Volume 13-3, Fall 2004

Venous thromboembolism (VTE), a highly prevalent vascular disorder, is frequently clinically silent, and is often difficult to diagnose. VTE consists of both deep vein thrombosis (DVT) and pulmonary embolism (PE), both of which are associated with potentially significant morbidity and mortality. With the availability of safe and effective antithrombotic therapy, the standard of medical care should be the routine use of thromboprophylaxis. The risk of developing VTE increases with advancing age, and the performance of surgery to repair a fractured hip increases this risk even more. Thus elderly hip fracture patients are always considered to be at the highest risk for developing fatal PE. Over the last decade, new anticoagulants, such as the factor Xa inhibitor fondaparinux, have been developed that specifically target individual components of the coagulation system. Fondaparinux is a selective, synthetic factor Xa inhibitor that has been shown to significantly reduce the risk of VTE versus enoxaparin in patients undergoing surgery for hip fracture. Extended (4-week) prophylaxis with fondaparinux can produce a 96% reduction in risk of DVT and an 89% reduction in risk of symptomatic VTE events relative to perioperative (1-week) prophylaxis. As the only anticoagulant approved in the United States for thromboprophylaxis in hip fracture patients, fondaparinux offers more effective prophylaxis against VTE without compromising safety. (Journal of Surgical Orthopaedic Advances 13(3):139–148, 2004) Key words: anticoagulants, deep vein thrombosis, factor Xa inhibitors, hip fracture, prophylaxis, pulmonary embolism, venous thromboembolism

The purpose of this study was to determine the effects of botulinum toxin type A treatment on ankle muscle activity during gait of children who are idiopathic toe-walkers. Five children who were idiopathic toe-walkers with a mean age was 4.34 years participated. Gait of the subjects was evaluated prior to, 20 days following, and 12 months following bilateral botulinum toxin type A injection of the gastrocnemius and soleus muscles. Subjects received physical therapy following the 20-day evaluation. Dependent variables were type of foot contact pattern and duration of swing-phase tibialis anterior activity and onset of stance-phase gastrocnemius relative to ground contact. Prior to treatment 51% of foot contacts were with the toe (heel just off the ground) or were digitigrade, while the remaining contacts were flat foot or heel strike. At approximately 20 days following treatment, only 8% of foot contacts were toe contact or digitigrade. Prior to treatment, mean gastrocnemius onset was 30 ms prior to foot contact and the duration of swing-phase tibialis anterior was only 345 ms. Following treatment (and a more normal foot contact pattern), mean gastrocnemius onset followed ground contact by 36 ms and tibialis anterior duration increased through terminal swing and into the loading response. The posttreatment improvement was maintained at 12-month follow-up. It appears that botulinum toxin type A treatment normalizes the ankle EMG pattern during gait and a more normal foot-strike pattern is obtained. These data are discussed in terms of a neuromotor rationale for the rehabilitation of children who are idiopathic toe-walkers to maintain posttreatment improvements. (Journal of Surgical Orthopaedic Advances 13(3):149–155, 2004) Key words: botulinum toxin, EMG, gait, idiopathic toe-walkers

The Jones fracture, defined as a proximal junctional metaphyseal/diaphyseal fracture of the fifth metatarsal, presents a challenge to the orthopaedic surgeon, especially in the competitive athlete. The purpose of this study is to characterize the Jones fracture in the elite athletic community and review the variety of treatments for these fractures in the National Football League (NFL). Between 1988 and 2002, 4758 elite collegiate football players participated in the NFL Combine. All athletes were evaluated clinically and radiographically. There were 86 Jones fractures identified in 83 athletes (incidence of 1.8%). Fifty-three percent (46 of 86) of the fractures were treated surgically. Eighty-nine percent (41 of 46) healed without complications and 7% (3 of 46) developed a nonunion. Twenty percent (8 of 40) of the fractures treated nonoperatively developed a nonunion while 80% (32 of 40) healed. The NFL injury surveillance system was also studied and revealed 17 Jones fractures occurred during the seasons 1996–2001. All of these fractures were treated with intramedullary screw fixation. The union rate was 94% (16 of 17 fractures). A questionnaire was also sent to all NFL team physicians regarding their experience with these fractures. The concensus was that this is not a common injury, but when it occurs, surgical treatment is recommended (77%) over nonsurgical treatment (23%). After reviewing the data, it was found that intramedullary screw fixation of Jones fractures is the treatment of choice for most physicians who treat elite collegiate and professional football athletes. (Journal of Surgical Orthopaedic Advances 13(3):156–160, 2004) Key words: elite athlete, Jones fracture

Fifteen adult patients with an unstable ununited fracture of the distal third of the radius and severe radial deviation deformity resembling a radial club hand were retrospectively reviewed at an average of 25 months after operative treatment. There were eight women and seven men with an average age of 57 years (range, 33–79 years). The average duration of nonunion was 56 months (range, 6–252 months). Six patients had a concomitant fracture of the ulna and four had dislocation of the distal radioulnar joint. Three patients were treated with wrist arthrodesis and 12 with plate fixation and autogenous bone grafting. The distal ulna was excised and used for bone graft in eight patients. Correction of deformity was facilitated by z-lengthening of the brachioradialis and flexor carpal radialis in four patients and distraction histogenesis (Ilizarov) in two patients. One patient failed to heal the fracture and was treated with wrist arthrodesis. Functional alignment and use of the hand was restored in all patients. (Journal of Surgical Orthopaedic Advances 13(3):161–165, 2004) Key words: distal radius, fracture, internal fixation, nonunion, reconstruction

Conventional wisdom holds that the Pemberton innominate osteotomy improves acetabular coverage and decreases acetabular volume through hinging of the acetabular dome through the triradiate cartilage. The aim of this study was to identify the site of hinging through the triradiate cartilage and characterize any alteration in acetabular volume produced by this procedure. Pemberton innominate osteotomies were performed under fluoroscopic control on six fresh immature pig innominate bones. The site of hinging at the triradiate cartilage was identified through observation during the procedure. Just prior to and immediately after the procedure, the acetabular dimensions were measured and recorded. Hinging was observed to occur through the extra-articular portion of the ilioischial limb of the triradiate cartilage. No alteration of acetabular volume was observed following successful Pemberton innominate osteotomies. The Pemberton osteotomy improves femoral head coverage through redirection of the acetabulum rather than alteration of acetabular shape. (Journal of Surgical Orthopaedic Advances 13(3):166–169, 2004) Key words: acetabular dimensions, Pemberton osteotomy

Vascular injuries during the implantation of orthopaedic devices can lead to fatal complications. Most injuries will be apparent intraoperatively, while others may be delayed in their presentation. Most articles documenting these injuries during the treatment of hip fractures involve lacerations of the deep femoral vessels by cortical bone screws (1–6) and avulsed lesser trochanter bone fragments (5, 7–10). Hohmann retractors (11) and guidewire pins (12) have also been implicated in intraoperative vascular injuries during hip surgery.

A case report of a 54-year-old man who underwent a revision arthroplasty 13 years after his original hip replacement is presented. The patient presented to the clinic with a 2-month history of hip pain. Severe pelvic osteolytic lesions were seen on radiographs. The revision procedure consisted of debridment of the osteolytic lesions and bone grafting. An arthroscopic shaver was used to remove the osteolytic lesions proximal to the acetabular cup. Excellent debridment was obtained. Cortical bone allograft was the used to fill the void areas behind the cup. The patient did well postoperatively with no recurrence of osteolysis as seen on radiographs obtained 7 months after surgery. This report presents a successful case of pelvic osteolytic debridment with the use of an arthroscopic shaver. (Journal of Surgical Orthopaedic Advances 13(3):174–176, 2004) Key words: hip, osteolysis, revision

Cannulated screws can be inserted in a precise manner with minimal damage to surrounding structures but lack the mechanical strength of solid screws. Our method allows the insertion of a solid screw with the precision of the cannulated technique. With the use of equipment from a variety of operative sets from one manufacturer, a ‘‘custom’’ equipment set can be developed. This ‘‘custom’’ equipment set allows the surgeon to benefit from the strength of solid screws while preserving the precision of a cannulated system. (Journal of Surgical Orthopaedic Advances 13(3):177–179, 2004) Key words: cannulated screw, screw strength, solid screw