Volume 21-3, Fall 2012

Although introduced more than 20 years ago, endoscopic carpal tunnel release (ECTR) continues to generate debate and controversy among surgeons. This review examines a single surgeon’s technique for ECTR over the past 13 years to better understand the effects of a surgeon’s experience on outcomes. A retrospective review was performed on a case series of 129 patients ages 25 to 89 years old who underwent an ECTR at Duke University. Ninety-six percent of patients reported improvement in nerve symptoms. There were no nerve complications in the series. The billed cost of ECTR at Duke University was 9% less than standard open release and the average return to work by report by patients was 3 weeks. Previous recommendations against ECTR have focused on increased complication rates and cost, with no reported differences in long-term clinical outcomes. The results demonstrate increased success and lower complication rates for this series of patients. This may indicate a significant correlation between a surgeon’s expertise and outcomes for ECTR. (Journal of Surgical Orthopaedic Advances 21(3):117–121, 2012) Key words: carpal tunnel release, endoscopic, outcomes

The pathogenesis of hip arthrosis is complex with many risk factors. Femoroacetabular impingement abnormalities are thought to be a factor. To determine the prevalence of femoroacetabular impingement in younger patients who had undergone hip arthroplasty, the authors reviewed preoperative radiographs to determine radiographic indices of femoroacetabular impingement in 142 patients (92 men and 50 women) younger than 50 years old and who had undergone hip replacement. The average age of the patients was 43.4 years. The center-edge angle (Wiberg), the alpha angle (Notzli), and the sacrococcygeal–symphysis distance were measured. The range of a sacrococcygeal–symphysis distance in both men and women was used to identify retroverted acetabuli in properly centered radiographs. In this population, radiographic signs of cam-type femoroacetabular impingement were prevalent in patients younger than 50 years old who had undergone hip arthroplasty. Ninety-two (65%) patients had an abnormal alpha angle indicating cam impingement: 63 men (68%, alpha angle 69°) and 29 women (58%, alpha angle 51°). Sixteen patients (11%) had signs of a retroverted acetabulum, suggesting pincer impingement. Of these, 11 had an abnormal alpha angle. Sixteen patients had hip dysplasia; of these, 10 had an abnormal alpha angle. Patients presenting with hip pain, minimal osteoarthritic changes, and indices of femoroacetabular impingement may be suitable candidates for early operative intervention to decompress the impingement that may potentially retard or arrest the progression of arthrosis in these patients. (Journal of Surgical Orthopaedic Advances 21(3):122–125, 2012) Key words: alpha angle, femoroacetabular impingement, hip arthroplasty, osteoarthritis

The lateral midfoot is significantly more mobile than the corresponding medial joints, thereby giving some surgeons concern over the use of arthrodesis in patients with symptomatic fourth and fifth tarsometatarsal arthritis. Limited treatment options exist for these patients when nonoperative measures fail to provide adequate pain relief. A retrospective, consecutive case series was performed to evaluate the short-term results for patients who underwent ceramic interpositional arthroplasty of the lateral tarsometatarsal joints. All five patients had subjectively improved lateral midfoot pain and retained some motion following the procedure. There were no implant failures or cases of subsidence identified. Two patients experienced wound healing complications and four patients required concomitant procedures at the time of interpositional arthroplasty, highlighting the complexity that is often involved when treating patients with midfoot arthritis. Long-term results are needed to determine the ultimate role for ceramic interpositional arthroplasty in the lateral midfoot. (Journal of Surgical Orthopaedic Advances 21(3):126–131, 2012) Key words: ceramic interpositional arthroplasty, lateral column, midfoot arthritis, Orthosphere, tarsometatarsal joint

The technical description of a new surgical method (Pedersen–Noor operation) to treat refractory external snapping hip [coxa saltans externa (CSE)] is presented. The method consists of distal lengthening of the iliotibial band by Z-plasty under local anesthesia and on an outpatient basis. Five patients with refractory CSE were treated with the new method. Postoperatively, the outcome was evaluated by phone interview and physical examination, 3 to 4 months and 1 year postoperatively, respectively. The snapping disappeared in all five patients. No postoperative complications were reported. Three patients were very satisfied and two patients were satisfied with the result of the operation. All five patients would recommend the operation to another patient with similar symptoms. The described method is simple, economic, and effective and can be recommended in the treatment of refractory CSE. (Journal of Surgical Orthopaedic Advances 21(3):132–135, 2012) Key words: coxa saltans externa, hip pain, iliotibial band, lengthening, snapping hip, Z-plasty

Recent advances in plating technology for the pediatric femur fracture have demonstrated early mobilization of the extremity and early weight bearing. Submuscular techniques allow for minimal soft tissue disruption and provide a theoretical healing advantage. This article presents results of the treatment of pediatric femur fractures using a locked submuscular bridge plating technique. The authors reviewed 16 patients between 6 and 12 years of age who sustained a femoral shaft fracture treated with minimally invasive submuscular locked plating. Patients were followed for an average of 25 months and made full weight bearing within 6 weeks of surgery. All patients achieved radiographic and clinical union with an average time of 2.6 months. Range of motion of the knee and hip were equivalent to the contralateral extremity at 2.1 months. Average time of hardware removal was 11 months. Benefits of locked plating of pediatric femur fractures include high union rates, early weight bearing, early recovery of range of motion, and minimal complications. (Journal of Surgical Orthopaedic Advances 21(3):136–140, 2012) Key words: femur fracture, locked submuscular plating, pediatric, surgical treatmen

The mechanism of dorsal dislocation of the metacarpophalangeal (MCP) joint is with forced hyperextension of the joint and the main structure injured is the volar plate. A simple dislocation can be reduced by closed means whereas a complex dislocation cannot. Care must be taken not to put traction across the joint, which may cause the volar plate to slip into the joint, converting a simple dislocation into a complex dislocation. Volar dislocations are rare and mainly treated nonoperatively. Sagittal band injuries can be treated with extension splinting or surgical management with direct repair or reconstruction. A locked MCP joint can usually be treated with closed manipulation. This article discusses these injuries and management options. (Journal of Surgical Orthopaedic Advances 21(3):141–146, 2012) Key words: capsule, collateral ligaments, dislocation, metacarpophalangeal joint, sagittal band, transverse metacarpal ligament, volar plate

Chronic pain and gait disturbance are possible complications of subtalar arthroereisis. Despite literature indicating a considerably high rate of such complications, subtalar arthroereisis continues to be commonly performed for children with pes planus. The goals of this study are to identify common presenting features and an approach to the treatment of foot pain after subtalar arthroereisis. This case report includes six feet in which subtalar implants were used to treat flatfoot deformities in children. After failing conservative management for chronic postoperative pain, all patients had their implants removed resulting in relief of pain. The expedited removal of subtalar implants in cases of chronic foot pain after arthroereisis is encouraged. The authors do not recommend the use of subtalar arthroereisis in pes planus given its potential complications and literature review indicating a paucity of cases with improved function and activity level as a result of the procedure. (Journal of Surgical Orthopaedic Advances 21(3):147–150, 2012) Key words: arthrodesis, arthroereisis, arthrorisis, flatfoot, hindfoot valgus, sinus tarsi syndrome, subtalar

A pretibial cyst after anterior cruciate ligament (ACL) reconstruction is a rare complication. This report presents a case of a subcutaneous pretibial ganglion with direct communication to the tibial tunnel, after ACL reconstruction with a quadrupled hamstrings tendon autograft, in a 26-year-old Caucasian male. The hamstrings tendon graft was fixed to the tibia using a 9-mm poly-L-lactide interference screw, 4 years earlier. There were no clinical signs of inflammation at the time the cyst appeared. The patient underwent excision of the cyst and curettage of the tibial tunnel. Fibrous tissue and gelatinous material exuded, whereas the screw had completely bioabsorbed. The cyst wall and the content were sent for histological examination (HE). Arthroscopically the graft was probed and found to be intact. HE showed a few giant cells and macrophages. This complication is believed to occur because of a diversion of the biodegrading–bioabsorbing process of the poly-L-lactic acid fixation screw, which led to direct communication between the joint and the pretibial subcutaneous tissue through a fibrous tibial tunnel. (Journal of Surgical Orthopaedic Advances 21(3):151–156, 2012) Key words: ACL reconstruction, PLLA screws, pretibial cyst

This report presents a rare case of a child who presented with neglected intra-articular entrapment of the median nerve, ulnar nerve palsy, and intra-articular incarceration of the medial epicondyle following closed reduction of an elbow dislocation. In the present case, as in most other cases, the diagnosis and treatment were delayed. Careful initial and postreduction neurological examination, as well as careful interpretation of the plain radiographs, is necessary for early detection of any nerve complications and associated fractures of an elbow dislocation. The authors’ opinion is that a child with an elbow dislocation, which is initially neurologically intact but advances to a median or ulnar nerve deficit after the reduction, must undergo early surgical exploration, especially when the dislocation is associated with a medial epicondyle fracture. (Journal of Surgical Orthopaedic Advances 21(3):157–161, 2012) Key words: elbow dislocation, median nerve entrapment, ulnar nerve palsy

Traumatic dislocation of a single testicle is an exceedingly rare event and bilateral dislocation is even less common. Traumatic testicular dislocation occurs by the mechanism of direct pressure exerted on the scrotum. Motorcycle collisions are the most frequent causative mechanism, usually related to deceleration straddle injuries. Since traumatic testicular dislocation is associated with other severe injuries, it is usually a late finding, leading to delayed diagnosis and treatment. This report describes a rare case of a patient involved in a motorcycle crash who sustained bilateral testicular dislocation associated with an anterior posterior compression pelvic fracture. To date, there are no reported cases involving management of bilateral testicular dislocation discovered during open reduction and internal fixation of the pelvis. Because the orthopaedic traumatologist may be the first to assess patients with pelvic fracture requiring surgery, the authors feel it is important to raise awareness of this injury. (Journal of Surgical Orthopaedic Advances 21(3):162–164, 2012) Key words: motorcycle accidents, pelvis fracture, pelvic trauma, scrotal injury, testicular dislocation

A 32-year-old man with a painful osteoblastic osteosarcoma of the right hip was initially diagnosed as having Paget’s disease of bone. He was treated with alendronate for presumptive Paget’s disease. The patient’s bone pain was dramatically reduced by the administration of alendronate for 7 months. Following discontinuation of alendronate, his pain promptly recurred, culminating in a more thorough evaluation that led to the correct diagnosis. Despite chemotherapy, the patient succumbed to metastatic osteosarcoma. The main purpose of this publication is to report the potential for pain relief when an osteosarcoma is treated with bisphosphonate medication. Clinicians are advised not to consider an alendronate-associated pain reduction in an osteoblastic lesion as an indicator of an underlying benign process of bone. The evaluation of painful sclerotic bone lesions is briefly reviewed. (Journal of Surgical Orthopaedic Advances 21(3):165–169, 2012) Key words: alendronate, diagnostic delay, osteosarcoma, Paget’s disease, pain relief

There has been considerable initial success with the use of total hip and resurfacing metal–metal implants tempered by poor performance of certain bearing designs, specifically small and/or abnormal component orientation. With a growing number of reports relating to adverse local tissue reactions, the need to monitor ion levels is crucial. This report presents a case of an extremely active bilateral metal–metal implant patient who had severe arthritis of the left hip and was originally treated with a cementless metal-on-polyethylene surface replacement. This implant lasted 12 years and after complete wear through of the polyethylene, the prosthesis was converted to metal-on-metal total hip. The patient continued to cycle vigorously and engaged in downhill skiing. Eventually his contralateral hip developed arthritis and he underwent metal-on-metal surface arthroplasty. Since his last surgery 8 years ago, the patient has resumed his activities, cycling an average of 6,400 miles and skiing over 60 days a year. He has been followed clinically and radiographically for 23 years with ion levels measured serially. (Journal of Surgical Orthopaedic Advances 21(3):170–175, 2012) Key words: high activity, high performance, hip arthroplasty, hip resurfacing, metal-on-metal

Haglund’s syndrome is a triad of posterosuperior calcaneal prominence, retrocalcaneal bursitis, and insertional Achilles tendonitis. Endoscopic treatment of patients with this triad allows for earlier weight bearing, direct visualization of the Achilles insertion, and less soft tissue disruption. In addition, it allows excellent visualization of the pathology. The authors present a technique of endoscopic calcaneoplasty in the prone position with the monitor at the foot of the bed and the surgeon standing beside the patient. Prone positioning allows for easier access to the Haglund’s deformity, a more logical view on the monitor, and a more ergonomic hand position. (Journal of Surgical Orthopaedic Advances 21(3):176–180, 2012) Key words: arthroscopic, calcanectomy, endoscopic calcaneoplasty, Haglund’s deformity, insertional Achilles tendonitis