Volume 22-4, Winter 2013

Subacromial impingement syndrome (SIS) occurs when the rotator cuff is compressed by the overlying acromion during shoulder flexion resulting in shoulder pain. The objective of this study was to demonstrate significant relief of symptoms and improved function from physical therapy over longterm follow-up. Eighty-one patients were followed. Patients had subjective and strength assessments at the initial physical therapy visit and 2-year follow-up. Statistical analysis was done using paired t-tests for binomial data and Shapiro–Wilk test for the variable data. At 2 years, the Penn shoulder score (81) statistically significantly improved from the initial score (59) for 20 subjects (p D .002). The DASH score improved from 25 to 15 (p D .005). Average external rotation strength deficits compared with the contralateral side improved from 20% to 7% (p D .009). Physical therapy for SIS alleviates symptoms and improves function according to patient-based surveys and strength measurements over a 2-year period. (Journal of Surgical Orthopaedic Advances 22(4):251–255, 2013) Key words: nonoperative, physical therapy, shoulder impingement, subacromial impingement

The purpose of this study is to report the percentage of patients achieving union, time to union, and complications with the use of bone morphogenetic protein-2 (rh-BMP-2) in surgical repair of established nonunion in the hand and wrist. Twenty-seven patients with nonunion of the hand and wrist were treated between 2005 and 2011 with surgical repair and augmentation using 4.2 mg of rh-BMP-2. Sites of nonunion included the phalanx (seven), carpus (nine), distal radius (five), and distal ulna (six). Radiographic union and complications were the primary and secondary outcomes, respectively. Eightynine percent (24/27) of patients achieved union within an average of 4.3 š 2.8 months of surgery. There were no direct complications from administration of rh-BMP-2. Radiographic union was consistent with published rates for nonunion repair of scaphoid, phalanx, and distal radius fractures. Rh-BMP-2 did not produce superior rates of union in the patients with wrist and hand nonunion. (Journal of Surgical Orthopaedic Advances 22(4):256–262, 2013) Key words: bone morphogenetic protein, hand, nonunion, wrist

The purpose of this study is to retrospectively review the results of proximal third femur fractures treated with retrograde nailing (RGN) and compare those results to a cohort from the same period treated with antegrade nailing (AGN). Adult patients with femur fractures within 10 cm of the lesser trochanter who were treated with intramedullary nails were reviewed. Two groups, patients treated with AGN (n=35) and RGN (n=34), were compiled. Demographic information, comorbidities, associated injuries, radiographic outcomes, complicatons, and secondary procedures were compared. There were two malunions in the AGN group and three in the RGN group. The AGN group had two nonunions while the RGN group had one. Subgroup analysis demonstrated that a higher body mass index (BMI) (p=.011) and a higher AO/OTA fracture classification (p=.019) were the only factors predictive of malunion. Regardless of starting point, there were no differences between groups in the number of secondary procedures, nonunions, malunions, or time until union. (Journal of Surgical Orthopaedic Advances 22(4):263–269, 2013) Key words: antegrade, femur, fracture, intramedullary nail, retrograde

Anteromedialization of the tibial tubercle has been shown to unload contact pressure in the distal and lateral region. No study has evaluated pressures after anteriorization of the quadriceps tendon as a way to decrease contact pressures at the patella. In this controlled laboratory study, six cadaveric knees were tested by placing Fuji pressure film to measure patellar contact area, pressure, and force at 0°, 30°, 60°, and 90° in the intact state and after anteromedialization of the tibial tubercle, lateral release, and anteriorization of the quadriceps tendon. The addition of anteriorizing the quadriceps tendon decreased patellar contact area and force in the distal and lateral patella more than anteromedialization of the tibial tubercle and lateral release alone, though not in the proximal aspects of the patella as hypothesized. (Journal of Surgical Orthopaedic Advances 22(4):270–276, 2013) Key words: anteromedialization, biomechanics, Fulkerson, osteotomy, patellofemoral

Fourteen patients (17 shoulders) were identified who had been treated by one surgeon from 1992 to 2008 for symptomatic shoulder osteonecrosis using proximal humerus core decompression with fibular allograft strut placement. Pre- and postoperative radiographs were available, along with active range of motion and postoperative function: SPADI, ASES, SF-12. Two patients (two shoulders) were lost to follow-up. Radiographs were staged using the Cruess classification system as eight precollapse (stages I and II) (mean age 44 years) and six postcollapse shoulders (stages III and IV) (mean age 30 years). Groups had similar preoperative and postoperative flexion, external rotation, and functional scores. Two stage II shoulders and one stage IV shoulder were subsequently converted to hemiarthroplasty. This minimally invasive surgical technique could expand indications for strut grafting and joint salvage to treatment of patients with advanced osteonecrosis. (Journal of Surgical Orthopaedic Advances 22(4):277–282, 2013) Key words: fibular strut allograft, humeral head collapse, ON, osteonecrosis, proximal humerus core decompression, surgical technique

Anecdotal evidence suggests that temporal and environmental factors may contribute to the variance in the volume of pediatric orthopaedic injuries (POI), and knowing the effect of these factors could help in the allocation of resources and personnel in pediatric emergency rooms. All POI presenting to a level 1 pediatric emergency department over a 3-year period were reviewed. Environmental data, including minimal, maximal, and average daily temperatures; amount of precipitation; and lunar phase, were obtained for the study region, as were day of the week and month and season of the year. Multiple logistic regression determined which variable or combination of variables might affect the rate of POI. In the 6770 POI seen over the study period (average 6.2 per day), the day of the week and lunar phase had no effect on the rate of POI, the presence of precipitation lowered the rate slightly, and temperature had a dramatic effect, with the highest number of injuries occurring in the average daily temperature range of 70° to 79°. Winter months of November through February had the lowest rates of POI, while May had the highest. (Journal of Surgical Orthopaedic Advances 22(4):283–287, 2013) Key words: effect of environmental factors, emergency room visits, pediatric orthopaedic injuries

The goal of this study was to evaluate the biomechanical properties of an alternative method for connecting sutures using a crimp and to compare this method with a knot connection. Multifilament stainless steel suture (3-0 USP size) was connected by means of knot tying or crimp application and compared with FiberWire (3-0 USP size) connected by knot tying. Ultimate tensile strength (UTS) and stiffness were tested on a servohydraulic testing machine. The total UTS of the crimped constructs was significantly stronger and stiffer than the knotted groups, although the strength per strand was not statistically significant. Crimps offer an alternative method for connecting sutures. They have mechanical advantages over knot tying and allow the connection of multiple suture strands as well as the additional advantage of attaching both sides of the repair independently. This may provide precise pretensioning and potentially reduced surgical exposure. (Journal of Surgical Orthopaedic Advances 22(4):288–294, 2013) Key words: ACL repair, biomechanics, crimp, fixation, flexor tendon, ligament, stainless steel, suture, tenorrhaphy

Surgical site infections are associated with increased morbidity, mortality, and resource utilization. To identify risk factors for infection, the authors reviewed all orthopaedic spine operations at Duke University Medical Center from 2005 to 2010. Of the 3138 patients treated during the study period, 115 developed a surgical site infection (3.7%). Demographics, comorbidities, and perioperative blood glucose levels were analyzed in the infected and uninfected cohorts. History of myocardial infarction, congestive heart failure, renal disease, pneumonia, urinary tract infection, and diabetes mellitus (DM) were associated with a higher risk of infection. Notably, a diagnosis of DM nearly doubled the risk of infection. Even in patients without DM, perioperative blood glucose levels greater than 140 mg/dL doubled the risk of infection. The authors propose that strict blood glucose control in both DM and non-DM patients may significantly reduce the risk of infection after spinal surgery. (Journal of Surgical Orthopaedic Advances 22(4):295–298, 2013) Key words: cervical spine, diabetes mellitus, fusion, lumbar spine, thoracic spine

For metatarsalgia and lesser toe deformities, a commonly performed procedure is the Weil osteotomy, which inevitably depresses the metatarsal head, changing the intrinsic muscle axis and generating phalanx extension. The objective of this study is to present a new metatarsal osteotomy that shortens or lengthens and elevates the metatarsal head, the elevating metatarsal osteotomy (EMO), with its geometrical analysis and possible applications. A geometrical model was designed, planning an oblique subcapital osteotomy with slice resection and distal displacement. A trigonometric analysis was done to calculate how to shorten, elevate, or lengthen the metatarsal head. The EMO elevates the head in one-third of the width of the resected slice. Distal and dorsal displacement of the metatarsal head results in an elevation and lengthening of the metatarsal bone (60% elevation and 65% lengthening). Performing an elevating metatarsal osteotomy will lengthen and elevate the metatarsal head, which sometimes is necessary when treating toe deformities and instability. (Journal of Surgical Orthopaedic Advances 22(4):299–303, 2013) Key words: elevation, geometrical, metatarsalgia, trigonometric, Weil

The purpose of this study is to qualitatively and quantitatively describe the morphology of the biceps insertion on the radial tuberosity. Twenty-four preserved human elbows were carefully dissected and the insertions of the biceps conserved. The radius and the shape of the biceps insertion on the radial tuberosity were computerized using a three-dimensional digitizer. The length, width, and surface area of the footprints were measured. The soft tissue status of the muscle insertions and shape of the footprints were qualitatively described. The mean length of the biceps footprint was 24.1 š 2.4 mm, the mean width was 11.1 š 2.6 mm, and the mean area of the footprint was 219.0 š 60.2 mm2. Avascular, degenerate tissue fibers, consistent with tissue fibrosis were observed in 46% of the specimens. These changes may demonstrate natural changes of the distal biceps tendon and may improve our understanding of biceps tendinopathy and its prevalence. (Journal of Surgical Orthopaedic Advances 22(4):304–309, 2013) Key words: biceps brachii, enthesopathy, footprint, partial tendon rupture, tendinosis

There is no literature describing the use of indocyanine green angiography in orthopaedic trauma. This study describes four cases in which the novel application of laser-assisted indocyanine green angiography (LA-ICGA) was used to assist surgical decision making in orthopaedic trauma. It is an observational, retrospective case series of four primary trauma patients in which LA-ICGA was used to qualitatively evaluate tissue perfusion in the intraoperative setting. Poor perfusion on LA-ICGA was associated with negative clinical outcome, including progression to necrosis or amputation. LAICGA provides an assessment of soft tissue perfusion that may be correlated to tissue prognosis. It is safe for patient use, can be used at the bedside or intraoperatively, and allows for multiple repeat assessments within a short period. This technology holds promise for more widespread use in orthopaedic trauma, especially in controversial fields, such as defining the threshold for amputation versus reconstruction. (Journal of Surgical Orthopaedic Advances 22(4):310–315, 2013) Key words: amputation, angiography, ICG, orthopaedics, trauma

Ring external fixators such as the Ilizarov external fixator (IEF) and Taylor Spatial Frame (TSF) have revolutionized management of limb deformity. This study examines radiographic outcomes for treatment of malunions and nonunions with secondary emphasis on comparing radiographic union rates of TSF and IEF. A retrospective chart and radiograph review was performed. Fifty-four patients were included. Most injuries were in the tibia (96%). Fifty patients (93%) achieved radiographic union, two patients required further fixation, and two patients elected to undergo amputation. The preoperative coronal deformity improved from a mean of 12° (range, 0° –41°ı to within 3° anatomic. Sagittal deformity improved from a mean of 11° (range, 0° –49°ı to within 5° anatomic with some patients intentionally left in recurvatum to accommodate plantarflexion contractures. Limb length discrepancies were corrected to within 1 cm. Twenty-five patients experienced complications (mostly superficial pin tract infections). No statistically significant differences in the radiographic outcomes of TSF compared to IEF were identified. (Journal of Surgical Orthopaedic Advances 22(4):316–320, 2013) Key words: deformity, Ilizarov, malunion, nonunion, ring fixator

Lymphomatous spread to peripheral nerves is a rare but long recognized complication, most commonly involving aggressive B-cell lymphomas. A 67-year-old woman with a history of a low-grade, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, which was in remission, presented with a leftsided forearm mass and numbness over the dorsolateral aspect of the thumb. Magnetic resonance imaging revealed a mass associated with the superficial radial sensory nerve in the distal forearm, which demonstrated fluorodeoxyglucose avidity on positron emission tomography. An ultrasound-guided needle biopsy was performed yielding a diagnosis of low-grade lymphoma, consistent with extranodal marginal zone lymphoma. Subsequently, she was found to have bilateral sciatic nerve involvement. This case describes the first known reported spread of MALT lymphoma to peripheral nerves in the limbs. (Journal of Surgical Orthopaedic Advances 22(4):321–325, 2013) Key words: mucosa-associated lymphoid tissue, neurolymphomatosis, peripheral nerve lymphoma

Cervical spine fractures in osteogenesis imperfecta are rare. The purpose of this article is to describe the successful outcomes of the nonoperative and operative treatment of C2 pars fracture and operative treatment of C7 compression fracture in two children with osteogenesis imperfecta. Patient 1, a 22-month-old female, had a C2 pars fracture managed nonoperatively with a cervical orthosis. Patient 2, a 15-year-old male, had concurrent C2 pars and C7 compression fractures; the C2 pars fractures were treated operatively via a posterior approach and open reduction and internal fixation, and the C7 compression fracture was treated via a C7 corpectomy, iliac crest strut autograft, and anterior plating from C6 to T1. Patient 1 had delayed union but complete healing at latest follow-up (31 months postpresentation). At latest follow-up, patient 2 remained asymptomatic. (Journal of Surgical Orthopaedic Advances 22(4):326–329, 2013) Key words: cervical, hangman’s fracture, osteogenesis imperfecta, pars

Iliosacral screw removal is occasionally necessary during index or revision pelvic ring surgery. This procedure can necessitate a two-step process: screw removal followed by retained washer removal. On attempted removal of the screw–washer complex, the washer will not uncommonly dissociate itself from the screw. Its retrieval can be challenging, add unnecessary operative time, and result in larger incisions and increased soft tissue disruptions. This article introduces a simple technique for retained washer retrieval when removing or exchanging iliosacral screws. This technique involves an ‘‘interference fit’’ between the retained washer and a screw or tap of larger diameter, allowing for reliable and simple washer extraction. Advantages of this technique include removal through the same soft tissue tract as initial screw insertion and subsequent screw removal. It also obviates the need for introduction of various clamps to extract the washer, which can result in soft tissue injury and increased reliance on fluoroscopy. (Journal of Surgical Orthopaedic Advances 22(4):330–332, 2013) Key words: iliosacral screw, removal, retrieval, technique, washer

This article describes a novel, simple, and effective technique for limiting extensor mechanism damage during total knee arthroplasty (TKA) performed via the medial parapatellar (MPP) approach. Immediately on making the quadriceps tendon split in the MPP approach, a figure-of-eight stitch is placed at the apex of the split. The prophylactic stitch technique has been used by one surgeon in 1000 consecutive TKAs over the past 5 years. This technique has eliminated proximal extension of the quadriceps tendon split into the muscle belly and may help to decrease postoperative pain, increase postoperative quadriceps strength, and improve patient satisfaction and outcomes. (Journal of Surgical Orthopaedic Advances 22(4):333–335, 2013) Key words: medial parapatellar approach, quadriceps injury, technique, total knee arthroplasty