Simple, Hybrid Deep Venous Thrombosis/ Pulmonary Embolus Prophylaxis After Total Hip Arthroplasty--William G. Ward, MD; Matthew D. Olin, MS

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A 7.1% deep venous thrombosis rate followed total hip arthroplasty in 56 patients using a hybrid prophylactic regimen against deep venous thrombosis and pulmonary embolus. There were no bleeding complications, no symptomatic pulmonary emboli, and no unexplained deaths. The regimen consisted of an initial loading dose of warfarin, usually 10 mg, the night of surgery followed by 2.5 mg/day for 3 weeks, with dosage adjustments only in cases of over-anticoagulation. This regimen was combined with elevated sling suspension of the operative leg, bilateral pedal intermittent pneumatic compression devices, and early mobilization. This prophylactic regimen is simple, inexpensive, efficacious, and compatible with an early hospital discharge.

Minimally Invasive Surgical Technique for Unicondylar Knee Arthroplasty--John A. Repicci, DDS, MD; Robert W. Eberle

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Between August 1992 and December 1996, more than 700 unicondylar knee arthroplasty (UKA) procedures were done by the senior author (J.A.R.), using well-defined patient selection criteria, which is paramount to the outcome of the procedure. The UKA procedure described is done through a smaller incision than that required for total knee arthroplasty (TKA) (3 inches versus 8 inches), thus minimizing blood loss (less than 200 mL), avoiding normal tissue sacrifice (opposite compartment, patellar bone, and cruciate ligaments), and decreasing morbidity (no patellofemoral disruption). The UKA costs less because it is done as an outpatient procedure in 80% of cases; since postoperative physical therapy is minimal or unnecessary, recovery time is shorter (90% independent function at 2 weeks after operation). Whereas TKA can have universal application, UKA is patient specific and cannot replace TKA in all circumstances. Likewise, the techniques for TKA and UKA are not interchangeable. However, with the use of well-defined patient populations and surgical techniques, the intermediate results of UKA have paralleled reported outcomes of TKA.

Recurrent Carpal Tunnel Syndrome: Treatment Options--Michael F. Pizzillo, MD; Dean G. Sotereanos, MD; Matthew M. Tomaino, MD

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With the evolution of microsurgical techniques, upper extremity flaps have gained widespread acceptance for use in the hand and various indications have been refined. The use of local, regional, and distal flaps has been invaluable in the soft tissue treatment of loss. In addition, these flaps are effective adjuncts in managing traction neuritis, recurrent peripheral nerve entrapment in the upper extremity. In this review, we summarize the treatment alternatives available when addressing recurrent carpal tunnel syndrome. These options range from simple, repeat carpal tunnel release to complex, free tissue transfer. The objective in all cases is to provide a favorable local environment for the median nerve in which normal excursion is possible.

Southern Medicine During the War Between the States*--Waldo E. Floyd, MD

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In this article, I will describe a subject that is close to my heart—the practice of medicine during the War of Northern Aggression. While the doctors in most of Georgia had gone to war, my paternal grandmother’s father, William Emanuel McElveen, dispensed medicine and was a local practitioner in Southeast Georgia (Bulloch County) under a certificate approved by the Savannah Medical College. During this conflict, my mother had two paternal great uncles, Martin Daniel Hilliard and Charles Wesley Hilliard, who served as surgeons in the Alabama Army. One graduated from the Reserve Medical School in Macon, Georgia, in 1842. The other graduated from the same school in 1846. They both distinguished themselves during the war. Afterwards, one moved to Florida and the other to Texas.

Knee Arthroplasty: Pain and Swelling 6 Years Later--Harold R. Neitzschman, MD; Johnny U. V. Monu, MD

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This 69-year-old man had posttraumatic arthritis and had a total right knee arthroplasty at an outlying facility. Six years later he came to our orthopedic clinic with severe pain in the right knee and marked swelling; he was unable to walk. The knee was erythematous, tender to palpation, and there was a large joint effusion. He also had crepitus, grinding of the prosthesis, and instability in all planes.

Reconstruction of Longitudinal Stability of the Forearm After Disruption of Interosseous Ligament and Radial Head Excision (Essex-Lopresti Lesion)--David S. Ruch, MD; David S. Chang, BA; L. Andrew Koman, MD

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The restoration of longitudinal stability of the forearm after a radial head fracture with an acute distal radioulnar dislocation and damage to the interosseous membrane (Essex-Lopresti lesion) is a difficult problem. While most authors agree that early recognition of the pathology and reconstruction of the radial head is the ideal treatment for longitudinal instability associated with a radial head fracture, this may not always be possible. 1-3 The ability to reconstruct the radial head depends on the degree of fracture comminution and proper identification of associated pathology. Late recognition of the injury may preclude osteosynthesis of the radial head and result in chronic pain necessitating conversion to one bone fusion.4

Volar Intercalated Segment Instability After Scapholunate Ligament Reconstruction--David S. Ruch, MD; Gary R. Kuzma, MD

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We describe an 18-year-old man with an acute lunate dislocation treated with open reduction, ligament repair, capsulodesis, and percutaneous pinning. After pin removal and mobilization, the patient was found to have midcarpal collapse; the lateral radiographs showed a volar intercalary segment instability. We now, besides open reduction internal fixation scapholunate repair, recommend routine pinning of the lunotriquetral interval and careful evaluation of the dorsal radiocarpal ligament during repair of lunate and perilunate dislocations.

The Terrible Triad of the Shoulder--Stephanie S. Martin, MD; Thomas J. Limbird, MD

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The concomitant presentation of a rotator cuff tear, brachial plexus injury, and an anterior shoulder dislocation has been termed the “terrible triad” of the shoulder.1-3 This combination of injuries has been reported previously only in patients over age 40. We report the case of an 18- year-old man with a simultaneous rotator cuff tear, brachial plexus injury, and anterior shoulder dislocation, showing that this terrible triad can occur in younger individuals than reported previously. We emphasize the need for a high index of suspicion when examining the multiple injuries of the shoulder.

Regeneration of an Acromioclavicular Joint After a Type III Dislocation in an Adult--Eugene E. Berg, MD

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Arthritis as a sequela of acromioclavicular (AC) joint injury usually occurs after minor type I and II injuries and results from lax (stretched) ligamentous restraints that permit excessive motion and wear of this small articulation.1-3 Since the AC joint is dissociated and no longer in continuity, arthritis as a consequence of type III dislocation is not invoked as an indication for an acute repair or reconstruction.2-7 Hence, treatment of third-degree AC joint dislocations is controversial.3,6-9 However, even those who tout nonoperative treatment describe treatment failures due to persistent pain,5,6 though the sources of this pain are rarely identified or explained.

Retroacetabular Osteolysis--John Birkedal, MD; Douglas Kilgus, MD

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Retroacetabular osteolysis is a significant problem in total hip arthroplasty. Clinical, radiographic, and histologic data have linked particulate debris from component wear to progressive bone loss, loosening, and eventual failure of the implant.1-3 Not only does this osteolysis result in eventual failure of the implant, but also it provides considerable technical difficulty during revision surgery. Obtaining a stable platform for the revision acetabular component is dependent on the quality of the remaining bone and the location and the severity of the bone loss.

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