Volume 22-2, Summer 2013

Treatment of brachial artery injuries in children, particularly those resulting from supracondylar humeral fractures, is controversial when distal pulses are absent yet the hand remains warm and pink. This article presents a retrospective study of eight children, ages 3 to 13, who underwent brachial arterial exploration because of absent distal pulses following arm trauma. Absent pulses indicate diminished blood flow, and in all eight cases brachial artery obstruction or severance was confirmed at surgery. In four of the children, who presented with cold, devascularized hands as a result of posterior elbow dislocations, supracondylar humeral fracture, or dog bites, there is no debate regarding revascularization. The other four children, with type III supracondylar humerus fractures, had pulseless, pink hands as a result of brachial artery thrombosis or arterial tethering. Brachial artery flow was reestablished in all cases with return of distal pulses, and no vascular complications. The authors believe that artery exploration is indicated when distal pulses are not present. Key words: brachial artery, elbow dislocation, pink pulseless hand, supracondylar fracture

The purpose of this review is to update the reader on more recent, less invasive lumbar interbody fusion procedures. The article contains a brief history on the development of lumbar interbody fusion methods, as well as the indications and descriptions of the various open and minimally invasive procedures, their complications, and outcomes. In contrast to the more traditional open methods of performing anterior and posterior interbody fusions, surgeons doing the less invasive techniques of transforaminal lumbar interbody fusion, extreme lateral and direct lateral interbody fusion, and the presacral axial approach are reporting less morbidity, shorter hospital stays, high rates of fusion, and improved patient outcomes. Although each technique has a different anatomical plane of approach, the goal is to achieve a solid interbody fusion of the pain generating segment(s) without complications. Key words: complications, interbody, lumbar, outcomes fusion

Femoral component size selection during total knee arthroplasty should not vary from surgeon to surgeon for patients with the same bone size. This study explored if systematic variations in femoral component size selection exist. Thirteen surgeons’ choices of femoral component size (Duracon, n=1388; Triathlon, n=740) were analyzed using a generalized linear model with femoral component size as the dependent variable and surgeon identification, years in practice, and adult reconstruction fellowship training as the independent variables. The model adjusted for differences in bone size. It was found that more experienced surgeons implant larger femoral components. New instruments and training protocols may be necessary to adjust for surgeon experience. Key words: femoral component size, surgeon, total knee arthroplasty

Hunters who fall from deer stands can sustain a variety of injuries. A retrospective review was conducted at a single institution to gauge the experience in treating patients injured in falls from deer stands from 2002 to 2008. Medical records were analyzed for patient demographics, tree stand characteristics, and injury details. Patients were contacted to complete a SF-12 health survey to assess their functional outcome following their injuries. Of the 30 patients who sustained a fracture, an average of 2.08 fractures were sustained per patient. Sixteen patients sustained a spinal column fracture, and four of these sustained a spinal cord injury. Twenty-one patients underwent at least one surgical procedure by the trauma surgery (two), neurosurgery (four), or orthopaedic surgery (15) teams. The importance of understanding deer stand instructions should be emphasized during hunting education classes, and all hunters should follow safe hunting recommendations pertaining to firearms and tree stands. Key words: falls from deer stands, Injury Severity Score, SF-12 scores, spinal cord injuries, trauma surgery

Septic arthritis following anterior cruciate ligament (ACL) reconstruction is an uncommon but potentially serious complication. The incidence of infection is approximately 0.44%. Staphylococcus and streptococcus strains are the most common infectious pathogens. Infection is typically via direct inoculation. Articular cartilage damage is primarily the result of the unregulated host inflammatory response. The timing of presentation is typically

Professional and recreational athletes involved in contact sports and sports with repetitive overhead motion are at increased risk for rotator cuff tears. Shoulder anatomy, pathology, and biomechanics place unique stress on the rotator cuff tendons during sports activity. Athletes demand effective treatment to quickly return to elite competition. A PubMed search assessed treatment options providing expedited recovery time and return to competition. Twelve of 231 articles fit the objective criteria; 90.5% of professional contact athletes, 40% of professional overhead athletes, and 83.3% of recreational athletes fully recovered following rotator cuff tear surgical repair. Prompt surgical treatment for full-thickness rotator cuff tears may be appropriate for contact athletes and recreational overhead athletes. Although professional overhead athletes have low recovery rates, surgical repair of full-thickness rotator cuff tears may still be indicated. The authors propose a treatment algorithm based on the limited literature (mainly level 4 and 5 evidence). Key words: athlete, chronic sports injury, contact sports injury, overhead athlete, professional athlete, rotator cuff tear, rotator cuff treatment, systematic review

This study evaluated the use of arthroscopic bursectomy for pain relief in patients with trochanteric bursitis after hip arthroplasty. In this retrospective case series of 12 patients undergoing arthroscopic treatment of recalcitrant trochanteric bursitis after hip arthroplasty, outcomes were assessed via phone interview with a numeric pain rating scale from 1 to 10 and were compared with preoperative pain ratings. Patients were asked the percentage of time they had painless hip function and whether they would have the surgery again. At an average 36-month follow-up (range, 4–85 months), the average numeric pain scale rating improved from 9.3 to 3.3. At an average of 62% of the time, patients had painless use of the hip. Ten of 12 patients in the study felt the pain relief gained was substantial enough to warrant having procedure again. In these patients, arthroscopic bursectomy was a viable option for patients with recalcitrant bursitis after hip arthroplasty. Key words: arthroscopic bursectomy, hip arthroplasty, trochanteric bursitis

Digital templating has been used as a method of reducing hospital costs by eliminating the need for acetate films. Digital templating techniques have been used for preoperative planning for total hip arthroplasty (THA). Fifty-four patients who underwent THA were selected for the study. Templating was performed using acetate templating overlays and digital templating software. Acetabular component sizes were accurate in 96% of patients using the acetate method and in 93% using the digital method. Femoral component sizes were accurate in 80% in the acetate method and 74% in the digital method. Digital templating is safe and effective for preoperative planning for THA. Key words: acetate versus digital, digital templating, PACS, preoperative planning, total hip arthroplasty

Exchange of the tibial liner in revision knee arthroplasty for wear and other indications is controversial. The purpose of the study was to determine the clinical success and reoperation rate for liner exchange performed for four groups of patients. Thirty-nine revisions were identified in which modular liner exchange was performed: polyethylene wear (12 knees), acute infection (11 knees), instability (4 knees), and a variety of other diagnoses (12 knees). The knees were evaluated using the systems of the Knee Society. The mean follow-up time was 4.3 years. Liner exchange for wear was successful in all 12 patients: for acute infection, in 9 of 11 patients; for instability, in 3 of 4 patients; for other diagnoses, in 10 of 12 patients. There were significant improvements in the pain score in all four groups and significant improvement in the function score in the infection and other diagnoses groups. With the use of six criteria, these observations suggest that liner exchange for wear is successful. Key words: liner exchange, osteolysis, revision, total knee, wear

Substantial postoperative stiffness requiring manipulation is a well-recognized complication of total knee replacement. This study sought to determine whether the Medial-Pivot (MP) knee (Wright Medical, Memphis, TN) or the Double-High (DH) knee (Wright Medical) is more often associated with manipulation under anesthesia (MUA) for post–total knee arthroplasty (TKA) knee stiffness. It was hypothesized that manipulation rates would be similar. Retrospective review of 755 TKA patients showed that 4.1% required MUA, which is comparable to the literature. Manipulation by MUA for DH and MP knees was generally successful, with an average overall improvement in knee flexion of nearly 30°. MP and DH knees appear to have a lower than average prevalence of post-TKA knee stiffness requiring manipulation when compared with the literature. The number of MP and DH knees requiring MUA did not appear to differ substantially. Key words: knee flexion, knee manipulation, knee stiffness, manipulation under anesthesia, range of motion

The purpose of this study was to assess the relationship between prefracture characteristics and length of stay (LOS) at the authors’ institution. Three hundred eighty-nine consecutive elderly hip fracture patients’ preoperative characteristics, comorbidities, fracture type, and surgical and hospital course were retrospectively reviewed. Multiple regression was used to determine which subset of potential independent variables would be good predictors of LOS. Predictors of increased LOS included cerebral vascular disease (C1.28 days, p < .0352), chronic renal insufficiency (C1.17 days, p < .0363), and American Society of Anesthesiologists (ASA) score (C1.27 days per ASA class, p < .0005). For each increase in age by 1 year, LOS decreased by amean of 0.085 days (p < .0041). Fracture type, prefracture mobility, or other examined comorbidities were found not to be significant predictors of LOS. Identifying high-risk patients in the preoperative period andminimizing certain perioperative events will be important to optimize care of patients who fracture their hip and to minimize future costs. Key words: comorbidities, hip fracture, length of hospital stay, patient characteristics

A case report of an adolescent with a fracture of the talus with an associated talus partitus is presented. Unlike the more common os trigonum, which arises from a secondary ossification center, the talus partitus is substantially larger and may include articulation with the ankle and subtalar joint, making its preservation via osteosynthesis with the talus desirable. Key words: adolescent fracture, talus, talus partitus

Acute lumbosacral plexus injury from gluteal compartment syndrome is extremely rare. Physicians should be aware of this diagnosis when examining patients with altered mental status, prolonged immobilization, and gluteal muscle compression. This case report presents a patient with acute complete left lumbosacral plexus paralysis and acute renal failure after gluteal compartment syndrome secondary to prolonged immobilization from drug abuse. Clinical examination, imaging of the pelvis, renal function, creatine phosphokinase, and urine myoglobin were indicative of gluteal compartment syndrome and rhabdomyolysis. Electrodiagnostic studies showed complete limb paralysis. Medical treatment and rehabilitation was administered. Renal function recovered within the 1st week; function at the proximal muscles of the left lower limb improved within 6 months, with mild discomfort on sitting at the buttock, foot drop, and sensory deficits at the leg and dorsum of foot. Key words: Key words: EMG/NCS, gluteal compartment syndrome, lumbosacral plexopathy, MR imaging

Extensor pollicis longus (EPL) tendon entrapment has been rarely reported as a complication of closed treatment of a pediatric Smith’s type distal radius fractures. This article presents the unique case of an initially functional EPL tendon that became entrapped in fracture callus in a 9-year-old boy, the youngest reported in the literature. Key words: distal radius fracture, EPL entrapment, extensor pollicis longus entrapment

Cement intravasation of the venous system is a rare complication of total hip arthroplasty. This is a case report of a 54-year-old female who sustained cement occlusion of the first perforator vein of the femur after hybrid total hip arthroplasty. However, she was asymptomatic and attained excellent clinical outcome. Differential diagnoses for the radiographic appearance are discussed as well as possible reasons for this occurrence. Key words: cement, extrusion, intravasation, occlusion, perforator vein, total hip arthroplasty

Orthopedic surgeons are becoming more involved in the care of patients with septic arthritis and bursitis caused by yeast species. This case report involves a middle-aged immunocompromised female who developed a Candida glabrata septic olecranon bursitis that developed after she received a corticosteroid injection in the olecranon bursa for presumed aseptic bursitis. Candida (Torulopsis) glabrata is the second most frequently isolated Candida species from the bloodstream in the United States. Increased use of fluconazole and other azole antifungal agents as a prophylactic treatment for recurrent Candida albicans infections in immunocompromised individuals is one reason why there appears to be increased resistance of C. glabrata and other nonalbicans Candida (NAC) species to fluconazole. In this patient, this infection was treated with surgery (bursectomy) and intravenous caspofungin, an echinocandin. This rare infectious etiology coupled with this intravenous antifungal treatment makes this case novel among cases of olecranon bursitis caused by yeasts. Key words: bursectomy, Candida glabrata, caspofungin, elbow, olecranon bursitis

Review of available English literature suggests that combined injuries involving a clavicle shaft fracture and an acromioclavicular (AC) separation are rare. The force dissipation after the occurrence of either a midshaft clavicle fracture or an AC separation typically renders the injuries mutually exclusive. This article presents a review of literature on this combined injury pattern. A variety of treatment approaches have been put forth, including nonoperative, operative, and hybrid management of the two distinct injuries. The most appropriate treatment rendered depends on the degree of AC joint instability. This case report involves a midshaft clavicle fracture associated with a type IV AC separation in a patient ejected during a high-speed motor vehicle collision. Internal fixation of each injury was chosen and the patient had a successful final result. Other reported treatment options and recommendations are reviewed. Key words: acromioclavicular dislocation, acromioclavicular separation, middle-third clavicle fracture, midshaft clavicle fracture, open reduction internal fixation