Volume 24-3, Fall 2015

Collaborative Establishment of an Integrated Orthotic and Rehabilitation Pathway

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Returning to active military duty and to recreational activities has been difficult for service members sustaining combat-related high-energy lower extremity trauma (HELET). The Return to Run (RTR) clinical pathway was introduced in 2009 with favorable results in returning active duty service members to running, sports participation, active duty, and deployments. The RTR pathway was introduced at a second institution in 2011 to determine if the pathway could be reproduced at a different institution. In this study, a series of patients is presented who underwent limb salvage procedures after sustaining HELET at an outside military treatment facility and subsequently participated in the authors’ RTR protocol. They received a novel orthotic device from the San Antonio Military Medical Center and returned to their home institution for rehabilitation. In this cohort, an improvement in functional capability was obtained in nearly all patients. In conclusion, successful translation of the integrated orthotic and rehabilitation initiative to outside institutions is possible. ( Journal of Surgical Orthopaedic Advances 24(3):155–158, 2015) Key words: limb salvage, lower extremity, orthotic, rehabilitation, trauma

Body Mass Index as an Indicator of Associated Intra-articular Injuries in Patients With Anterior Cruciate Ligament Tears

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This study assessed the relationship between body mass index (BMI), anterior cruciate ligament (ACL) injury, and associated meniscal and cartilage injury. Age, ACL classification, and Tegner activity score were considered. A total of 1968 ACL reconstruction patients (2/1/1996 to 5/1/2012) were analyzed. All graft types, age groups, and activity levels were included. A BMI ½30 correlated with a significant likelihood of medial meniscus tears (p D .022). Patients with a BMI ½30 were 21.6% more likely to have a medial meniscus tear with an ACL injury. Grade III and IV chondral lesions correlated with a BMI ½30 (p D .029). Patient’s age predicted medial meniscus outcome (p D .013). Patients whose age was >25 had a 25.7% higher risk of medial meniscus tear. Chronic ACL patients were 52.6% more likely to have a meniscus injury. BMI, age, Tegner activity score, and ACL classification are good predictors of medial meniscus injury. Patients with a BMI ½30 exhibit a greater risk of medial meniscus tear with ACL instability; however, BMI does not significantly contribute to increased chondral damage in ACL-deficient patients. ( Journal of Surgical Orthopaedic Advances 24(3):159–163, 2015) Key words: ACL, articular damage, BMI, intra-articular cartilage injury; medial meniscus injury, obesity

Functional Outcomes After Both Bone Forearm Fractures in Adults

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The purpose of this study was to evaluate midterm outcomes after both bone forearm fractures. A retrospective review of patients treated with open reduction and internal fixation (ORIF) at three level 1 trauma centers was completed. Eligible patients were sent three questionnaires: Disabilities of the Arm, Shoulder and Hand (DASH), Short Form-12 (SF-12), and questions about postinjury experience. Twenty-nine patients with an average age of 45 years returned the materials. The forms were completed an average of 60 months after ORIF. The mean DASH was 22 for all respondents. Twenty-one subjects participated in physical therapy (72%). Eight patients (28%) screened positive for posttraumatic stress disorder (PTSD). The mean SF-12 physical component score was 39 and the SF-12 mental component score was 40, both of which were lower than the non-PTSD group, indicating a lower subjective level of health (p <.05). The data suggest that, years after surgery, patients have decreased functional outcomes. ( Journal of Surgical Orthopaedic Advances 24(3):164–169, 2015) Key words: both bone forearm fracture, Disabilities of the Arm, Shoulder and Hand (DASH), open reduction and internal fixation, physical therapy, posttraumatic stress disorder

Conversion From Limb Salvage to Late Amputation: Lessons Learned From Recent Battlefields With Application to Civilian Trauma

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Battlefield injuries and high-energy civilian trauma present orthopaedic surgeons with treatment challenges. Despite efforts at limb salvage, some patients elect late amputation. This article reviews risk factors that predispose to late amputation. Using a MEDLINE search, English language peer-reviewed articles from 1993 to 2013 having data on late amputation following limb salvage were included. Late lower extremity amputation after limb salvage varied from 3.9% to 40% in civilian patients and from 5.2% to 15.2% in military patients. Factors influencing a patient’s decision to undergo late amputation included a combination of complex pain symptoms with neurologic dysfunction, infection, a desire for improved limb functionality, and unwillingness to endure an often complicated and lengthy course of treatment. In military patients, rank was a significant risk factor since officers were 2.5 times more likely to elect late amputation (p < .05) than enlisted personnel. Despite often extraordinary efforts toward limb salvage, results may be disappointing. ( Journal of Surgical Orthopaedic Advances 24(3):170–173, 2015) Key words: amputation late, battlefield injuries, civilian trauma, limb salvage

Patient Satisfaction After Limb Lengthening With Internal and External Devices

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External fixation has long been used for limb lengthening but can result in many complications, such as tethering of the soft tissues, pain, decreased joint motion, scarring, and nerve injury. Recently, a controllable, telescopic, internal lengthening nail was developed to address many of these issues and hopefully improve the overall experience for the patient. The satisfaction rates of internal and external fixation for limb lengthening were compared in 16 patients, all of whom have experienced both methods. Thirteen out of 16 patients responded to a limb-lengthening questionnaire, developed by the authors for this patient population. Patients preferred the internal device with respect to overall satisfaction, reduced pain, ease of physical therapy, and better cosmetic appearance. When asked which device they would prefer if another surgery was required, all patients chose the internal device. From the patients’ perspective, the internal lengthening device is an improvement over the traditional external fixator. ( Journal of Surgical Orthopaedic Advances 24(3):174–179, 2015)

Comparison of Intraoperative C-Arm Fluoroscopy to Postoperative Radiographs in Operative Fracture Fixation

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The purpose of this study is to evaluate the differences between intraoperative C-arm images and postoperative plain film radiographs and the utility of each in assessing fracture fixation and determining postoperative management. Intraoperative and postoperative images with varying fracture types and locations were analyzed. C-arm images were compared to postoperative plain film radiographs for each treated fracture and reviewed by two orthopaedic surgeons. Image adequacy and quality for each radiograph were analyzed. The quality of reduction and fixation was also analyzed. Information was apparent on the postoperative radiographs, such that a reviewer felt that the postoperative treatment plan should change in 8.2% of cases. In the cases where treatment change was recommended, fracture gap, rotation, and angulation were found to be the strongest predictors. The ability of intraoperative and postoperative images to reflect fracture gap, rotation, and angulation may vary between images. (Journal of Surgical Orthopaedic Advances 24(3):180–183, 2015) Key words: fracture management, imaging

Anthropometry of the Human Scaphoid Waist by Three-Dimensional Computed Tomography

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Published measurements for the scaphoid are scarce. The purpose of this study is to define anthropometric norms for the waist of the scaphoid to assist in optimizing bone graft quantity and implant use. Computed tomography images of the wrist were reviewed by three surgeons. Anthropometric data were gathered, including the scaphoid waist diameter in two dimensions and the scaphoid waist volume. Each study was measured twice, allowing for determination of inter- and intraobserver reliability. Fortythree studies were examined (23 female and 20 male). Average measurements of the scaphoid waist were 11.28 š 0.26 mm in the sagittal plane and 8.70 š 0.17 mm in the coronal plane, and the waist volume was 715 š 33.0mm3. Specific measures of the narrowest portion of the scaphoid are provided by this study. Measurements of the scaphoid waist through the use of three-dimensional imaging are an accurate method with good inter- and intraobserver reliability. The measurements obtained from this study can be applied to guide graft and implant selection for treatment of scaphoid waist fractures and nonunions. ( Journal of Surgical Orthopaedic Advances 24(3):184–187, 2015) Key words: anthropometric, bone graft, headless compression screw, nonunion, scaphoid

Fracture of the Medial Humeral Epicondyle in Children: A Comparison of Operative and Nonoperative Management

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To compare clinical and radiographic outcomes of medial epicondylar fractures treated operatively to those treated nonoperatively, 30 patients with 31 fractures were divided into three groups: (a) nondisplaced, six treated nonoperatively; (b) incarcerated fragment, four with operative treatment; and (c) displaced but not incarcerated, 21 fractures, 14 treated operatively and seven nonoperatively. Clinical outcomes were assessed with follow-up examination and the Japanese Orthopaedic Association elbow assessment score. Average elbow scores were 98 in nondisplaced fractures, 94 with an incarcerated fragment, 95 in displaced fractures treated operatively, and 94 in displaced fractures treated nonoperatively. The only nonunion was in a fracture with an incarcerated fragment. Both operative and nonoperative treatment produced good outcome scores in displaced but not incarcerated fractures, but radiographic deformity and instability were more frequent in those treated nonoperatively. (Journal of Surgical Orthopaedic Advances 24(3):188–192, 2015) Key words: children, medial epicondyle fracture, nonoperative treatment, operative treatment, outcomes

Use of a Fascial Flap to Stabilize an Unstable Ulnar Nerve in Its Bed During In Situ Decompression

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This case report involves a man with ulnar neuropathy at the elbow, who was to undergo an in situ decompression of the ulnar nerve. When the nerve was noted intraoperatively to sublux partially over the posterior portion of the medial epicondyle, the surgeon stabilized the nerve in situ by using a fascial flap that was secured to the anterior rim of the cubital tunnel and loosely sutured posteriorly to the medial side of the olecranon, rather than performing an anterior transposition or medial epicondylectomy. This method could be considered a middle-ground surgical technique because it allowed the nerve to remain in its bed, did not disturb its blood supply, dealt with the problem of a slightly unstable ulnar nerve with a fascial flap, and avoided methods that could be considered as having greater surgical magnitude. ( Journal of Surgical Orthopaedic Advances 24(3):193–197, 2015) Key words: cubital tunnel syndrome, fascial flap, in situ decompression ulnar nerve, ulnar nerve decompression elbow, ulnar neuropathy elbow

Achilles Tendinitis

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Achilles tendinitis is a common etiology of heel pain, which is a common patient complaint. Achilles tendinitis can be classified into noninsertional tendinosis and insertional tendinitis on the basis of clinical features, radiologic signs, and pathologic findings. Magnetic resonance imaging (MRI) allows classification and reveals associated findings, including retrocalcaneal bursitis, paratendinitis, and paratenonitis. Furthermore, MRI may not only confirm findings of Achilles tendinitis but also diagnose other etiologies of heel pain. This article reviews the MRI findings and terminology of Achilles tendinitis often found in radiology reports. ( Journal of Surgical Orthopaedic Advances 24(3):198–202, 2015) Key words: Achilles insertional tendinitis, Achilles noninsertional tendinosis, Achilles tendinitis, Achilles tendon, Haglund’s deformity, paratendinitis, paratenonitis, retrocalcaneal bursitis

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