Improved Percutaneous Slipped Capital Femoral Epiphysis Treatment: Continuous Biplanar--John T. Killian, MD; Michael J. Conklin, MD; Thomas Kramer, MD; Stan White, SA

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In 1990, a report was published outlining a technique of percutaneous fixation of slipped capital femoral epiphyses dramatically diminishing the morbidity associated with the open technique. Technical difficulties are still encountered with the morbidly obese child and the percutaneous technique. Two fluoroscopic units used continuously during the technique facilitate placement of the guide wire in a more acceptable anatomic location. Guide wire stiffness was also measured and used in preoperative planning. Ten hips were treated with this technique, and a prospective analysis of the surgical time and fluoroscopy time was done. Using the new technique, we found a significant reduction in surgical and fluoroscopic times.

Cortical Strut Allografts for the Treatment of Femoral Fractures and Deficiencies in Revision Total Hip Arthroplasty--Kevin J. Logel, MD; Paul F. Lachiewicz, MD; Gregory A. Schmale, MD; Scott S. Kelley, MD

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Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.

Initial Biomechanical Properties of Anterior Cruciate Ligament Reconstruction Autografts--Timothy R. Stapleton, MD; David T. Curd, MS; Champ L. Baker, Jr., MD

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To provide more information to consider when selecting a reconstruction technique, we did a side-by-side comparison of some of the initial biomechanical properties of currently accepted reconstruction methods. Our research hypotheses were that a quadrupled, woven semitendinosus and gracilis graft is as strong as any of the other commonly used graft materials and that quadrupling and weaving the hamstring graft may increase the stiffness of the overall construct. Using lower extremity cadaveric specimens harvested from young donors, we fashioned seven each of seven types of graft: 9-mm, 10-mm, and 11-mm-wide patellar tendon graft (PTG); 10-mm-wide central quadriceps tendon graft; doubled semitendinosus graft; tripled semitendinosus graft; and quadrupled, woven semitendinosus and gracilis graft. Specimens were stripped of remaining soft tissue, and anterior cruciate ligament (ACL) constructs were created for biomechanical testing. The tibia was translated anteriorly on the femur, mimicking a pivot shift maneuver, and failure strength, failure mechanism, and construct stiffness were recorded. No differences in mean strength were detected. The quadrupled, woven graft was significantly stiffer than the doubled semitendinosus graft and no less stiff than any of the PTG constructs. All grafts showed similar and adequate initial absolute strength to reconstruct the ACL. Quadrupling and weaving the semitendinosus and gracilis graft increases the stiffness of the reconstructed specimen to a level statistically similar to that of specimens reconstructed with a PTG.

Marjolin Ulcers: Secondary Carcinomas in Chronic Wounds--Robert J. Esther, MD; Laura Lamps, MD; Herbert S. Schwartz, MD

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Marjolin ulcers are malignant tumors arising in chronic wounds. Strictly defined, they include carcinomas that transform from the chronic open wounds of pressure sores or burn scars. They behave aggressively and have a propensity for local recurrence and lymph node metastases. A retrospective study was done at a single institution identifying six individuals who had chronic wound ulcers that underwent malignant transformation into a carcinoma. Sinus tract degeneration in osteomyelitis was not included. The average latency time between ulcer formation and documentation of a malignancy was 30 years. All wounds were about the pelvis or flank. Major oncologic surgical procedures were done in an attempt to eradicate the cancer. High-grade tumors had positive lymph node metastases, portending a grave prognosis. All four individuals with nodal metastases eventually died of systemic disease. Early recognition and proper staging offers the best chance for cure.

Epidermoid Inclusion Cysts of the Hand*--George L. Lucas, MD

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Epidermoid inclusion cysts occur second only to ganglions in terms of tumefaction presentations in the hand. This review describes 60 such lesions and reviews the clinical presentation, diagnosis, and treatment. The epidermoid inclusion cyst probably arises from some traumatic event that drives epithelial cells into the subcutaneous tissues where they survive, grow, and produce keratin.

Open Fractures of the Hand*--Mark H. Gonzalez, MD Michael Jablon, MD Norman Weinzweig, MD

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Open fractures of the hand are a challenging clinical problem for the orthopedic surgeon. The fracture is often comminuted with substance loss. Additionally, the fracture site can be contaminated by foreign material. The soft tissue envelope is violated with a variable degree of tissue devitalized. The wound contamination and tissue destruction lead to a rate of infection that can be much higher than that for a closed fracture. Initially, management of a significant soft tissue injury must take precedence over definitive fracture fixation. Proper staging of debridement, wound closure, and definitive fixation is paramount in minimizing infection while obtaining fracture union.

Carpal Tunnel Syndrome: Current Concepts--Robert R. Slater, Jr., MD

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Carpal tunnel syndrome (CTS) is a clinical syndrome manifested by characteristic signs and symptoms resulting from an entrapment neuropathy of the median nerve at the wrist. It is the most common compression neuropathy in the upper extremity. In this paper, the etiology and pathophysiology of CTS are reviewed, as well as the clinical examination and other tests that may be useful in establishing its diagnosis. A variety of surgical techniques have been espoused for treating CTS refractory to nonoperative treatment and the proposed advantages and disadvantages of the new procedures are discussed. If the diagnosis is correct, then surgical results are reliably good.

Replantation of Completely Amputated Distal Forearm—1965--Jesse H. Meredith, MD; L. Andrew Koman, MD

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Although replantation of completely amputated wrists and forearms is now commonplace, in 1965 the replantation of this “wrist level” amputation was the first reported in the western world. The details of the technique used are contrasted with current standard of care.

Fibrosarcoma of the Sacrum in a Child: Management by Sacral Resection and Reconstruction--James F. Mooney III, MD; Steven S. Glazier, MD; Charles S. Turner, MD; Anthony J. DeFranzo, Jr., MD

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Posterior Extradural Lumbar Disk Fragment--Scott D. Hodges, DO; S. Craig Humphreys, MD; Jason C. Eck, MS; Laurie A. Covington, BS

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We present the unique case of a patient with a sequestered disk fragment posterior to the thecal sac producing symptoms of spinal stenosis with neurogenic claudication. The majority of sequestered disk fragments migrate in either a cranial or caudal direction. In only a few cases have disk fragments been identified posterior to the thecal sac. Our patient had a sudden onset of bilateral groin and anterior thigh pain. Magnetic resonance imaging showed relatively severe stenosis at L4-5 with mild disk bulging. Intraoperatively, a large posteriorly placed encapsulated mass of soft tissue was found compressing the posterior portion of the thecal sac. Patients with acute onset of symptoms of spinal stenosis should have herniated disk included in their differential diagnosis, even in the absence of imaging confirmation.

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