Volume 17-2, Summer 2008

The coracoacromial (CA) ligament plays an important role in the stability of the shoulder joint by limiting superior translation of the glenohumeral joint. This ligament is further divided into anterolateral and posteromedial bands. Attached to the CA ligament, a supportive structure was noted in some previous studies. The purpose of this study was to learn more about the anatomy of this structure. Twenty eight shoulders were obtained. Deltoid and trapezius muscles were removed without damaging the rotator cuff and coracoacromial arch. The CA ligament was dissected further to reveal two constituent bands, an anterolateral and a posteromedial band. A connective tissue structure was noted between the posteromedial band, CA ligament, and rotator interval capsule. This structure was oriented as an L-shaped curtain, which the authors termed the ‘‘coracoacromial veil.’’ Anatomical position of this veil provides a stabilizing link between the CA ligament and the rotator interval capsule. This structure potentially limits inferior translation of the glenohumeral joint. (Journal of Surgical Orthopaedic Advances 17(2):69–73, 2008) Key words: coracoacromial ligament, coracoacromial veil, shoulder joint

This study assesses the relationship between capillary refill time (CRT) and arterial blood flow (ABF) in the lower extremities of pediatric patients to determine if a correlation exists that would demonstrate CRT as an accurate means of monitoring tissue perfusion. The ABF and CRT were evaluated in 20 pediatric patients at four different pressures (0, 1/2 systolic blood pressure [SBP], SBP, and 11/2 SBP) using Doppler ultrasound and a stop-frame digital camera. While the mean ABF in the popliteal artery, dorsalis pedis, and posterior tibialis decreased dramatically with the increased pressure, the mean CRT showed only minor increases in duration. The >90% decrease in ABF between 0 and 11/2 SBP correlated to only a 0.8925-second change in CRT. Thus, at significantly decreased rates of blood flow, a possible inverse relationship exist between ABF and CRT in the lower extremities of this pediatric population. However, the change in CRT correlating to the decrease in ABF is too small to be considered practically useful for clinically monitoring tissue perfusion. (Journal of Surgical Orthopaedic Advances 17(2):74–76, 2008) Key words: arterial blood flow, capillary refill time, pediatrics, tissue perfusion

Minimal-incision technique in total hip arthroplasty (THA) has been previously defined as requiring an incision of 10 cm or less. A higher complication rate for overweight or muscular patients has been demonstrated when this arbitrary cutoff is used. The purpose of this study was to perform minimal-incision technique surgery without a specific incision length cutoff on a cohort of nonselected, consecutive THA patients to determine if patient height, weight, body mass index, gender, type of femoral fixation, and/or age correlated with incision length. A total of 115 patients underwent THA (posterior approach) using minimal-incision technique by a single, experienced surgeon who performed the smallest incision that was feasible. There was a significant correlation between incision size and patient weight (p < .0001)), height (p D .007), and gender (p D .04). Complications included one patient each with postoperative instability, an intraoperative calcar fracture, and an intraoperative distal incision skin tear. These findings demonstrate that larger patients can expect a longer incision with this technique, and that for a given weight, women will have longer incisions than men. Selecting appropriate incision length for minimally invasive THA reduces potential associated complications. (Journal of Surgical Orthopaedic Advances 17(2):77–81, 2008) Key words: gender, height, incision length, minimally invasive surgery, total hip arthroplasty, weight

A retrospective analysis of 13 patients who underwent endoscopic hardware removal to resolve residual foraminal stenosis issues was performed to determine the feasibility and validity of utilizing endoscopic techniques to entirely remove spinal hardware. Tubular retractors were utilized for the procedure with a diameter of 15 to 18 mm. Surgical times ranged from 58 to 268 minutes, with the largest time delay being the need to cut the crossbars in vivo due to stripped screws, bony overgrowth, or bent hardware. Entire hardware systems can be removed via an endoscopic approach. Blood loss averaged around 90 cc but surgical times were over an hour for most procedures. Endoscopic removal of entire hardware systems can be accomplished but it offers little advantage over conventional hardware removal. The main advantages include reduced trauma and the ability of the surgery to be performed on an outpatient basis. (Journal of Surgical Orthopaedic Advances 17(2):82–84, 2008) Key words: endoscopic spine surgery, hardware removal, minimally invasive spinal surgery

Ulnar artery thrombosis should be considered in patients presenting with cold intolerance or ischemia of the small and ring fingers, or a mass in the hypothenar area. Frequently this diagnosis is associated with a history of repetitive blunt trauma to the ulnar hand, thereby traumatizing the ulnar artery in Guyon’s canal. This report presents a case of ulnar artery thrombosis associated with an abnormal muscle originating on the palmar antebrachial fascia, traversing volar to the ulnar artery and nerve, and inserting on the ulnar border of the abductor digiti minimi. This muscle is an abductor digiti minimi accessorius. (Journal of Surgical Orthopaedic Advances 17(2):85–88, 2008) Key words: anomalous muscle, Guyon’s canal, hypothenar, thrombosis, ulnar artery

Lymphangioma is a benign congenital tumor rarely experienced in the upper extremity. There are few reports of the outcomes of treatment of this tumor to guide treatment when it occurs in the finger. Treatment of this disease is challenging. This report presents two cases of lymphangioma in the fingers of children. (Journal of Surgical Orthopaedic Advances 17(2):89–92, 2008) Key words: congenital vascular tumor, finger, lymphangioma

An anomalous origin of the long head of the biceps tendon (LHBT) from the rotator cable has not been described in the orthopaedic surgery literature. This case report describes the intraoperative findings of this aberrant origin, found incidentally during diagnostic arthroscopy. The concept of the rotator cable and crescent is discussed, and a literature review of aberrant anatomy of the LHBT origin is included. (Journal of Surgical Orthopaedic Advances 17(2):93–95, 2008) Key words: anatomic variant, long head of the biceps tendon

Articular fractures of the distal part of the humerus represent a challenging therapeutic problem, because they require thorough understanding of the complex local anatomy, extensile approaches, and reduction and fixation of small fragments that mainly consist of subchondral bone and articular cartilage. This report presents two cases of a unique fracture pattern of the lateral humeral column with a fracture line in the coronal plane separating the capitellum with a substantial portion of the lateral trochlear ridge, and with a second fracture line in the sagittal plane separating the residual, posterior portion of the lateral column, almost through the level of the capitellotrochlear sulcus, thus creating concomitant but distinct ‘‘low’’ lateral column and capitellum fractures. The radiographic findings that would suggest to the orthopaedic surgeon the possibility of this fracture pattern, the surgical approach that provides access to this complex articular fracture, and the fixation method are described. (Journal of Surgical Orthopaedic Advances 17(2):96–101, 2008) Key words: biplane, coronal shear fracture, distal humerus, lateral column

Acute compartment syndrome following fracture of the distal radius occurs in less than 1% of cases, but if the diagnosis is delayed, the potential consequences may be devastating. The majority of the cases involve high-energy injuries in young patients, and increasing pain ‘‘out of proportion to the injury sustained’’ is a constant finding and constitutes the hallmark of the diagnosis. This case report describes a rare presentation of an acute compartment syndrome in the forearm and wrist after fracture of the distal radius that developed in the absence of acute pain symptoms, in an older individual, and in the context of a low-energy injury. This report of an unusual case highlights the existence of atypical presentations, discusses the potential role of the pronator quadratus space, and further emphasizes the need for vigilance even in ‘‘low-risk’’ cases of distal radius fracture. (Journal of Surgical Orthopaedic Advances 17(2):102–106, 2008) Key words: compartment syndrome, distal radius, forearm, low-energy injury, pain, pronator quadratus

Idiopathic clubfoot is a common condition seen by orthopaedic surgeons and is characterized by complex three-dimensional deformity of the foot. It is recognized that clubfoot treatment is a challenging issue in orthopaedics because it is an ongoing process, beginning in early infancy and continuing until the patient has reached skeletalmaturity. This review article summarizes two important stages of clubfoot treatment. First, methods of initial correction — including nonoperative, semi-operative, and operative techniques — that have been used in the last 20 years are described. Second, the management of the recurrent clubfoot is discussed in terms of methods used to address specific deformities. (Journal of Surgical Orthopaedic Advances 17(2):107–114, 2008) Key words: congenital clubfoot, nonoperative treatment, operative treatment, semi-operative treatment

To perform an arthroscopic rotator cuff or labral tear, surgeons need to know how to tie athroscopic knots. The ideal knot should be able to withstand large biomechanical loads while being easy to tie. With numerous knot configuration options available to surgeons, many recent studies have assessed the biomechanical characteristics of some of the more commonly used knots. Different studies have referred to the flip knot used by the senior author (DMD) as the ‘‘Dines knot,’’ and in many of these studies, it has exhibited the best loop security, resistance to sliding, distance to failure, knot security, knot weight, and resistance to reverse slippage. To date, there is no published technique note on how to tie the Dines knot, which is referred to in this note as the ‘‘DMD knot.’’ (Journal of Surgical Orthopaedic Advances 17(2):115–118, 2008) Key words: arthroscopic knot, DMD knot, flip knot

Chronic exertional compartment syndrome is a condition that typically fails conservative management and requires a fasciotomy for the patient to return to activity. Fasciotomies performed through single or multiple incisions may fail to fully release the fascia of the afflicted compartment(s) and also may result in injury to neurovascular structures that cannot be visualized. Endoscopic assistance may minimize the intraoperative and postoperative complications associated with compartment release and offer improved cosmesis. This article describes an endoscopically assisted technique using a balloon dissector designed to address the shortcomings of open and semi-blind techniques. (Journal of Surgical Orthopaedic Advances 17(2):119–121, 2008) Key words: balloon dissector, chronic exertional compartment syndrome, endoscopic technique

Trial component reduction in hip arthroplasty is a crucial and essential step in the operation because it enables the surgeon to test hip stability and leg length, to exclude prosthesis impingement, and to make the necessary adjustments (1). Redislocation and removal of a well-fixed trial component can be demanding, especially if the joint is very tight. We have noted that difficult dislocations often can be easily accomplished by passing a cloth tape around the prosthetic neck, using it for leverage.