Volume 15-2, Summer 2006

There is reported to be no increased risk for developmental dysplasia of the hip in children with idiopathic clubfoot. The purpose of this study was to determine the incidence of radiographic hip dysplasia in infants with idiopathic clubfoot. Fifty-one children with idiopathic clubfoot who underwent surgical release by a single surgeon had anterior-posterior pelvis radiographs obtained at 4 or more months of age to screen for developmental dysplasia of the hip. The acetabular index measured more than 28° in eight children (16%). This study suggests an association between idiopathic clubfoot and developmental dysplasia of the hip.

Follow-up of indigent patients is difficult. Demographics collected at initial hospitalization change often and are unreliable. In a boxer fracture study, at 1-year follow-up, 3 out of 100 patients were available. This poor performance prompted investigation of new methods for intake/ongoing care. A direct comparison of two studies was conducted. In study 1, demographics were obtained per standard hospital procedure. Patients were paid $50.00 per visit as an incentive. In study 2, expanded demographics were gathered. Related contactswere identified and credibilitywas verified. Rapport was established with the patient and family. In both studies, 100% follow-up was obtained. Significant difficulty was experienced obtaining follow-up in study 1. Patients attempted to renegotiate compensation. Follow-up was perceived as unnecessary and unpleasant. Study 2 patients kept appointments, expressed comfort during follow-up, and felt part of the treatment team. In both cases, availability of patients for follow-up increased dramatically. Financial compensation was troublesome. Providing access to an interested medical team was less cumbersome and provided superior results.

Few areas in orthopaedics have evolved so dramatically over the past few decades as our knowledge of knee physiology, knee kinematics, and knee replacement surgery. This article addresses major breakthroughs in knee replacement surgery, the thought process behind these concepts, and their impact on clinical practice. It focuses on compartmental arthroplasty, use of minimally invasive surgery, advances in biomaterials, and biological solutions for treating arthritis. Compartmental knee replacements are gaining popularity, especially for medial compartment arthritis. Minimally invasive surgery (i.e., quadriceps sparing arthroplasty) has become very popular in the last few years and is being used routinely for unicompartmental knee replacement and increasingly used for total knee replacement. Computer-assisted surgery has the ability to help the surgeon place the components in the desired position, thereby avoiding component malpositioning, which can cause pain, instability, limited range of movement, excessive polyethylene wear, and subsequent implant loosening. Recent advances in the metallurgy have led to the introduction of tantalum trabecular metal which offers several advantages over other current conventional materials used for implants. Expanding knowledge regarding cartilage biochemistry and the pathogenesis of osteoarthritis has focused the research on slowing the progression of osteoarthritis and promoting cartilage matrix synthesis. Perichondrial transplantation as well as periosteal transplantation have been tried by a few investigators but they have limited and temporary success. Autologous chondrocyte implantation is another technique that is gaining popularity. The chondrocytes harvested from the patient are cultured and reimplanted after 3–4 weeks of culturing. In the future, we are likely to see advances in diagnosis as well as management of osteoarthritis. The treatment modalities will probably evolve at the cellular level and it will not be long before a patient-specific medication can be given to a asymptomatic patient in order to prevent development of steoarthritis. Patients with end-stage osteoarthritis will be offered a combination of treatments (e.g., partial replacement of one compartment or localized cartilage repair if there is localized cartilage defect in the other compartment).

Osteonecrosis (ON) is a common complication following femoral neck fracture and most studies have reported the incidence of ON after less than 3 years follow-up. Here we report a case of delayed osteonecrosis 7 years after initial treatment for a femoral neck fracture. This example supports the need for continued clinical and radiographic follow-up over an extended period after femoral neck fracture and suggests that 3 years is too short a time to reliably rule out ON as a postoperative complication.

Pediatric radial neck fractures are relatively common injuries resulting from a fall onto an outstretched arm. However, radial neck fractures with medial displacement of the shaft are difficult and fortunately rare injuries, having only been described twice in the literature. This case report describes the presentation and treatment of a pediatric elbow fracture where the radial shaft displaced medial to the coronoid process and pierced the joint capsule, requiring open reduction with internal fixation.

Intraarticular fractures of the distal humerus are challenging problems for the treating surgeon. When these fractures are complicated by severe comminution and poor bone quality, open reduction and internal fixation may lead to poor clinical outcomes when compared with those treated with primary total elbow arthroplasty. The population in which this clinical scenario most often arises is the elderly. An unusual case is presented in which a 38-year-old individual was successfully treated with primary total elbow arthroplasty for a highly comminuted, intraarticular distal humerus fracture with severe osteopenia due to osteogenesis imperfecta in which standard plate osteosynthesis was unlikely to provide sufficient stable fixation.

A case report is presented of an 18-year-old boy with advanced fibrodysplasia ossificans progressiva. The patient’s right hip was ankylosed in 35° of flexion. Excision of the heterotopic bone from the right hip was followed by a combination of a single fraction irradiation (7Gy) given in the first postoperative day, and an 11-day treatment with indomethacin (25 mg, three times daily, orally). One year postoperatively, the patient ambulates nearly normally and he is able to sit and stand up without significant difficulty. Radiographs of the right hip showed a small amount of heterotopic bone formation at the operative site. In contrast with the results published in the literature, the clinical result of the operation is considered satisfactory. Further investigation of the combined use of indomethacin and single fraction irradiation as a preventivemeasure after surgical excision of heterotopic bone in patients with fibrodysplasia ossificans progressiva FOP should be performed.

This report presents two cases of pseudomalignant myositis ossificans (PMO) of the fifth proximal phalanx and their management. The charts, X-rays, pathology specimens, and clinical outcome for two patients treated for PMO were retrospectively reviewed. Both patients presented with isolated swelling and pain over the proximal phalanx of the fifth digit and underwent biopsy of the lesions. In both cases the pathology results were conclusive for PMO. Both patients had improvement in pain and swelling postoperatively. There was no recurrence in either patient. PMO can easily be confused with a malignancy. Proper workup, including biopsy, should be performed in order to accurately make the diagnosis. Radical procedures or amputations should not be performed until a diagnosis has been made. Excision is indicated when nerve compression or loss of joint motion secondary to mass effect occurs. Historically, recurrence has not been a problem after excision.

Osteolysis and aseptic loosening are the major causes of failure of total hip replacements (THRs). These processes are induced by wear debris released from components of implants over time. Wear particles are a clinically relevant size (0.1–10 µm) that activates macrophages and induces a foreign-body response. Activated macrophages stimulate the production of proinflammatory cytokines (IL-1, IL-6, and TNF-²) to the synovial capsule, leading to chronic inflammation and bone resorption. Wear mechanics, including characteristics of wear particles from metal, polyethylene, and ceramic articulating surfaces, fixation materials, and surface coatings, have been reported in the literature and are compiled here. Data concerning the pathophysiological effects of wear debris are reported in this article, whereas data on the metal ions released from implants are presented in the following article (see pp. 113–114). Clinical data obtained from in vivo use and laboratory studies conducted in vitro are summarized.

Total hip joint arthroplasty is performed in increasing numbers — about 0.16–0.2% of population per year in industrial countries. In most cases, an implant is a metallic component articulating with a metal, ceramic, or polyethylene liner, used in the hip, knee, and spine. The metal implants release ions in vivo. Toxic concentrations of ions can lead to many adverse physiological effects, including cytotoxicity, genotoxicity, carcinogenicity, and metal sensitivity. Reference levels of ion concentrations in body fluids and tissues determined by many studies are compiled, reviewed, and presented in this article. The concentrations of ions released from different alloys — including cobalt, chromium, nickel, molybdenum titanium, aluminum, and vanadium — are also presented. This article reviews the literature pertaining to clinical data on metal ion concentrations in patients with metal joint prostheses and laboratory data on the physiological effects of the metals.

Mallet fingers are difficult to treat, especially in surgeons, who need to sterilize their hands continuously and who have constant strains placed on their fingers. We successfully treated a nondominant, fifth-digit, nonbony mallet finger in a surgical resident with a splint method composed of a bent, semitubular, small-fragment plate and Steri-strips (3-M, St. Paul, MN). This splinting method allowed the resident to continue performing surgeries while the injury healed.