Volume 15-4, Winter 2006

Clinical pathways, or caremaps, have become key tools for hospitals to streamline patient care. They are most applicable in situations where a high degree of predictability regarding treatment and/or diagnostic intervention is expected. Perceived advantages include cost savings, more uniform nursing care, and improved patient satisfaction. Total joint replacement is an ideal indication for implementation of clinical pathways. At the authors’ institution, despite the adoption of a clinical pathway for these procedures, postoperative orders continue to be handwritten de novo adding variability that may be detrimental to patient safety. This article describes the authoring and implementation of a computerized order process for the care of postoperative total joints patients using a multidisciplinary approach.Clinical pathways, or caremaps, have become key tools for hospitals to streamline patient care. They are most applicable in situations where a high degree of predictability regarding treatment and/or diagnostic intervention is expected. Perceived advantages include cost savings, more uniform nursing care, and improved patient satisfaction. Total joint replacement is an ideal indication for implementation of clinical pathways. At the authors’ institution, despite the adoption of a clinical pathway for these procedures, postoperative orders continue to be handwritten de novo adding variability that may be detrimental to patient safety. This article describes the authoring and implementation of a computerized order process for the care of postoperative total joints patients using a multidisciplinary approach. (Journal of Surgical Orthopaedic Advances 15(4):195–200, 2006)

Treatment of pseudarthrosis of the cervical spine has been debated extensively with various solutions being proposed. This article reviews 18 cases of pseudarthrosis after attempted anterior cervical discectomy and fusion with tricortical iliac crest autograft using the Smith–Robinson method. All cases were subsequently treated with posterior fusion using cancellous iliac autograft and fixation with Halifax clamps. All cases showed radiographic union at the 6-month follow-up. There were no complications related to the application of the device. One device showed loss of fixation in the follow-up period. The Halifax clamp is technically simple to apply and can be done safely. High success rates in obtaining fusion after failed anterior discectomy and fusion in the cervical spine and ease of application make this method of posterior fixation and fusion an attractive alternative for dealing with pseudarthrosis. (Journal of Surgical Orthopaedic Advances 15(4):201–202, 2006)

Posterior lumbar interbody fusion is an accepted surgical technique to treat disabling lower back pain due to degenerative disc disease. In the techniques that prevail, installation of large fixed-size twin cages dictate the sacrifice of the posterior stabilizing structures. Moreover, excessive retraction of the dural sac imposes potential neurological hazard. The authors present a novel technique based on a spacer capable of threefold expansion once it has been installed in the disc space. The spacer was laboratory tested under controlled loading conditions. Strength and fatigue tests of an isolated spacer were performed using an artificial model. Pullout resistance and ultimate compression strength of the surgical construct were evaluated using a cadaveric specimen. The yield force and the ultimate force for the single spacer averaged 2660 +/- 483 N and 4313 +/- 420 N, respectively, while the endurance limit at 5 million cycles averaged 931 N. The single-spacer resistance to pullout averaged 556 +/- 207 N, while the ultimate compressive strength of bone–spacer interface averaged 3399 +/- 136 N for a pair of spacers. The results of the study indicate that the B-twin ESS is expected to withstand the loads imposed upon it during everyday activity and resist migration or significant subsidence until fusion is achieved. (Journal of Surgical Orthopaedic Advances 15(4):203–208, 2006)

Alveolar soft part sarcoma (ASPS) is a rare soft tissue sarcoma that most commonly arises in the deep soft tissues of the lower extremities of adults. Median survival of patients with metastatic ASPS has been reported to be from 3 to 3.3 years. The time between detection of metastases and death varies from 10 months to 6.2 years. In this article, a case of an 11-year-old male with primary ASPS of the right forearm is presented. Successful long-term local control of the primary tumor was achieved with wide margin surgical resection and adjuvant radiation therapy. Three years after diagnosis, the patient developed pulmonary metastases. Chemotherapy was unsuccessfully used to control the metastatic disease. Despite that, the patient survived longer than expected, and passed away 9 years after the detection of pulmonary metastases. This time to death after the development of metastases vastly exceeded the previously reported survival rates of patients with metastatic ASPS. (Journal of Surgical Orthopaedic Advances 15(4):209–213, 2006)

Entrapment of the median nerve in pediatric both-bone forearm fractures is a rare occurrence, but there are multiple reports of such cases in the literature. This case report discusses the recognition and management of median nerve entrapment in a 13-year-old female who presented acutely with a bothbone forearm fracture and a reproducible neurologic deficit in the median nerve distribution. She was treated with acute open reduction and internal plate fixation and median nerve exploration. Her median nerve function was near normal 14 weeks after surgery. This report stresses the importance of a complete neurologic examination in all forearm fractures and demonstrates the recovery potential of a median nerve damaged by bony entrapment. (Journal of Surgical Orthopaedic Advances 15(4):214–216, 2006)