Volume 22-3, Fall 2013

The goals of the current study were to review the published research over the past decade and to summarize the findings related to pharmacologic approaches in the treatment of sport-related concussion (SRC). PubMed searches across all databases were employed using combinations of the key words and search phrases ‘‘concussion,’’ ‘‘mild traumatic brain injury,’’ ‘‘pharmacology,’’ ‘‘treatment,’’ and ‘‘sports,’’ along with specific classes of pharmacologic agents. The few studies found were based primarily on clinician experience, with frequent reference to animal models. No clinical pharmacologic trials of SRC were found. The pharmacologic treatment of SRC remains focused on specific symptoms, and there is as yet no evidence-based treatment. On the basis of the limited published research, the authors offer some preliminary guidelines regarding the use of pharmacologic therapies in SRC. Key words: concussion, mild traumatic brain injury, pharmacology, sports

Four cases of necrotizing soft tissue infections of the upper extremity are presented. Each involved minor wounds to the hand that gradually progressed to fulminant infection. Two of the patients reported a history of alcohol abuse. One patient had psychiatric illness that led to delay in recognizing the infection and seeking intervention. The causative organism in all cases was group A beta hemolytic streptococcus. Fortunately, none of the patients suffered loss of the affected extremity, although long-term function is limited. The necrotizing soft tissue infection encountered in these cases represents a less severe presentation than classic necrotizing fasciitis. Necrotizing soft tissue infections are properly recognized as a spectrum of disease and can, as in these cases, follow a prolonged progression with limited systemic involvement. The current literature regarding diagnosis and treatment of necrotizing soft tissue infections is reviewed. Key words: tissue infections, upper extremity

This study investigated complication rates for 68 solid-organ transplant patients who had undergone 94 primary hip or knee joint replacements at a single institution from 1995 to 2008. There was a deep infection rate of 6.8% in the transplant patients compared to a 1.9% deep infection rate for all primary joint replacement patients at the Medical University of South Carolina over the same time period (odds ratio 4.48). All four infections in the transplant group occurred in diabetic patients. The joint revision rate for transplant patients was 13% (deep infection 6.8%, aseptic loosening 5.1%, instability 1.7%). Other complications included superficial infections (5.1%), deep venous thromboses (3.4%), and a nonfatal pulmonary embolus (1.7%). The deep infection rate for joint replacement in solid-organ transplant patients was higher than rates reported by most similar studies, and diabetic patients may be at particular risk. Key words: complications, infection, solid-organ transplant, total hip arthroplasty, total knee arthroplasty

Proximal metatarsal osteotomies are inherently unstable and difficult to fix. The purpose of this study was to compare the mechanical stiffness in sawbone models of medially versus dorsally placed plates and then to compare semilocked versus nonlocked plates in different osteotomy configurations. Thirty sawbone models were constructed, fixed either with titanium self-locking or steel mini-fragment plates. They were divided in groups and their stiffness was measured. The stiffness of any model fixed with medial titanium or steel plates was on average 158% and 228% greater, respectively, compared to dorsal plates. Adding a dorsal shelf of bone to a proximal closing wedge osteotomy increases its stiffness. Using locked plates increased the mechanical stiffness in only one configuration. The article suggests that models fixed with medial plates have greater resistance to failure than models fixed with dorsal plates. Using locked plates does not increase the mechanical stiffness of the construct. Key words: mechanical analysis, metatarsal osteotomies, plate fixation, sawbone models, titanium plates

Scapular winging resulting from long thoracic nerve palsy is a painful, disabling condition often associated with periscapular weakness and decreased active shoulder range of motion. Observation, therapy, and symptomatic treatment have customarily been the recommended treatment, often with disappointing results. Recently, encouraging results have been reported following decompression of the long thoracic nerve. Six patients who underwent a supraclavicular long thoracic nerve decompression from 2008 to 2010 for painful posttraumatic scapular winging were identified retrospectively. Four males and two females with a mean age of 28 years at the time of surgery were treated for an average of 9 months following injury. Mean follow-up was 16 months following surgery. All patients had decreased pain, disability, and scapular winging, and improved shoulder range of motion. One patient had recurrence following a second injury. This procedure has resulted in good outcomes without the morbidity associated with tendon or nerve transfer. Key words: DASH, long thoracic nerve palsy; neurolysis, scapular winging, serratus anterior paralysis, VAS

Naturally derived tendon scaffolds have the potential to improve the treatment of flexor tendon injuries. Seeded and unseeded tendon scaffolds were maintained in the presence or absence of physiologic strain for 7 days. After 7 days, the tensile properties and associated messenger RNA expression were compared. Seeded scaffolds maintained in the absence of strain had significantly lower tensile properties than unseeded tendons and fresh-frozen tendons. The loss of tensile properties was associated with elevated matrix metalloproteinase-2 and collagen III expression. Tensile properties of seeded scaffolds maintained in the presence of strain for 7 days after seeding did not differ from those of fresh-frozen tendons. This study demonstrates that the tensile properties of seeded, naturally derived tendon scaffolds will degrade rapidly in the absence of cyclic strain. Seeded scaffolds used for tendon reconstruction should be maintained under cyclic strain to maintain essential tensile properties. Key words: bioreactor, flexor tendon, strain, tensile testing, tissue engineering

The authors’ hypothesis was that weakening the gastrocnemius muscle at the time of tendon transfer will reduce the risk of rupture and facilitate faster rehabilitation with increased active dorsiflexion and improved overall outcome, because the transferred tendon is spared the antagonistic effect of the gastrocnemius during the early recovery period. A retrospective chart review identified 12 patients who underwent a tibialis posterior tendon (PTT) transfer with gastrocnemius Botox injection for foot drop. All statistical analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, North Carolina). There were no failures or tendon ruptures. All patients had zero dorsiflexion (DF) strength preoperatively, and those with DF strength documented postoperatively had a mean DF strength at final clinical evaluation of 3.9 (p < .001) with a mean active DF of 4°. It was concluded that gastrocnemius chemodenervation with Botox at the time of PTT transfer is a safe and effective means of restoring active dorsiflexion. Key words: Botox, foot drop, tendon transfer, tibialis posterior

A patient with a cemented centrally located intramedullary tibial nail that occluded the proximal tibial canal underwent knee reconstruction with a total knee design utilizing a custom hollow tibial stem. In this oncology case, a rotating-hinge knee design was used that incorporates an intra-articular inverted postin-channel central rotational post design. This design allowed for a rather straightforward reconstruction that functioned well for 3 years. Although rarely encountered, utilization of a hollow-stemmed tibial total knee component may allow salvage of an extremity with central occlusion of the proximal tibial canal. Key words: arthroplasty, custom prosthesis, hollow stem, retained intramedullary nail, total knee replacement

Glenoid component loosening is the most frequently cited complication related to total shoulder arthroplasty (TSA). The mechanism behind glenoid loosening remains an area of active investigation. Distant migration of the implant following loosening has not been described. Both glenoid implant removal and revision have demonstrated successful results following symptomatic loosening. This report presents the case of a 61-year-old female who experienced a complete glenoid component dissociation following TSA with migration of the implant into the subcutaneous tissue of the posterior shoulder. The patient underwent implant removal without glenoid revision and has experienced an excellent outcome at midterm follow-up. Although glenoid component loosening remains the most common complication associated with TSA, this particular scenario and the subsequent management have not been previously reported. Key words: component, failure, glenoid, loosening, total shoulder arthroplasty

This case report identifies a 41-year-old male patient who developed anterior shoulder pain in the setting of humeral head osteonecrosis. As a consequence of the cartilage degeneration, multiple loose bodies formed and migrated into the bicipital tendon sheath, causing attrition tendinitis, which was a feature of the clinical presentation. The patient was treated by a combination of arthroscopic glenohumeral joint debridement and open tenodesis of the biceps using a suture anchor. Follow-up revealed asymptomatic shoulder function by 18 months. This is the first report in the literature of bicipital tendinitis in the context of avascular necrosis of the shoulder. Key words: biceps, groove, humeral, osteonecrosis, shoulder, tendinitis