Volume 13-2, Summer 2004

Necrotizing soft tissue infections encompass a wide variety of clinical syndromes resulting from introduction of various pathogens into injured or devitalized tissue. The extent of microbial involvement in such tissue may range from simple contamination to overt and progressive local tissue necrosis, which, if untreated, may lead to septicemia and death. Early differentiation among these infections is not always possible, as there are overlapping classification criteria. These infections exist along a continuum of clinical severity with different etiological agents and associated medical conditions. The often subtle clues heralding the presence of a necrotizing soft tissue infection must be sought so that expeditious surgical debridement and broad-spectrum antibiotic management are initiated. Although experience enables the clinician to make a specific diagnosis based on early findings, aggressive and proper treatment of suspected infections remains the priority. The purpose of the article is to provide an overview of necrotizing soft tissue infections in the upper extremity, focusing on gas gangrene, or clostridial myonecrosis, and necrotizing fasciitis, to facilitate early diagnosis and optimal management of these lethal diseases. (Journal of Surgical Orthopaedic Advances 13(2):57–68, 2004) Key words: clostridial myonecrosis, gas gangrene, necrotizing fasciitis, soft tissue infections

Four patients with acromioclavicular joint injuries (one type II, two type III, one type V), two patients without acromioclavicular joint injury, and a fresh-frozen cadaver underwent magnetic resonance imaging (MRI) and plain radiographs. The normal conoid and trapezoid ligaments were easily identified in the cadaver and the two uninjured patients. Magnetic resonance imaging revealed disruption of both coraclavicular ligaments in the three patients with type II and type III injuries. However, the patient with the type V injury had disruption of the trapezoid ligament alone. Thus, the grade of injury, as determined by the change in the coracoclavicular interval onplain radiography and defined by the Rockwood classification system, failed to correlate with the pathoanatomy seen on MRI in two of the four injured patients. These findings suggest that improvements in the classification of these injuries may be necessary. (Journal of Surgical Orthopaedic Advances 13(2):69–75, 2004) Key words: acromioclavicular ligament, conoid, coracoclavicular ligaments, injury classification, magnetic resonance imaging (MRI)

A prospective cohort study with annual follow-up was conducted on 172 children with spastic type cerebral palsy receiving botulinum toxin type A (BTX) injections for spasticity management. A mixed modeling procedure was used to identify changes in both physical functioning outcomes for the child (using the WeeFIM measure) as well as quality of life of the parent caregiver (using the Stein and Reissman Impact on the Family Scale) with increasing utilization of BTX injections. The study found that each additional BTX injection administration was associated with a 2.3% improvement in the WeeFIM compared to the average baseline score (p < .01). Similarly, the study found an improvement of 2.5% compared to baseline in the parent’s overall perception of the severity of the child’s condition with each additional BTX injection administration (p < .001). These findings suggest that BTX injections may be associated with beneficial outcomes in childhood spasticity. (Journal of Surgical Orthopaedic Advances 13(2):76–80, 2004) Key words: botulinum toxin type A injection, cerebral palsy, health outcomes, longitudinal study, spasticity

This review article deals with ankle fusions, their indications, preoperative assessment, surgical technique, and postoperative treatment along with a discussion of complications and long-term results. (Journal of Surgical Orthopaedic Advances 13(2):81–90, 2004)

The vascularity of the acetabular free fragment in Ganz osteotomies has remained a concern. This study aims to assess the role of MR imaging in the postoperative evaluation of Ganz osteotomies. Twenty patients (19 females, 1 male), average age 24 years (range, 12–36 years), had sequential magnetic resonance imaging studies of the pelvis at 6 weeks and 6 months following Ganz osteotomies. Normal healing with no evidence of periosteotomy edema was seen in 17 patients at 6 weeks. Three patients showed evidence of reduced vascularity. In two of these, there were focal changes suggestive of subclinical ischemia. The other had gross signal changes in the osteotomy fragment suggestive of diffuse ischemia. The patients with focal changes were asymptomatic and had normal 6-month scans. The patient with diffuse changes complained of persistent groin pain, which resolved after 4 months. The 6-month scan showed some persistent vascular changes. The scan at 1 year showed complete resolution. The study suggests that Ganz osteotomy has minimal effect on the vascularity of the acetabular free fragment. (Journal of Surgical Orthopaedic Advances 13(2):91–93, 2004) Key words: Ganz, MRI, osteotomy, vascularity

The wear in hip implants is one of the main causes for premature hip replacements. The wear affects the potential life of the prosthesis and subsequent removals of in vivo implants. Therefore, the objective of this article is to review various joints that show lower wear rates and consequently higher life. Ceramics are used in hip implants and have been found to produce lower wear rates. This article discusses the advantages and disadvantages of ceramics compared to other implant materials. Different types of ceramics that are being used are reviewed in terms of the wear characteristics, debris released, and their size together with other biological factors. In general, the wear rates in ceramics were lower than that of metal-on-metal and metal-on-polyethylene combinations. (Journal of Surgical Orthopaedic Advances 13(2):94–105, 2004) Keywords: articulating surfaces, ceramic implants, ceramic-on-ceramic, hip prosthesis, metal-on-metal, metal-on-polyethylene, total hip arthroplasty, wear debris, wear rate

A technique for surgical treatment of anterior cervical osteophytes is presented. A midline trough is created in the osteophytes using a burr under fluoroscopy down to the anterior cervical line. A rongeur is used to remove the remaining osteophytes while protecting the lateral soft tissues. Two patients presented with symptoms of progressive dysphagia secondary to anterior cervical osteophytes. Each underwent surgical ostectomy without complication after failing conservative treatment. This technique provides a safe, effective method to remove anterior cervical osteophytes. (Journal of Surgical Orthopaedic Advances 13(2):106–109, 2004) Key words: cervical spine, degenerative, dysphagia, osteophyte, surgery

Giant cell tumor of the tendon sheath has frequently been described in the hand, but it is much less common in the foot. The case report presents an apparent cystic bony lesion of the proximal phalanx of the second toe of the foot. The operative findings and histological examination revealed a giant cell tumor of the tendon sheath that had eroded the phalanx. The case demonstrates that in the differential diagnosis of a cystic lesion of bone, extrinsic soft-tissue lesions should be considered. (Journal of Surgical Orthopaedic Advances 13(2):110–111, 2004) Key words: case report, enchondroma, foot, giant cell tumor

Lower extremity injuries secondary to close-range, low-velocity gunshot wounds are frequently seen in both civilian and military populations. A close-range, low-velocity injury produces high energy and often results in comminuted and complicated fractures with significant morbidity. In this study, four femoral, four tibial, and three combined tibia and fibular comminuted diaphyseal fractures secondary to closerange, low-velocity gunshot wounds in 11 military personnel were treated with debridement followed by compression-distraction lengthening using a circular external fixator frame. Fracture union was obtained in allwithout significant major complications. Fracture consolidation occurred at a mean of 3.5months. At follow-up of 46.8 months, there were no delayed unions, nonunions, or malunions. Minor complications included four pin-tract infections and knee flexion limitation in two femur fractures. Osteomyelitis and deep soft tissue infection were not observed. This technique provided an alternative to casting, open reduction internal fixation, or intermedullary fixation with an acceptable complication rate. (Journal of Surgical Orthopaedic Advances 13(2):112–118, 2004) Key words: close-range, low-velocity gunshot wounds, tibia and femoral diaphyseal fractures

Patient and surgeon goals for joint replacements have changed over the last 3 decades. Initially performed for relief of pain, expectations now include higher functional demands and return to normal or near normal activities. Formulating a set of activity guidelines for patients after joint replacement surgery is difficult because data on which recommendations can be based are meager. Therefore, such recommendations are based for the most part on surgeon preference.

Giant cell tumor of tendon sheath is a common synovial tumor that usually occurs in the hands and feet but rarely occurs around large joints (1–3). Orthopedic surgeons do not generally encounter diagnostic problems because of its typical location and classical radiological and clinical appearance. This clinical entity may sometimes cause osseous changes like erosion or external pressure findings (4, 5). The purpose of this report is to present a misinterpretation of a case with giant cell tumor of tendon sheath as a giant cell tumor of bone involving the proximal tibial plateau.