Volume 17-4, Winter 2008

Botulinum Toxin Type A Injections for the Management of Flexion Contractures Following Total Knee Arthroplasty - Thorsten M. Seyler, MD, Riyaz H. Jinnah, MD

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The development of knee flexion contractures following total knee arthroplasty is detrimental to a patient’s functional capabilities. Despite using aggressive rehabilitative modalities postoperatively, some knee arthroplasty patients do not respond and continue to experience muscle spasms. Botulinum toxin type A has been used as a temporary neuromuscular transmitter blocker to treat muscle spasms in patients with neurological disorders, and it has been utilized as a treatment method for clubfoot. The purpose of this study was to evaluate botulinum toxin type A as a new treatment modality for patients with flexion contractures following total knee arthroplasty that were recalcitrant to standard treatment methods. By 2 years following injections, 9 out of 11 knees achieved extension within 10° of neutral position, and 8 of the 11 maintained this improved range of motion by a mean follow-up of 36 months. There were two failures in patients who had a revision knee arthroplasty, suggesting that this treatment is more effective in patients following primary cases. Based on these results, botulinum toxin type A should be considered as a potential treatment modality, especially in difficult-to-treat cases of knee flexion contracture that are recalcitrant to standard therapy. (Journal of Surgical Orthopaedic Advances 17(4):231–238, 2008) Key words: botulinum toxin type A, flexion contracture, knee arthroplasty, outcome

High Tibial Osteotomies: Indications and Techniques - Andreas F. Mavrogenis, MD, Panayiotis J. Papagelopoulos, MD, DSc, Evanthia A. Mitsiokapa, MD, Christos V.

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The rationale, definition, and techniques of high tibial osteotomies are discussed. The principle indication includes unicompartmental medial or varus knee gonarthrosis with a well-maintained range of motion. Preservation of bone stock and intraarticular structures and realignment during chondral resurfacing procedures are the major advantages of high tibial osteotomies. Newer techniques have provided for less invasive surgical methods, more rigid fixation, accelerated rehabilitation, and improved accuracy of correction for high tibial osteotomies. However, permanent pain relief with high tibial osteotomies is unlikely; overall survival approximates 8 to 10 years. Subsequent conversion to a total knee arthroplasty may at times be technically demanding but the long-term results are likely to be similar to a primary total knee replacement. (Journal of Surgical Orthopaedic Advances 17(4):239 251, 2008) Key words: closing wedge osteotomy, external fixation, high tibial osteotomy, internal fixation, opening wedge osteotomy, valgus gonarthrosis, varus gonarthrosis

A Technique for Low-Profile Intramedullary Fixation of Intraarticular Proximal Ulnar Fractures - Edward K. Rodriguez, MD, PhD, and Andrew Eglseder, MD
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A technique for low-profile fixation of intraarticular proximal ulnar fractures using an intramedullary (IM) screw is described. A retrospective study of the early outcome of patients treated with this technique versus patients treated with 3.5-mm LCDP plating is also presented. The authors report on 33 patients managed with IM fixation and 16 managed with plate fixation. Mean follow-up time was 16 months. Injuries managed with IM fixation had decreased flexion contractures and improved pronation (p < .05) compared with injuries treated with plating. Elbow arc of motion and supination did not differ significantly. Hardware removal was required in 56% of injuries treated with plating and in 9% of injuries treated with IM fixation. Release for limited motion was required in about 25% of patients in both groups. Mayo scores did not differ between both groups. Low-profile intramedullary fixation facilitates wound closure and soft tissue management and results in similar short term outcomes as plating. The authors recommend this technique for cases with significant soft tissue injury where plating may result in a difficult closure or prominent hardware. (Journal of Surgical Orthopaedic Advances 17(4):252–261, 2008) Key words: elbow, intramedullary screw, olecranon fracture, ulna fracture

Acute Distal Radioulnar Joint Instability - Grant E. Garrigues, MD, Vani Sabesan, MD, and J. Mack Aldridge III, MD

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The distal radioulnar joint (DRUJ) is critical for pronosupination of the forearm and for upper extremity function in general. Because of its critical role in tool handling, some authors place the human DRUJ on par with the opposable thumb in the evolution of man. This seemingly simple cylindrical joint is stabilized by a complex network of soft tissue constraints, primarily components of the triangular fibrocartilage complex. Chief among these are the dorsal and palmar radioulnar ligaments. Any injury that disrupts these stabilizers, their balanced tension, or the bony congruity of the joint will have a major deleterious effect on hand function. Although they can occur in isolation, injuries causing acute DRUJ instability generally are associated with other trauma to the forearm wrist complex. When managing these associated injuries, it is paramount to have a high index of suspicion for associated acute DRUJ instability. If the DRUJ is evaluated and stabilized in the acute setting, the more difficult clinical problem of chronic DRUJ instability can be avoided. (Journal of Surgical Orthopaedic Advances 17(4):262–266, 2008) Key words: distal radioulnar joint, TFCC, wrist ligaments

Unusual Locations for Metastatic Malignancy of the Hand: A Report of Three Cases - Elke R. Ahlmann, MD, Nathan W. Greene, MD, Lawrence R. Menendez, MD, FACS

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Metastatic tumors of the hand bones are very rare. This report presents three cases of metastatic lesions involving the bones of the hand. These metastases, with adenocarcinoma of the lung as the primary malignancy, were the first clinical presentation of adenocarcinoma in two of these patients. The hamate bone was involved in one patient and the proximal phalanx of the ring finger was involved in the other patient. The third patient developed metastatic disease to the distal phalanx 8 months after initial diagnosis. The authors emphasize that a lytic lesion in the hand may be the first clinical sign of a malignancy or progression to metastatic disease. (Journal of Surgical Orthopaedic Advances 17(4):267–270, 2008) Key words: acrometastases, hamate, metastatic disease

Overview of the Locking Compression Plate and Its Clinical Applications in Fracture Healing - Danielle L. Miller, Tarun Goswami, and Michael J. Prayson, MD

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Open reduction and internal fixation of fractures involves the use of metallic implants to support bone reduction. This procedure is often used in situations in which adequate alignment and stability of the bone cannot be achieved using nonsurgical methods such as casting. The locking compression plate is a contemporary implant that allows for both conventional screw placement (using nonlocking screws) and locking screw placement (where screw heads lock into the plate at a predetermined angle). This allows for greater versatility in the application of internal fixation. This article presents a general overview of locking compression plate application along with a review of the locking compression plate literature. (Journal of Surgical Orthopaedic Advances 17(4):271–281, 2008) Key words: fracture, internal fixation, locking compression plate

A Technique to Direct and Retrieve a Free-Hand Interlocking Screw - B. Sonny Bal, MD, MBA

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Interlocking screws placed without a guide can be difficult to direct in the soft tissues and retrieval of a missed screw can be challenging. The retrieval of a misplaced free-hand guided screw using a suture has been described previously (1). This report describes a modification of the technique that is useful in less invasive surgery done with smaller incisions. This technique facilitates both the direction of the screw through the soft tissues and retrieval of the screw without enlarging the incision.

The Cup Fulcrum: A Technical Tip to Improve Femoral Exposure in Total Hip Arthroplasty - James V. Bono, MD, Jason E. Lang, MD, and James J. Nicholson, MD

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An unobstructed view of the proximal femur is a necessity in total hip arthroplasty for proper femoral preparation and to minimize the risk of femoral fractures and damage to the proximal soft tissues. A novel leverage technique is described that uses a trial head and liner to improve femoral visualization for the posterolateral approach. The cup fulcrum technique may minimize the risk of component malposition and damage, femoral fractures, and wound complications. Because there is no additional instrumentation or cost associated with this technique, it should prove useful for all surgeons who perform total hip arthroplasty through the posterolateral approach. (Journal of Surgical Orthopaedic Advances 17(4):284–286, 2008) Key words: complications, cosmesis, exposure, hip, minimal

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