Opinion -- Pseudoscientific Explanations -- David Ring, MD, PhD, and Madeline McCarthy, BA
Humans have learned to use science to overcome shortcomings in their thought processes. These shortcomings can be more obvious in intelligent people. As any good magician can tell you, smart people are easier to fool (1). Smart people are better at pattern forming, rationalization, and other factors that facilitate the magician’s illusion, that lead smart people to believe weird things (2), and that make us convinced of something that is not true (3).
Management of Open Fractures in Adult Patients: Current Teaching in ACGME Accredited Residency Programs -- William F. Lavelle, MD, Richard Uhl, MD, Michael Krie
The purpose of this study is to determine the methods of treatment for open fractures that are currently used by academic orthopaedic residency programs. AWeb-based survey was constructed and e-mailed to program directors of orthopaedic residencies. Seventy-four programs out of a total of 140 (53%) surveyed programs responded. Data were tabulated and charts were created in an Excel spreadsheet. Type I fractures were treated bymost with a cephalosporin alone (99%) for less than 48 hours (86%). Type II fractures were treated by most programs with a cephalosporin alone with no aminoglycoside (85%) for less than 48 hours (81%). Type IIIa fractures were treated by most programs with a cephalosporin and an aminoglycoside (55%) for less than 48 hours (54%). Type IIIb fractures were treated by most with a cephalosporin and aminoglycoside (55%) for less than 48 hours (54%). Type IIIc fractures were also treated by most with a cephalosporin and an aminoglycoside (57%) for less than 48 hours (49%). Wounds were closed by most responders for type I (88%), type II (86%), and type IIIa (57%), but not type IIIb (5%) and type IIIc (11%) fractures. Fifty-four percent of programs reported having trauma rooms and 58% of programs allow residents to irrigate and d ´ ebride wounds in the emergency room. The study concluded that most orthopaedic residencies utilize a cephalosporin alone for types I and II open fractures with an aminoglycoside added for type III fractures. Antibiotic treatment is typically given for 48 hours or less. A delay of 6 hours is accepted for types I and II fractures but not type III fractures.
Treatment of Angular Deformities of the Tibia in Children: Acute Versus Gradual Correction -- James J. McCarthy, MD, Arthur K. Mark, MD, and Richard S. Davidson
This is a retrospective review of 25 tibial osteotomies (in 19 patients) performed with either acute or gradual correction to determine the outcome of treatment and incidence of neurovascular complications. Patients undergoing gradual correction had fewer neurovascular complications and greater correction than those undergoing acute correction (27° vs. 18°, respectively). It was concluded that gradual correction tends to be a safer technique for the treatment of tibial deformities and allows greater correction.
Shoulder Replacement in End-Stage Rotator Cuff Tear Arthropathy: 5- to 11-Year Follow-up Analysis of the Bi-Polar Shoulder Prosthesis -- Efrain Diaz-Borjon, MD
Between 1991 and 1997, 49 patients with rotator cuff arthropathy underwent 52 Bi-Polar shoulder replacements and were followed for 5–11 years (average follow-up 6.7 years). Active forward flexion increased an average of 35.2° (from 45° preoperatively to 80.2° postoperatively). UCLA scores improved from 8.4 (range 4–16) preoperatively to 24.3 (range 15–35) postoperatively. Average age- and sexadjusted Constant scores were 83.4% and ASES index was 68.5 points at the time of final review. Two shoulders (3.8%) were revised — both secondary to periprosthetic fracture requiring long-stem implants. Probability of survival at 11 years using Kaplan-Meier survival estimates was 93.3% (95% Cl: 84%–100%). Bipolar shoulder arthroplasty is an effective way to treat end-stage rotator cuff arthropathy with clinical results as good or better than those reported in the literature for hemiarthroplasty and total shoulder replacement with reasonable follow-up.
Applicability of the Mini-Subvastus Total Knee Arthroplasty Technique: An Analysis of 725 Cases With Mean 2-Year Follow-up -- William C. Schroer, MD; Paul J. D.
Recent total knee arthroplasty (TKA) studies suggest a more rapid functional recovery with minimally invasive surgical (MIS) techniques. These studies often fail to disclose the percentage of primary TKA that underwent the MIS technique, raising the concern that positive clinical outcomes are a result of patient selection. This study evaluates the applicability of the mini-subvastus technique in one surgeon’s consecutive primary TKA patients. The applicability was determined utilizing a computer record review to determine the percentage of primary TKA patients in which the surgeon utilized a MIS surgical technique. The mini-subvastus approach was applied to 99% of 732 consecutive primary TKA. There was no patient selection based on age or weight. Traditional TKA, utilizing a medial parapatellar arthrotomy, was more likely to be performed on patients with a diagnosis of traumatic arthritis and in knees that required stems or augments. Preoperative tibiofemoral angle and mean knee deformity were not predictors of which procedure would be utilized. Despite employing this new surgical approach in nearly all primary TKAs, there was no increase in the complication rate. This high applicability rate with the mini-subvastus technique obviates concerns that the positive clinical outcomes in these patients are a result of patient selection.
Computer-Assisted Preoperative Planning in the Surgical Treatment of Acetabular Fractures -- Robert Nathaniel Reddix, Jr., MD, and Lawrence Xavier Webb, MD
Displaced acetabular fractures are among the most complex of all orthopaedic injuries. Keys to accurate reduction and improved outcomes are accurate imaging studies and a complete understanding of the nature of the fracture. The orientation of complex fractures may be difficult to understand or conceptualize. Traditionally, surgeons have relied on orthogonal Judet views of the pelvis with computed tomography images as tools to use in order to formulate a preoperative plan; however, these modalities may not communicate subtle characteristics of the fracture. The expansion of the power and capabilities of three-dimensional (3D) computer reconstructions has been recognized most recently as a useful adjunct in preoperative planning. The case of a 61-year-old patient with a both-column acetabular fracture and vertically unstable pelvis — in which 3D computer reconstructions and a novel computerassisted planning tool, Trauma CAD, were used in order to devise an accurate preoperative plan after fully understanding the nature of the injury — is presented.
Fat Suppression Imaging in Epidural Lipomatosis: Case Report -- J. Brian Gill, MD, MBA
A case of epidural lipomatosis associated with steroid use in rheumatoid arthritis is presented to describe the role of fat suppression imaging as a diagnostic tool. The plain radiographs revealed several vertebral compression fractures and the magnetic resonance imaging (MRI) showed a large extradural mass. A fat suppression MRI was obtained, which confirmed the diagnosis of epidural lipomatosis. A fat suppression MRI scan is a special imaging technique that is used in particular to either suppress the signal from adipose tissue or detect adipose tissue. An MRI scan is the imaging tool of choice to examine soft tissue lesions of the spine, and fat suppression imaging will provide additional information about any fatty soft tissue lesion, as in the case of epidural lipomatosis. This imaging modality is particularly useful in those patients who are morbidly obese or taking exogenous corticosteroids, because these conditions can proliferate adipose tissue leading to epidural lipomatosis.
Periprosthetic Thyroid Metastasis After Total Knee Arthroplasty: A Report of Two Cases and Review of the Literature -- Kris J. Alden, MD, PhD, Kristy L. Weber
Total knee arthroplasty (TKA) is an attractive option for relief of pain secondary to degenerative joint disease. Overall, knee replacement surgery typically results in excellent outcomes. Nevertheless, failure caused by malalignment, infection, wear, and osteolysis is known to occur. Pain after TKA may be secondary to numerous etiologic factors — most commonly, loosening, fracture, infection, and malposition of components. This case report presents two patients who developed pain after TKA that was caused by periprosthetic thyroid metastasis and who subsequently sustained a fracture below the tibial component. Clinical and radiographic examinations, as well as surgical follow-up, are presented to underscore the need for a focused history and physical examination in the initial evaluation of a patient with a painful TKA.