Deep Vein Thrombosis and Pulmonary Embolism in Patients Undergoing Total Hip Arthroplasty: The Promise of New Oral Anticoagulants - James Muntz, MD, FACP

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Although effective agents exist for thromboprophylaxis to decrease risk of venous thromboembolism, particularly following major orthopaedic surgery, including total hip arthroplasty, these agents are underused, and thromboembolic events continue to occur in patients undergoing these surgical procedures. One reason for suboptimal treatment may be concern about bleeding; another may be dissatisfaction with currently available prophylactic agents. New oral anticoagulants appear to be equally efficacious and will provide easier administration and management. They hold promise for improving utilization of thromboprophylaxis and consequently for reducing the incidence of venous thromboembolism. Key words: venous thromboembolism, thromboprophylaxis, warfarin, Factor Xa inhibitors, thrombin inhibitors

Spinous Process Wiring Versus Lateral Mass Fixation for the Treatment of Anterior Cervical Pseudarthrosis: A Biomechanical Comparison - Hideki Murakami, MD, Cla

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Our objective was to compare the stiffness of lateral mass screws versus two different spinous process wiring constructs in a cadaveric model of plated anterior cervical pseudoarthrosis. When treating an anterior plated pseudoarthrosis via a posterior approach, it is unclear whether the added expense, muscle exposure, and risk of lateral mass fixation are justified biomechanically versus a simpler, cheaper, and potentially less morbid wiring technique, because the presence of the anterior plate likely reduces motion over the unplated situation. Seven cadaveric cervical spines were loaded in compression, flexion, extension, lateral bending, and torsion. Each load sequence was applied to: 1) the intact spine; 2) after application of a plated ACDF construct (pACDF); and 3) after the insertion of lateral mass (LM) screws, ‘‘modified’’ triple wiring (TW), or Roger’s wiring (RW), in alternating order for each specimen. For each sequence, load deformation curves and stiffness were obtained. Supplemental LM fixation significantly (p 0.05) increased stiffness versus pACDF in all six modes tested. TW significantly increased stiffness versus pACDF in compression, flexion, and torsion, but not in extension, or lateral bending. RW significantly increased stiffness versus pACDF only in axial torsion. When comparing LM to the wiring constructs, LM fixation was significantly stiffer than RW in flexion, extension, and lateral bending; LM fixation was stiffer than TW in lateral bending. LM fixation produced the stiffest overall constructs in stabilizing a plated pseudarthrosis ACDF model. It was significantly stiffer in more modes versus RW than TW. Key words: Pseudarthrosis, Cervical Spine, Lateral Mass Screws, Spinous Process Wiring, Cervical Plate

Effects of Supplemental Oxygen and Hyperbaric Oxygen on Tendon Healing in a Rat Model - Ryan Sieg, MD, E’Stephan J. Garcia, MD, Andrew J. Schoenfeld, MD, Todd C

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Systemic supplemental oxygen therapy (SOT) and hyperbaric oxygen therapy (HBOT) have been shown to positively impact wound healing. The purpose of this study was to evaluate the effects of SOT and HBOT on tendon healing in a rat tendon model. The right patellar tendon of 90 male Sprague-Dawley rats was completely sectioned. Animals were randomized to receive HBOT, SOT, or room air therapy. Animals were sacrificed at 3- and 6-weeks postoperatively. The ultimate tensile strength in axial extension was compared between groups. Statistical significance was calculated using the Student’s t-test. The SOT group exhibited the highest tensile strength at both time-points, although HBOT was the only treatment that exhibited a statistically significant increase in tensile strength between time-periods (p = 0.006). There was no statistical difference in ultimate tensile strength when the three groups were compared at the 3- or 6-week time-points. Results presented here cannot support the premise that intermittent HBOT or SOT significantly increases the healing of tendon repairs. Key words: Hyperbaric Oxygen Therapy, Supplemental Oxygen Therapy, Oxygen, Tendon Healing, Wound Healing

Treatment of High-Energy Supracondylar/Intercondylar Fractures of the Distal Humerus - Lisa Cannada, MD, B. Loeffler, MD, M. B. Zadnik, MD, and W. A. Eglseder

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Operative treatment of high-energy intra-articular fractures of the distal humerus is challenging and controversial. We conducted a retrospective study at a Level I trauma center to evaluate the results of a specific treatment protocol. Seventy-one patients were treated through a posterior olecranon osteotomy. Capsulectomy was performed in patients who perceived their functional range of motion to be limited after an average of 10 months. Clinical followup consisted of physical examination, radiography, and completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Average followup duration was 22 (range, 6 to 70) months. Sixty-five percent of the patients achieved excellent or good results, 28% fair, and 7% poor. Thirty-one percent underwent capsulectomy, with 59% of those patients achieving excellent or good results. This is the largest series reported to date. Our patients experienced mild functional impairment and a low rate of nonunion. We advocate capsulectomy for patients with limited range of motion postoperatively. Key words: high-energy supracondylar/intercondylar fractures, distal humerus, olecranon osteotomy fixation, capsulectomy, ulnar nerve transposition

Surgical Reconstruction of End-Stage Ankle Arthritis and Concomitant Stage II Posterior Tibial Tendon Insufficient Flat Foot - Sarang Desai, DO; Randolph Griers

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End-stage degenerative joint disease of the ankle and concomitant ipsilateral Stage II posterior tibial tendon insufficient flat foot is a well known entity. Despite this, treatment options have not been discussed in the orthopaedic literature. A case series consisting of five patients was conducted to determine the efficacy of our treatment proposal. Our surgical treatment included an ankle fusion and concomitant flat foot reconstruction with a medializing calcaneal osteotomy, lengthening calcaneal osteotomy, and flexor digitorum longus transfer. At the final followup visit all patients were content with the results of the procedure, and would have it performed again. Each patient had significant relief of ankle and foot pain, and believed they had improved quality of life and function. Complications included two ankle nonunions treated with revision bone grafting and internal fixation, painful hardware and iliac crest hematoma. We conclude that our method of treatment is a viable option for this complex problem. A long recovery period should be anticipated and patients should be counseled accordingly. Key words: ankle arthritis, posterior tibial tendon insufficiency, flat foot, ankle degenerative joint disease

Case Report: Lead Toxicity Associated with an Extra-Articular Retained Missile 14 Years After Injury - William C. Eward, DVM, MD, Dennis Darcey, MD, Leslie G. D

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Lead toxicity associated with extra-articular retained missiles (EARMs) is an uncommon yet potentially devastating complication of gunshot wounds. While the risk of lead toxicity with intra-articular retained missiles is well-known, EARMs are routinely permitted to remain in tissues indefinitely without surveillance for lead toxicity. We present a 34 year-old man who was found to have symptomatic lead toxicity 14 years after sustaining a gunshot-associated femoral fracture with retention of lead bullet fragments. A fluidfilled cyst containing two large lead bullet fragments was identified intraoperatively. Whole-blood lead concentration decreased after removal of the lead-filled cyst. Cyst formation and concomitant bone fracture are two of the risk factors for lead toxicity in patients with EARMs after gunshot wounds. Recognizing risk factors for EARM-associated elevation in lead levels is important as the adverse effects of increased lead burden may be asymptomatic and difficult to diagnose, yet debilitating and potentially lethal. Key words: Lead, Lead Toxicity, Retained Missiles, Gunshot Wounds, Lead Bullets

Use of a Free-Functioning Muscle Transfer from a Paralyzed Lower Extremity to Restore Upper Extremity Elbow Flexion - Brian T. Carlsen, MD, Matthew C. Wendt, MD

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This report documents the use of a free-functioning gracilis muscle transfer from a lower extremity paralyzed from a spinal cord injury to restore elbow flexion in the patient’s upper extremity which was paralyzed from a brachial plexus injury. The transfer was performed nine months after injury and resulted in functional elbow flexion. Clinical examination and EMG analysis document function of the transferred muscle with grade 4 muscle strength. The resultant effect on the skeletal muscle is different after upper motor neuron injury versus lower motor neuron injury. The successful function of a free-functioning muscle transfer after a spinal cord injury in this case has important implications for patients with spinal cord injury. Key words: Free-Functioning Muscle Transfer, Brachial Plexus Injury, Spinal Cord Injury, Tetraplegia

Traumatic Laceration of the Long Head of the Biceps Brachii from a Displaced Surgical Neck Fracture of the Humerus: Case Report - Jaehon M. Kim, MD and Jesse B.

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This case report identifies a traumatic laceration of the long head of the biceps brachii associated with a displaced surgical neck fracture of the humerus in a 37-year-old woman who sustained a fall while skiing. At the time of surgery, the tendon was found sharply divided and repaired primarily. The fracture was fixed with a proximal humeral blade plate. Followup revealed nearly full glenohumeral motion and a functional biceps muscle by 4 months. Key words: long head biceps brachii rupture, proximal humerus fracture

H-Wave Effects on Blood Flow and Angiogenesis in Longitudinal Studies in Rats - Thomas L. Smith, PhD, Michael F. Callahan, PhD, Kenneth Blum, PhD, Nicho

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Effects of repeated H-Wave device stimulation (HWDS) on blood flow and angiogenesis in the rat hind limb were studied. The hypothesis tested was that HWDS acutely increases hind limb blood flow, and that repeated HWDS would elicit angiogenesis. Animals were HWDS-conditioned (‘‘Conditioned’’) or shamstimulated (‘‘Sham’’) (n D 5/group) daily for 3 weeks. The contralateral limb in both groups served as the control. Each animal was injected with bromodeoxyuridine (BrDU). After 3 weeks, rats were anesthetized and iliac artery blood flow was measured bilaterally before, during, and after acute HWDS. HWDS of the Conditioned limbs elicited a 247% increase in blood flow above resting conditions compared to a 200% increase in control legs. Sham animals did not demonstrate between-leg differences in flow. Hindlimb musculature staining for BrDU revealed angiogenesis in Conditioned versus Sham groups. Flow changes accompanying HWDS corroborated earlier microvascular findings demonstrating a significant striated muscle arteriolar dilation with HWDS. Key words: Angiogenesis, microcirculation, arteriolar vasodilation, striated muscle, blood ow, H-Wave treatment

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