Volume 20-3, Fall 2011

Litigation involving Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS), because of its complexities, is often difficult to prove or defend. In our review of 56 verdicts and settlements in the state of Florida, in cases involving a diagnosis or misdiagnosis of RSD or CRPS, over half resulted in a substantial verdict or settlement for the plaintiff. (Journal of Surgical Orthopaedic Advances 20(3):153–157, 2011) Key words: Lawsuit, Verdict, Malpractice, Reflex Sympathetic Dystrophy, Complex Regional Pain Syndrome, RSD, CRPS

Management of symptomatic pre-collapse osteonecrosis of the femoral head continues to be controversial. Patients are often young and active, therefore hip-preserving procedures such as free vascularized fibular grafting (FVFG) have been developed to relieve pain and restore function, thereby delaying or preventing the need for joint arthroplasty. This study compared the cost-effectiveness of FVFG to total hip arthroplasty (THA) in the young adult. A Markov decision model was created for a cost-utility analysis of FVFG compared to THA. Outcome probabilities and effectiveness, expressed in QALYs gained, were derived from existing literature. Principal outcome measures included average incremental costs, effectiveness, and net health benefits. Multivariate sensitivity analysis was used to validate the model. THA resulted in a greater average incremental cost (C$5,933) while at a lower average incremental effectiveness (
0.15 QALY) compared to FVFG. On average, THA gained 22.08 QALYs at a cost-effectiveness (C/E) ratio of $1026/QALY, whereas FVFG gained 22.23 QALYs at a C/E ratio of $752/QALY. Threshold sensitivity analysis determined that the yearly all-cause probability of revision for FVFG would have to be more than three times greater than THA before THA became more cost-effective. Free vascularized fibular grafting is a more cost-effective procedure to treat osteonecrosis in certain populations. Markov decision analysis accounts for the impact of treatment strategies over the lifetime of a patient cohort. These findings can inform clinical decision making in the absence of universally accepted management strategies. (Journal of Surgical Orthopaedic Advances 20(3):158–167, 2011) Key words: Cost-Effectiveness Analysis, Markov Cohort, Cost Analysis, Osteonecrosis, Avascular Necrosis, Free-Vascularized Fibular Graft

Subatmospheric pressure (SAP) therapy has evolved as a mainstay in the treatment of acute and chronic wounds over the past 20 years. The significant improvement in wound healing upon application of a SAP therapy system such as the Vacuum Assisted Closure (V.A.C.; KCI, San Antonio, TX) device, historically has been related to general principles such as edema reduction, bacterial clearance, and increased perfusion to the wound bed. Recent investigations have also indicated that microdeformation and regulation of biochemical mediator expression play a role in the improved outcomes seen with SAP therapy. Future studies will pursue further the mechanisms by which SAP functions to render such impressive results in wound healing. (Journal of Surgical Orthopaedic Advances 20(3):168–175, 2011) Key words: Subatmospheric Pressure; Negative Pressure Wound Therapy; V.A.C. Therapy; Wound Healing

The purpose of this study was to report on radiographic, objective, and functional outcomes in patients with 2- and 3-part proximal humerus fractures treated with an Evans staple. Six patients (three males and three females) who had had acute, displaced proximal humerus fractures requiring operative treatment were identified and their medical records reviewed. There were four 2-part and two 3-part fractures as described by Neer. Mean age was 68.5 (range, 57 to 73) years; mean followup was 71.1 (range, 30 to 98) months. The senior author (T.W.W.) was the treating physician who determined the treatment method. All patients were treated within 2 weeks of injury using an Evans staple (Smith & Nephew, Memphis, TN), with or without tension band. Clinical outcome measurements were fracture healing, range of motion, complications, Shoulder Pain and Disability Index (SPADI) score, and radiologic outcome. All six fractures reached clinical and radiographic union at a mean of 4.2 months without postoperative complications. Two patients required subsequent hardware removal. Mean SPADI score at last followup was 36.8 (good). Average radiologic neck/shaft angle was 110 (range, 92 to 136) degrees. The Evans staple is a valuable implant for treatment of 2- and 3-part proximal humerus fractures requiring a relatively simple surgical implantation and minimal soft tissue dissection. (Journal of Surgical Orthopaedic Advances 20(3):176–181, 2011) Key words: Proximal Humerus Fracture; Evans Staple; SPADI; Shoulder Pain and Disability Index

Total joint arthroplasty followup will become an increasingly important issue as the numbers of arthroplasty patients rise. The predictors of return for routine 1- and 2-year followup are not known. A retrospective review of 290 total knee arthroplasty patients was performed. Hospital operative records and clinical notes were used to determine demographic indicators and clinical followup compliance. Patient followup compliance decreased over time [6 months (82%), 1 year (78%), 2 year (37%)]. Using a logistic model, attendance at 6-month followup was found to be a significant positive predictor for 1-year followup. Using a multivariate model, obesity was found to be a negative predictor for 2-year followup, and compliance with 6-month and 1-year followup was found to be a positive predictor for 2-year followup. The data shows that current patient-dependent followup protocols are ineffective beyond one year, with only 37% of patients returning for their 2-year visit. Inclusion of a 6-month visit may improve 1-year followup, but 2-year followup remained low. (Journal of Surgical Orthopaedic Advances 20(3):182–187, 2011) Key words: Arthroplasty, Total Joint, Degenerative Knee Disease

We prospectively studied 110 consecutive patients with intertrochanteric hip fractures treated with the 130° angle, 10-mm short IMHS intramedullary hip screw (IMHS, Smith & Nephew, Richards, Memphis, TN). Surgery was performed within 36 hours from admission; all patients were mobilized immediately postoperatively. Fracture union, pre- and post-operative mobility status and complications were evaluated. Eighty patients were included in the postoperative evaluation for a mean followup of 14 (range, 9 to 25) months. Mortality was 19%. Union occurred in 79 fractures within 6 months from surgery; there was one case of screw cut-out and one case of deep venous thrombosis. Periprosthetic femoral shaft fractures were not observed. At the latest examination, the mean mobility score decreased from 8.4 š 1.6 to 7.1 š 2.1 (p D 0.0001); 26 patients (32%) fully achieved the preoperative mobility score and 54 patients (68%) achieved more than 90% of the preoperative mobility score. The IMHS intramedullary hip screw represents a reliable method for the treatment of patients with intertrochanteric hip fractures, and provides for early mobilization and rehabilitation of the patients with acceptable complications. (Journal of Surgical Orthopaedic Advances 20(3):188–192, 2011) Key words: Intertrochanteric Hip Fracture, Intramedullary Hip Screw, Postoperative Mobility

The use of autogenous bone graft in spinal fusion is progressively declining. Different allografts including the human bone morphogenetic protein have been proposed to facilitate fusion rates but are associated with various adverse effects. Osteocel(R) belongs to a new class of allograft tissue material that is a re-absorbable biomaterial with allogenic mesenchymal stem cells. The purpose of the present retrospective study was to analyze the clinical effectiveness of mesenchymal stem cells allograft (Osteocel(R)) to achieve radiological arthrodesis in adult patients undergoing lumbar interbody fusion surgery for different indications. Fifty-two consecutive patients received lumbar interbody fusion at one (69%) or two contiguous (31%) levels of lumbar spine for various indications. The mean age was 50 (range, 27 to 77) years; 60% were females; 43% were habitual smokers and 21% had previously failed surgery at the index level(s). Outcome measures: Radiographic analyses of fusion by plain films and CT scans. Procedures performed were circumferential fusion (67%), ALIF (17%) and TLIF (16%). Followup radiographic data was analyzed to establish arthrodesis versus failure (pseudarthrosis), number of months until achievement of fusion, and possible factors affecting the fusion rate. Followup ranged from 8 to 27 (median, 14) months. Solid arthrodesis was achieved in 92.3% of patients at median followup time of 5 months (95% CI; range, 3 to 11 months). Kaplan-Meier survival curves and Mantle-Cox test were conducted to assess the effect of various factors on the rate of fusion. Statistics showed that increasing age (older than 50 years) (p = 0.017) and habitual smoking (p D 0.015) delayed the fusion time and increased the risk of pseudarthrosis. The use of Osteocel(R) allograft is safe and effective in adult patients undergoing lumbar interbody spinal fusion procedure. Increased age and habitual smoking delays fusion but gender, previous surgery at the index level, type of procedure and number of levels do not affect the fusion rates. (Journal of Surgical Orthopaedic Advances 20(3):193–197, 2011) Key words: Lumbar spine, Interbody fusion, Allograft, mesenchymal stem cells.

Heterotopic ossification is rarely encountered following repair of a distal biceps tendon by an anterior approach. Although much less common than with a classic two-incision approach, a review of the literature demonstrates that heterotopic ossification may still occur following anterior single incision techniques. We describe only the second reported case to our knowledge of symptomatic heterotopic ossification following repair of a distal biceps tendon rupture with an EndoButton. (Journal of Surgical Orthopaedic Advances 20(3):198–201, 2011) Key words: Heterotopic Ossification; Distal Biceps Tendon

We report a 6-year-old girl, with no history of previous anaphylactic reaction, who sustained a wasp sting to the volar aspect of her left hand. The child did not present any symptoms at the beginning. She was first examined at the emergency department with developed compartment syndrome, after more than 24 hours later and she was urgently taken to the operating theatre. The midpalmar, thenar, and hypothenar spaces were decompressed, and the transverse carpal ligament was released. At the 11-month followup, she presented with normal function of the hand and normal 2-point discrimination in all fingers. Although the accurate mechanism of the development of compartment syndrome after a wasp sting in children is not thoroughly clear, the treatment seems to be the same as in all other cases of compartment syndrome; urgent fasciotomy. It is very important to keep in mind the possibility, even if it is extremely low, of compartment syndrome after a wasp sting in children; even of those with no history of anaphylactic reaction. (Journal of Surgical Orthopaedic Advances 20(3):202–205, 2011) Key words: Wasp Sting, Child, Compartment Syndrome, Hand

It is predicted that the number of revision hip and knee arthroplasties will double by the years 2026 and 2015, respectively. As the burden of end-stage prosthetic disease increases, there will be a greater potential need for total femoral arthroplasty. This report describes a patient with a femoral neck fracture nonunion with an ipsilateral multiply revised failed total knee arthroplasty treated by a tissue sparing total femoral arthroplasty. The technique is described, and potential benefits are reviewed. (Journal of Surgical Orthopaedic Advances 20(3):206–209, 2011) Key words: Total Femoral Arthroplasty, Revision Hip and Knee Surgery