Knee Manipulation After Total Knee Arthroplasty--Thomas J. Ellis, MD; Eric Beshires, MD; George W. Brindley, MD; Rebecca L. Adams, RN; Cheryl Preece, MS

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To determine if any factors are associated with knee stiffness after total knee arthroplasty (TKA), we retrospectively reviewed the medical records and radiographs of patients who had knee manipulation after total knee replacement at Scott & White Memorial Hospital from 1983 to 1993. Twenty-five patients who had knee manipulation after TKA were matched by surgeon, year of surgery, and age (± 5 years) with a study group of 25 patients who did not have knee manipulation after TKA. Patients in the manipulated group had decreased flexion at the time of discharge from the hospital after the knee arthroplasty and a decreased final flexion. The age of the patient, time from surgery to manipulation, and preoperative flexion did not correlate with final flexion attained in the manipulated group. Relative to the control study group, the manipulated group had an increase in postoperative anteroposterior femoral thickness. A decrease in patellar height was noted both in the manipulated group and in the control nonmanipulated group. There was no significant difference between groups for a change in patellar height.

Unilateral Elbow Arthrodesis: The Preferred Position--Stephen M. Nagy III, MD; Robert M. Szabo, MD; MPH Neil A. Sharkey, PhD

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Twenty-five volunteers had unilateral elbow immobilization for 24 hours in each of two positions of flexion, 45° and 90°. Twenty-two of the 25 volunteers preferred a position of 90° of flexion. Standard functional testing revealed significant limitations in each position of immobilization, confirming that there is no single optimal position of elbow arthrodesis. This study suggests that, for most individuals, 90° is the preferred position of elbow arthrodesis for activities of daily living. However, factors such as age, sex, occupation, and dominance of the extremity should be considered when choosing a position of arthrodesis.

Wrist Arthrodesis Using a Wrist Fusion Plate--Fraser J. Leversedge, MD; John G. Seiler III, MD; Marcia Toye-Vego, CHT, PT, OT; Lamar L. Fleming, MD

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All wrist arthrodeses done between 1990 and 1996 using a Synthes wrist fusion plate were reviewed. Independent assessment done by a certified hand therapist included a patient survey, standardized Jebsen-Taylor hand function test and activities of daily living test, and a Buck- Gramcko and Lohmann evaluation. We evaluated 13 wrists in 11 patients. Overall satisfaction was 100% of patients (mean follow-up, 31.5 months; range, 13 to 61 months). Mean preoperative and postoperative pain scores improved from 7.2 to 0.8, respectively, and functional scores improved from 5.0 to a postoperative mean value of 7.4. Jebsen-Taylor scores were virtually identical for fused and uninvolved wrists. There were no pseudarthroses, no plate failures, no tendon ruptures, and no significant postoperative infections; there was a single plate removal because of tenuous skin coverage. Short-term results using a comprehensive assessment of a custom plate designed for wrist arthrodesis show promising clinical outcomes.

Congenital Dislocation of the Knee: Overview of Management Options--Kermit S. Muhammad, MD; L. Andrew Koman, MD; James F. Mooney III, MD; Beth P. Smith, PhD

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Congenital dislocation of the knee (CDK) is rare and includes a spectrum of hyperextension disorders of the knee. Early recognition of CDK is important, and careful evaluation is required to rule out associated hip deformity. Early manipulation, combined with splinting and casting, is the mainstay of initial treatment. Patients with seemingly fixed contractures may respond rapidly to serial casting and then can be placed in a Pavlik harness. Severe recalcitrant deformities or late presentation of the deformity may require surgical release. We highlight the importance of diagnostic categorization, show management options, and provide an overview of this rare but clinically significant problem. We present two case reports that illustrate the full range of management options.

Penetrating Bladder Injury Caused by a Medially Placed Acetabular Screw--J. C. Kinmont, MB, BS, FRCS

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Cancellous bone screws are used frequently to improve the early stability of hydroxyapatite (HA) coated acetabular components during total hip arthroplasty.1-4 Occasional complications have been reported: medially placed screws may cause neurovascular damage, especially to the external iliac and obturator vessels, and the sciatic and obturator nerves.1-5 Avoidance of the anterosuperior and anteroinferior quadrants is recommended for transacetabular screw placement.1-5 Although it has not previously been considered an at risk structure, I report a case of bladder injury associated with a medially placed acetabular screw.

Heterotopic Ossification Complicating Total Elbow Replacement in a Patient With Rheumatoid Arthritis--Diane M. Allen, MD; James A. Nunley II, MD

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Heterotopic ossification after total elbow replacement is a new complication. In this particular case, it resulted in severe limitation of motion. Excision of the heterotopic bone resulted in an excellent functional outcome for the patient.

Median Nerve Palsy Presenting as Absent Elbow Flexion: A Result of a Ruptured Pectoralis Major to--Robert J. Spinner, MD; James A. Nunley, MD; Robert E. Lins, MD; Richard D. Goldner, MD

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We describe a patient with a preexisting posttraumatic brachial plexopathy who had a complete high median nerve palsy due to rupture of the pectoralis major to biceps transfer near its distal insertion at the elbow region.

The Nocebo Effect: Do No Harm--Morton L. Kasdan, MD Kathleen Lewis, BA Anne Bruner, BA Amy L. Johnson, BS

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The nocebo effect creates negative expectations about symptoms and can have devastating influence on patient recovery. Just as the placebo effect works by making patients believe they will get better, the nocebo effect can serve to make patients worse. Two case histories are presented in which patients were assigned diagnoses without objective physical findings. This resulted in poor outcomes. Physicians should avoid assigning a diagnosis without objective physical evidence and thus avoid creating the nocebo effect in patients.

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