Arthroscopic Rotator Cuff Tear Repair--Champ L. Baker, MD, Andrew L. Whaley, MD, and Mark Baker, PT

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Rotator cuff injuries or disease can be particularly troubling to patients by causing them pain, weakness, and dysfunction of the shoulder. Surgery of the shoulder and, in particular, of the rotator cuff, has evolved over the years from open surgery to include arthroscopic treatment for many conditions. Although technically demanding, arthroscopic repair of full- and partial-thickness rotator cuff tears has been shown to produce satisfactory results. Along with the advantages of the arthroscopic technique, smaller skin incisions, access to the glenohumeral joint for inspection and treatment of intra-articular lesions, no detachment of the deltoid, and less soft-tissue dissection, patients’ results are comparable with those obtained with the open method of repair. The three phases of shoulder rehabilitation for patients who have undergone surgical treatment of rotator cuff disease are described: Phase 1, the immediate postoperative, or protective, phase; phase 2, the progressive strengthening phase; and phase 3, the advanced conditioning and return-to-sport phase. The postoperative rehabilitation programs for the arthroscopic and mini-open rotator cuff repair are essentially the same. (Journal of Surgical Orthopaedic Advances 12(4):175–190, 2003) Key words: arthroscopy, glenohumeral joint, mini-open repair, rotator cuff, subacromial decompression

Orthopedic Pearls in Deep Vein Thrombosis: Questions Frequently Asked--James E. Muntz, MD

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As an orthopedist performing knee and hip replacement surgery, what should be my start time and my length of therapy with low-molecular-weight heparins (LMWH), and are all patients the same? therapy will be extended as a number of duration of prophylaxis trials have all showed benefits in the reduction in deep vein thrombosis (DVT) rates with longer treatment

Mid- to Long-Term Clinical Findings in Nailing of Distal Femoral Fractures--Philipp T. Funovics, MD, Vilmos V´ecsei, MD, and Gerald E. Wozasek, MD

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The purpose of the study was to evaluate clinical long-term results after nailing of distal femoral fractures. The first 22 consecutive cases of distal femoral fractures in 22 patients (2 males and 20 females, age 65 years, range, 16–97 years) treated with retrograde femoral nailing from October 1994 to May 1997 are reported. Indications were AO 33 A1 (n = 7), 33 A2 (n = 2), 33 A3 (n = 3), and 33 C2 (n = 7) fractures. In 11 cases these were periprosthetic fractures of either total hip arthroplasty or hemiarthroplasty of the hip (five) or dynamic hip screw (six), four patients were polytraumatized, one patient had a floating-knee injury. No infections or thrombosis were observed postoperatively. In 17 cases primary union was achieved within 11 weeks (8–17 weeks); five patients died before consolidation. Patients returned to full weightbearing after 5 weeks (4–12 weeks); active knee motion ranged from 80° to 130°. In five patients slight malalignment <10° was radiographically assessed, with two showing incipient degenerative joint disease. Patients younger than 60 years returned to full preoperative activity level. Eleven patients surviving an average of 5.2 years (4.3–6.9 years) were available for long-term follow-up. As a subgroup they were evaluated according to the Leung score for distal femoral fractures with seven excellent and four good results and an average score of 84.3 points (70–92 points). The mid- to long-term results confirm retrograde femoral nailing to be a good alternative to plate osteosynthesis for AO 33 A- and C2-type fractures.

Treatment of Nonunions Following Anterior Cervical Discectomy and Fusion with Interspinous Wiring and Bone Grafting--Donald R. Gore, MD, and Michael Brechbuler, BS

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Between 1979 and 2000, 25 posterior arthrodeses were performed for repair of symptomatic nonunions following anterior discectomy and fusion. The surgical technique in all cases was an interspinous wiring with an autogenous bone graft in 20 and morselized allograft bone in five. The average follow-up was 5 years (range, 1–14 years). In all patients, the anterior pseudarthrosis progressed to a solid union as judged by an independent musculoskeletal radiologist. In 17 patients, their preoperative pain was relieved; however, of these, six developed recurrent pain caused by degeneration at an adjacent level on an average of 5 years (range, 1–14 years) after their posterior surgery. The authors propose that posterior interspinous wiring with a bone graft is a safe and efficacious method of repair of an anterior pseudarthrosis. However, patients must be cautioned that even though the pseudarthrosis can be predictably repaired by a posterior procedure, preoperative pain may not be relieved. (Journal of Surgical Orthopaedic Advances 12(4):214–217, 2003) Key words: anterior cervical discectomy, nonunion, posterior arthrodesis

Inter- and Intraobserver Variance of Cobb Angle Measurements with Digital Radiographs--Matthew G. Zmurko, MD; James F. Mooney III, MD; David A. Podeszwa, MD; Glenn J. Minster, MD; Michael J. Mendelow, MD, and Ashraf Guirgues, MD

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This study compares the intra- and interobserver variance of Cobb angle measurements of primary and secondary curves on digital radiographs versus traditional radiographs. Four orthopaedic surgeons of varying experience measured the Cobb angles from a standard posteroanterior thoracolumbar scoliosis radiograph (25 digital, 25 traditional) on two occasions 2 weeks apart. The intra- and interobserver variances were calculated and compared for major versus minor curves and the digital versus traditional radiographs. There was no statistical difference in the mean error index, the variability in choosing the end vertebra on successive measurements, between the digital and traditional groups. Similarly, there was no significant difference in the intraobserver or interobserver variance between the digital and traditional groups. Digital radiographs are comparable to the use of traditional radiographs for following patients with adolescent idiopathic scoliosis. Furthermore, increasing years of experience appears to result in fewer errors and more consistency using the Cobb method. (Journal of Surgical Orthopaedic Advances 12(4):208–213, 2003) Key words: Cobb angle, radiographs, scoliosis

Fine-Needle Aspiration Cytology, Frozen Section, and Open Biopsy: Relative Significance in Diagnosis of Musculoskeletal Tumors--Maninder Singh Shah, MS; Vishal Garg, MBBS, MS; Sudhir K. Kapoor, MS; B. K. Dhaon, MS, MNAMS, and Ranjana Gondal, MD

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Fine-needle aspiration cytology (FNAC) is a minimally invasive technique used extensively in diagnosis of various tumors. Frozen section biopsy is known for its usefulness in assessing adequacy of margins of resection intraoperatively. This study assesses the usefulness and significance of these procedures in tumors of musculoskeletal origin. This study includes 91 patients and all the patients were subjected to a preoperative FNAC test on an outpatient basis. An open biopsy was done in every case under appropriate anesthesia and representative tumor tissue was sent for frozen section analysis. Out of 91 patients, FNAC was feasible in 78 patients. Out of the 78 patients aspirated, a type-specific diagnosis was made in 79.5% of cases (62 out of 78). Frozen section was possible in 85 cases. The percentage of specific diagnosis by frozen section in this study is 85.9% (73 out of 85) and overall diagnostic accuracy of 96.5% (82 out of 85). FNAC and frozen section are reliable diagnostic modalities, in the presence of clinico-radiological correlation, in the diagnosis of musculoskeletal tumors. (Journal of Surgical Orthopaedic Advances 12(4):203–207, 2003) Key words: biospy, FNAC, frozen section, musculoskeletal tumors, sarcoma

Low Back Pain Intervention:Conservative or Surgical?--Daniel Lee, MD

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Low back pain (LBP) is a very common disorder with a U.S. population incidence of 80%. The risk for developing chronic LBP is relatively low but the majority of the costs associated with LBP are generated specifically by this group. Unfortunately, there is no gold standard intervention and few comparative, randomized, prospective treatment studies have been done. Therefore, the optimal treatment approach continues to be controversial. Surgery is usually reserved for those patients with severe and debilitating symptoms and, with careful selection, can result in good outcomes with rapid return to function. For patients who are not surgical candidates, conservative treatment must emphasize restoration and maintenance of functional movement. (Journal of Surgical Orthopaedic Advances 12(4):200–202, 2003) Key words: acute low back pain, chronic low back pain, internal disc derangement, low back sprain, lumbar spondylosis, mechanical low back pain

Metastatic Bone Tumors of the Pelvis and Lower Extremity--David Buggay, MD, and Kenneth Jaffe, MD

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The evaluation and surgical treatment ofmetastatic lesions of the lower extremity and pelvis are reviewed. The initial evaluation, biopsy considerations, treatment options, special techniques, and controversial areas are discussed. (Journal of Surgical Orthopaedic Advances 12(4):192–199, 2003) Key words: bone, lower extremity, metastatic, pelvis, surgery

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