Digital Flexor Sheath: Repair and Reconstruction of the Annular Pulleys and Membranous Sheath--John G. Seiler III, MD, Fraser J. Leversedge, MD

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Rupture or transection of the digital pulley may necessitate repair or reconstruction to treat symptomatic flexor tendon bowstringing. When reconstruction is necessary, intrasynovial tendon grafts may provide superior gliding characteristics when compared with traditional extrasynovial tendon grafts. Lacerations of the membranous portion of the digital sheath and of noncritical annular pulleys usually do not require operative repair.

Iliac Crest Autogenous Bone Grafting: Donor Site Complications--John Gray Seiler III, MD, Joseph Johnson, MD

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Autogenous bone grafting is often done in orthopaedic surgery for a variety of conditions. The iliac crest is currently the most common donor site for obtaining autogenous bone graft. We searched the literature to summarize reported complications related to the donation of autogenous bone from the iliac crest. Our review revealed reports of arterial injury, ureteral injury, herniation, chronic pain, nerve injury, infection, fracture, pelvic instability, cosmetic defects, hematoma, and tumor transplantation. Currently, autogenous bone grafting is a necessary part of the treatment of various orthopaedic conditions. Obtaining bone from the iliac crest can be associated with significant morbidity. As bone grafting technology emerges, the known complications of the current standard should be weighed against the risk of alternate therapies.

Transesophageal Echocardiography in Quantification of Emboli During Femoral Nailing: Reamed Versus Unreamed Techniques--Robert E. Coles, MD, Fiona M. Clements, MD, J. W. Lardenoye, MD, G. V. Wermeskerken, MD, Lloyd A. Hey, MPH, MD, James A. Nunley, MD, L. Scott Levin, MD, Albert W. Pearsall IV, MD

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We quantified the embolic load to the lungs created with two different techniques of femoral nailing. Eleven patients with 12 traumatic femur fractures were randomized to reamed (7 fractures) and unreamed (5 fractures) groups. Intramedullary nailing was with the AO/ASIF* universal reamed or unreamed nail. Transesophageal echocardiography (TEE) was used to evaluate the quantity and quality of emboli generated by nailing. Data were analyzed using software that digitized the TEE images and quantified the area of embolic particles in each frame. The duration of each level of embolic phenomena (zero, moderate, severe) was used to determine total embolic load with various steps (fracture manipulation, proximal portal opening, reaming, and nail passage). Manual grading of emboli correlated highly with software quantification. Our data confirm the presence and similarity of emboli generation with both methods of intramedullary nailing. Unreamed nails do not protect the patient from pulmonary embolization of marrow contents.

Fractures of the Ankle: Pathogenesis and Treatment*--Frank C. Wilson, MD

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The management of ankle fractures is based on an understanding of their pathogenesis. As stated in the Sermon on the Mount, “By their fruits, ye shall know them” (Matthew 7:20). Thus, from the radiographic appearance, one may determine the mechanism of injury, and from the end result, the adequacy of treatment. The terms adduction, supination, and inversion will be used synonymously, as will the terms abduction, pronation, and eversion—except in the Lauge-Hansen classification, in which eversion refers to external rotation.

Past, Present, and Future of the Clinical Orthopaedic Society--Joseph C. DeFiore, Jr., MD

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It has been an honor and a privilege to be President of the Clinical Orthopaedic Society. During the past year, I have attended the regional society meetings, as well as those of the American Orthopaedic Association and the American Academy of Orthopaedic Surgeons. All of these in addition to the specialty, state, and local orthopaedic groups are evaluating membership and potential membership from a new viewpoint. The reason for this is multifaceted. Because of poorer reimbursement from governmental and private insurance companies, younger members must more selective in which groups they will join and which meetings they will attend.

Arthroscopy of the Elbow for Synovial Chondromatosis--J. W. Thomas Byrd, MD

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Two cases of arthroscopic removal of multiple loose bodies are presented. Successful results were achieved, and patients had 4-year follow-up. Both cases involved classic manifestations of synovial chondromatosis. Associated degenerative changes were present in one case; histologic examination could not confirm synovial origin of the disease. Arthroscopy for removal of symptomatic loose bodies is an excellent choice as exemplified by these two cases. Care should be taken to review histologic findings, which may help in understanding the natural history of this type of process.

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