elevation occurs. This finding was noted to be more reliable than two-point discrimination or a sharp/dull discrimination.

       

    The importance of early detection and treatment of PCS cannot be overemphasized. Muscle undergoes necrosis within 4 hours of ischemia and
    FCS. 

       

    After fasciotomy, the deep and unrelenting pain in the foot dissipates immediately. This pain relief was particularly notable in patients that had fasciotomy performed under local anesthesia.

      

    Surgical Treatment –

    Manoli and Weber recommended a medial incision for decompressing the medial compartment and reflecting the abductor hallucis muscle superiorly. Next the fibrous intermuscular septum is opened longitudinally to release the calcaneal compartment. The superficial compartment is released by following the medial surface of the medial compartment, which decompresses the flexor digitorum
    brevis. This muscle is retracted plantarward, which allows access to the lateral compartment containing the abductor digiti minimi and flexor flexor digiti minimi
    brevis. Two dorsal incisions are used to decompress the individual interosseous compartments. The adductor hallucis compartment is approached by stripping muscles off the medial aspect of the second metatarsal.

       

    Patients who had undergone fasciotomy typically underwent skin closure 5 to 10 days after the procedure. 

       

    Summary –

    FCS is a recognized clinical entity that has few consistent clinical signs except tense swelling. A high degree of clinical suspicion is necessary to provide appropriate treatment. Invasive direct pressure monitoring is needed to diagnose FCS High-energy injuries are known to cause FCS, but individual risk factors, such as prolonged venous occlusion and blood dyscrasias, are causative factors.

       

  • Christopher Bibbo, DO, Sheldon S. Lin, MD, Heather A. Beam, BS, and Fred F. Behrens, MD [ From the Orthopaedic Research Laboratory [HAB], Foot and Ankle Division [SSL], Department of Orthopaedics [CB, FFB], New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey


    Complications of Ankle Fractures in Diabetic Patients


    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.113-133

       

    Ankle fractures in patients with diabetes mellitus [DM] have long been recognized s a challenge to practicing clinicians in terms of delays in fracture healing, difficulties with wound healing, and the development of Charcot
    arthropathy.

       

    Significant controversy exists as to whether diabetic ankle fractures are best treated noninvasively or by open reduction, and internal fixation [ORIF]. 

       

    The existing series are reviewed in this article, followed by a discussion of the basic science behind delayed fracture healing and impaired wound healing in diabetics as well as Charcot arthropathy.

       

    Kristriansen reviewed the result of 10 diabetic ankle fractures treated by operative fixation. Of these patients, 40% were neuropathic. Ninety percent went on to fracture union, 10% developed a Charcot ankle, and 60% developed a surgical infection.

       

    In light of the high surgical complication rate for elderly, low-demand patients, that surgical intervention may be ill advised and that a malunion may be an acceptable outcome. 

       

    The poor clinical outcome of nonoperative intervention in displaced ankle fractures in patients with DM portends the need for surgical intervention.

       

    Diagnosis of neuropathy and peripheral vascular disease were found to be statistically significant factors for the development of a complication in diabetic patients.

       

    Conclusions from these studiesare as follows. First, diabetic ankle fractures heal, but significant delays in bone healing exist. Second, patients with DM are at risk for wound and soft tissue problems associated with ankle fractures. Third, Charcot ankle arthropathy occurs more commonly in patients who were undiagnosed and immobilized late or have a displaced ankle treated
    nonoperativetly. 

        

    Understanding the basic science behind the pathogenesis of these complications may provide insignt on how best to manage patients with DM and ankle fractures to avoid these complications. 

       

    Delayed Fracture Healing 

    The tensile strength of fracture callus in diabetic rats is considerably less than in normal animals.

          

    Bone healing seems to stagnate in untreated diabetic animals.



    A greater amount of calcium was deposited in the control and insulin treated diabetic animals compared with the untreated diabetic animals.

       

    Impaired collagen synthesis is theorized to be one cause of delayed fracture healing. This decreased collagen production in animals with DM occurs in bone and cartilage and correlates with the degree of hyperglycemia.

       

    DM bone metabolism is impaired by the inability to maximize bone turnover and remodeling. This situation in part may be caused by decreased gut calcium absorption in diabetics. 

       

    Currently, control of blood glucose seems to be an important factor in the overall regulation of fracture healing. 

       

    Several animal studies support this concept and show improved bone healing in DM animals using basic fibroblast growth factor. Fibrin stabilizing factor [Factor XIII] is another factor under investigation for clinical use. In DM rats, the addition of Factor XIII showed a positive effect on wound healing with increased bone deposition.

       

    Wound Healing –

    Wound healing in DM hs long been recognized as a major complication of the disease and a formidable challenge to overcome.

       

    To understand the pathogenesis of altered wound healing in diabetics, the two fundamental pathophysiologic states, hyperglycemia and hypoxia, must be explored.

        

    Hyperglycemia is the essence of DM. Structural and functional proteins [e.g. enzymes] exposed to prolonged periods of elevated blood glucose engage in enzymatic glycosylation.

       

    Over time, these proteins may undergo nonenzymatic glycosylation reactions yielding irreversible advanced glycosylation products. These advanced glycosylation products attach to collagen, basement membrane, low density lipoproteins, and inflammatory cell receptors. 

        

    Measurement of glycosylated hemoglobin levels [hemoglobin A1c] allows for an average estimate of blood glucose levels.

        

    Some tissues, such as the kidney, nerves, blood vessels, and eye lens, do not require insulin for glucose transport; hyperglycemia results in elevated intracellular glucose, which is shunted to the sorbitol pathway. 

        

    The end result is decreased myo-insitol levels and cell damage, as evidenced by the neuropathy of DM.

        

    Tissue hypoxia is a common secondary phenomenon of DM. 

       

    Compounding this ischemia, it has been shown that patients with DM have a higher blood viscosity; their red blood cells are less deformable; and glycosylated hemoglobin has a higher affinity for oxygen, impairing oxygen delivery to ischemic tissues.

        

    The combination of local ischemia and elevated blood glucose creates a poor environment for wound healing.

        

    Wound collagen deposition is directly proportional to wound oxygen tension and perfusion, and collagen production is limited severely in DM wounds.

        

    Commonly used wound dressing agents, such as providone-iodine, have shown no beneficial effect no epithelialization. Povidine-iodine has been shown to delay wound healing in DM models and in steroid depressed wounds. 

        

    One valuable clinical marker of adequate local perfusion for healing in patients with DM is transcutaneous oxygen tension [TcPO2] measurements.

        

    Additional risk factors for poor healing in patients with DM [besides elevated glycosylated hemoglobin] include vasculopathy, smoking, hypertension, dyslipidemia, and advanced age.

        

    Vital to the wound healing process is the initial inflammatory reaction. The weak initial inflammatory response in human DM wounds results in not only delayed 

        

    restoration of the epidermal barrier but also decreased tensile strength of healing DM wounds.

        

    The adverse effects on wound healing resulting from uncontrolled blood glucose altering the inflammatory response have been corroborated in the laboratory.

        

    Charcot Arthropathy –

    Many issues, such as its cause, proposed pathomechanism, and predictive risk factors, for the development of Charcot arthopathy still are unknown. A warm, swollen, erythematous limb often signifies the early clinical presentation of Charcot arthropathy. 

        

    Charcot arthopathy range from microfractures, to progressive bone fragmentation, to severe joint destruction and subluxation as a result of repetitive ligamentous and bone injuries.

        

    Current research has concentrated on two major theories : [1] repetitive minor trauma in the presence of neuropathy and [2] vascular changes secondary to autonomic dysfunction.

        

    The small nerve fibers initially are affected in the process of developing DM peripheral neuropathy.

        

    Secondary to the reduction of peripheral sensorineural function, patients become increasingly susceptible to unrecognized traumatic events [i.e., ankle sprain].

        

    The presence of peripheral neuropathy, with an inciting traumatic event [e.g., an ankle fracture], commonly leads to Charcot arthropathy. 

        

    Marked increases in peripheral blood flow have been noted in the limbs of neuropathic DM patients secondary to arteriovenous shunting. 

        

    These anastomoses are richly innervated and controlled primarily by the sympathetic nervous system. When sympathetic innervation is abolished because of denervation 

    [i.e., severe neuropathy], the loss of constriction of arteriovenous anatomoses results in maximal dilation. 

        

    This excessive blood flow secondary to peripheral neuropathy may lead to abnormal bone cell activity and eventual reduction in bone density.

        

    Hyperemia and neurovascular changes secondary to an autonomic neuropathy may contribute to a generalized osteopenia in patients with DM. 

        

    In conjunction with a traumatic event, the resultant additional increased blood flow is theorized to increase osteoclast activity, promote excessive bone resorption, increase fracture risks, and lead to neuropathic Charcot arthropathy. 

         

    Summary –

    For nondisplaced ankle fracture, a nonoperative approach with increased duration of immobilization seems successful based on experience of the limited series. A displaced ankle fracture in a patient with DM requires a surgical intervention.

        

    Authors advocate tight glucose control in both groups to improve the fracture milieu and to ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution.

       

  • Gabl
    VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur
    Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und
    Spektroskopie, Innsbruck, Germany]

    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]

    Handchir Microchir Plast Chir 28: 317-321, 1996

        

    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.

       

    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.

        

    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.

         

    They conclude that MRI was useful in detecting the presence and extent of pulley injury.

          

  • Jack Abboudi, and Randall W. Culp (From the Hand Surgical Associates, Bryn Mawr (JA); The Philadelphia Hand Center, King of Prussia (RWC); and the Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia (JA, RWC), Pennsylvania

    Treating Fractures of the Distal Radius with Arthroscopic Assistance

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 307-315

         

    Displaced intra articular fractures of the distal radius pose difficulties in management. The outcome of such fractures is radial shortening and residual articular step off. For this reason accurate intra-operative articular evaluation is crucial, to achieve articular congruity within 1 mm.

        

    The role and technique of arthroscopy when used in such fractures is discussed. Radiographic evaluation is the standard method used for grading fracture reduction which gives a two dimensional view of a three dimensional object. Compared with standard radiography fluoroscopy can be deceiving. But when arthroscopy is used as an adjunct to fluoroscopy a much greater accuracy is achieved.

        

    Technical details are discussed. Favourable outcomes have been reported for the reduction of displaced intraarticular fractures of the distal radius. 

         

  • Carrie R. Swigart, and Scott W. Wolfe (From the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut (CRS); and the Hospital for Special Surgery, New York, New York (SWW)

    Limited Incision Open Techniques for Distal Radius Fracture Management

    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 317-327

         

    Gartland and Werley outlined four components of distal radial fracture that require correction if a good functional result is to be obtained. The most important one being restoration of normal volar tilt of the distal radius and prevention of radial shortening.

         

    Traditional treatment has evolved over the years depending on the facilities available.

         

    This article discusses recent innovations in the management of these fractures. Clinical and bio-mechanical studies have shown that stable fixation can be achieved with small implants aligned in an orthogonal fashion. This reduces soft tissue dissection and allows for early mobilisation of the wrist leading to a better outcome.

         

  • Andrew D. Markiewitz, and Harris Gellman (From the Department of Orthopaedic Surgery, University of Arkansas, Little Rock, Arkansas (ADM); and the Department of Orthopaedic Surgery, University of Miami, Miami, Florida (HG) 

    Five-Pin External Fixation and Early Range of Motion for Distal Radius Fractures

    Orth. Cl. of N. A. April 2001Vol. 30 (2) p.329-335

        

    Distal radius fractures are complex and require individualised therapy. Regardless of treatment protocol restoration of normal anatomy by restoring radial length, joint surface continuity and volar tilt of the distal articular surface is vital.

         

    Although external fixation devices may maintain radial length, there may still be a displaced or angulated position. The addition of a dorsal pin in combination with an external fixation device can easily connect the dorsal tilt. This pin helps the reduction of those fractures that would not improve with traction and with maintenance of reduction. 

       

    The five-pin technique provides another tool to the hand surgeon faced with a difficult fraction.

               

  • Amy L. Ladd, and Nathan B. Pliam (From the Divisions of Hand (ALL) and Orthopaedic (ALL, NBP) Surgery, Stanford University School of Medicine, Palo Alto, California

    “The Role of Bone Graft and Alternatives in Unstable Distal Radius Fracture Treatment”

    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 337-351

       

    This article updates one’s knowledge on the materials currently available and in development of mineral substitutes and growth factors as a viable alternative to host graft with a review of their characteristics and shortcomings.

        

    Investigations uniformly cite autograft as the gold standard among graft materials. In comparison, controlled studies have shown that bone graft substitutes perform as well as autograft. These substitutes have broadened the surgeons armamentarium for the treatment of distal radial fractures. No single graft substitute is ideal for all fractures. Major advances in the biology of growth factors eventually will lead to a new generation of biologically active products. 

        

  • Brian D. Adams, and Brian J. Divelbiss (From the Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa

    Reconstruction of the Posttraumatic Unstable Distal Radioulnar Joint

    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 353-363

       

    Although not a common problem, this article focuses on the various methods for reconstruction of the unstable distal radioulnar joint.

         

    Restoration of stability and a full painless arc of rotation are the goals of treatment for the posttraumatic unstable distal radioulnar joint.

        

    Attention focuses specifically on anatomic reconstruction of distal radioulnar ligaments. The authors’ technique is presented in detail.

         

  • Luis R. Scheker, Bryan A. Babb, and Patricia E. Killion (From the Christine M. Kleinert Institute for Hand and Micro Surgery (LRS, BAB, PEK); and the Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine (LRS), Louisville, Kentucky

    Distal Ulnar Prosthetic Replacement

    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 365-379

        

    A stable functioning distal radioulnar joint not only provides supination and pronation of the forearm but is also essential to gripping and lifting. Therefore when distal radioulnar joint deterioration occurs, proper repair is crucial. Ulnar head resection is often performed, however a prosthesis may be needed to replace all or part of the joint. This article discusses the advantages and disadvantages of four prostheses, including a total joint replacement designed by the authors. 

         

  • Joseph J. Crisco, Scott W. Wolfe, Corey P. Neu and Sandi Pike (Department of Orthopaedics, Brown University School of Medicine, Rhode Island Hospital (JJC); Division of Engineering, Brown University, Providence, Rhode Island; The Hospital for Special Surgery and Weill Medical College of Cornell University, New York (SWW))

    Advances in the In Vivo Measurement of Normal and Abnormal Carpal Kinematics


    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 219-231

         


    This article presents a non-invasive in vivo three dimensional methodology using markerless bone registration (MBR) for examining the normal and abnormal kinematics of the wrist carpal bones.

         


    This method provides clinicians with an excellent new technique to study the carpus and enhance the understanding of carpal kinematics. It permits the study of injured and reconstructed carpus.

          


    The authors have developed a new MBR algorithm to evaluate the normal and abnormal kinematics of the carpus. Their findings suggest that the carpal mechanics cannot be described only by the row and column theory but by complex combinations of each that are dependent on the direction of wrist movement.

         


    The limitations of this methodology are the use of CT and intensive computational analysis. The authors’ measurements have been limited to the main movements of flexion extension and radio-ulnar deviation. This study also does not prove that the abnormal kinematics seen after trauma may have existed before trauma.

          


    Further studies will permit a better understanding of these findings.

        

  • David S. Ruch, and Beth Paterson Smith (Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina)

    Arthroscopic and Open Management of Dynamic Scaphoid Instability

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 233-240

         


    In 1984, Watson and Ballet focussed attention on posttraumatic arthritis of the wrist. Several studies since then have documented the disruption of the normal kinematics of the wrist after scapholunate ligament disruption. Although these changes are well documented the ideal management of this condition remains controversial.

         


    This study reviews the anatomic structures associated with dynamic rotatory subluxation of the scaphoid and the results of the treatment.

         


    The decision of whether to perform arthroscopic surgery or open capsulodesis for dynamic scapholunate instability depends on 

    (1) Radiographic instability (2) Diagnostic arthroscopy

         


    Preoperative radiography may show an increase on the scapholunate angle (as compared to the opposite side) without evidence of capitolunate instability.

          


    Arthroscopy may reveal an interval between the scaphoid and the lunate, permitting the passage of the arthroscope through the radio-carpal to the midcarpal space.

        


    When either of these findings is present, an open stabilization is advocated, and when these findings are not present, arthroscopic surgery is advocated.

          

  • Joseph F. Slade III, Jonathan N. Grauer and John D. Mahoney (Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut)

    Arthroscopic Reduction and Percutaneous Fixation of Scaphoid Fractures with a Novel Dorsal Technique

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 247-261

         


    This article presents a technical description of a novel dorsal technique of arthroscopic reduction and percutaneous fixation of scaphoid fractures on 16 consecutive patients with excellent results.

        


    This method permits early, rigid internal fixation with minimal morbidity. Rehabilitation can be started earlier. This method allows far more precise control of pin and screw placement avoids the vulnerable anatomy and allows the proximal segment to be compressed into the distal fragment.

         

  • Alexander Y. Shin, and Allen T. Bishop (Department of Orthopaedic Surgery, University of California, San Diego; the Division of Hand and Microvascular, Department of Orthopaedic Surgery, Naval Medical Center, San Diego, California; the Department of Orthopaedic Surgery, Mayo Graduate School of Medicine, and the Division of Hand Surgery, Department of Orthopaedic Surgery and Surgery of the Hand, Mayo Clinic and Foundation, Rochester, Minnesota)

    Vascularized Bone Grafts for Scaphoid Nonunion and Kienbock’s Disease 

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 263-277

       


    This article focuses on the principles, anatomy, application and experimental and clinical studies of carpal vascularized bone graft for the treatment of scaphoid nonunions and Kienbock’s disease.

        


    Vascularized bone grafts offer the ability to transfer bone with viable osteoblasts and osteoclasts with a preserved circulation. The vascular anatomy of the distal radius permits fabrication of reverse flow pedicled vascularized bone grafts which are useful to treat disorders of the carpus. It offers the advantage of a single incision for graft harvest and donor site preparation.

       


    Faster union times, the ability to revascularize necrotic bone and technical ease of harvest have made these grafts clinically useful tools for treatment of scaphoid non union and Kienbock’s disease.

         

  • Sheldon R. Cober, and Thomas E. Trumble (Division of Hand and Microvascular Surgery, Department of Orthopaedics, University of Washington, Seattle, Washington)

    Arthroscopic Repair of Triangular Fibrocartilage Complex Injuries

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 279-294


         



    The triangular fibrocartilage complex (TFCC) performs a vital function in the biomechanics of the wrist. It serves as the pivot point for rotation of the radius and the carpus on the ulna – a complex motion comprising elements of rotation, translation, and load transmission. TFCC itself is a functionally and anatomically intricate group of structures located at the ulnar aspect of the wrist.

        


    Injury to the TFCC affects the biomechanics of the wrist and makes functional restoration difficult.

       


    Repairing TFCC injuries arthroscopically minimizes scar formation and therefore seems better than open surgery. Numerous techniques have been used and reviewed. 

         

  • Robert Yaghoubian, Felix Goebel, Douglas S. Musgrave, and Dean G. Sotereanos (Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania)

    Diagnosis and Management of Acute Fracture – Dislocation of the Carpus

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 295-305

          

    Though fracture dislocation of the carpus is an infrequent injury, inadequate treatment can lead to wrist pain and dysfunction and traumatic arthritis. Accurate diagnosis and early treatment are essential for good results.

          


    This article presents the anatomy, epidemiology, and mechanism of injury of the carpus and the diagnosis, treatment, and treatment results of dislocation of the carpus.

         


    Radiography (postero anterior and lateral views and distraction radiography) is done and may show loss of co-linearity between the bones. Occasionally a CT scan or MRI may be required.

         


    Although early closed reduction is recommended, early anatomic open reductions, internal fixation and ligamentous repair are vital for optimal results.

      

  • LTC William C. Doukas, and Kevin P. Speer (Sports Medicine and Shoulder Section, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina)

    Anatomy, Pathophysiology, and Biomechanics of Shoulder Instability 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 381-391

         


    Instability in the athlete presents a unique challenge to the orthopaedic surgeon. A spectrum of both static and dynamic pathophysiology as well as gross and microscopic histopathology contribute to this complex clinical continuum. 

        


    Biochemical studies of the shoulder and ligament cutting studies in recent years have generated a more precise understanding of the individual contributions of the various ligaments and capsular regions to shoulder instability. 

        


    An understanding of the underlying pathology and accurate assessment of the degree and directions of the instability by clinical examination and history are essential to developing appropriate treatment algorithms. 

         

  • Stephen Owens and, John M. Itamura (USC Orthopaedic Surgery Associates, Los Angeles, California)

    Differential Diagnosis of Shoulder Injuries in Sports

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 393-398

        


    Shoulder injuries are common problems in all types of sports. The demanding combination of power and flexibility the repetition of movements in overhand sports makes it highly vulnerable to falls and direct blows. 

        


    The sportsman may not be able to express correctly his symptoms and this makes the diagnosis difficult. The history is particularly important because many aspects of the examination are variable. 

        


    A relaxed patient and systematic evaluation is the best approach. Radiographs and even MRIs are often negative in the young athlete. 

        


    This article looks at various shoulder injuries that are relevant to sports and discusses their differential diagnosis.

         

  • Brian J. Cole, Anthony A. Romeo, and Jon J. P. Warner (Shoulder Section, Department of Orthopaedic Surgery, Rush-Presbyterian St. Luke’s Medical Center, Chicago, Illinois, and the Harvard Shoulder Service, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts)

    Arthroscopic Bankart Repair with the Suretac Device for Traumatic Anterior Shoulder Instability in Athletes

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 411-421


         



    Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade.

         


    Currently, most techniques use the suture and suture anchors. However the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing and knot tying. 

          


    Stabilization using the Suretac device simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intra-articular knot tying. However a successful outcome depends upon accurate patient selection.

         


    Pre operative evaluation examination under anesthesia and a thorough arthroscopic examination is the most effective treatment strategy.

         


    The ideal candidate is an athlete with a pure traumatic anterior instability pattern with detachment pathology and minimal capsular deformity.

          

  • David W. Altchek, and William R. Hobbs (Department of Orthopaedic Surgery, The Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York)

    Evaluation and Management of Shoulder Instability in the Elite Overhead Thrower 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 423-430


      
       


    The elite throwing athlete places significant stress on the soft tissue stabilizers of the shoulder with every pitch. Anterior translation forces can be as high as 40% of the body weight and distraction forces as high as 80% of body weight during throwing.

        


    Injury to the static and dynamic stabilizers can lead to significant pain and loss of function in these athletes. To successfully treat this injured thrower, it is important to accurately diagnose the pathologic process.

          


    This article reviews the biomechanics of throwing and pathologic processes seen in the elite thrower. This article covers the essentials of the history and physical examination and concludes with a discussion of the various treatment regimens. 

            

  • Stephen S. Burkhart, and Craig Morgan (San Antonio Orthopedic Group, Baylor College of Medicine, and University of Texas Health Science Center, San Antonio, Texas; the Department of Orthopedic Surgery, Allegheny University, Philadelphia, Pennsylvania; and the Alfred I. DuPont Institute, Wilmington, Delaware)

    Slap Lesions in the Overhead Athlete 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 431-441

        


    The ‘dead arm’ has recently come alive as a topic of interest in sports medicine. It now appears that one potential cause of the ‘dead arm’ is the type II superior labrum anterior and posterior (SLAP) lesion. 

         


    This prevents the thrower from performing at his pre-injury velocity and control because of a combination of pain and subjective unease in the shoulder.

       


    The lesion is extremely disabling and potentially career ending to the overhead athlete. The ability to successfully diagnose, surgically manage and rehabilitate this condition is the focus of this article. 

        


    The historical perspective, etiology, biomechanics, surgical repair and rehabilitation are discussed in detail.

        


    The authors report an 87% rate of return to pre-injury levels of throwing in 54 basketball players and 84% rate of return to pre-injury performance levels in pitchers after repair of type II SLAP lesions.

         

  • John E. Conway (Orthopedic Specialty Associates, Fort Worth, Texas)

    Arthroscopic Repair of Partial-Thickness Rotator Cuff Tears and SLAP Lesions in Professional Baseball Players 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 443-456

        


    During the last 30 years pain in the thrower’s shoulder has been attributed to many different causes. The most common findings in the thrower’s shoulder include rotator cuff tear, superior labrum tear, inferior glenohumeral ligament attenuation, internal rotation deficit and hypertrophic subacromial bursa. 

         

    The authors understanding of the conditions that affect the throwing shoulder continues to evolve. Surgical techniques also have advanced and the arthroscopic repair of rotator cuff tears SLAP lesions and capsular ligament attenuation is now possible.

         

    This article discusses technical details necessary to treat this condition.

       

  • Felix H. Savoie, Larry D. Field, and Stephen Atchinson (Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center; Department of Orthopaedic Surgery, University of Mississippi School of Medicine, Jackson, Mississippi; and the Department of Orthopaedics, Louisiana State University Medical Center, Shreveport, Louisiana) 

    Anterior Superior Instability With Rotator Cuff Tearing: Slac Lesion 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 457-461





    Anterosuperior instability of the shoulder can occur from a variety of pathological lesions, both traumatic and non traumatic. The authors have described a specific lesion involving the anterosuperior corner of the glenohumeral articulation associated with the undersurface tearing of the supra-spinatus tendon (SLAC – superior labrum anterior cuff). They have retrospectively isolated 40 patients with this lesion. 



    This report details their findings regarding the mechanism of injury, symptoms, physical findings, diagnostic studies, non operative and operative management surgical findings and the results associated with this injury pattern.



    Overhead activities were the most common aetiological factor. Load and shift instability testing and Whipple rotator cuff testing were the most common physical examination findings. MRI with saline or gadolinium injection was a useful diagnostic aid. Glenoid chondromalacia, labral fraying and / or detachment was commonly seen.



    Surgical repair was successful in 37 of 40 patients. The SLAC lesion is a definable surgical entity with predictable history, physical findings, surgical findings with satisfactory results from surgery.

       

  • John Antoniou, and Douglas T. Harryman (Department of Orthopaedic Surgery, McGill University, Jewish General Hospital, Montreal, Quebec, Canada) 

    Posterior Instability 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 463-473



    Posterior instability of the shoulder though reported to be between 2% – 12% of all shoulder instability, is increasingly seen in athletes. The pathophysiology clinical and radiological evaluation and treatment have been discussed with particular emphasis on the authors preferred operative technique.



    Recent cadaveric and arthroscopic work has identified the importance of glenohumeral integrity and glenoid depth in the maintenance of shoulder stability. 



    Arthroscopic techniques for repair of these pathology are emerging. Until recently attention was focussed on capsular glenohumeral stability by altering two separate mechanisms – viz deepening the glenoid and reducing capsular joint volume by shifting the capsule to buttress the glenoid labrum, to increase the compressive force vector into a deep glenoid.



    The authors have shown that posteroinferior shoulder instability is associated with both capsular laxity and the well defined pathological lesions of the glenolabral concavity. They therefore advocate arthroscopic posterior capsulolabral repair and augmentation as a useful tool to restore the depth of the glenolabral concavity as also to reduce the redundant posteroinferior capsule.



    This technique is effective in treating posteroinferior instability.

       

  • William N. Levine, William D. Prickett, Marcel Prymka, and Ken Yamaguchi (Shoulder and Elbow Service, Washington University, St Louis, Missouri; and the Shoulder and Sports Medicine Service, New York Presbyterian Medical Center, New York, New York)

    Treatment of the Athlete With Multidirectional Shoulder Instability 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 475-484



    Multidirectional instability of the shoulder is an important source of dysfunction and pain in both athletes and sedentary individuals. Although previously considered to be uncommon there has been an increased awareness of this condition now. The treatment of this condition continues to be a challenging problem.



    Repetitive microtrauma seen in athletes can lead to multidirectional instability by overstretching the capsule and ligaments of the shoulder just as much as in young sedentary patients with ligamentous laxity.



    A redundant capsular pouch is a consistent finding along with a labroligamentous avulsion.



    The symptoms may be complex, vague and difficult to sort out. It is important to correlate the symptoms with the arm position. One must look for signs of ligamentous laxity in other joints as well. Rarely one finds hypermobile acromioclavicular and / or stenoclavicular joints.



    Plain radiographs are usually normal. Double contrast CT arthrograms might prove useful. Recently MRI scanning has also proved useful. 



    The treatment initially is non operative. However in those who show no response, operative treatment may be required, either open surgery or by arthroscopy.



    Longer follow ups may be necessary before any definite conclusion can be drawn.

       

  • Melyssa M. Paulson, Neil F. Watnik, and David M. Dines (Long Island Jewish Medical Center, New Hyde Park, New York)

    Coracoid Impingement Syndrome, Rotator Interval Reconstruction and Biceps Tenodesis in the Overhead Athlete 

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 485-493





    Anterior shoulder problems are extremely common in throwing athletes. Overhead activities place significant strain on the shoulder i.e. stresses on both the static and dynamic restraints of the glenohumeral joint. 



    This may result in several kinds of problems e.g. impingement syndromes, macro and micro instability, tendonitis and rotator cuff pathology labral lesions, biceps disorders, radiculopathy and thoracic outlet syndromes. 



    This article focuses on the anatomy, pathophysiology, clinical presentation diagnosis and surgical treatment of these problems. Particular attention is paid to coracoid impingement lesions of the long head of the biceps and rotator interval lesions.

       

  • Robert D. Travis, Wayne Z. Burkhead, and Robert Doane (W. B. Carrell Memorial Clinic, Dallas, Texas)

    Technique for Repair of the Subscapularis Tendon

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 495-500



    Subscapularis tendon injuries if left undiagnosed can result in significant disability. The article outlines the anatomy techniques of diagnosis and a method of repair that has been successful.



    Patients with sudden loss of active motion after an external rotation or hyperextension injury should be viewed with a high index of suspicion for a subscapularis tear.



    Pain in the shoulder particularly at night with painful limitation of shoulder elevation. Pain is also present with the arm by the side and on external rotation. 



    A positive left off test or belly press test combined with appropriate radiography (plain film, arthrography, CT scan or MRI) will lead to an early diagnosis.



    Careful surgical repair combined with a good rehabilitation program will give good results.

       

  • Gary M. Gartsman (Department of Orthopaedic Surgery, University of Texas Houston Health Science Center, and the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas)

    All Arthroscopic Rotator Cuff Repairs

    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 501-510

     



    The role of the arthroscope in the management of rotator cuff lesions is evolving. It was first used as a diagnostic tool, but is also used now as a therapeutic tool for even complicated operations. 



    The advantages are that it allows smaller skin incisions, glenohumeral joint inspection, treatment of intra articular lesions with minimal soft tissue dissection or damage, less pain and more rapid rehabilitation.



    However these advantages must be balanced against the technical difficulty of this method which limits its application to surgeons skilled in both open and arthroscopic surgery.



    This article contains many technical details to simplify and improve all arthroscopic cuff repairs.

       

  • Lavernia CJ, Sierra RJ, Gomez-Marin O (Univ of Miami, Fla)

    Smoking and Joint Replacement: Resource Consumption and Short Term Outcome

    Clin Orthop 367: 172-180, 1999



    It has been known that many adverse effects of smoking extend to surgical procedures, and delayed healing of skin flaps and higher complication rates in treatment of non-unions shown by microvascular and trauma surgeons, spine surgeons also reported delayed fusion.



    Conclusion – Surgical fraternity is becoming aware of numerous adverse effects of smoking on surgical outcomes. This study is of particular interest in that it offers some financial data to further underscore the adverse effect of smoking. For those who smoked there were surprising findings – longer surgical time and increased surgical charges.

       

  • 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 difficult to diagnose – normally one considers, arthritis, bursitis, tendinitis, abductor muscle strain, abnormal insertions of gluteal muscles.



    Persistent pain not properly relieved by conservative treatment were subjected to MRI CT Scan. Out of 6 patients 4 showed avulsion of gluteal tendon and 1 showed partial thickness tear.



    Conclusion – It is somewhat embarrassing to clinical practice that how many avulsions and tears have been missed. Surgical repair provides improvement but not completely.

       

  • Marder RA, Timmerman LA (Univ of California at Davis, Sacramento)

    Primary Repair of Patellar Tendon Rupture Without Augmentation

    Am J Sports Med 27: 304-307, 1999



    Introduction – Patellar tendon rupture is mostly seen in sports person and usually repaired by primary suture with cerclage augmentation. This method gives good results but some patients remain still.



    15 consecutive patients with acute traumatic ruptures of patellar tendon were treated (all were men – mean age 33).



    Rehabilitation programme started with heel slides with flexion of up to 450 and then after 3 weeks 450-900.



    Results – 12 out of 14 patients returned to their level of activities.



    Conclusion – Introduction of the Krachow whip stitch has improved the management of many soft tissue tendon-ligamentous injuries. Heavy no. 5 suture is used.

       

  • 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.



    Methods- For 6 weeks, 53 patients (28 women), with average of 27 years with unilateral patellofemoral pain syndrome were given intensive isometric quadriceps exercises once daily and oral NSAD (20 days). NSAD + lidocaine injections (B) and intra-articular 5 injections of glycosaminoglycan polysulfate (C).



    The patients were examined at 6 months and after 7 years.



    With the above groups, functional, clinical subjective and radiographic findings were improved in all patients in 6 months. At 7 years no significant changes.

       

  • Naudie D, Bourne RB, Rorabeck CH, et al (Univ of Western Ontario, London)

    Survivorship of the High Tibial Valgus Osteotomy: A 10- to 22- Year Followup Study

    Clin Orthop 367: 18-27, 1999



    Numerous studies have demonstrated that the satisfactory results of high tibial valgus osteotomy deteriorate over time. Most studies have reported satisfactory results in 80% of patients in 5 years and 60% of patients at 10 years follow-up.



    In USA as the HTO results have declined more and more TKR is being offered.



    Conclusion- Careful selection of both patients and surgical technique can significantly improve the survival rate for
    HTO.

       

  • 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



    It is a common experience that in leg lengthening there is a delay in healing and external fixator has to be kept for a long time and has its problem of pins.



    The experience obtained in rabbits to use demineralized bone at the site of osteotomy shortened the latency period, prevented delay in bone formation. It seems very appropriate now to set up a clinical trial of this technique in limb-lengthening patients.

       

  • Trauma and Amputation Surgery



    Ahlborg HG, Josefsson PO (Malmo Univ, Sweden)

    Pin-Tract Complications in External Fixation of Fractures of the Distal Radius

    Acta Orthop Scand 70: 116-118, 1999



    It is a very interesting article where the author has highlighted the complications of the external fixations in about 21%. These can be controlled with antibiotics as being the pin tract infection.



    Severe complications are rare even in older patients.

       

  • Van den Bosch EW, Van der Kleyn R, Hogervorst M, et al (Leiden Univ, The Netherlands; Univ Hosp Rotterdam, The Netherlands) 

    Functional Outcome of Internal Fixation for Pelvic Ring Fractures

    J Trauma 47: 365-371, 1999



    Pelvic fractures are uncommon and occur in 3-8% of trauma patients. 46% of these fractures were unstable and stabilization with internal fixation in patients were needed and to see the outcome.



    Various types of surgery were employed i.e.

    1) Internal fixation of pubic and 

    2) Combined anterior and posterior approach.

    3) External fixation.

    4) Percutaneous posterior screw fixation with additional anterior external fixation.



    Patients treated with internal fixation for pelvic ring fractures have limitation in functioning even after long term follow up. Combined anterior and posterior internal fixation yielded better results than combined internal and external fixation.

       

  • Femur Shaft Fractures



    Wolinksy PR, McCarty E, Shyr Y, et al (Vanderbilt Univ, Nashville, Tenn)

    Reamed Intramedullary Nailing of the Femur: 551 Cases

    J Trauma 46: 392-399, 1999



    Reamed intramedullary nailing is a highly successful treatment for femoral shaft fractures. Locked nails is now indicated for all fracture pattern.



    The overall union rate was 99%. The fixation of hardware was removed in 38% of fractures because of pain.



    Hardware breakage was present – nails, bolts.

       

  • Tornetta P III, Tiburzi D (Boston Med Ctr; Brookdale Med Ctr, Brooklyn, NY)

    Reamed Versus Nonreamed Anterograde Femoral Nailing

    J Orthop Trauma 14: 15-19, 2000



    Femoral nail insertion without reaming results is significantly slower union than nail insertion with reaming of the distal femur.



    It has been found by comparison of reamed and unreamed fractures that the union rate is definitely much better in reamed fractures, may be because of the tight fit of the metal.

       

  • Herscovici D Jr, Ricci WM, McAndrews P, et al (Tampa Gen Hosp, Fla; Washington Univ, St Louis) 

    Treatment of Femoral Shaft Fracture Using Unreamed Interlocked Nails

    J Orthop Trauma 14: 10-14, 2000



    It has also been found that placement of larger diameter nails to prevent bending and loss of fixation, there is cortical thinning and loss of medullary blood supply. This article shows that higher incidence of complications in reaming.



    The healing rate of femoral fractures treated with interlocked nails without reaming were no different than reaming.

       

  • Tibia Fractures



    Bhandari M, Adili A, Leone J, et al (McMaster Univ, Hamilton, Ont; St Joseph’s Hosp, Hamilton, Ont; Hamilton Health Sciences Corp, Ont)

    Early Versus Delayed Operative Management of Closed Tibial Fractures

    Clin Orthop 368: 230-239, 1999



    Highlights: It has been seen in this article that some patients were operated for tibial fracture within 12 hours of injury and some were operated after 12 hours and the complications which were seen were more in patients who were operated after 12 hours.



    It is very difficult to come to the conclusion as hardly any change is detected in the status of the callus. It is presumed that plating of the fractures of the tibia caused more complication than internal fixation by nailing.



    As far as the authors’ knowledge goes delayed intervention was better that immediate surgery as one disturbs the haematoma.

       

  • Moore KD, Goss K, Anglen JO (Univ of Missouri, Columbia)

    Indomethacin Versus Radiation Therapy for Prophylaxis Against Heterotopic Ossification in Acetabular Fractures: A Randomised, Prospective Study

    J Bone Joint Surg Br 80-B: 259-263, 1998



    For the prevention of heterotopic ossification after surgery indomethacin and single-dose radiation treatment are safe and effective. Radiation is 200 times costlier than medicinal treatment.

       

  • Kay NRM, Morris-Jones H (Westwood House, Sheffield, England)

    Pain Clinic Management of Medico-legal Litigants

    Injury 29: 305-308, 1998



    Litigation problems are not localized to any given society. Those with compensation claims are difficult to treat. 

       

  • Kanaya F, Ibaraki K (Univ of the Ryukyus, Okinawa, Japan)

    Mobilization of a Congenital Proximal Radioulnar Synostosis With Use of a Free Vascularized Fascio-Fat Graft 

    J Bone Joint Surg Am 80-A: 1186-1192, 1998



    Congenital radioulnar synostosis has been treated with vascularized fasciofat graft to gain mobility at superior radioulnar joint – worth a trial.



    This is first of its kind reported results show good future. Follow up for long time is required.

       

  • Reuben JD, Meyers SJ, Cox DD, et al (Univ of Texas, Houston; Rice Univ, Houston; Hermann Hosp, Houston)

    Cost Comparison Between Bilateral Simultaneous, Staged, and Unilateral Total Joint Arthroplasty

    J Arthroplasty 13: 172-179, 1998



    In good center and experienced surgeon, quality of the health of the patients if found good then one time surgery will certainly reduce the cost and ease of the rehabilitation
    programme.

       

  • Raab SS, Slagel DD, Robinson RA, et al (Allegheny Univ, Pittsburgh, Pa; St Mary’s Hosp, Grand Junction, Colo; Univ of Iowa, Iowa City)

    The Utility of Histological Examination of Tissue Removed During Elective Joint Replacement: A Preliminary Assessment 

    J Bone Joint Surg Am 80-A: 331-335, 1998



    It is not very necessary to do routine H.P. exam in every case as the cost of the procedure is prohibitive but guarded opinion as the tissue naked eye can mimic any path and medicolegal problem will have to be faced.

       

  • Bolhofner BR, Russo PR, Carmen B (Bayfront Med Ctr, St Petersburg, Fla)

    Results of Intertrochanteric Femur Fractures Treated With a 135-Degree Sliding Screw With a Two-hole Slide Plate

    J Orthop Trauma 13: 5-8, 1999



    Satisfactory healing, low blood loss, short surgical time with 2-hole side plate given as good results as 4 hole plate where more dissection, more hardware is required but remember reduction, reduction, reduction this should be the mantra of the surgeon managing displaced femoral fractures with internal fixation.

       

  • Heck DA, Melfi CA, Mamlin LA, et al (Indiana Univ, Indianapolis; Eli Lilly & Company, Indianapolis, Indiana; Roudebush VA Med Ctr, Indianapolis, Indiana)

    Revision Rates After Knee Replacement in the United States

    Med Care 36: 661-669, 1998



    Overall revision rates for knee replacement surgery were low in this Medicare patient group. Nevertheless, specific risk factors could be identified, some of which may relate to greater demands placed on the artificial joints by some patients.

       

  • Gerber JP, Williams GN, Scoville CR, et al (Keller Army Community Hosp, West Point, NY)

    Persistent Disability Associated With Ankle Sprains: A Prospective Examination of an Athletic Population

    Foot Ankle Int 19: 653-660, 1998



    Residual ankle pain and dysfunction are common problems after ankle sprains. Although almost all injured athletes are able to return to activity within 6 weeks after injury, some are left with chronic dysfunction at 6 months. Syndesmosis pain was high and carried an increased risk of prolonged disability.

       

  • Fracture 

    Jensen SL, Andresen BK, Mencke S, et al (Aalborg Hosp, Denmark)

    Epidemiology of Ankle Fractures: A Prospective
    Population-based Study of 212 Cases in Aalborg,
    Denmark

    Acta Orthop Scand 69: 48-50, 1998



    Ankle fracture occur more commonly in males before 50 years of age and in females after 50 years of age. They result from substantial trauma occurring during physical activity.



    Osteoporosis does not appear to be of major importance in the occurrence of ankle fracture.

       

  • Fracture of the Clavicle

    Robinson CM (Royal Infirmary of Edinburgh, Scotland)

    Fractures of the Clavicle in the Adult: Epidemiology and Classification

    J Bone Joint Surg Br 80-B: 476-484, 1998



    Fractures of the clavicle are quite common in all age groups. Lots of classifications are described but in this article simple classification i.e. Type 1 medial 1/5 fractures, 2A
    undispl m aced diaphyseal fractures and type 3A fractures of the outer fifth.



    Complication more often occurred in type 2B comminuted and displaced fractures.



    This being simple classification one can adopt it but in case subgroups are made then it might be complicated.

       

  • Gartsman GM, Khan M, Hammerman SM (Texas Orthopedic Hosp, Houston; Academic Information Services, Houston)

    Arthroscopic Repair of Full-thickness Tears of the Rotator Cuff 

    J Bone Joint Surg Am 80-A: 832-840, 1998



    Advances in operative technique have enabled the use of full-thickness tears of the rotator cuff to be repaired arthroscopically.



    In this article the authors have analyzed 73 patients, mean age being 60.7 years. Various grades were found from 1cm – 5 cm.



    The outcome was that active and passive range of motion were significantly improved post-operatively. Resisted elevation strength increased from 7.5 to 14 lbs.



    In conclusion arthroscpic repair of full thickness tears of the rotator cuff yields satisfactory results according to both traditional orthopedic and patient-assessed criteria.



    The advantages of this technique include smaller incisions, access to the glenohumeral joint for inspection and treatment of intra-articular lesions, and no need of detaching the deltoid. This method is technically difficult.

       

  • Quads 

    Konrath GA, Chen D, Lock T, et al (Desert Orthopedic Ctr, Palm Springs, Calif; Henry Ford Hosp, Detroit; Wayne State Univ, Detroit)

    Outcomes Following Repair of Quadriceps Tendon Ruptures

    J Orthop Trauma 12: 273-279, 1998



    Quadriceps tendon ruptures as such not so common and mostly occur above the age of 40 years.



    Most of the patients were surgically treated and outcome was good although more than half of the patients could not go to their original work but had range of movements up to 1250.

       

  • Spinner RJ, Goldner RD, Fada RA, et al (Mayo Clinic and Found, Rochester, Minn; Duke Univ Med Ctr, Durham, NC; Joint Implant Surgeons Inc, Columbus, Ohio; et al) 

    Snapping of the Triceps Tendon Over the Lateral Epicondyle 

    J Hand Surg [Am] 24A: 381-385, 1999 

     

    Snapping of the triceps of the lateral epicondyle may be a variation within the normal population, much like that of snapping of the triceps over the medial epicondyle.



    Snapping of the lateral triceps over the lateral epicondyle and a clinical maneuver referred to as the “lateral snap test,” which can be used to establish this diagnosis.



    This condition probably represents a variation of normal and “will become increasingly recognized in the future.” It is likely that the pain associated with the snapping is due to a bursitis/tendonitis, which would explain why patients may have asymptomatic snapping on one side and yet be symptomatic on the other.

       

  • Darder-Prats A, Fernandez-Garcia E, Fernandez-Gabarda R, et al (Hosp Clinico Universitario, Valencia, Spain)

    Treatment of Mallet Finger Fractures by the Extension-Block K-Wire Technique

    J Hand Surg [Br] 23B: 802-805, 1998 

     

    For mallet finger fractures that involve more than one third of the articular surface or include a subluxated distal phalanx, anatomical reduction of the joint surfaces via surgery is typically recommended.



    The Ishiguro method – a closed technique that provides anatomical reduction via an extension-block Kirschner wire (K wire) with transarticular K wire fixation.



    The anatomical reduction began with the patient under digital block anesthesia. After flexing of the distal phalanx, a 0.9- or 1.0-mm K wire is inserted through the head of the middle phalanx just proximal to the bone fragment, at a dorsal angulation of 300 to 400. 



    The fracture is reduced by passively extending the DIP joint, then the DIP joint is fixed with a second K wire to maintain the reduction. No splinting is used postoperatively, to allow early active motion of the proximal interphalangeal and metacarpophalangeal joints. 



    The extension-block K wire is removed at 4 weeks, and the transfixion K wire is removed at 5 weeks. None of the patients had DIP joint osteoarthritis or infections of pin tracks.

       

  • Katzman BM, Klein DM, Mesa J, et al (State Univ of New York, Brooklyn)

    Immobilization of the Mallet Finger: Effects on the Extensor Tendon 

    J Hand Surg [Br] 24B: 80-84, 1999



    Isolated splinting of the distal interphalangeal (DIP) joint is an effective treatment for mallet finger, although a small extensor lag can persist. This technique allows full motion of the extensor apparatus proximal to the DIP joint.



    When only the DIP joint was immobilized neither gap or retraction of the intrinsics occurred with joint motion proximal to the DIP joint.



    In mallet finger, a tendon gap results from movement of the distal tendon edge during DIP joint flexion, rather than by retraction of the proximal tendon edge. 



    Immobilization of only the DIP joint is necessary to approximate the edges of the terminal tendon. Adding PIP joint immobilization is of no benefit.

       

  • Tomaino MM, Plakseychuk A (Univ of Pittsburgh, Pa)

    Identification and Preservation of Palmar Cutaneous Nerves During Open Carpal Tunnel Release

    J Hand Surg [Br] 23B: 607-608, 1998



    Some patients undergoing carpal tunnel release are left with postoperative pillar pain and tenderness of the scar. 



    Division of cutaneous nerves crossing the palm may be responsible for the increased rate of painful incisions.



    The crossing nerves were consistently in the most proximal portion of the palm, just distal to the wrist flexion crease and superficial to the palmar fascia. The branch was often multifascicular, but there was never more than 1 branch. 



    This experience demonstrates the feasibility of preserving cutaneous nerves crossing the palm during open carpal tunnel release. 



    P. C. Amadio comments that, despite careful incisions, nerve branches across a carpal tunnel incision are common and, when encountered, should be preserved.

       

  • Shayfer SS, Toledano B, Ruby LK (Tufts Univ, Boston)

    Wrist Arthrodesis: An Alternative Technique

    Orthopedics 21: 1139-1143, 1998



    Wrist arthrodesis is widely used to treat pain and deformity. An alternative fixation method for arthrodesis of the wrist for nonrheumatoid arthritis was reported.



    The surgeon centers a straight dorsal incision over Lister’s tubercle. The surgeon then releases the dorsal radiocarpal and intercarpal ligaments to allow decortication. Using a high-speed burr, the surgeon removes all cartilage and subchondral bone from the radius and carpus, except for the carpometacarpal and scaphotrapezial-trapezoid joints. 



    With the wrist held in 100 to 150 of extension and 50 to 100 of ulnar deviation, two or three 3/32-inch smooth Steinmann pins are driven from the radius distally into the carpus.



    The surgeon then packs cancellous bone from the iliac crest into the radiocarpal and intercarpal joints. The oblique pin technique results in an excellent fusion rate in any desired position at a low cost. 



    This technique is fast and simple and avoids the cost of a plate and the possible expense of removing such a plate.

       

  • Herren DB, Lehmann O, Simmen BR (Schulthess Clinic, Zurich, Switzerland)

    Does Trapeziectomy Destabilize the Carpus?

    J Hand Surg [Br] 23B: 676-679, 1998



    The trapezium was completely removed in 86 patients, aged 42 to 80 years, for treatment of arthritis. Tendon suspension-interposition with a distally based strip of the flexor carpi radialis tendon was also performed in 61 patients.



    Trapeziectomy does not appear to result in significant destabilization of the wrist joint.

       

  • Ueba Y, Nosaka K, Seto Y, et al (Shiragikuen Hosp, Tosa, Japan; Shimada Municipal Hospitalm, Japan; Med Ctr for Children, Shiga, Japan; et al)

    An Operative Procedure for Advanced Kienbock’s Disease: Excision of the Lunate and Subsequent Replacement With a Tendon-Ball Implant

    J Orthop Sci 4: 207-215, 1999



    Excision of the lunate and subsequent replacement with a tendon-ball implant is the most appropriate procedure for advanced Kienbock’s disease. 



    After the collapsed lunate is removed, a tendon-ball implant, made of the palmaris longus and plantaris tendons, is placed in the resultant space in the carpus. A forearm distractor is applied during the operation, and distraction is continued for 4 weeks postoperatively.



    It is interesting to note that calcification or ossification can be seen in implanted tendon-balls by x-ray examination in about half the cases. The calcification was gradually transformed into ossification, and solid ossification in similar to original lunate was seen in several cases.

       

  • Menth-Chiari WA, Poehling GG, Wiesler, ER, et al (Wake Forest Univ, Winston-Salem, NC; Univ of Vienna)

    Arthroscopic Debridement for the Treatment of Kienbock’s Disease 

    Arthroscopy 15: 12-19, 1999



    Arthroscopic debridement of necrotic lunate effectively relieves pain but does not prevent disease progression.



    The immediate pain of Kienbock’s disease may be clinically improved after arthroscopic debridement, there is no consideration for the very likely progression of degeneration of the articular surfaces as the carpal collapse increases.



    A proximal row carpectomy or a midcarpal arthrodesis based upon the scaphoid will reduce the patients’ ROM, they are intended to provide extremely long-term protection from degenerative disease due to progressive mechanical instability. 



    R. A. Berger cautions readers to strongly consider a stabilization procedure of their choice when performing a lunatectomy for Kienbock’s disease.

       

  • Kulkarni RW, Wollstein R, Tayar R, et al (St Helier Hosp, Carshalton, England)

    Patterns of Healing of Scaphoid Fractures: The Importance of Vascularity 

    J Bone Joint Surg Br 81-B: 85-90, 1999



    Nonunion is a common problem after scaphoid fraction. An MRI study was performed to assess vascularity and healing in 46 consecutive scaphoid fractures. 



    On early MRI scans, the fractures fell into 4 patterns. In type 1 (8 cases), both fragments retained their vascularity and showed a hypervascular healing response.



    The most common pattern was type 2, seen in 35 cases. In this pattern, the proximal fragment appeared avascular, while the distal fragment showed a hypervascular healing response. 



    Type 2 fractures went on to nonunion. Type 3 fracture, with the distal fragment showing avascularity and the proximal fragment a hypervascular healing response. Type 4 fractures, in which both fragments were avascular.



    The 6-week MRI appearance may help to identify fractures that will not progress to union, and thus should be considered for early internal fixation. 

       

  • Mathoulin C, Brunelli F (Clinique Jouvenet, Paris)

    Further Experience With the Index Metacarpal Vascularized Bone Graft

    J Hand Surg [Br] 23B: 311-317, 1998



    When surgical treatment of scaphoid nonunion fails, a corticocancellous vascularized bone graft harvested from the distal part of the index metacarpal can be used to effect repair and to correct any palmar flexion by restoring the scaphoid to its correct position and supplying vascularity to the area.



    Use of a corticocancellous vascularized bone graft resulted in successful scaphoid union.



    This article has an excellent description of the pertinent vascular anatomy. While this vascularized bone graft has not been widely applied for scaphoid nonunion, it has some appeal, especially in the multiply operated-on wrist.

       

  • Shah J, Jones WA (Broadgreen Hosp, Liverpool, England)

    Factors Affecting the Outcome in 50 Cases of Scaphoid Nonunion Treated With Herbert Screw Fixation 

    J Hand Surg [Br] 23B: 680-685, 1998



    Many factors, such as the duration and location of nonunion and the vascular status of the proximal fragment, are known to affect the outcomes of this procedure.



    A longer duration of nonunion is associated with a lower rate of union, perhaps because of the increased incidence of avascular necrosis.



    This is an important study of scaphoid nonunions because it looks at factors beyond the surgeon’s control. Nonunions longer than 5 years had a 50% union rate with bone grafting, but those less than 5 years had an 80% rate.



    Patients with a fibrous nonunion and without displacement (ie, stable non-union), with an internal fixation screw alone (Herbert screw), union was achieved in each patient (100%).

       

  • Inoue G, Shionoya K (Nagoya Univ, Japan)

    Late Treatment of Unreduced Perilunate Dislocations 

    J Hand Surg [Br] 24B: 221-225, 1999



    For patients with chronic perilunate dislocation, open reduction and temporary fixation produces satisfactory results if performed within 2 months after injury. 



    In longer-standing cases, proximal row carpectomy produces good results if the cartilage on the proximal pole of the capitate is intact. Lunate excision does not give good results.



    Chronic perilunate dislocation may cause few symptoms for a long time; such cases often present with symptoms of median nerve compression or tendon rupture, rather than wrist deformity.



    In some cases of very severe perilunate fracture dislocations, proximal row carpectomy can be a very appropriate treatment even in the acute setting.

       

  • Ishii S, Palmer AK, Werner FW, et al (State Univ of New York, Syracuse)

    An Anatomic Study of the Ligamentous Structure of the Triangular Fibrocartilage Complex 

    J Hand Surg [Am] 23A: 977-985, 1998



    The triangular fibrocartilage complex (TFCC) and the interosseous membrane of the forearm play a crucial role in the stability of the distal radioulnar joint (DRUJ).



    The distal radioulnar ligament consists of dorsal, palmar, superficial, and deep portions. The meniscus homologue is the tissue located between and integrated into the ulnar aspect of the superficial part of the distal radioulnar ligament and the ulnar capsule.



    The anatomy of the triangular fibrocartilage complex has been confusing and controversial for anyone working on problems associated with disorders in the ulnar aspect of the wrist.



    This manuscript goes far in furthering our understanding of the complex anatomy of the triangular fibrocartilage complex. The most important features, in my opinion, are the deep attachments of the dorsal and palmar radioulnar ligaments to the foveal region at the base of the styloid process as well as on the ulnar styloid process itself.

       

  • Barbier O, Saels P, Rombouts JJ, et al (Univ of Louvain, Brussels)

    Long-term Functional Results of Wrist Arthrodesis in Rheumatoid Arthritis 

    J Hand Surg [Br] 24B: 27-31, 1999



    In patients with severe rheumatoid arthritis (RA), the goal of wrist arthrodesis is to achieve strong, stable, pain-free fusion while preserving forearm supination and pronation.



    The arthrodeses averaged 80 of extension and 90 of ulnar deviation. The findings support wrist arthrodesis as an effective procedure in patients with RA. Wrist fusion provides good pain relief and patient satisfaction without additional loss of function compared with the opposite side.

       

  • Gudmundsson KG, Arngrimsson R, Arinbjarnarson S, et al (The Health Care Ctr and Region Hosp, Blonduos, Iceland; Univ of Iceland, Reykjavik; The Region Hosp, Akureyri, Iceland)

    T- and B-Lymphocyte Subsets in Patients With Dupuytren’s Disease: Correlations With Disease Severity

    J Hand Surg [Br] 23B: 724-727, 1998



    Previous studies suggested that Dupuytren’s disease may be a T-cell-mediated autoimmune disorder and that immune dysregulation may play an important pathogenetic role. The response to steroids and interferon g also support the autoimmune hypothesis. 



    Patients with Dupuytren’s disease have significant elevations of activated peripheral blood T lymphocytes. The findings are consistent with the suggestion that immune system dysregulation, involving activated T cells and probably B cells, plays a role in the pathogenesis of Dupuytren’s disease.

       

  • Foucher G, Lallemand S, Pajardi G (Clinique du Parc, Strasbourg, France)

    What’s New in the Treatment of Dupuytren’s Contracture? [French]

    Ann Chir Plast Esthet 43: 593-599, 1998



    Under local anesthesia and tourniquet the cords of Dupuytren were cut with the tip of a 19-guage needle passed percutaneously. The procedure was performed in one session, beginning in the finger and proceeding in the palm, with an attempt to cut the cords at multiple levels. 



    The dressing lasted for 24 hours, but a night splinting in extension was maintained for at least 1 month.



    The ideal indication for this simple treatment is a bowing cord progressing slowly and flexing predominantly the metacarpophalangeal in an elderly patient.



    This excellent article reviews a newer, less invasive treatment for selected cases of Dupuytren’s contracture – needle
    aponeurotomy.

       

  • Stephen AB, Lyons AR, Davis TRC (Queen’s Med Centre, Nottingham, England)

    A Prospective Study of Two Conservative Treatments for Ganglia of the Wrist 

    J Hand Surg [Br] 24B: 104-105, 1999



    Although highly effective, surgical excision of wrist ganglia is an expensive treatment that carries a risk of complications. The success rates of reported conservative therapy options vary. These options include simple ganglion aspiration and multiple puncture of the ganglion wall, the latter a relatively painful procedure.



    Among conservative treatments for ganglia of the wrist, multiple puncture does not improve on the results of simple aspiration. Aspiration and reassurance that the ganglion is benign may reduce the number of patients desiring surgical excision.

       

  • Gary S. Fanton, and Amir M. Khan (Sports Orthopaedic and Rehabilitation Group, Menlo Park, California)

    Monopolar Radiofrequency Energy for Arthroscopic Treatment of Shoulder Instability in the Athlete 

    Orth Cl of N A July 2001Vol. 32 (3) Pg. 511-523

        


    Shoulder instability is one of the most common causes of functional limitation in recreational and competitive athletes. 

         


    Although open surgery can correct capsule redundancy it may not permit return to active competitive sports. Arthroscopy offers a better alternative than surgery, but the techniques are quite demanding.

       


    The use of thermal energy to ‘shrink’ rather than sew the stretched out glenohumeral ligaments was pioneered in early 1990s.

        


    Monopolar radiofrequency energy is increasingly being used in the treatment of shoulder instability. Early clinical results have shown successful shrinkage of the shoulder capsule. This procedure is useful in treating certain traumatic and recurrent shoulder instability especially where the range of motion is preserved. 

       


    It is easy to perform and its complication rate is low. There is little disruption or alteration of the anatomy. Success however depends on proper patient selection, patient compliance, and proper rehabilitation. 

        


    Long term follow-ups are required before definite advantages can be cleared.

           

  • Mark H. Field, T. Bradley Edwards, and Felix H. Savoie (Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi)

    Technical Note: A “New” Arthroscopic Sliding Knot 

    Orth Cl of N A July 2001Vol. 32 (3) Pg. 525-526

        


    Many arthroscopic knots, both sliding and non sliding have been described. The authors describe the arthroscopic implementation of another sliding knot originally used in tying the common bile duct (FHS unpublished version).

        


    This knot was first described by FHS and subsequently modified by the first author. The technique has been described and discussed. 

         


    As with any other knot, this should be practiced in the dry lab setting before it can be used on a patient.

           

  • W. Ben Kibler, John McMullen, and Tim Uhl (Lexington Sports Medicine Center, and the Division of Athletic Training, University of Kentucky, Lexington, Kentucky)

    Shoulder Rehabilitation Strategies, Guidelines, and Practice 

    Orth Cl of N A July 2001Vol. 32 (3) Pg. 527-538

        


    Shoulder rehabilitation can best be understood and implemented as the practical application of biomechanical and muscle activation guidelines to the repaired anatomic structures in order to allow the most complete return to function.

         


    The shoulder works as a link in the kinetic chain of joint motions and muscle activations to produce optimum athletic function.

         


    Rehabilitation should start with the establishment of a stable base of support and muscle felicitation in the trunk and legs and then proceeds to the scapula as healing is achieved and proximal control is gained.

         


    The pace of this flow of exercises is determined by the achievement of the functional goals of each segment of the kinetic chain. In the early rehabilitation stages the incompletely healed shoulder structures are protected by exercises that are directed towards the proximal segments.

         


    As healing proceeds the weak scapular and shoulder muscles are facilitated in their reactivation by the use of proximal leg and trunk muscles to re-establish normal coupled activations.

        


    Closed chain axial loading exercises form the basis for scapular and glenohumeral functional rehabilitation as they more closely stimulate normal scapula and shoulder positions, proprioceptive input, and muscle activation patterns.

         


    In the late rehabilitative stages, glenohumeral control and power production complete the return of function to the shoulder and the kinetic chain.

         


    In this integrated approach glenohumeral emphasis is part of the entire program and is towards the end of rehabilitation rather than being the entire program or being at the beginning of the program.

          

  • Alistair Stirling, Tony Worthington et al 

    Association Between Sciatica and Propionibacterium acnes 

    Lancet, Vol.357, June 23, 2001, Pg. 2024-25

           

    Summary : Authors hypothesised that the inflammation seen around the nerve root in patients with sciatica may be caused by microbial infection. They used a newly developed serological test to diagnose deep-seated infections caused by low virulent gram-positive microorganisms.

          

    43 of 140 (31%) patients with sciatica tested positive. Intervertebral disc material from a further 36 patients with severe sciatica who had undergone microdiscectomy was cultured for the presence of microorganisms.

          

    19 of these patients (53%) had positive cultures after long-term incubation. Propionibacterium acnes was isolated from 16 of the 19 (84%) positive samples. Low virulent organisms, in particular P. acnes, might be causing a chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica. These microorganisms could have gained access to spinal disc after previous minor trauma.

          

  • Servier’s Dual Approach to Osteoporosis

    Scrip May 17th, 2002, pg. 26

      

    Servier’s novel osteoporosis product, Protos (strontium ranelate), has a dual action in prevention and treatment of osteoporosis. Protos stimulates bone formation (osteoblast action) and inhibits bone absorption (osteoclast action).

      

    The sum total is increased bone density. Clinical trials have demonstrated this effect.

       

BACK

 


 

         

Speciality Spotlight

 

 

  • Hanlon M, Krajbich JI [ Saint Heliens, Auckland, New Zealand; Shriners Hosp for Children, Portland, Ore]
    Rotationplasty in Skeletally Immature Patients : Long Term Follow-up Results
    Clin Orthop 358 : 75-82, 1999
      
    Lower extremity sarcomas are usually treated by amputations. There are a few viable alternatives like rotationplasty, resection arthrodesis, allograft  replacement and endoprosthetic replacement. In immature skeletons these procedures may not be satisfactory. Rotationplasty offers a biologic functional joint at the level of the knee, prosthetic tolerance secondary to loading of normal weightbearing tissue, maintenance of growth and the ability to tailor the procedures and prosthesis to obtain limb length equality at maturity.
      
    Six of twenty one patients died and one was lost to follow up. The follow up [ 5 – 10.5 years] had good or excellent results functionally.
       

  • Shih H-N, Wen-Wei Hsu R, Sim FH [Chang Gung Mem Hosp, Kweishan, Taoyuan, Taiwan, China]
    Excision Curettage and Allografting of Gaint Cell Tumor
    World J Surg 22: 432-437, 1998
      
    Gaint cell tumor [GCT] of bone is a benign, aggressive lesion of long bones. The results of wide excision, phenol cautery therapy and bone grafting have been reviewed.
      
    22 patients were followed up for at least 2 years. The tumor size of about 60 ml and grade II to grade III lesions. No patient received chemotherapy.
      
    The results of this treatment show that it can be safe and effective.
          

  • Kochar MS, Gebhardt MC, Mankin HJ [Massachusetts Gen Hosp, Boston; Harvard Med School, Boston; Children Hosp, Boston]
    Reconstruction of the Distal Aspect of the Radius with Use of an Osteoarticular Allograft After Excision of a Skeletal Tumor
    J Bone Joint Surg Am 80-A: 407-419, 1998
     
    The authors repeat them experience with the use of osteoarticular allograft to reconstruct the distal aspect of the radius after excision of skeletal neoplasms.
     
    24 cadaveric osteoarticular allografts were implanted in 24 patients [13 women and 11 men] who had undergone distal radius surgery for giant-cell tumor. The radiocarpal ligaments were also reconstructed and internal fixation was used. The average follow up was 10-9 years.
     
    In 2 patients, there was local recurrence [primary giant cell tumor and desmoplastic fibroma ]. 8 patients required revision because of a fracture wrist pain and local recurrence or volar dislocation of carpus.
     
    They conclude that the rate of local recurrence was low, function was restored in these wrists with a moderate range of motion and little pain during the performance of moderate activation. However 33% needed revision. Nonetheless this operation is a good option for reconstruction of the distal aspect of the radius after skeletal tumor excision.
        

  • Hornicek FJ Jr, Mnaymneh W, Lackman RD, et al [Univ of Miami/ Jackson Mem Med Ctr, Fla; Thomas Jefferson Univ, Philadelphia; Univ of Zurich, Switzerland]
    Limb Salvage with Osteoarticular Allografts After Resection of Proximal Tibia Bone Tumors
    Clin Orthop 352: 179-186, 1998
     
    The clinical behavior of proximal tibial osteoarticular allografts after bone tumor resection was investigated and long term outcomes for patients receiving chemotherapy were compared with those not receiving chemotherapy.
     
    38 patients receiving proximal tibial allografts after wide resection of benign and malignant tumors were studied. 55% of patients experienced one or more complications of the allograft. Patients receiving chemotherapy had a higher incidence of fractures [58%] than those not receiving chemotherapy [ 50%]. However with proper management of the complications, allograft is still a viable option for reconstruction of defects after wide resection of tibial tumors.
      

  • Jeon D-G, Kawai A, Boland P, et al [Korea Cancer Ctr Hosp, Seoul; Okayama Univ, Japan; Mem Sloan – Kettering Cancer Ctr, New York]
    Algorithm for the Surgical Treatment of Malignant Lesions of the Proximal Tibia
    Clin Orthop 358: 15-26, 1999
     
    A retrospective study of 40 cases who had total knee replacements after proximal tibial resection was conducted. Various reconstructive methods were used to fix the prosthesis re-establish the extensor mechanism and provide soft tissue cover.
     
    They conclude that aggressive multistage management of infection is necessary. Those requiring chemotherapy or who have short potential survival should undergo prosthetic replacement. Failure may be caused by weakness of the extensor mechanism. Primary reconstruction with an uncemented rotating hinge knee replacement is the most suitable prosthesis.
         

  • Outcome
    Felder-Puig R, Formann AK, Mildner A, et al [ St Anna Children’s Hosp, Vienna; Univ of Vienna]
    Quality of Life and Psychosocial Adjustment of Young Patients After Treatment of Bone Cancer
    Cancer 83: 69-75, 1998
      

  • Serletti JM, Carras AJ, O’Keefe RJ, et al [ The cancer Ctr, Rochester, NY; Univ of Rochester Med Ctr, NY]
    Functional Outcome After Soft-Tissue Reconstruction for Limb Salvage After Sarcoma Surgery
    Plast Reconstr Surg 102: 1576-1585, 1998
     
    Significant soft tissue defects occur in patients treated for soft tissue sarcoma. These need reconstructive procedure. The functional outcome of such cases has been investigated.
     

  • Kawai A, Backus SI, Otis JC, et al [Mem Sloan-Kettering Cancer Ctr, New York; Hosp for Special Surgery, New York]
    Interrelationships of Clinical Outcome, Length of Resection, and Energy Cost of Walking After Prosthetic Knee Replacement Following Resection of a Malignant Tumor of the Distal Aspect of the Femur
    J Bone Joint Surg Am 80-A: 822-831, 1998
     
    ISOLS [International Society of Limb Salvage] system is now commonly used to report functional outcome after prosthetic replacement. The relationship between ISOLS scores and objective measures of function after resection of malignant musculoskeletal tumors followed by total knee replacement was investigated.
     
    Surgeons are non encouraged to do more radical tumor excisions because muscle mass can be functionally compensated for by the innervated free muscle transfer.
      

  • Wedin R, Bauer HCF, Wersall P [ Karolinksa Hosp, Stockholm]
    Failures After Operation for Skeletal Metastatic Lesions of long Bones
    Clin Orthop 358: 128-139, 1999
      
    Skeletal metastases with patholigic fracture have a high risk of failure after surgery, particularly in the femur. A long survival time is an important risk factor for local failure. The failure rate may be reduced by rigid internal fixation and filling of bone defects with acrylic cement. A retrospective study identifies the other causes of fracture. The study includes [ 92 patients with 228 metastatic lesions. Surgical treatment consisted of intralesional curettage [ 133 patients] resection and reconstruction [ 18 patients ] and stabilization only [ 77 patients]. An endoprosthesis was used for 54 patients having reconstruction. An osteosynthetic device was used for 162 patients and cement only in 10 patients.
     
    They conclude that endoprostheses reconstruction is better than osteosynthetic devices. Surgery is safe even in seriously ill patients.
        

  • Wang PTH, Bonavita JA, DeLone FX Jr, et al [Crozer-Chester Med Ctr, Upland,Pa]
    Ultrasonic Assistance in the Diagnosis of Hand Flexor Tendon Injuries
    Ann Plast Surg 42: 403-407, 1999
       
    This study examines the contribution of ultrasonography to the diagnosis of flexor tendon injuries.
      
    Eight patients were studied, clinically there was inability to flex the finger. Evaluation was performed using an ATL-HDI-3000 US unit with a high -resolution 5- to -9 MHz hockey stick linear probe. Real-time flexor tendon manipulation was performed to stimulate the patient’s symptoms. These findings were compared with the operative findings.
       
    3 cases of flexor digitorum profundus tendon rupture were diagnosed by USG. These injuries resulted from forceful extension, penetrating injury, delayed rupture 3 weeks after previous repair respectively. In all 3 cases the US findings were confirmed at surgery. In the remaining 5 cases [forceful extension, penetrating trauma, phalangeal fracture and crush injury]. The US showed the tendons to be intact; at operation, in 3 cases these findings were confirmed. 
       
    The authors conclude that US is a useful diagnostic tool for clinically equivocal flexor tendon injuries.
          

  • Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat, Paris]
    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation
    Skeletal Radiol 27: 617-624, 1998
      
    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.
      
    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.
      
    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 
       
    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.
           

  • Failla JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]
    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations
    J Hand Surg [Am] 24A: 257-266, 1999
       
    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.
        
    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is an useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.
        

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]
    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation
    Injury 30: 59-63, 1999
      
    Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging is an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.
        

  • Wolf JM, Weiss A-PC [Brown Univ, Providence, RI]
    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery
    J Hand Surg [Am] 24A: 182-184, 1999
      
    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.
       
    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.
      
    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.
      
    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.
          

  • Turgeon TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]
    J Hand Ther 12: 7-15, 1999
      
    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.
      
    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.
      
    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.
      
    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.
      
    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.
          

  • Marx RG, Bombardier C, Wright JG [Univ of Toronto]
    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?
    J Hand Surg [Am] 24A: 185-193, 1999
      
    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.
     
    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.
     
    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.
     
    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.
        

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]
    Transthecal Digital Nerve Block: An Anatomical Appraisal
    J Hand Surg [Br] 23B: 490-493, 1998
     
    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.
     
    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.
       
    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.
     
    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.
     
    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.
     
    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.
        

  • Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]
    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility
    J Hand Surg [Am] 24A: 219-224, 1999
      
    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.
      
    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.
      
    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.
      
    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.
           

  • Wright JG, Hawker GA, Bombardier C, et al [Univ of Toronto; Sunnybrook & Women’s College Hosp, North York, Ont; Vanderbilt Univ, Nashville, Tenn; et al]
    Physician Enthusiasm as an Explanation for /area Variation in the Utilization of Knee Replacement Surgery
    Med Care 37: 946-956, 1999
       
    This study examines the variation in the utilization of knee replacement surgery by county in the Canadian province of Ontario. The factors evaluated included the characteristics and opinions of the physicians and specialists, severity of disease, access to the procedure, use of alternative surgery and population factors.
       
    Knee replacement was more frequently used in older patients and in medical school affiliated hospitals. The referring physicians were usually males, trained outside North America. Orthopedic surgeons had a higher propensity for performing knee replacements and better perceptions of the outcomes. 
       
    The authors conclude that the local orthopedic surgeons have a major influence on the rate of knee replacement in a given geographic area. Efforts to reduce variation in surgeon opinion might reduce although not eliminate, geographic variation.
        

  • Coyte PC, Hawker G, Croxford R, et al [Univ o Toronto; Women’s College Hosp, Toronto; Hosp for Sick Children, Toronto]
    Rates of Revision Knee Replacement In Ontario, Canada
    J Bone Joint Surg Am 81-A: 773-782, 1992
       
    This analysis includes 18,520 knee replacements performed in Ontario from 1984 to 1991. One study algorithm was used to identify primary versus revision 
    knee replacements and another was used to link revision to primary knee replacements.
       
    The survival of the primary knee replacements was assessed using the Kaplan Meier method and factors affecting survival were identified using a proportional – hazards regression model. 
       
    Overall 7% of the total number of knee replacements were revisions. Osteoarthritis was the commonest indication for primary knee replacement. The time to revision surgery was significantly longer for patients older than 55 years, rural population and in those with rheumatoid arthritis revision.
       
    Revision replacement surgery was done earlier in teaching or speciality hospitals. Long term revision rates were low. The estimated rate of revision within 7 years varied significantly according to the algorithm used from 4.3% to 9%.
       
    They conclude that revision knee replacement is a rare event. Many factors affect thus likelihood like age, sex, area of residence and type of hospital.
        

  • Robertsson O, Borgquist L, Knutspm K, et al [Univ Hosp, Lund, Sweden; Linkoping Univ, Sweden]
    Use of Unicompartmental Instead of Tricompartmental Prostheses for Unicompartmental Arthrosis in the Knee is a Cost-effective Alternative : 15,437 Primary Tricompartmental Prostheses Were Compared With 10,624 Primary Medial or Lateral Unicompartmental Prostheses 
    Acta Orthop Scand 70: 170-175, 1999
       
    This study evaluates the cost of UKA [Unicompartmental] and TKA [Tricompartmental] procedures including implant cost. Length of hospital stay and the difference in the number of expected revisions. 
       
    The analysis included 15,437 primary TKAs and 10,624 primary medial or lateral UKAs over an 11 year period. Registry data was used to compare length of hospital stay in the 2 groups. Survival data was used to calculate the cumulative revision rate [CRR] and relative risk of revision. The risk of second revision and infection were calculated as well. 
       
    The proportion of patients undergoing UKA implantation declined during the period of study. ‘The average age at primary operation was 73 years [TKA] and 71 years [UKA]. The postoperative stay averaged 12.3 days [TKA] and 10.7 days [UKA]. The 10 year CRR was 12% [TKA] AND 16% [UKA]. The rate of serious complications was significantly lower in UKA group. The cost of a UKA was 57% that of TKA procedure.
       
    The conclusion is that the cost of UKA implantation is lower than TKA implantation [inclusive of higher revision rate]. It also has a shorter hospital stay. The costs may be further reduced by proper selection of patients.
       

  • Parentis MA, Rumi MN, Deol GS, et al [Pennsylvania State Univ, Hershey] 
    A Comparison of the Vastus Splitting and Median Parapatellar Approaches in Total Knee Arthroplasty
    Clin Orthop 367 : 107-116, 1999
        
    This is a controlled prospective study [randomized] comparing the two approaches.
       
    42 consecutive patients [51 knees] with degenerative disease of the knee were subjected to TKA.
       
    The median parapatellar approach used a standard midline incision. In the vastus medialis splitting approach the same incision was used; however at the level of the supero medial corner of the patella, the vastus medialis fascia was incised along the margin of the quadriceps tendon and elevated medially. The muscle was then split bluntly. 
       
    Electromyography performed pre and postoperatively was used to evaluate the two approaches relative to their effect on the innervation of the quadriceps mechanism. 
       
    The two randomized groups were similar in age, weight and other clinical parameters. Postoperatively, no significant differences were noted during the hospital stay at 2, 6 and 12 weeks in terms of straight leg raise, ROM and hospital for special surgery scores, short arc quadriceps strength or tourniquet time. Blood loss was significantly greater in the standard approach [ 200 vs 129.6 ml]. 9 patients [43%] who had vastus splitting approach had abnormal postoperative electromyograms.
       
    The two approaches are similar when compared clinically. Longer tern studies, however, are needed to determine the clinical significance of denervation of the vastus medialis muscle by the vastus splitting approach.
           

  • Aglietti P, Buzzi R, De Felice R, et al [Univ of Florence, Italy]
    The Insall-Burstein Total Knee Replacement in Osteoarthritis : A 10-Year Minimum Follow-up
    J Arthroplasty 14: 560-565, 1999
       
    The Insall-Burstein posterior stabilized [IBPS] TKA was designed to improve maximal flexion and function. Previous studies have presented midterm results with this prosthesis. This study presents a ten year follow up result using the IBPS in patients with osteoarthritis. 
      
    99 IBPs TKAs in 86 patients [76 women and 10 men average age 69 years] with osteoarthritis were followed up. Follow up evaluation consisted of annual clinic visits, including the knee Society Score and radiographs. 10-15 years follow up data were available on 60 knees.
       
    58% had excellent results [Knee Society Scores ], 25% had good results, 7% had fair results and poor results in 10%. The knees had an average of 1060 of flexion. 9% had moderate patellofemoral crepitation. 8% showed osteolysis around the tibial and femoral components whereas 12% showed polyethylene wear. The 10% failure rate included 4 knees with aseptic loosening, 1 with deep infection and 1 with recurrent patellar dislocation. The 10 year cumulative success rate with revision as the end point was 92%.
       
    The IBPS TKA replacement achieves good results on a long term basis.
        

  • Cloutier J-M, Sabouret P, Deghrar A [Universite de Montreal]
    Total Knee Arthroplasty with Retention of Both Cruciate Ligaments : A Nine to Eleven -year Follow-up Study
    J Bone Joint Surg Am 81-A: 697-702, 1999
        
    Most current knee replacement systems retain the posterior or both the ACL and PCL. Despite arguments that ACL retention complicates the knee replacements procedure, the authors routinely seek to retain both ligaments when possible. A prospective study of 163 TKAs with retention of both cruciate ligaments.
       
    Of 204 TKAs performed from 1986-1988 both cruciate ligaments were retained in 163. Follow-up results were available on 107 knees of 89 patients: 96 women and 34 men with an average age of 67 years at index arthroplasty. [75% had osteoarthritis 25% had rheumatoid arthritis]. Varus deformity was present in 67% valgus in 16%. At operation ACL appeared normal in 96 knees and partially degenerated in 67. 
       
    At 10 year follow up, 97% had good to excellent results. 91% had good pain relief with an average range of flexion of 107. AP stability was normal in 89% with movement of less than 5 mm. The remaining 11% had 5-10 mm of movement. Mediolateral stability was normal in 90% whereas 10% had 5-10 mm of movement. Varus alignment was between 50 to 100 in 88%. The average knee score was 91 points, with an average functional score of 82. 10 year revision free survival was 95%. The revision rate was 4% with no revisions for patellar problems or aseptic loosening of the tibial component.
       
    The ten year follow up shows good results.
        

  • Gill GS, Joshi AB, Mills DM [ Lubbock, Tex]
    Total Condylar Knee Arthroplasty : 16- to 21-Year Results
    Clin Orthop 367: 210-215, 1999
       
    This study reports the long-term results of posterior cruciate retention total condylar knee arthroplasty performed by a single surgeon in private practice.
    159 knee arthroplasties were performed [139 patients] using total condylar knee prostheses between 1976-1982. A 16 year follow-up was available on 72 knees of 63 patients [42 men, 21 women] average age 61 years]. The main indication was osteoarthrosis. Follow up included clinical evaluation based on knee society clinical rating systems and radiographs.
       
    5 knees experienced delayed complications [ 3 had patellar stress fracture; 1 each of delayed supracondylar fracture and patellar tendon rupture]. Revision surgery was performed on 1 knee. 2 more cases were advised revision surgery but declined on medical risk grounds. There were no cases of aseptic loosening. The mean knee score improved from 40.3 points preoperatively to 88.4 points at follow up.
       
    86% had excellent results, 7% had good to fair result and poor in 7%. Among patients undergoing revision surgery, 20 year prosthesis survivorship was 98.6%. 
       
    Total Condylar Knee arthroplasty with posterior cruciate ligament retention gives excellent results in private practice.
      

  • Li PLS, Zamora J, Bentley G [King’s College Hosp, London; Southend Gen Hosp, Essex, England; Royal Natl Orthopaedic Hosp, Stanmore, England]
    The Results at Ten Years of the Insall-Burstein II total Knee Replacement: Clinical, Radiological and Survivorship Studies
    J Bone Joint Surg Br 81-B:647-653, 1999
       
    The 10 year results of the use of Insall-Burstein II prosthesis in a general orthopaedic unit are discussed. 
        
    146 total knee replacements [IB-II prosthesis] were performed on 121 patients [ 39 men, 82 women aged 46-86 years]. At ten years, 78 patients [94 knees] were available for follow-up. The hospital for special surgery [HSS] scoring system and the knee society rating system were used to evaluate outcome.
    79% had good to excellent result, 14% had a fair result and 9% had a poor result. The average knee society score was 87 [ at 10 years] and the average functional score was 56 [advanced age and infirmity]. The average knee society pain score increased significantly from 4 [pre-operatively] to 45 at 10 years. The mean ROM improved from 88% to 100%, walking distance improved from less than 500 m. to 500-1000 m. There were 9 revisions because of infection [n=5] aseptic loosening [n=4] for a cumulative survival rate at 92.3% at 10 years. Secondary patellar resurfacing was necessary in 8 patients with severe anterior knee pain. 3 had to undergo knee lateral release for patellar maltracking. 1 had a patellar tendon rupture repair, 6 had postoperative infection, one had a nonfatal pulmonary embolus. 4 had deep vein thrombosis. 1 had a stroke and 1 had a fracture of the posterolateral cortex of tibia. 7 patients had to be manipulated under anesthesia. 
       
    Radiographs of 104 knees were available for follow up. 10 tibial components showed radiolucent lines but none required revision. 
      
    The long term results of Insall-Burstein II total knee replacement orthroplasty are good with 90% , 10 year survival.
        

  • Osep E. Armagan, MD, and Michael J. Shereff, MD [ From the Section of Foot and Ankle Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois [OEA]; the Division of Orthopaedic Surgery, Department of Surgery, University of South Carolina; and the Foot and Ankle Center, Orthopaedic Specialties of Charleston, Charleston, South Carolina [MJS]
    Injuries to the Toes and Metatarsals 
    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos. 1-9
       
    Studies on force distribution of the forefoot during the stance phase of gait indicate that each of the lesser metatarsals supports an equal load [1/6 of body weight].
       
    Athletic, inversion-type injuries are a common cause of fractures of the fifth metatarsal, which is injured the most frequently. 
       
    Stress fractures, as described in military recruits, runners, and dancers, are the next most common and occur in the second and third metatarsals. Fractures of the first metatarsal are less common because of its relative size and mobility.
       
    Acute direct forces occur most commonly as a result of crushing-type injuries, such as a heavy object falling onto the dorsum of the foot, producing transverse or comminuted fracture patterns, often of adjacent metatarsals, with varying degrees of skin injury. In these cases, a compartment syndrome of the foot must be suspected and treated with early fasciotomy if indicated.
       
    There is less risk of displacement of fractures of the base of the metatarsals because of the retraining effect of the capsular attachments, interosseous ligaments, and balanced tendinous insertions of the tibialis posterior and peroneus longus muscles.
       
    Injuries to the metatarsal shaft are relatively more common than injuries to the base.
      
    The strong flexor tendons usually force the distal fragment of the metatarsal fracture in a plantar and proximal direction. More distal the fracture of the metatarsal, the more significant plantar flexion, which in turn, increased the plantar prominence of the metatarsal head, and the more likely that distal fractures will require open reduction. 
        
    To minimize the postoperative stiffness of the metatarsophalangeal joint. 
       
    Myerson advocates placing the anterograde Kirschner -wire through the distal metatarsal with the toes only slightly dorsiflexed, such that the Kirscher-wire engages the plantar aspect of the base of the proximal phalanx, avoiding scarring to the plantar plate.
       
    Regarding surgical incisions, dorsal longitudinal incisions are recommended, centered over the affected shaft or the web space between adjacent fractures. 
       
    Fractures of the fifth metatarsal deserve special attention their prevalence and their because of historical incidence of delayed union.
       
    These injuries can occur without direct trauma. The bone anatomy consists of the common articulation between the cuboid and the fourth and fifth metatarsals, which is the anatomic basis for the classification of the fractures of the fifth metatarsal.
       
    Fractures proximal to the articulation of the fourth and fifth metatarsal are referred to as tuberosity fractures, fractures involving this articulation are referred to as Jones fractures, and fractures distal to this articulation are refined to as diaphyseal stress fractures.
        
    Tuberosity fractures are avulsion-type injuries caused by an indirect force, causing tension on the lateral band of the plantar fascia. They are commonly referred to as pseudo-jones fractures and are treated symptomatically with rigid soled shoes and activities as tolerated, with an excellent prognosis for healing in 4 to 6 weeks.
        

  • Paul Juliano, MD, and Hoan-Vu Nguyen, MD [ From Department of Orthopedic Surgery, Hershey Medical Center, Hershey, Pennsylvania]
    Fractures of the Calcaneus
    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001,Pg.Nos.35- 51 
        
    Fractures o the calcaneous [os calcis] are the most common of tarsal bone fractures. 
        
    There is considerable debate regarding their treatment and overall management.
        
    Conservative management through rest and elevation remained the mainstay of treatment until the 1990s. In 1908, Cotton and Wilson described their closed reduction technique in an attempt to restore normal anatomy.
       
    In 1931, Bohler modified this technique using pin traction and clamps in an attempt to restore normal anatomy.
       
    He emphasized the need to restore the tuber angle [Bohler’s angle]. Operative fixation of calcaneal fractures in the United States focused on primary subtalar arthrodesis alone or triple arthrodesis. 
       
    In 1943, Gallie first described primary subtalar arthrodesis. These four treatment options conservative management, closed reduction, open reduction and primary arthrodesis- continue to be viable treatment alternatives today.
       
    The calcaneus has a thin cortical shell and is composed mostly of cancellous bone. The exceptions include the cortical thickening that supports the posterior facet [known as the thalamic portion], the dense cortical bone in the sustentaculum tali, and the thick cortex in the angle of Gissane.
       
    The first widely accepted classification system was proposed by Essex-Lopresti in 1952. 
       
    Essex-Lopresti Classification –
    I. Not involving subtaloid joint
    A. Tuberosity fractures
         1. Beak type
         2. Avulsion medial border
         3. Vertical
         4. Horizontal
    B. Involving calcaneocuboid joint
    A. Without displacement
    B. With displacement
         1. Tongue type, with displacement
         2. Centrolateral depression of joint
         3. Sustentaculum tali fracture along
         4. With comminution from below
              [including severe tongue and joint depression type]
         5. From behind forward with Dislocation subtaloid joint
        
    With the advent of the CT scan, new classification systems were developed to assist in the diagnosis of calcaneus fractures.
       
    The cause of these fractures is a fall from a height. The most common signs of a fracture include tenderness, swelling, ecchymosis, and distortion of the normal anatomy around the heel. Although not pahognomonic for calcaneal fractures, plantar ecchymosis is specific for these fractures. The skin blistering that commonly is seen usually occurs within the first 36 hours after injury.
        
    At the time of initial presentation, the patient’s foot should be placed in a Jones dressing and foot pump to reduce the amount of swelling. A posterior splint should be applied and the leg elevated to minimize swelling and prevent blister formation or excessive swelling until the wounds epithelialize and the skin passes the wrinkle test. The skin on the lateral surface of the heel should wrinkle along the normal skin creases on dorsiflexion and eversion of the foot. It may take 2 to 3 weeks for the skin to wrinkle.
        
    Most physicians have agreed on the treatment of extra-articular fractures, which generally have a more favorable result than treatment of intra-articular fractures. 
        
    The options for treatment of avulsion fractures are various, but most clinicians agree that optimal treatment is nonoperative. Recommendations include a woven elastic [Ace] bandage and crutches for 2 weeks, non-weight bearing and short leg cast for 4 weeks, and non-weight bearing for 8 weeks. 
        
    These fractures may take 1 year to become asymptomatic. Fragments greater than 2 cm generally require operative treatment.
       
    The treatment of intra-articular fractures is controversial. Nonoperative treatment continues to be the preferred method for undisplaced fractures.
       
    Displaced and comminuted fractures can be treated conservatively without reduction and early range of motion, with closed reduction, with primary arthrodesis – subtalar or triple – or with open reduction and internal fixation.
       
    The overall result was better, however, in the operative fractures if the posterior facet was anatomically reduced.
       
    Complications after calcaneus fractures can be divided into two categories – early and late. Early complications include fracture blisters and compartment syndrome. Fracture blisters should be debrided and allowed to epithelialize before surgical intervention. Compartment syndrome or suspicion thereof should be followed with immediate fasciotomy. The clinical consequences of an untreated compartment syndrome include clawing of the lesser toes, stiffness, aching, weakness, sensory changes, atrophy, and fixed deformities of the forefoot. 
       
    Late complications include wound dehiscence, wound infection, subtalar arthritis, lateral impingement syndrome, and sural neuritis.
       
    Subtalar arthritis should be treated conservatively initially through activity change, shoe modifications, and anti-inflammatory medications. Subtalar or triple arthrodesis should be considered if these means fail.
       
    The technique for primary subtalar fusion is identical to open reduction and internal fixation of the calcaneus. 
       
    The advantages of this approach is that the geometry of the foot is restored [i.e. length, width, height, and valgus alignment]. This advantage precludes the need to wait 6 or 9 months to see if the patient will improve, be out of work, or be in pain with a fracture that has a high probability of future fusion. This is a judgement call- but why keep a laborer out of work when the probability is high hat a fusion ultimately will be needed?
       

  • Gregory C. Berlet, MD, FRCS[C], Thomas H. Lee, MD, and Eric G. Massa, DPM [ From the Orthopedic Foot and Ankle Center [GCB, THL, EGM]; and the Division of Foot and Ankle Surgery [THL], Department of Orthopaedic Surgery [GCB, THL], The Ohio State University [THL], Columbus, Ohio
    Talar Neck Fractures 
    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.53-64
       
    Immediate reduction and use of compression screws in displaced talar neck fractures – a recommendation that prevails today. Methods of surgical approaches and fixation may differ, but the evolved theme remains early open reduction and internal fixation, with awareness of the major complications of varus malunion and a vascular necrosis [AVN] of the talus.
       
    In Roman times, the heel bone of a horse was used as dice and called taxillus. This word evolved into talus. The talus is the second largest bone in the tarsus. It has no muscular origins, and 70% of its surface is covered with cartilage. The talus is the torque converter of the lower extremity, allowing for foot flexibility to adapt to uneven ground but providing a rigid lever for propulsion. 
       
    In cases of talar injury, restoration of the complex spatial relationship of its three parts – the head, neck, and body – is imperative to achieve good functional results.
       
    The neck of the talus projects anteromedially and downward from the body. Its average length is 17 mm, and angle of the medial deviation is 150 to 20o in adults. Plantar deviation of the neck is approximately 240. 
       
    Although there are no muscular origins, te talus is bound tightly to the ankle mortise, calcaneus, and navicular bone by multiple ligamentous and capsular soft tissues. This extensive soft tissue complex about the talus allows for stability and motion and provides the conduit for blood supply to the bone itself.
       
    The talar blood supply has been shown to be rich through a vast but fragile network of extraosseous blood supply comes from the three arteries- the posterior tibial artery, anterior tibial artery, and perforating peroneal artery. These arteries anastomose to form a vascular sling around the talus. 
       
    The main artery supplying blood to the body of the talus is the artery of the tarsal canal. Most blood supplied to the head and neck of the talus arises from the dorsalis pedis artery.
       
    The intraosseous blood supply is a network of three or four anastomoses throughout the body of the talus. The branches of these anastomoses originate mainly from the artery of the tarsal canal.
       
    The portion of the talus most vulnerable to vascular compromise is the body because of the lack of true nutrient artery. 
      
    A vascular plexus rich with anastomoses may provide vascularity to the talar body when a major vascular source is disrupted.
      
    Although the medial neurovasculature is at risk in severe talar neck fracture-dislocations, it usually is protected by the flexor hallucis longus tendon and the fact that the talar body rotates away from the vital structures.
       
    CT scanning can be used to assess displacement and comminution of the fracture as well as to evaluate the joints associated with the fracture. 
       
    Treatment of the talar neck fracture is difficult. Any fracture that involves a joint complicates treatment and outcome. Most of the talus is covered with cartilage and because of its intricate structure and function, exact anatomic reduction is needed to prevent long term arthritis and mechanical dysfunction resulting from varus malunion.
       
    Although risk of AVN may be determined at the time of injury, prompt and accurate anatomic reduction can decrease its likelihood.
       
    Hansen believes that no talar neck fracture should be treated by casting alone because it precludes early motion and that internal fixation should be performed instead. These fractures carry a favorable prognosis with no cases of nonunion, and minimal risk of AVN of the body.
       
    Surgical exposure of the talus is difficult secondary to its anatomy and the anatomy of the surrounding tissues and structures. Because talar neck fractures with dislocation have been reported to have 3 times greater incidence of nonunion associated with a twofold delay in return to work, the authors believe open reduction and internal fixation should be performed.
       
    The medial approach is used most frequently for open reduction and internal fixation of talar neck fractures. 
       
    The medial approach is mandatory for reduction and grafting in the case of medial comminution to prevent varus malalignment of the talar head.
       
    The authors often augment the medial approach with an anterolateral approach to visualize the subtalar joint and to assist with placement of fixation.
       
    Screws are placed from anterolateral to posteromedial into dense talar bone. This approach achieves compression and reduces the tendency for the fracture to collapse into varus malalignment.
       
    The anterolateral approach avoids damage to the deltoid artery and permits easy access to the talus.
       
    The posterolateral approach to the talus is excellent for fixation placement and avoidance of the body’s blood supply, but visualization of the subtalar joint and the body of the talus is difficult.
       
    Posterior-lateral -to -anterior -medial screw placement into the talar head has been found to be biomechanically superior to anterior-to posterior fixation. 
       
    Two-screw fixation placed perpendicular to the fracture line should be a goal in surgery because it can allow for early motion, prevent axial rotation, and guard against shear forces. Titanium fixation allows for postoperative MR imaging when staging for AVN.
       
    The basic tenet in treating severe talar neck fractures is to achieve a prompt, anatomic, stable reduction 
       
    The current trend is to treat these fractures using careful open reduction and internal fixation and to reserve arthrodesis for limb salvage.
      

  • Mark D, Perry, MD, and Arthur Manoli II, MD [ From the Foot and Ankle Service, Department of Orthooedic Surgery, University of South Alabama College of Medicine, Mobile Alabama [MDP]; and the Michigan International Foot & Ankle Center, Pontiac, Michigan
    Foot Compartment Syndrome
    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.103-111
        
    Foot compartment syndrome [FCS] has undergone increased refinement over the past decade, resulting in improved understanding of the anatomic structure, clinical presentation, treatment, and clinical outcome. 
        
    The pathophysiology of FCS is similar to the mechanism of acute, posttraumatic compartment syndrome of the lower extremity.
       
    The traumatic event usually causes an initial increase in the interstitial fluid ressure secondary to edema or hemorrhage within the foot compartment.
       
    Secondary to a rise in interstitial compartment pressure [greater than the capillary filling pressures], decreased capillary blood flow and local muscle ischemia occur gradually.
       
    This ischemic process promotes vasodilation and increased capillary permeability. The influx of fluid into an already compromised space leads to additional intracompartmental edema and increased tissue pressure.
       
    This rising compartment pressure finally results in a tamponade phenomenon and sustained muscle ischemia. 
    Consequently the ischemic muscle undergoes necrosis, fibrosis, and contracture.
       
    Nerves can sustain compression for longer periods than muscles and show some reversibility. 
         
    The modern compartment concept of the foot is one of a multicompartmentalized structure with three of the compartments running along the entire length of the foot [medial, lateral, and superficial] and 6 localized compartments.
        
    Calcaneal compartment contains the quadratus plantae muscle and the lateral plantar nerve. In addition, a communication was shown between the calcaneal compartment and the deep posterior compartment of the leg through the flexor retinaculum, which originates from the medical malleolus. 
        
    Claw toe deformity, following a calcaneus fracture, appears to be secondary to a late contracture of the quandratus plantae muscle in the calcaneal compartment.
        
    As the pressure rises, the quadratus plantae muscle becomes ischemic within the calcaneal compartment. If untreated, the quadratus plantae [ with its insertion into the flexum digitorum longus tendon] contracts, and fibrosis secondary to the ischemic process occurs. 
       
    Two unusual circumstances causing FCS are blood dyscrasia and inappropriate prolonged positioning. 
       
    The consistent message is that constant vigilance by the treating physician is crucial, especially in light of the significant morbidity of a missed FCS. FCS can develop slowly or quickly, depending on the energy expended at the time injury. Sometimes, FCS can occur as late as 36 hours after time of injury. 
       
    The clinical signs of FCS are vague and ill defined compared with the clasic presentations of compartment syndrome of the lower extremity.
       
    Patients with calcaneal fractures and subsequently proven FCS describe clinical symptoms of a severe, relentless, burning pain involving the entire foot.
       
    Pain on passive dorsiflexion of the toes loss of two-point discrimination, decreased light touch, and loss of pinprick sensation. Objective motor deficit was difficult to document and was considered unreliable. 
        
    The most consistent finding was presence of tense swelling, with only half of the conscious patients, having increased plain with passive range of motion of the toe or sensory deficits to the foot.
       
    The only way of diagnosing compartment syndrome reliably is direct tissue pressure measurement. 
       
    Phillips et al described the clinical finding of decreased vibratory perception of 256 Hz as the earliest and most reliable modality change when a 35 to 40 mm Hg elevation occurs. This finding was noted to be more reliable than two-point discrimination or a sharp/dull discrimination.
       
    The importance of early detection and treatment of PCS cannot be overemphasized. Muscle undergoes necrosis within 4 hours of ischemia and FCS. 
       
    After fasciotomy, the deep and unrelenting pain in the foot dissipates immediately. This pain relief was particularly notable in patients that had fasciotomy performed under local anesthesia.
      
    Surgical Treatment –
    Manoli and Weber recommended a medial incision for decompressing the medial compartment and reflecting the abductor hallucis muscle superiorly. Next the fibrous intermuscular septum is opened longitudinally to release the calcaneal compartment. The superficial compartment is released by following the medial surface of the medial compartment, which decompresses the flexor digitorum brevis. This muscle is retracted plantarward, which allows access to the lateral compartment containing the abductor digiti minimi and flexor flexor digiti minimi brevis. Two dorsal incisions are used to decompress the individual interosseous compartments. The adductor hallucis compartment is approached by stripping muscles off the medial aspect of the second metatarsal.
       
    Patients who had undergone fasciotomy typically underwent skin closure 5 to 10 days after the procedure. 
       
    Summary –
    FCS is a recognized clinical entity that has few consistent clinical signs except tense swelling. A high degree of clinical suspicion is necessary to provide appropriate treatment. Invasive direct pressure monitoring is needed to diagnose FCS High-energy injuries are known to cause FCS, but individual risk factors, such as prolonged venous occlusion and blood dyscrasias, are causative factors.
       

  • Christopher Bibbo, DO, Sheldon S. Lin, MD, Heather A. Beam, BS, and Fred F. Behrens, MD [ From the Orthopaedic Research Laboratory [HAB], Foot and Ankle Division [SSL], Department of Orthopaedics [CB, FFB], New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
    Complications of Ankle Fractures in Diabetic Patients
    The Orthopedic Clinics of North America, Volume 32, Number 1, January 2001, Pg.Nos.113-133
       
    Ankle fractures in patients with diabetes mellitus [DM] have long been recognized s a challenge to practicing clinicians in terms of delays in fracture healing, difficulties with wound healing, and the development of Charcot arthropathy.
       
    Significant controversy exists as to whether diabetic ankle fractures are best treated noninvasively or by open reduction, and internal fixation [ORIF]. 
       
    The existing series are reviewed in this article, followed by a discussion of the basic science behind delayed fracture healing and impaired wound healing in diabetics as well as Charcot arthropathy.
       
    Kristriansen reviewed the result of 10 diabetic ankle fractures treated by operative fixation. Of these patients, 40% were neuropathic. Ninety percent went on to fracture union, 10% developed a Charcot ankle, and 60% developed a surgical infection.
       
    In light of the high surgical complication rate for elderly, low-demand patients, that surgical intervention may be ill advised and that a malunion may be an acceptable outcome. 
       
    The poor clinical outcome of nonoperative intervention in displaced ankle fractures in patients with DM portends the need for surgical intervention.
       
    Diagnosis of neuropathy and peripheral vascular disease were found to be statistically significant factors for the development of a complication in diabetic patients.
       
    Conclusions from these studiesare as follows. First, diabetic ankle fractures heal, but significant delays in bone healing exist. Second, patients with DM are at risk for wound and soft tissue problems associated with ankle fractures. Third, Charcot ankle arthropathy occurs more commonly in patients who were undiagnosed and immobilized late or have a displaced ankle treated nonoperativetly. 
        
    Understanding the basic science behind the pathogenesis of these complications may provide insignt on how best to manage patients with DM and ankle fractures to avoid these complications. 
       
    Delayed Fracture Healing 
    The tensile strength of fracture callus in diabetic rats is considerably less than in normal animals.
          
    Bone healing seems to stagnate in untreated diabetic animals.

    A greater amount of calcium was deposited in the control and insulin treated diabetic animals compared with the untreated diabetic animals.
       
    Impaired collagen synthesis is theorized to be one cause of delayed fracture healing. This decreased collagen production in animals with DM occurs in bone and cartilage and correlates with the degree of hyperglycemia.
       
    DM bone metabolism is impaired by the inability to maximize bone turnover and remodeling. This situation in part may be caused by decreased gut calcium absorption in diabetics. 
       
    Currently, control of blood glucose seems to be an important factor in the overall regulation of fracture healing. 
       
    Several animal studies support this concept and show improved bone healing in DM animals using basic fibroblast growth factor. Fibrin stabilizing factor [Factor XIII] is another factor under investigation for clinical use. In DM rats, the addition of Factor XIII showed a positive effect on wound healing with increased bone deposition.
       
    Wound Healing –
    Wound healing in DM hs long been recognized as a major complication of the disease and a formidable challenge to overcome.
       
    To understand the pathogenesis of altered wound healing in diabetics, the two fundamental pathophysiologic states, hyperglycemia and hypoxia, must be explored.
        
    Hyperglycemia is the essence of DM. Structural and functional proteins [e.g. enzymes] exposed to prolonged periods of elevated blood glucose engage in enzymatic glycosylation.
       
    Over time, these proteins may undergo nonenzymatic glycosylation reactions yielding irreversible advanced glycosylation products. These advanced glycosylation products attach to collagen, basement membrane, low density lipoproteins, and inflammatory cell receptors. 
        
    Measurement of glycosylated hemoglobin levels [hemoglobin A1c] allows for an average estimate of blood glucose levels.
        
    Some tissues, such as the kidney, nerves, blood vessels, and eye lens, do not require insulin for glucose transport; hyperglycemia results in elevated intracellular glucose, which is shunted to the sorbitol pathway. 
        
    The end result is decreased myo-insitol levels and cell damage, as evidenced by the neuropathy of DM.
        
    Tissue hypoxia is a common secondary phenomenon of DM. 
       
    Compounding this ischemia, it has been shown that patients with DM have a higher blood viscosity; their red blood cells are less deformable; and glycosylated hemoglobin has a higher affinity for oxygen, impairing oxygen delivery to ischemic tissues.
        
    The combination of local ischemia and elevated blood glucose creates a poor environment for wound healing.
        
    Wound collagen deposition is directly proportional to wound oxygen tension and perfusion, and collagen production is limited severely in DM wounds.
        
    Commonly used wound dressing agents, such as providone-iodine, have shown no beneficial effect no epithelialization. Povidine-iodine has been shown to delay wound healing in DM models and in steroid depressed wounds. 
        
    One valuable clinical marker of adequate local perfusion for healing in patients with DM is transcutaneous oxygen tension [TcPO2] measurements.
        
    Additional risk factors for poor healing in patients with DM [besides elevated glycosylated hemoglobin] include vasculopathy, smoking, hypertension, dyslipidemia, and advanced age.
        
    Vital to the wound healing process is the initial inflammatory reaction. The weak initial inflammatory response in human DM wounds results in not only delayed 
        
    restoration of the epidermal barrier but also decreased tensile strength of healing DM wounds.
        
    The adverse effects on wound healing resulting from uncontrolled blood glucose altering the inflammatory response have been corroborated in the laboratory.
        
    Charcot Arthropathy –
    Many issues, such as its cause, proposed pathomechanism, and predictive risk factors, for the development of Charcot arthopathy still are unknown. A warm, swollen, erythematous limb often signifies the early clinical presentation of Charcot arthropathy. 
        
    Charcot arthopathy range from microfractures, to progressive bone fragmentation, to severe joint destruction and subluxation as a result of repetitive ligamentous and bone injuries.
        
    Current research has concentrated on two major theories : [1] repetitive minor trauma in the presence of neuropathy and [2] vascular changes secondary to autonomic dysfunction.
        
    The small nerve fibers initially are affected in the process of developing DM peripheral neuropathy.
        
    Secondary to the reduction of peripheral sensorineural function, patients become increasingly susceptible to unrecognized traumatic events [i.e., ankle sprain].
        
    The presence of peripheral neuropathy, with an inciting traumatic event [e.g., an ankle fracture], commonly leads to Charcot arthropathy. 
        
    Marked increases in peripheral blood flow have been noted in the limbs of neuropathic DM patients secondary to arteriovenous shunting. 
        
    These anastomoses are richly innervated and controlled primarily by the sympathetic nervous system. When sympathetic innervation is abolished because of denervation 
    [i.e., severe neuropathy], the loss of constriction of arteriovenous anatomoses results in maximal dilation. 
        
    This excessive blood flow secondary to peripheral neuropathy may lead to abnormal bone cell activity and eventual reduction in bone density.
        
    Hyperemia and neurovascular changes secondary to an autonomic neuropathy may contribute to a generalized osteopenia in patients with DM. 
        
    In conjunction with a traumatic event, the resultant additional increased blood flow is theorized to increase osteoclast activity, promote excessive bone resorption, increase fracture risks, and lead to neuropathic Charcot arthropathy. 
         
    Summary –
    For nondisplaced ankle fracture, a nonoperative approach with increased duration of immobilization seems successful based on experience of the limited series. A displaced ankle fracture in a patient with DM requires a surgical intervention.
        
    Authors advocate tight glucose control in both groups to improve the fracture milieu and to ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution.
       

  • Gabl VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck, Germany]
    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]
    Handchir Microchir Plast Chir 28: 317-321, 1996
        
    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.
       
    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.
        
    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.
         
    They conclude that MRI was useful in detecting the presence and extent of pulley injury.
          

  • Jack Abboudi, and Randall W. Culp (From the Hand Surgical Associates, Bryn Mawr (JA); The Philadelphia Hand Center, King of Prussia (RWC); and the Department of Orthopaedic Surgery, Jefferson Medical College, Philadelphia (JA, RWC), Pennsylvania
    Treating Fractures of the Distal Radius with Arthroscopic Assistance
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 307-315
         
    Displaced intra articular fractures of the distal radius pose difficulties in management. The outcome of such fractures is radial shortening and residual articular step off. For this reason accurate intra-operative articular evaluation is crucial, to achieve articular congruity within 1 mm.
        
    The role and technique of arthroscopy when used in such fractures is discussed. Radiographic evaluation is the standard method used for grading fracture reduction which gives a two dimensional view of a three dimensional object. Compared with standard radiography fluoroscopy can be deceiving. But when arthroscopy is used as an adjunct to fluoroscopy a much greater accuracy is achieved.
        
    Technical details are discussed. Favourable outcomes have been reported for the reduction of displaced intraarticular fractures of the distal radius. 
         

  • Carrie R. Swigart, and Scott W. Wolfe (From the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut (CRS); and the Hospital for Special Surgery, New York, New York (SWW)
    Limited Incision Open Techniques for Distal Radius Fracture Management
    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 317-327
         
    Gartland and Werley outlined four components of distal radial fracture that require correction if a good functional result is to be obtained. The most important one being restoration of normal volar tilt of the distal radius and prevention of radial shortening.
         
    Traditional treatment has evolved over the years depending on the facilities available.
         
    This article discusses recent innovations in the management of these fractures. Clinical and bio-mechanical studies have shown that stable fixation can be achieved with small implants aligned in an orthogonal fashion. This reduces soft tissue dissection and allows for early mobilisation of the wrist leading to a better outcome.
         

  • Andrew D. Markiewitz, and Harris Gellman (From the Department of Orthopaedic Surgery, University of Arkansas, Little Rock, Arkansas (ADM); and the Department of Orthopaedic Surgery, University of Miami, Miami, Florida (HG) 
    Five-Pin External Fixation and Early Range of Motion for Distal Radius Fractures
    Orth. Cl. of N. A. April 2001Vol. 30 (2) p.329-335
        
    Distal radius fractures are complex and require individualised therapy. Regardless of treatment protocol restoration of normal anatomy by restoring radial length, joint surface continuity and volar tilt of the distal articular surface is vital.
         
    Although external fixation devices may maintain radial length, there may still be a displaced or angulated position. The addition of a dorsal pin in combination with an external fixation device can easily connect the dorsal tilt. This pin helps the reduction of those fractures that would not improve with traction and with maintenance of reduction. 
       
    The five-pin technique provides another tool to the hand surgeon faced with a difficult fraction.
               

  • Amy L. Ladd, and Nathan B. Pliam (From the Divisions of Hand (ALL) and Orthopaedic (ALL, NBP) Surgery, Stanford University School of Medicine, Palo Alto, California
    “The Role of Bone Graft and Alternatives in Unstable Distal Radius Fracture Treatment”
    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 337-351
       
    This article updates one’s knowledge on the materials currently available and in development of mineral substitutes and growth factors as a viable alternative to host graft with a review of their characteristics and shortcomings.
        
    Investigations uniformly cite autograft as the gold standard among graft materials. In comparison, controlled studies have shown that bone graft substitutes perform as well as autograft. These substitutes have broadened the surgeons armamentarium for the treatment of distal radial fractures. No single graft substitute is ideal for all fractures. Major advances in the biology of growth factors eventually will lead to a new generation of biologically active products. 
        

  • Brian D. Adams, and Brian J. Divelbiss (From the Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa
    Reconstruction of the Posttraumatic Unstable Distal Radioulnar Joint
    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 353-363
       
    Although not a common problem, this article focuses on the various methods for reconstruction of the unstable distal radioulnar joint.
         
    Restoration of stability and a full painless arc of rotation are the goals of treatment for the posttraumatic unstable distal radioulnar joint.
        
    Attention focuses specifically on anatomic reconstruction of distal radioulnar ligaments. The authors’ technique is presented in detail.
         

  • Luis R. Scheker, Bryan A. Babb, and Patricia E. Killion (From the Christine M. Kleinert Institute for Hand and Micro Surgery (LRS, BAB, PEK); and the Division of Plastic and Reconstructive Surgery, University of Louisville School of Medicine (LRS), Louisville, Kentucky
    Distal Ulnar Prosthetic Replacement
    Orth. Cl. of N. A. April 2001 Vol. 30 (2) P. 365-379
        
    A stable functioning distal radioulnar joint not only provides supination and pronation of the forearm but is also essential to gripping and lifting. Therefore when distal radioulnar joint deterioration occurs, proper repair is crucial. Ulnar head resection is often performed, however a prosthesis may be needed to replace all or part of the joint. This article discusses the advantages and disadvantages of four prostheses, including a total joint replacement designed by the authors. 
         

  • Joseph J. Crisco, Scott W. Wolfe, Corey P. Neu and Sandi Pike (Department of Orthopaedics, Brown University School of Medicine, Rhode Island Hospital (JJC); Division of Engineering, Brown University, Providence, Rhode Island; The Hospital for Special Surgery and Weill Medical College of Cornell University, New York (SWW))
    Advances in the In Vivo Measurement of Normal and Abnormal Carpal Kinematics

    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 219-231
         
    This article presents a non-invasive in vivo three dimensional methodology using markerless bone registration (MBR) for examining the normal and abnormal kinematics of the wrist carpal bones.
         
    This method provides clinicians with an excellent new technique to study the carpus and enhance the understanding of carpal kinematics. It permits the study of injured and reconstructed carpus.
          
    The authors have developed a new MBR algorithm to evaluate the normal and abnormal kinematics of the carpus. Their findings suggest that the carpal mechanics cannot be described only by the row and column theory but by complex combinations of each that are dependent on the direction of wrist movement.
         
    The limitations of this methodology are the use of CT and intensive computational analysis. The authors’ measurements have been limited to the main movements of flexion extension and radio-ulnar deviation. This study also does not prove that the abnormal kinematics seen after trauma may have existed before trauma.
          
    Further studies will permit a better understanding of these findings.
        

  • David S. Ruch, and Beth Paterson Smith (Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina)
    Arthroscopic and Open Management of Dynamic Scaphoid Instability
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 233-240
         
    In 1984, Watson and Ballet focussed attention on posttraumatic arthritis of the wrist. Several studies since then have documented the disruption of the normal kinematics of the wrist after scapholunate ligament disruption. Although these changes are well documented the ideal management of this condition remains controversial.
         
    This study reviews the anatomic structures associated with dynamic rotatory subluxation of the scaphoid and the results of the treatment.
         
    The decision of whether to perform arthroscopic surgery or open capsulodesis for dynamic scapholunate instability depends on 
    (1) Radiographic instability (2) Diagnostic arthroscopy
         
    Preoperative radiography may show an increase on the scapholunate angle (as compared to the opposite side) without evidence of capitolunate instability.
          
    Arthroscopy may reveal an interval between the scaphoid and the lunate, permitting the passage of the arthroscope through the radio-carpal to the midcarpal space.
        
    When either of these findings is present, an open stabilization is advocated, and when these findings are not present, arthroscopic surgery is advocated.
          

  • Joseph F. Slade III, Jonathan N. Grauer and John D. Mahoney (Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut)
    Arthroscopic Reduction and Percutaneous Fixation of Scaphoid Fractures with a Novel Dorsal Technique
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 247-261
         
    This article presents a technical description of a novel dorsal technique of arthroscopic reduction and percutaneous fixation of scaphoid fractures on 16 consecutive patients with excellent results.
        
    This method permits early, rigid internal fixation with minimal morbidity. Rehabilitation can be started earlier. This method allows far more precise control of pin and screw placement avoids the vulnerable anatomy and allows the proximal segment to be compressed into the distal fragment.
         

  • Alexander Y. Shin, and Allen T. Bishop (Department of Orthopaedic Surgery, University of California, San Diego; the Division of Hand and Microvascular, Department of Orthopaedic Surgery, Naval Medical Center, San Diego, California; the Department of Orthopaedic Surgery, Mayo Graduate School of Medicine, and the Division of Hand Surgery, Department of Orthopaedic Surgery and Surgery of the Hand, Mayo Clinic and Foundation, Rochester, Minnesota)
    Vascularized Bone Grafts for Scaphoid Nonunion and Kienbock’s Disease 
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 263-277
       
    This article focuses on the principles, anatomy, application and experimental and clinical studies of carpal vascularized bone graft for the treatment of scaphoid nonunions and Kienbock’s disease.
        
    Vascularized bone grafts offer the ability to transfer bone with viable osteoblasts and osteoclasts with a preserved circulation. The vascular anatomy of the distal radius permits fabrication of reverse flow pedicled vascularized bone grafts which are useful to treat disorders of the carpus. It offers the advantage of a single incision for graft harvest and donor site preparation.
       
    Faster union times, the ability to revascularize necrotic bone and technical ease of harvest have made these grafts clinically useful tools for treatment of scaphoid non union and Kienbock’s disease.
         

  • Sheldon R. Cober, and Thomas E. Trumble (Division of Hand and Microvascular Surgery, Department of Orthopaedics, University of Washington, Seattle, Washington)
    Arthroscopic Repair of Triangular Fibrocartilage Complex Injuries
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 279-294
         
    The triangular fibrocartilage complex (TFCC) performs a vital function in the biomechanics of the wrist. It serves as the pivot point for rotation of the radius and the carpus on the ulna – a complex motion comprising elements of rotation, translation, and load transmission. TFCC itself is a functionally and anatomically intricate group of structures located at the ulnar aspect of the wrist.
        
    Injury to the TFCC affects the biomechanics of the wrist and makes functional restoration difficult.
       
    Repairing TFCC injuries arthroscopically minimizes scar formation and therefore seems better than open surgery. Numerous techniques have been used and reviewed. 
         

  • Robert Yaghoubian, Felix Goebel, Douglas S. Musgrave, and Dean G. Sotereanos (Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania)
    Diagnosis and Management of Acute Fracture – Dislocation of the Carpus
    Orth. Cl. of N. A. April 2001 Vol. 30(2) P. 295-305
          
    Though fracture dislocation of the carpus is an infrequent injury, inadequate treatment can lead to wrist pain and dysfunction and traumatic arthritis. Accurate diagnosis and early treatment are essential for good results.
          
    This article presents the anatomy, epidemiology, and mechanism of injury of the carpus and the diagnosis, treatment, and treatment results of dislocation of the carpus.
         
    Radiography (postero anterior and lateral views and distraction radiography) is done and may show loss of co-linearity between the bones. Occasionally a CT scan or MRI may be required.
         
    Although early closed reduction is recommended, early anatomic open reductions, internal fixation and ligamentous repair are vital for optimal results.
      

  • LTC William C. Doukas, and Kevin P. Speer (Sports Medicine and Shoulder Section, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina)
    Anatomy, Pathophysiology, and Biomechanics of Shoulder Instability 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 381-391
         
    Instability in the athlete presents a unique challenge to the orthopaedic surgeon. A spectrum of both static and dynamic pathophysiology as well as gross and microscopic histopathology contribute to this complex clinical continuum. 
        
    Biochemical studies of the shoulder and ligament cutting studies in recent years have generated a more precise understanding of the individual contributions of the various ligaments and capsular regions to shoulder instability. 
        
    An understanding of the underlying pathology and accurate assessment of the degree and directions of the instability by clinical examination and history are essential to developing appropriate treatment algorithms. 
         

  • Stephen Owens and, John M. Itamura (USC Orthopaedic Surgery Associates, Los Angeles, California)
    Differential Diagnosis of Shoulder Injuries in Sports
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 393-398
        
    Shoulder injuries are common problems in all types of sports. The demanding combination of power and flexibility the repetition of movements in overhand sports makes it highly vulnerable to falls and direct blows. 
        
    The sportsman may not be able to express correctly his symptoms and this makes the diagnosis difficult. The history is particularly important because many aspects of the examination are variable. 
        
    A relaxed patient and systematic evaluation is the best approach. Radiographs and even MRIs are often negative in the young athlete. 
        
    This article looks at various shoulder injuries that are relevant to sports and discusses their differential diagnosis.
         

  • Brian J. Cole, Anthony A. Romeo, and Jon J. P. Warner (Shoulder Section, Department of Orthopaedic Surgery, Rush-Presbyterian St. Luke’s Medical Center, Chicago, Illinois, and the Harvard Shoulder Service, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts)
    Arthroscopic Bankart Repair with the Suretac Device for Traumatic Anterior Shoulder Instability in Athletes
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 411-421
         
    Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade.
         
    Currently, most techniques use the suture and suture anchors. However the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing and knot tying. 
          
    Stabilization using the Suretac device simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intra-articular knot tying. However a successful outcome depends upon accurate patient selection.
         
    Pre operative evaluation examination under anesthesia and a thorough arthroscopic examination is the most effective treatment strategy.
         
    The ideal candidate is an athlete with a pure traumatic anterior instability pattern with detachment pathology and minimal capsular deformity.
          

  • David W. Altchek, and William R. Hobbs (Department of Orthopaedic Surgery, The Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York)
    Evaluation and Management of Shoulder Instability in the Elite Overhead Thrower 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 423-430
         
    The elite throwing athlete places significant stress on the soft tissue stabilizers of the shoulder with every pitch. Anterior translation forces can be as high as 40% of the body weight and distraction forces as high as 80% of body weight during throwing.
        
    Injury to the static and dynamic stabilizers can lead to significant pain and loss of function in these athletes. To successfully treat this injured thrower, it is important to accurately diagnose the pathologic process.
          
    This article reviews the biomechanics of throwing and pathologic processes seen in the elite thrower. This article covers the essentials of the history and physical examination and concludes with a discussion of the various treatment regimens. 
            

  • Stephen S. Burkhart, and Craig Morgan (San Antonio Orthopedic Group, Baylor College of Medicine, and University of Texas Health Science Center, San Antonio, Texas; the Department of Orthopedic Surgery, Allegheny University, Philadelphia, Pennsylvania; and the Alfred I. DuPont Institute, Wilmington, Delaware)
    Slap Lesions in the Overhead Athlete 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 431-441
        
    The ‘dead arm’ has recently come alive as a topic of interest in sports medicine. It now appears that one potential cause of the ‘dead arm’ is the type II superior labrum anterior and posterior (SLAP) lesion. 
         
    This prevents the thrower from performing at his pre-injury velocity and control because of a combination of pain and subjective unease in the shoulder.
       
    The lesion is extremely disabling and potentially career ending to the overhead athlete. The ability to successfully diagnose, surgically manage and rehabilitate this condition is the focus of this article. 
        
    The historical perspective, etiology, biomechanics, surgical repair and rehabilitation are discussed in detail.
        
    The authors report an 87% rate of return to pre-injury levels of throwing in 54 basketball players and 84% rate of return to pre-injury performance levels in pitchers after repair of type II SLAP lesions.
         

  • John E. Conway (Orthopedic Specialty Associates, Fort Worth, Texas)
    Arthroscopic Repair of Partial-Thickness Rotator Cuff Tears and SLAP Lesions in Professional Baseball Players 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 443-456
        
    During the last 30 years pain in the thrower’s shoulder has been attributed to many different causes. The most common findings in the thrower’s shoulder include rotator cuff tear, superior labrum tear, inferior glenohumeral ligament attenuation, internal rotation deficit and hypertrophic subacromial bursa. 
         
    The authors understanding of the conditions that affect the throwing shoulder continues to evolve. Surgical techniques also have advanced and the arthroscopic repair of rotator cuff tears SLAP lesions and capsular ligament attenuation is now possible.
         
    This article discusses technical details necessary to treat this condition.
       

  • Felix H. Savoie, Larry D. Field, and Stephen Atchinson (Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center; Department of Orthopaedic Surgery, University of Mississippi School of Medicine, Jackson, Mississippi; and the Department of Orthopaedics, Louisiana State University Medical Center, Shreveport, Louisiana) 
    Anterior Superior Instability With Rotator Cuff Tearing: Slac Lesion 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 457-461


    Anterosuperior instability of the shoulder can occur from a variety of pathological lesions, both traumatic and non traumatic. The authors have described a specific lesion involving the anterosuperior corner of the glenohumeral articulation associated with the undersurface tearing of the supra-spinatus tendon (SLAC – superior labrum anterior cuff). They have retrospectively isolated 40 patients with this lesion. 

    This report details their findings regarding the mechanism of injury, symptoms, physical findings, diagnostic studies, non operative and operative management surgical findings and the results associated with this injury pattern.

    Overhead activities were the most common aetiological factor. Load and shift instability testing and Whipple rotator cuff testing were the most common physical examination findings. MRI with saline or gadolinium injection was a useful diagnostic aid. Glenoid chondromalacia, labral fraying and / or detachment was commonly seen.

    Surgical repair was successful in 37 of 40 patients. The SLAC lesion is a definable surgical entity with predictable history, physical findings, surgical findings with satisfactory results from surgery.
       

  • John Antoniou, and Douglas T. Harryman (Department of Orthopaedic Surgery, McGill University, Jewish General Hospital, Montreal, Quebec, Canada) 
    Posterior Instability 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 463-473

    Posterior instability of the shoulder though reported to be between 2% – 12% of all shoulder instability, is increasingly seen in athletes. The pathophysiology clinical and radiological evaluation and treatment have been discussed with particular emphasis on the authors preferred operative technique.

    Recent cadaveric and arthroscopic work has identified the importance of glenohumeral integrity and glenoid depth in the maintenance of shoulder stability. 

    Arthroscopic techniques for repair of these pathology are emerging. Until recently attention was focussed on capsular glenohumeral stability by altering two separate mechanisms – viz deepening the glenoid and reducing capsular joint volume by shifting the capsule to buttress the glenoid labrum, to increase the compressive force vector into a deep glenoid.

    The authors have shown that posteroinferior shoulder instability is associated with both capsular laxity and the well defined pathological lesions of the glenolabral concavity. They therefore advocate arthroscopic posterior capsulolabral repair and augmentation as a useful tool to restore the depth of the glenolabral concavity as also to reduce the redundant posteroinferior capsule.

    This technique is effective in treating posteroinferior instability.
       

  • William N. Levine, William D. Prickett, Marcel Prymka, and Ken Yamaguchi (Shoulder and Elbow Service, Washington University, St Louis, Missouri; and the Shoulder and Sports Medicine Service, New York Presbyterian Medical Center, New York, New York)
    Treatment of the Athlete With Multidirectional Shoulder Instability 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 475-484

    Multidirectional instability of the shoulder is an important source of dysfunction and pain in both athletes and sedentary individuals. Although previously considered to be uncommon there has been an increased awareness of this condition now. The treatment of this condition continues to be a challenging problem.

    Repetitive microtrauma seen in athletes can lead to multidirectional instability by overstretching the capsule and ligaments of the shoulder just as much as in young sedentary patients with ligamentous laxity.

    A redundant capsular pouch is a consistent finding along with a labroligamentous avulsion.

    The symptoms may be complex, vague and difficult to sort out. It is important to correlate the symptoms with the arm position. One must look for signs of ligamentous laxity in other joints as well. Rarely one finds hypermobile acromioclavicular and / or stenoclavicular joints.

    Plain radiographs are usually normal. Double contrast CT arthrograms might prove useful. Recently MRI scanning has also proved useful. 

    The treatment initially is non operative. However in those who show no response, operative treatment may be required, either open surgery or by arthroscopy.

    Longer follow ups may be necessary before any definite conclusion can be drawn.
       

  • Melyssa M. Paulson, Neil F. Watnik, and David M. Dines (Long Island Jewish Medical Center, New Hyde Park, New York)
    Coracoid Impingement Syndrome, Rotator Interval Reconstruction and Biceps Tenodesis in the Overhead Athlete 
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 485-493


    Anterior shoulder problems are extremely common in throwing athletes. Overhead activities place significant strain on the shoulder i.e. stresses on both the static and dynamic restraints of the glenohumeral joint. 

    This may result in several kinds of problems e.g. impingement syndromes, macro and micro instability, tendonitis and rotator cuff pathology labral lesions, biceps disorders, radiculopathy and thoracic outlet syndromes. 

    This article focuses on the anatomy, pathophysiology, clinical presentation diagnosis and surgical treatment of these problems. Particular attention is paid to coracoid impingement lesions of the long head of the biceps and rotator interval lesions.
       

  • Robert D. Travis, Wayne Z. Burkhead, and Robert Doane (W. B. Carrell Memorial Clinic, Dallas, Texas)
    Technique for Repair of the Subscapularis Tendon
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 495-500

    Subscapularis tendon injuries if left undiagnosed can result in significant disability. The article outlines the anatomy techniques of diagnosis and a method of repair that has been successful.

    Patients with sudden loss of active motion after an external rotation or hyperextension injury should be viewed with a high index of suspicion for a subscapularis tear.

    Pain in the shoulder particularly at night with painful limitation of shoulder elevation. Pain is also present with the arm by the side and on external rotation. 

    A positive left off test or belly press test combined with appropriate radiography (plain film, arthrography, CT scan or MRI) will lead to an early diagnosis.

    Careful surgical repair combined with a good rehabilitation program will give good results.
       

  • Gary M. Gartsman (Department of Orthopaedic Surgery, University of Texas Houston Health Science Center, and the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas)
    All Arthroscopic Rotator Cuff Repairs
    Orth. Cl. of N. A. July 2001 Vol. 32(3) P. 501-510
     

    The role of the arthroscope in the management of rotator cuff lesions is evolving. It was first used as a diagnostic tool, but is also used now as a therapeutic tool for even complicated operations. 

    The advantages are that it allows smaller skin incisions, glenohumeral joint inspection, treatment of intra articular lesions with minimal soft tissue dissection or damage, less pain and more rapid rehabilitation.

    However these advantages must be balanced against the technical difficulty of this method which limits its application to surgeons skilled in both open and arthroscopic surgery.

    This article contains many technical details to simplify and improve all arthroscopic cuff repairs.
       

  • Lavernia CJ, Sierra RJ, Gomez-Marin O (Univ of Miami, Fla)
    Smoking and Joint Replacement: Resource Consumption and Short Term Outcome
    Clin Orthop 367: 172-180, 1999

    It has been known that many adverse effects of smoking extend to surgical procedures, and delayed healing of skin flaps and higher complication rates in treatment of non-unions shown by microvascular and trauma surgeons, spine surgeons also reported delayed fusion.

    Conclusion – Surgical fraternity is becoming aware of numerous adverse effects of smoking on surgical outcomes. This study is of particular interest in that it offers some financial data to further underscore the adverse effect of smoking. For those who smoked there were surprising findings – longer surgical time and increased surgical charges.
       

  • 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 difficult to diagnose – normally one considers, arthritis, bursitis, tendinitis, abductor muscle strain, abnormal insertions of gluteal muscles.

    Persistent pain not properly relieved by conservative treatment were subjected to MRI CT Scan. Out of 6 patients 4 showed avulsion of gluteal tendon and 1 showed partial thickness tear.

    Conclusion – It is somewhat embarrassing to clinical practice that how many avulsions and tears have been missed. Surgical repair provides improvement but not completely.
       

  • Marder RA, Timmerman LA (Univ of California at Davis, Sacramento)
    Primary Repair of Patellar Tendon Rupture Without Augmentation
    Am J Sports Med 27: 304-307, 1999

    Introduction – Patellar tendon rupture is mostly seen in sports person and usually repaired by primary suture with cerclage augmentation. This method gives good results but some patients remain still.

    15 consecutive patients with acute traumatic ruptures of patellar tendon were treated (all were men – mean age 33).

    Rehabilitation programme started with heel slides with flexion of up to 450 and then after 3 weeks 450-900.

    Results – 12 out of 14 patients returned to their level of activities.

    Conclusion – Introduction of the Krachow whip stitch has improved the management of many soft tissue tendon-ligamentous injuries. Heavy no. 5 suture is used.
       

  • 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.

    Methods- For 6 weeks, 53 patients (28 women), with average of 27 years with unilateral patellofemoral pain syndrome were given intensive isometric quadriceps exercises once daily and oral NSAD (20 days). NSAD + lidocaine injections (B) and intra-articular 5 injections of glycosaminoglycan polysulfate (C).

    The patients were examined at 6 months and after 7 years.

    With the above groups, functional, clinical subjective and radiographic findings were improved in all patients in 6 months. At 7 years no significant changes.
       

  • Naudie D, Bourne RB, Rorabeck CH, et al (Univ of Western Ontario, London)
    Survivorship of the High Tibial Valgus Osteotomy: A 10- to 22- Year Followup Study
    Clin Orthop 367: 18-27, 1999

    Numerous studies have demonstrated that the satisfactory results of high tibial valgus osteotomy deteriorate over time. Most studies have reported satisfactory results in 80% of patients in 5 years and 60% of patients at 10 years follow-up.

    In USA as the HTO results have declined more and more TKR is being offered.

    Conclusion- Careful selection of both patients and surgical technique can significantly improve the survival rate for HTO.
       

  • 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

    It is a common experience that in leg lengthening there is a delay in healing and external fixator has to be kept for a long time and has its problem of pins.

    The experience obtained in rabbits to use demineralized bone at the site of osteotomy shortened the latency period, prevented delay in bone formation. It seems very appropriate now to set up a clinical trial of this technique in limb-lengthening patients.
       

  • Trauma and Amputation Surgery

    Ahlborg HG, Josefsson PO (Malmo Univ, Sweden)
    Pin-Tract Complications in External Fixation of Fractures of the Distal Radius
    Acta Orthop Scand 70: 116-118, 1999

    It is a very interesting article where the author has highlighted the complications of the external fixations in about 21%. These can be controlled with antibiotics as being the pin tract infection.

    Severe complications are rare even in older patients.
       

  • Van den Bosch EW, Van der Kleyn R, Hogervorst M, et al (Leiden Univ, The Netherlands; Univ Hosp Rotterdam, The Netherlands) 
    Functional Outcome of Internal Fixation for Pelvic Ring Fractures
    J Trauma 47: 365-371, 1999

    Pelvic fractures are uncommon and occur in 3-8% of trauma patients. 46% of these fractures were unstable and stabilization with internal fixation in patients were needed and to see the outcome.

    Various types of surgery were employed i.e.
    1) Internal fixation of pubic and 
    2) Combined anterior and posterior approach.
    3) External fixation.
    4) Percutaneous posterior screw fixation with additional anterior external fixation.

    Patients treated with internal fixation for pelvic ring fractures have limitation in functioning even after long term follow up. Combined anterior and posterior internal fixation yielded better results than combined internal and external fixation.
       

  • Femur Shaft Fractures

    Wolinksy PR, McCarty E, Shyr Y, et al (Vanderbilt Univ, Nashville, Tenn)
    Reamed Intramedullary Nailing of the Femur: 551 Cases
    J Trauma 46: 392-399, 1999

    Reamed intramedullary nailing is a highly successful treatment for femoral shaft fractures. Locked nails is now indicated for all fracture pattern.

    The overall union rate was 99%. The fixation of hardware was removed in 38% of fractures because of pain.

    Hardware breakage was present – nails, bolts.
       

  • Tornetta P III, Tiburzi D (Boston Med Ctr; Brookdale Med Ctr, Brooklyn, NY)
    Reamed Versus Nonreamed Anterograde Femoral Nailing
    J Orthop Trauma 14: 15-19, 2000

    Femoral nail insertion without reaming results is significantly slower union than nail insertion with reaming of the distal femur.

    It has been found by comparison of reamed and unreamed fractures that the union rate is definitely much better in reamed fractures, may be because of the tight fit of the metal.
       

  • Herscovici D Jr, Ricci WM, McAndrews P, et al (Tampa Gen Hosp, Fla; Washington Univ, St Louis) 
    Treatment of Femoral Shaft Fracture Using Unreamed Interlocked Nails
    J Orthop Trauma 14: 10-14, 2000

    It has also been found that placement of larger diameter nails to prevent bending and loss of fixation, there is cortical thinning and loss of medullary blood supply. This article shows that higher incidence of complications in reaming.

    The healing rate of femoral fractures treated with interlocked nails without reaming were no different than reaming.
       

  • Tibia Fractures

    Bhandari M, Adili A, Leone J, et al (McMaster Univ, Hamilton, Ont; St Joseph’s Hosp, Hamilton, Ont; Hamilton Health Sciences Corp, Ont)
    Early Versus Delayed Operative Management of Closed Tibial Fractures
    Clin Orthop 368: 230-239, 1999

    Highlights: It has been seen in this article that some patients were operated for tibial fracture within 12 hours of injury and some were operated after 12 hours and the complications which were seen were more in patients who were operated after 12 hours.

    It is very difficult to come to the conclusion as hardly any change is detected in the status of the callus. It is presumed that plating of the fractures of the tibia caused more complication than internal fixation by nailing.

    As far as the authors’ knowledge goes delayed intervention was better that immediate surgery as one disturbs the haematoma.
       

  • Moore KD, Goss K, Anglen JO (Univ of Missouri, Columbia)
    Indomethacin Versus Radiation Therapy for Prophylaxis Against Heterotopic Ossification in Acetabular Fractures: A Randomised, Prospective Study
    J Bone Joint Surg Br 80-B: 259-263, 1998

    For the prevention of heterotopic ossification after surgery indomethacin and single-dose radiation treatment are safe and effective. Radiation is 200 times costlier than medicinal treatment.
       

  • Kay NRM, Morris-Jones H (Westwood House, Sheffield, England)
    Pain Clinic Management of Medico-legal Litigants
    Injury 29: 305-308, 1998

    Litigation problems are not localized to any given society. Those with compensation claims are difficult to treat. 
       

  • Kanaya F, Ibaraki K (Univ of the Ryukyus, Okinawa, Japan)
    Mobilization of a Congenital Proximal Radioulnar Synostosis With Use of a Free Vascularized Fascio-Fat Graft 
    J Bone Joint Surg Am 80-A: 1186-1192, 1998

    Congenital radioulnar synostosis has been treated with vascularized fasciofat graft to gain mobility at superior radioulnar joint – worth a trial.

    This is first of its kind reported results show good future. Follow up for long time is required.
       

  • Reuben JD, Meyers SJ, Cox DD, et al (Univ of Texas, Houston; Rice Univ, Houston; Hermann Hosp, Houston)
    Cost Comparison Between Bilateral Simultaneous, Staged, and Unilateral Total Joint Arthroplasty
    J Arthroplasty 13: 172-179, 1998

    In good center and experienced surgeon, quality of the health of the patients if found good then one time surgery will certainly reduce the cost and ease of the rehabilitation programme.
       

  • Raab SS, Slagel DD, Robinson RA, et al (Allegheny Univ, Pittsburgh, Pa; St Mary’s Hosp, Grand Junction, Colo; Univ of Iowa, Iowa City)
    The Utility of Histological Examination of Tissue Removed During Elective Joint Replacement: A Preliminary Assessment 
    J Bone Joint Surg Am 80-A: 331-335, 1998

    It is not very necessary to do routine H.P. exam in every case as the cost of the procedure is prohibitive but guarded opinion as the tissue naked eye can mimic any path and medicolegal problem will have to be faced.
       

  • Bolhofner BR, Russo PR, Carmen B (Bayfront Med Ctr, St Petersburg, Fla)
    Results of Intertrochanteric Femur Fractures Treated With a 135-Degree Sliding Screw With a Two-hole Slide Plate
    J Orthop Trauma 13: 5-8, 1999

    Satisfactory healing, low blood loss, short surgical time with 2-hole side plate given as good results as 4 hole plate where more dissection, more hardware is required but remember reduction, reduction, reduction this should be the mantra of the surgeon managing displaced femoral fractures with internal fixation.
       

  • Heck DA, Melfi CA, Mamlin LA, et al (Indiana Univ, Indianapolis; Eli Lilly & Company, Indianapolis, Indiana; Roudebush VA Med Ctr, Indianapolis, Indiana)
    Revision Rates After Knee Replacement in the United States
    Med Care 36: 661-669, 1998

    Overall revision rates for knee replacement surgery were low in this Medicare patient group. Nevertheless, specific risk factors could be identified, some of which may relate to greater demands placed on the artificial joints by some patients.
       

  • Gerber JP, Williams GN, Scoville CR, et al (Keller Army Community Hosp, West Point, NY)
    Persistent Disability Associated With Ankle Sprains: A Prospective Examination of an Athletic Population
    Foot Ankle Int 19: 653-660, 1998

    Residual ankle pain and dysfunction are common problems after ankle sprains. Although almost all injured athletes are able to return to activity within 6 weeks after injury, some are left with chronic dysfunction at 6 months. Syndesmosis pain was high and carried an increased risk of prolonged disability.
       

  • Fracture 
    Jensen SL, Andresen BK, Mencke S, et al (Aalborg Hosp, Denmark)
    Epidemiology of Ankle Fractures: A Prospective Population-based Study of 212 Cases in Aalborg, Denmark
    Acta Orthop Scand 69: 48-50, 1998

    Ankle fracture occur more commonly in males before 50 years of age and in females after 50 years of age. They result from substantial trauma occurring during physical activity.

    Osteoporosis does not appear to be of major importance in the occurrence of ankle fracture.
       

  • Fracture of the Clavicle
    Robinson CM (Royal Infirmary of Edinburgh, Scotland)
    Fractures of the Clavicle in the Adult: Epidemiology and Classification
    J Bone Joint Surg Br 80-B: 476-484, 1998

    Fractures of the clavicle are quite common in all age groups. Lots of classifications are described but in this article simple classification i.e. Type 1 medial 1/5 fractures, 2A undispl m aced diaphyseal fractures and type 3A fractures of the outer fifth.

    Complication more often occurred in type 2B comminuted and displaced fractures.

    This being simple classification one can adopt it but in case subgroups are made then it might be complicated.
       

  • Gartsman GM, Khan M, Hammerman SM (Texas Orthopedic Hosp, Houston; Academic Information Services, Houston)
    Arthroscopic Repair of Full-thickness Tears of the Rotator Cuff 
    J Bone Joint Surg Am 80-A: 832-840, 1998

    Advances in operative technique have enabled the use of full-thickness tears of the rotator cuff to be repaired arthroscopically.

    In this article the authors have analyzed 73 patients, mean age being 60.7 years. Various grades were found from 1cm – 5 cm.

    The outcome was that active and passive range of motion were significantly improved post-operatively. Resisted elevation strength increased from 7.5 to 14 lbs.

    In conclusion arthroscpic repair of full thickness tears of the rotator cuff yields satisfactory results according to both traditional orthopedic and patient-assessed criteria.

    The advantages of this technique include smaller incisions, access to the glenohumeral joint for inspection and treatment of intra-articular lesions, and no need of detaching the deltoid. This method is technically difficult.
       

  • Quads 
    Konrath GA, Chen D, Lock T, et al (Desert Orthopedic Ctr, Palm Springs, Calif; Henry Ford Hosp, Detroit; Wayne State Univ, Detroit)
    Outcomes Following Repair of Quadriceps Tendon Ruptures
    J Orthop Trauma 12: 273-279, 1998

    Quadriceps tendon ruptures as such not so common and mostly occur above the age of 40 years.

    Most of the patients were surgically treated and outcome was good although more than half of the patients could not go to their original work but had range of movements up to 1250.
       

  • Spinner RJ, Goldner RD, Fada RA, et al (Mayo Clinic and Found, Rochester, Minn; Duke Univ Med Ctr, Durham, NC; Joint Implant Surgeons Inc, Columbus, Ohio; et al) 
    Snapping of the Triceps Tendon Over the Lateral Epicondyle 
    J Hand Surg [Am] 24A: 381-385, 1999 
     
    Snapping of the triceps of the lateral epicondyle may be a variation within the normal population, much like that of snapping of the triceps over the medial epicondyle.

    Snapping of the lateral triceps over the lateral epicondyle and a clinical maneuver referred to as the “lateral snap test,” which can be used to establish this diagnosis.

    This condition probably represents a variation of normal and “will become increasingly recognized in the future.” It is likely that the pain associated with the snapping is due to a bursitis/tendonitis, which would explain why patients may have asymptomatic snapping on one side and yet be symptomatic on the other.
       

  • Darder-Prats A, Fernandez-Garcia E, Fernandez-Gabarda R, et al (Hosp Clinico Universitario, Valencia, Spain)
    Treatment of Mallet Finger Fractures by the Extension-Block K-Wire Technique
    J Hand Surg [Br] 23B: 802-805, 1998 
     
    For mallet finger fractures that involve more than one third of the articular surface or include a subluxated distal phalanx, anatomical reduction of the joint surfaces via surgery is typically recommended.

    The Ishiguro method – a closed technique that provides anatomical reduction via an extension-block Kirschner wire (K wire) with transarticular K wire fixation.

    The anatomical reduction began with the patient under digital block anesthesia. After flexing of the distal phalanx, a 0.9- or 1.0-mm K wire is inserted through the head of the middle phalanx just proximal to the bone fragment, at a dorsal angulation of 300 to 400. 

    The fracture is reduced by passively extending the DIP joint, then the DIP joint is fixed with a second K wire to maintain the reduction. No splinting is used postoperatively, to allow early active motion of the proximal interphalangeal and metacarpophalangeal joints. 

    The extension-block K wire is removed at 4 weeks, and the transfixion K wire is removed at 5 weeks. None of the patients had DIP joint osteoarthritis or infections of pin tracks.
       

  • Katzman BM, Klein DM, Mesa J, et al (State Univ of New York, Brooklyn)
    Immobilization of the Mallet Finger: Effects on the Extensor Tendon 
    J Hand Surg [Br] 24B: 80-84, 1999

    Isolated splinting of the distal interphalangeal (DIP) joint is an effective treatment for mallet finger, although a small extensor lag can persist. This technique allows full motion of the extensor apparatus proximal to the DIP joint.

    When only the DIP joint was immobilized neither gap or retraction of the intrinsics occurred with joint motion proximal to the DIP joint.

    In mallet finger, a tendon gap results from movement of the distal tendon edge during DIP joint flexion, rather than by retraction of the proximal tendon edge. 

    Immobilization of only the DIP joint is necessary to approximate the edges of the terminal tendon. Adding PIP joint immobilization is of no benefit.
       

  • Tomaino MM, Plakseychuk A (Univ of Pittsburgh, Pa)
    Identification and Preservation of Palmar Cutaneous Nerves During Open Carpal Tunnel Release
    J Hand Surg [Br] 23B: 607-608, 1998

    Some patients undergoing carpal tunnel release are left with postoperative pillar pain and tenderness of the scar. 

    Division of cutaneous nerves crossing the palm may be responsible for the increased rate of painful incisions.

    The crossing nerves were consistently in the most proximal portion of the palm, just distal to the wrist flexion crease and superficial to the palmar fascia. The branch was often multifascicular, but there was never more than 1 branch. 

    This experience demonstrates the feasibility of preserving cutaneous nerves crossing the palm during open carpal tunnel release. 

    P. C. Amadio comments that, despite careful incisions, nerve branches across a carpal tunnel incision are common and, when encountered, should be preserved.
       

  • Shayfer SS, Toledano B, Ruby LK (Tufts Univ, Boston)
    Wrist Arthrodesis: An Alternative Technique
    Orthopedics 21: 1139-1143, 1998

    Wrist arthrodesis is widely used to treat pain and deformity. An alternative fixation method for arthrodesis of the wrist for nonrheumatoid arthritis was reported.

    The surgeon centers a straight dorsal incision over Lister’s tubercle. The surgeon then releases the dorsal radiocarpal and intercarpal ligaments to allow decortication. Using a high-speed burr, the surgeon removes all cartilage and subchondral bone from the radius and carpus, except for the carpometacarpal and scaphotrapezial-trapezoid joints. 

    With the wrist held in 100 to 150 of extension and 50 to 100 of ulnar deviation, two or three 3/32-inch smooth Steinmann pins are driven from the radius distally into the carpus.

    The surgeon then packs cancellous bone from the iliac crest into the radiocarpal and intercarpal joints. The oblique pin technique results in an excellent fusion rate in any desired position at a low cost. 

    This technique is fast and simple and avoids the cost of a plate and the possible expense of removing such a plate.
       

  • Herren DB, Lehmann O, Simmen BR (Schulthess Clinic, Zurich, Switzerland)
    Does Trapeziectomy Destabilize the Carpus?
    J Hand Surg [Br] 23B: 676-679, 1998

    The trapezium was completely removed in 86 patients, aged 42 to 80 years, for treatment of arthritis. Tendon suspension-interposition with a distally based strip of the flexor carpi radialis tendon was also performed in 61 patients.

    Trapeziectomy does not appear to result in significant destabilization of the wrist joint.
       

  • Ueba Y, Nosaka K, Seto Y, et al (Shiragikuen Hosp, Tosa, Japan; Shimada Municipal Hospitalm, Japan; Med Ctr for Children, Shiga, Japan; et al)
    An Operative Procedure for Advanced Kienbock’s Disease: Excision of the Lunate and Subsequent Replacement With a Tendon-Ball Implant
    J Orthop Sci 4: 207-215, 1999

    Excision of the lunate and subsequent replacement with a tendon-ball implant is the most appropriate procedure for advanced Kienbock’s disease. 

    After the collapsed lunate is removed, a tendon-ball implant, made of the palmaris longus and plantaris tendons, is placed in the resultant space in the carpus. A forearm distractor is applied during the operation, and distraction is continued for 4 weeks postoperatively.

    It is interesting to note that calcification or ossification can be seen in implanted tendon-balls by x-ray examination in about half the cases. The calcification was gradually transformed into ossification, and solid ossification in similar to original lunate was seen in several cases.
       

  • Menth-Chiari WA, Poehling GG, Wiesler, ER, et al (Wake Forest Univ, Winston-Salem, NC; Univ of Vienna)
    Arthroscopic Debridement for the Treatment of Kienbock’s Disease 
    Arthroscopy 15: 12-19, 1999

    Arthroscopic debridement of necrotic lunate effectively relieves pain but does not prevent disease progression.

    The immediate pain of Kienbock’s disease may be clinically improved after arthroscopic debridement, there is no consideration for the very likely progression of degeneration of the articular surfaces as the carpal collapse increases.

    A proximal row carpectomy or a midcarpal arthrodesis based upon the scaphoid will reduce the patients’ ROM, they are intended to provide extremely long-term protection from degenerative disease due to progressive mechanical instability. 

    R. A. Berger cautions readers to strongly consider a stabilization procedure of their choice when performing a lunatectomy for Kienbock’s disease.
       

  • Kulkarni RW, Wollstein R, Tayar R, et al (St Helier Hosp, Carshalton, England)
    Patterns of Healing of Scaphoid Fractures: The Importance of Vascularity 
    J Bone Joint Surg Br 81-B: 85-90, 1999

    Nonunion is a common problem after scaphoid fraction. An MRI study was performed to assess vascularity and healing in 46 consecutive scaphoid fractures. 

    On early MRI scans, the fractures fell into 4 patterns. In type 1 (8 cases), both fragments retained their vascularity and showed a hypervascular healing response.

    The most common pattern was type 2, seen in 35 cases. In this pattern, the proximal fragment appeared avascular, while the distal fragment showed a hypervascular healing response. 

    Type 2 fractures went on to nonunion. Type 3 fracture, with the distal fragment showing avascularity and the proximal fragment a hypervascular healing response. Type 4 fractures, in which both fragments were avascular.

    The 6-week MRI appearance may help to identify fractures that will not progress to union, and thus should be considered for early internal fixation. 
       

  • Mathoulin C, Brunelli F (Clinique Jouvenet, Paris)
    Further Experience With the Index Metacarpal Vascularized Bone Graft
    J Hand Surg [Br] 23B: 311-317, 1998

    When surgical treatment of scaphoid nonunion fails, a corticocancellous vascularized bone graft harvested from the distal part of the index metacarpal can be used to effect repair and to correct any palmar flexion by restoring the scaphoid to its correct position and supplying vascularity to the area.

    Use of a corticocancellous vascularized bone graft resulted in successful scaphoid union.

    This article has an excellent description of the pertinent vascular anatomy. While this vascularized bone graft has not been widely applied for scaphoid nonunion, it has some appeal, especially in the multiply operated-on wrist.
       

  • Shah J, Jones WA (Broadgreen Hosp, Liverpool, England)
    Factors Affecting the Outcome in 50 Cases of Scaphoid Nonunion Treated With Herbert Screw Fixation 
    J Hand Surg [Br] 23B: 680-685, 1998

    Many factors, such as the duration and location of nonunion and the vascular status of the proximal fragment, are known to affect the outcomes of this procedure.

    A longer duration of nonunion is associated with a lower rate of union, perhaps because of the increased incidence of avascular necrosis.

    This is an important study of scaphoid nonunions because it looks at factors beyond the surgeon’s control. Nonunions longer than 5 years had a 50% union rate with bone grafting, but those less than 5 years had an 80% rate.

    Patients with a fibrous nonunion and without displacement (ie, stable non-union), with an internal fixation screw alone (Herbert screw), union was achieved in each patient (100%).
       

  • Inoue G, Shionoya K (Nagoya Univ, Japan)
    Late Treatment of Unreduced Perilunate Dislocations 
    J Hand Surg [Br] 24B: 221-225, 1999

    For patients with chronic perilunate dislocation, open reduction and temporary fixation produces satisfactory results if performed within 2 months after injury. 

    In longer-standing cases, proximal row carpectomy produces good results if the cartilage on the proximal pole of the capitate is intact. Lunate excision does not give good results.

    Chronic perilunate dislocation may cause few symptoms for a long time; such cases often present with symptoms of median nerve compression or tendon rupture, rather than wrist deformity.

    In some cases of very severe perilunate fracture dislocations, proximal row carpectomy can be a very appropriate treatment even in the acute setting.
       

  • Ishii S, Palmer AK, Werner FW, et al (State Univ of New York, Syracuse)
    An Anatomic Study of the Ligamentous Structure of the Triangular Fibrocartilage Complex 
    J Hand Surg [Am] 23A: 977-985, 1998

    The triangular fibrocartilage complex (TFCC) and the interosseous membrane of the forearm play a crucial role in the stability of the distal radioulnar joint (DRUJ).

    The distal radioulnar ligament consists of dorsal, palmar, superficial, and deep portions. The meniscus homologue is the tissue located between and integrated into the ulnar aspect of the superficial part of the distal radioulnar ligament and the ulnar capsule.

    The anatomy of the triangular fibrocartilage complex has been confusing and controversial for anyone working on problems associated with disorders in the ulnar aspect of the wrist.

    This manuscript goes far in furthering our understanding of the complex anatomy of the triangular fibrocartilage complex. The most important features, in my opinion, are the deep attachments of the dorsal and palmar radioulnar ligaments to the foveal region at the base of the styloid process as well as on the ulnar styloid process itself.
       

  • Barbier O, Saels P, Rombouts JJ, et al (Univ of Louvain, Brussels)
    Long-term Functional Results of Wrist Arthrodesis in Rheumatoid Arthritis 
    J Hand Surg [Br] 24B: 27-31, 1999

    In patients with severe rheumatoid arthritis (RA), the goal of wrist arthrodesis is to achieve strong, stable, pain-free fusion while preserving forearm supination and pronation.

    The arthrodeses averaged 80 of extension and 90 of ulnar deviation. The findings support wrist arthrodesis as an effective procedure in patients with RA. Wrist fusion provides good pain relief and patient satisfaction without additional loss of function compared with the opposite side.
       

  • Gudmundsson KG, Arngrimsson R, Arinbjarnarson S, et al (The Health Care Ctr and Region Hosp, Blonduos, Iceland; Univ of Iceland, Reykjavik; The Region Hosp, Akureyri, Iceland)
    T- and B-Lymphocyte Subsets in Patients With Dupuytren’s Disease: Correlations With Disease Severity
    J Hand Surg [Br] 23B: 724-727, 1998

    Previous studies suggested that Dupuytren’s disease may be a T-cell-mediated autoimmune disorder and that immune dysregulation may play an important pathogenetic role. The response to steroids and interferon g also support the autoimmune hypothesis. 

    Patients with Dupuytren’s disease have significant elevations of activated peripheral blood T lymphocytes. The findings are consistent with the suggestion that immune system dysregulation, involving activated T cells and probably B cells, plays a role in the pathogenesis of Dupuytren’s disease.
       

  • Foucher G, Lallemand S, Pajardi G (Clinique du Parc, Strasbourg, France)
    What’s New in the Treatment of Dupuytren’s Contracture? [French]
    Ann Chir Plast Esthet 43: 593-599, 1998

    Under local anesthesia and tourniquet the cords of Dupuytren were cut with the tip of a 19-guage needle passed percutaneously. The procedure was performed in one session, beginning in the finger and proceeding in the palm, with an attempt to cut the cords at multiple levels. 

    The dressing lasted for 24 hours, but a night splinting in extension was maintained for at least 1 month.

    The ideal indication for this simple treatment is a bowing cord progressing slowly and flexing predominantly the metacarpophalangeal in an elderly patient.

    This excellent article reviews a newer, less invasive treatment for selected cases of Dupuytren’s contracture – needle aponeurotomy.
       

  • Stephen AB, Lyons AR, Davis TRC (Queen’s Med Centre, Nottingham, England)
    A Prospective Study of Two Conservative Treatments for Ganglia of the Wrist 
    J Hand Surg [Br] 24B: 104-105, 1999

    Although highly effective, surgical excision of wrist ganglia is an expensive treatment that carries a risk of complications. The success rates of reported conservative therapy options vary. These options include simple ganglion aspiration and multiple puncture of the ganglion wall, the latter a relatively painful procedure.

    Among conservative treatments for ganglia of the wrist, multiple puncture does not improve on the results of simple aspiration. Aspiration and reassurance that the ganglion is benign may reduce the number of patients desiring surgical excision.
       

  • Gary S. Fanton, and Amir M. Khan (Sports Orthopaedic and Rehabilitation Group, Menlo Park, California)
    Monopolar Radiofrequency Energy for Arthroscopic Treatment of Shoulder Instability in the Athlete 
    Orth Cl of N A July 2001Vol. 32 (3) Pg. 511-523
        
    Shoulder instability is one of the most common causes of functional limitation in recreational and competitive athletes. 
         
    Although open surgery can correct capsule redundancy it may not permit return to active competitive sports. Arthroscopy offers a better alternative than surgery, but the techniques are quite demanding.
       
    The use of thermal energy to ‘shrink’ rather than sew the stretched out glenohumeral ligaments was pioneered in early 1990s.
        
    Monopolar radiofrequency energy is increasingly being used in the treatment of shoulder instability. Early clinical results have shown successful shrinkage of the shoulder capsule. This procedure is useful in treating certain traumatic and recurrent shoulder instability especially where the range of motion is preserved. 
       
    It is easy to perform and its complication rate is low. There is little disruption or alteration of the anatomy. Success however depends on proper patient selection, patient compliance, and proper rehabilitation. 
        
    Long term follow-ups are required before definite advantages can be cleared.
           

  • Mark H. Field, T. Bradley Edwards, and Felix H. Savoie (Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi)
    Technical Note: A “New” Arthroscopic Sliding Knot 
    Orth Cl of N A July 2001Vol. 32 (3) Pg. 525-526
        
    Many arthroscopic knots, both sliding and non sliding have been described. The authors describe the arthroscopic implementation of another sliding knot originally used in tying the common bile duct (FHS unpublished version).
        
    This knot was first described by FHS and subsequently modified by the first author. The technique has been described and discussed. 
         
    As with any other knot, this should be practiced in the dry lab setting before it can be used on a patient.
           

  • W. Ben Kibler, John McMullen, and Tim Uhl (Lexington Sports Medicine Center, and the Division of Athletic Training, University of Kentucky, Lexington, Kentucky)
    Shoulder Rehabilitation Strategies, Guidelines, and Practice 
    Orth Cl of N A July 2001Vol. 32 (3) Pg. 527-538
        
    Shoulder rehabilitation can best be understood and implemented as the practical application of biomechanical and muscle activation guidelines to the repaired anatomic structures in order to allow the most complete return to function.
         
    The shoulder works as a link in the kinetic chain of joint motions and muscle activations to produce optimum athletic function.
         
    Rehabilitation should start with the establishment of a stable base of support and muscle felicitation in the trunk and legs and then proceeds to the scapula as healing is achieved and proximal control is gained.
         
    The pace of this flow of exercises is determined by the achievement of the functional goals of each segment of the kinetic chain. In the early rehabilitation stages the incompletely healed shoulder structures are protected by exercises that are directed towards the proximal segments.
         
    As healing proceeds the weak scapular and shoulder muscles are facilitated in their reactivation by the use of proximal leg and trunk muscles to re-establish normal coupled activations.
        
    Closed chain axial loading exercises form the basis for scapular and glenohumeral functional rehabilitation as they more closely stimulate normal scapula and shoulder positions, proprioceptive input, and muscle activation patterns.
         
    In the late rehabilitative stages, glenohumeral control and power production complete the return of function to the shoulder and the kinetic chain.
         
    In this integrated approach glenohumeral emphasis is part of the entire program and is towards the end of rehabilitation rather than being the entire program or being at the beginning of the program.
          

  • Alistair Stirling, Tony Worthington et al 
    Association Between Sciatica and Propionibacterium acnes 
    Lancet, Vol.357, June 23, 2001, Pg. 2024-25
           
    Summary : Authors hypothesised that the inflammation seen around the nerve root in patients with sciatica may be caused by microbial infection. They used a newly developed serological test to diagnose deep-seated infections caused by low virulent gram-positive microorganisms.
          
    43 of 140 (31%) patients with sciatica tested positive. Intervertebral disc material from a further 36 patients with severe sciatica who had undergone microdiscectomy was cultured for the presence of microorganisms.
          
    19 of these patients (53%) had positive cultures after long-term incubation. Propionibacterium acnes was isolated from 16 of the 19 (84%) positive samples. Low virulent organisms, in particular P. acnes, might be causing a chronic low-grade infection in the lower intervertebral discs of patients with severe sciatica. These microorganisms could have gained access to spinal disc after previous minor trauma.
          

  • Servier’s Dual Approach to Osteoporosis
    Scrip May 17th, 2002, pg. 26
      
    Servier’s novel osteoporosis product, Protos (strontium ranelate), has a dual action in prevention and treatment of osteoporosis. Protos stimulates bone formation (osteoblast action) and inhibits bone absorption (osteoclast action).
      
    The sum total is increased bone density. Clinical trials have demonstrated this effect.
       

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