Trapezial Resection Arthroplasty for Osteoarthritis: Use of Abductor Pollicis Longus Tendoplasty With Interpositional Material--Glen A. Barden, MD
In this series, 45 patients had 54 trapezial resection arthroplasties for carpometacarpal osteoarthritis, with nine of the patients having bilateral arthroplasties. A major slip of the abductor pollicis longus tendon was used as a sling, with the underlying flexor carpi radialis tendon as stabilizer. Palmaris longus tendon, when present (42 cases), and absorbable gelatin sponge, when palmaris was absent (12 cases), served as interpositional material. Review was done an average of 4.3 years (range, 1 to 11 years) after the procedure. The average space maintenance of resection site was 4.4 mm. This decreased to an average of 3.5 mm on the key pinch stress maneuver. Subjectively, the patients judged their results to be good to excellent in 49 instances (91%) and fair in 5 (9%).
Sever-L’Episcopo Tendon Transfer in Obstetric Brachial Plexus Palsy--Peter S. Vasiu, DO, Alfred V. Hess, MD,Dennis P. Grogan, MD
Obstetric brachial plexus palsy produces functional and cosmetic impairment. The Sever-L’Episcopo procedure has been successfully used to improve external rotation, primarily in younger patients. Previous studies have shown steady improvement in motion and function for 1 year from the date of surgery, with little additional change beyond this period. This is a retrospective study of 7 patients who have had the procedure at the Shriners Hospital for Children in Tampa, Florida. Functional and cosmetic results have been uniformly excellent at an average follow-up of 1 year 3 months. No complications have occurred. In addition, the degree of improvement seen in our relatively older patient population has not been previously detailed in the literature.
Subchondral Contusion of the Knee Caused by Axial Loading From Dashboard Impact: Detection by Magnetic Resonance Imaging--David Bealle, MD, Darren L. Johnson, MD
We studied the occurrence of “bone bruises” of the knee resulting from dashboard impaction and detected by magnetic resonance imaging (MRI). We chose 21 knees of 20 front seat occupants in head-on motor vehicle collisions. To ensure all knees had received a significant axial load, patients selected had ipsilateral posterior hip dislocations and/or posterior wall acetabular fractures. Anteroposterior and lateral knee radiographs were negative for fracture in all cases. T1- weighted axial and sagittal MRI of each knee with a 1.5-T magnetron scanner revealed signal changes consistent with subchondral microfracture or bone bruise in 8 of the 21 knees. Previous cadaveric, animal, and MRI studies have suggested that such changes may be precursors of posttraumatic osteoarthritis. With the increasing incidence of serious lower extremity injury as a result of motor vehicle accidents, these occult injuries may significantly affect individuals and society.
Lateral Extra-Articular Knee Reconstruction: Long-Term Patient Outcome and Satisfaction--Rolando Garcia, Jr., MD, Michael E. Brunet, MD, Stephen Timon, MD, Robert L. Barrack, MD
Fifty-two patients who had an extraarticular reconstruction for anterior cruciate ligament (ACL) insufficiency were interviewed at an average of 11.4 years after their reconstruction. During the follow-up period, 4 patients (8%) had intra-articular reconstructions for persistent instability or re-injury, and another 4 (8%) had arthroscopic surgery for meniscal lesions. The mean Lysholm score at follow-up was 76.9. Of the 52 patients, 5 had had subsequent surgery during the follow-up period. In the remaining 47 patients, the results were excellent in 14 (29%), good in 10 (23%), fair in 7 (15%), and poor in 16 (33%). Patients operated on acutely
Imaging of the Cervical Spine and Its Role in Clinical Decision Making--R. Bryan Murphy, BS, S. Craig Humphreys, MD, Desmond L. Fisher, MD, Scott D. Hodges, DO, Jason C. Eck, MS
Thorough imaging of the cervical spine often requires more than one test. The many available options from which to choose can often lead to redundancy and confusion regarding the best test series. In an effort to make the process of choosing the most effective imaging series more efficient, we review the current literature on cervical imaging and, from the information gathered, construct a diagnostic imaging algorithm for evaluating the cervical spine.
Posterior Lateral Mass Plate Fixation of the Cervical Spine*--Ronald W. Lindsey, MD, Theodore Miclau, MD
Historically, posterior fixation and fusion have been the most popular method of internally stabilizing the cervical spine after injury. Although techniques such as wiring are effective for most injuries, these methods are inadequate in the absence of intact posterior elements or extension and rotation injuries. We review the indications and techniques for posterolateral mass plate fixation that are useful in these difficult fractures.
Nonunion of the Fractured Clavicle: Evaluation, Etiology, and Treatment--Grant L. Jones, MD, George M. McCluskey III, MD, David T. Curd, MS
Although often viewed as benign injuries, clavicular fractures can lead to complications, particularly nonunions. The nonunion rate has been reported to be between 0.1% and 15%. Contributing factors to nonunion include severe initial trauma, marked initial displacement and shortening, soft tissue interposition, primary open reduction and internal fixation, refracture, open fracture, polytrauma, and inadequate initial immobilization. A clavicular nonunion is rarely asymptomatic and often results in disability from pain at the site of nonunion, altered shoulder mechanics, or a compression lesion involving the underlying brachial plexus or vascular structures. Treatment options include nonsurgical management, salvage procedures, and reconstructive procedures. The present goal is to obtain union with reconstructive procedures. The fixation methods described range from external fixation to plate and screw osteosynthesis. We prefer open reduction and internal fixation with plates and screws and with intercalary tricorticocancellous grafts to obtain union and restore the clavicle to its normal length.
Treatment of Acetabular Fractures--Steven J. Morgan, MD, Kyle Jeray, MD, James F. Kellam, MD
Acetabular fractures resulting from high-energy trauma generally occur in a younger adult population. The long-term ramifications of this intra-articular injury are severe if improperly diagnosed and mistreated. Late reconstructive options in this population are generally inferior to the acute reconstruction of the native hip joint. Early diagnosis and treatment or prompt referral to a surgeon comfortable with the care of acetabular fractures is paramount for achieving acceptable long-term functional outcomes. The purpose of this article is to summarize the concepts presented at the Southeastern Fracture Symposium, Greensboro, NC, January 1998.
Giving and Giving Back--Charles H. Classen, Jr., MD
When I was 8 years old, a momentous event occurred in my life. My mother became terminally ill with rheumatic fever, and I was propelled into an intimate contact with the medical profession. This shaped not only the rest of my life, but also my philosophy on medicine. As I see it, those in the medical profession “give” by applying all the knowledge acquired in training to their patients and “give back” by passing on their knowledge acquired in training to the next generation of physicians.
Rupture of the Flexor Digitorum Superficialis: Occurrence After Tendon Repair of an Adjacent Digit*--Mark H. Gonzalez, MD
A patient had a ruptured flexor digitorum sublimis tendon of the long finger in the region of decussation. The injury occurred several weeks after repair of a zone 2 flexor digitorum sublimis and flexor digitorum profundus tendon of the index finger.
The Decision to Salvage or Amputate a Severely Injured Limb--Mark D. Hiatt, MD, MBA, James M. Farmer, MD, Robert D. Teasdall, MD, ScM
The decision to salvage or amputate a severely injured limb is one of the most difficult an orthopaedic surgeon may face. The inclination to undertake heroic measures to save the limb should be tempered by the realization that doing so may lead to repeated hospitalizations, extensive complications, and a poor functional outcome. Several factors must be considered, including objective elements related to the patient’s injury and physical condition and subjective considerations related to the patient’s psychologic, social, and economic status. We present a framework, in the context of a case study, which may be used in deciding which patients can benefit from early amputation and review five predictive indices for limb salvage.