Fractures of the hand.

In managing any fractures of the hand, the basic principles of fracture management are the same whether treatment is closed or open. They are 1. Accurate reduction and stabilization of the fracture 2. Elevation and edema control 3. Mobilization of the unaffected joints 4. Early range of motion of the injured digit or digits when healing processes permit. Special situations and injuries require amendments to the basic principles. Open fractures require early and thorough wound debridement. Early fixation and serial wound debridement to assure a proper environment for bone or skin grafting are essential in caring for these severe injuries (Figs. 13-15). Numerous fixation techniques ranging from simple plaster splints, K-wires, external fixators, and small plates and screws are available for fracture care. Fractures of the hand are very common injuries that demand early recognition and treatment. The majority of fractures can be treated with closed methods. Recognition of those injuries that require operative treatment and prompt attention to detail and surgical technique will prevent many of the complications associated with these frequently encountered problems.

Femoral-sided fracture-dislocation of the knee.

OBJECTIVE: To document a previously undescribed fracture-dislocation of the knee that involves a femoral condyle and associated ligaments yet spares the tibial joint surface. DESIGN: Retrospective. SETTING: University. PATIENTS: Four cases of fracture-dislocation of the knee that involve ligamentous injury and fracture of the femoral condyle(s). RESULTS: At a minimum two-year follow-up (average 28.8 months, range 26 to 37 months), overall functional outcome is only fair to good in this injury pattern. The Lysholm knee rating averaged 60 (range 39 to 74) and KT-1000 I-N testing averaged three millimeters at thirty pounds. CONCLUSION: Despite treatment of this fracture-dislocation with internal fixation of the femoral condyle(s) and repair of the ligament(s), functional deficits occur in this severe knee injury patterns.

Arterial injuries in orthopaedics: the posteromedial approach for vascular control about the knee.

Combined orthopaedic and vascular injuries are becoming more common owing to an increasing incidence of high-energy trauma and gunshot wounds. We present our experience using the posteromedial approach in treating eight orthopaedic patients with popliteal arterial injuries. All patients underwent popliteal exploration by a vascular surgeon through a posteromedial approach (releasing the pes anserinus and the medial gastrocnemius). The arterial injuries were reconstructed in five patients using a reverse saphenous vein graft and directly repaired in three patients. Two patients had delayed healing of their incisions as a result of the original injury. There were no neural injuries. The posteromedial approach is extensile and utilitarian, and it represents the exposure of choice for arterial injuries about the knee.

Complications of metallic suture anchors in shoulder surgery: A report of 8 cases.

PURPOSE: Metallic suture anchors are widely used in open and arthroscopic operations about the shoulder. We report the cases of 8 patients who were referred to our institution with complications following shoulder surgery in which metallic suture anchors were used. TYPE OF STUDY: Retrospective case series. METHODS: There were 7 male patients and 1 female patient with an average age of 36 years (range, 18 to 76 years). The initial operation was open anterior reconstruction for anterior instability of the glenohumeral joint in 5 patients, open rotator cuff tear repair in 2 patients, and an open posterior capsular reconstruction for posterior instability in 1 patient. All patients were referred for evaluation after a failed index reconstructive procedure. RESULTS: On average, 5.5 suture anchors (range, 3 to 8) per shoulder were used. Of 4 patients undergoing reconstruction with glenoid anchors only, 3 patients had an extraosseously positioned device. In this subset of glenoid-sided reconstructions, when more than 3 anchors were used, at least 1 anchor was inserted in an extraosseous position. In 2 of 3 patients with isolated humeral anchors, there was evidence of migration over time (1 intra-articular, 2 bursal). Three patients (38%) developed severe articular damage that was directly caused by a loose or intra-articular metal suture anchor. One patient developed a wound infection after reconstructive surgery. In all 8 patients, the index procedure failed and required subsequent surgery. CONCLUSIONS: The use of metallic suture anchors about the shoulder is commonplace and useful, but, as with other hardware used about the shoulder, there are significant risks if the anchors are improperly placed or if the index procedure fails.

Management of shoulder dysfunction with an alternative model of orthopaedic physical therapy intervention: a case report.

One common approach to patient care in dealing with many musculoskeletal dysfunctions involves two to three patient visits to physical therapy per week over a period of weeks. Some patients may benefit from an alternative, graduated treatment model emphasizing a minimal number of office visits and focusing on intensive patient education, home program therapeutic exercise, and specific manual interventions. Patient education focuses on home program compliance and empowerment of the patient by adjusting office visits as needed based on patient progress rather than multiple patient contacts in the first weeks. This emphasis may improve long-term patient compliance by preventing the development of an external locus of control in which the patient is dependent upon the therapist for management of his/her condition. This case study is an example of the use of this alternative treatment model for the resolution of impingement syndrome and adhesive capsulitis in a 53-year-old female. A comprehensive program of patient education and home exercise was initiated during the first visit. Joint mobilization and active exercise were performed at each subsequent visit. The patient was seen a total of six visits over a period of approximately 10 1/2 weeks, followed up via telephone at 1 month after the last treatment and reexamined after 1 year. The objective exam revealed no abnormalities after the last visit or after 1 year. The patient subjectively reported compliance with the home program for 6 months after the last visit. This model of patient care was successful for the patient described in this case study. The treatment approach may have contributed to the development of an internal locus of control by allowing the patient to be as actively involved as possible in the treatment of her condition. In addition, this approach is timely when one considers current reimbursement systems. Though successful with this patient, this graduated treatment model is not intended to be applicable to every patient with this diagnosis.

The versatility of the gastrocnemius muscle flap.

The gastrocnemius muscle rotation flap is a utilitarian procedure for management of soft-tissue defects about the knee. Ten patients underwent medial gastrocnemius muscle rotation flaps at our institution during a 24-month period. Four of the 10 patients underwent primary muscle rotation-plasty for reconstruction following tumor resection; 3 patients had soft-tissue defects following trauma; 2 patients had skin ischemia following total knee arthroplasty; and 1 patient had a soft-tissue defect from scar formation. All procedures were performed by an orthopaedic surgeon. At follow-up of 6 to 24 months, the soft-tissue coverage was maintained in all patients. All of the muscle rotation flaps survived. The gastrocnemius rotation flap provides reliable anterior knee soft-tissue coverage and can be performed by most orthopaedic surgeons.

A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room.

There is no published data regarding the financial impact of training orthopaedic residents in the operating room. No comparisons between orthopaedic faculty and residents in regard to operative time and costs are known. One hundred eleven cases of anterior cruciate ligament reconstruction with or without partial meniscectomy were evaluated from 1996 to 1997. Fifty-three cases met the selection criteria of times, documentation and identification of the surgeon. Twenty-one cases were performed by the orthopaedic attending (RCS) while 32 cases were performed by the senior orthopaedic resident. All procedures had the same faculty member present in the operating room either as the primary surgeon or as an assistant providing supervision and instruction as needed. In a two year period, comparisons were made between the attending and residents for the total anesthesia time and actual operative case time. Attending case time and anesthesia times averaged 94.62 minutes (range 60-125 min) and 128.1 minutes (range 84-185 min) respectively. Resident case and anesthesia times averaged 137.09 minutes (range 95-210 min) and 190.48 minutes (range 145-255 min) respectively. The anesthesia time was significantly less for the attending (p<.0001) as was the case time (p<.0001). The true costs of training orthopaedic surgery residents in the operating room is not known. The operative time and subsequent cost difference between experienced faculty and orthopaedic residents in certain arthroscopic procedures is not inconsequential. On average, the difference is equivalent to $228.73 per case for anesthesia costs. Based on increased operative times, operating room costs, on average, were increased by $661.85. The significant differences demonstrated between residents and faculty suggest the need to develop strategies and technical training facilities in order to improve orthopaedic residents' surgical skills and efficiency outside of the cost-central operating room.

Successful revascularization of a partially avulsed foot in a 6-year-old child.

The foot of a 6-year-old child was revascularized successfully following an avulsion and partial amputation through the tibiotalar joint. Partial degloving had disrupted the anterior and posterior tibial arteries with resultant ischemia. We excised the entire damaged segment of the posterior tibial artery and performed a reverse saphenous vein graft, end-to-end reconstruction of the defect. Peroneal and tibial nerve function returned within 5 months. Four years later, the patient has regained full, painless range of motion and normal strength and sensibility with no evidence of premature growth plate closure or avascular necrosis of the talus.

Argument against use of food additives for osteoarthritis of the hip.

Food additives and other forms of alternative medicines have been embraced by the general public. Some of these compounds including glucosamine and chondroitin sulfate have shown efficacy in relieving pain associated with osteoarthritis. However, evidence is limited concerning the chondroprotective ability of these agents. More controlled studies and basic research is necessary to evaluate these claims especially because these compounds are not under regulatory control.

Biomechanical topography of human ankle cartilage.

The material properties of normal cadaveric human cartilage in the ankle mortice (tibiotalar articulation) were evaluated to determine a possible etiologic mechanism of cartilage injury of the ankle when an obvious traumatic episode is not present. Using an automated indentation apparatus and the biphasic creep indentation methodology, creep indentation experiments were performed in five sites in the distal tibia, one site in the distal fibula, and eight sites in the proximal talus of 14 human ankles (seven pairs). Results showed significant differences in the mechanical properties of specific human ankle cartilage regions. Topographically, tibial cartilage is stiffer (1.19 MPa) than talar cartilage (1.06 MPa). Cartilage in the anterior medial portion of the tibia has the largest aggregate modulus (HA = 1.34 MPa), whereas the softest tissue was found to be in the posterior lateral (0.92 MPa) and the posterior medial (0.92 MPa) regions of the talus. The posterior lateral ridge of the talus was the thickest (1.45 mm) and the distal fibula was the thinnest (0.95 mm) articular cartilage. The largest Poisson's ratio was found in the distal fibula (0.08). The lowest and highest permeability were found in the anterior lateral regions of the astragalus (0.80 x 10(-15) m4N-1sec-1) and the posterior medial region of the tibia (1.79 x 10(-15) m4N-1sec-1), respectively. The anterior and posterior regions of the lateral and medial sites of the tibia were found to be 18-37% stiffer than the anatomically corresponding sites in the talus. The biomechanical results may explain clinically observed talar dome osteochondral lesions when no obvious traumatic event is present. Cartilage lesions in a repetitive overuse process in the ankle joint may be related to a disparity of mechanical properties between the articulating surfaces of the tibial and talar regions.

Immediate vascular and ligamentous repair in a closed knee dislocation: case report.

Traumatic dislocation of the knee is a significant injury, and concomitant neurovascular injury generally occurs in greater than one in three cases reported. This paper describes a patient with multiple injuries who sustained a traumatic knee dislocation with vascular compromise. Initial treatment included a vein graft of the arterial injury and reconstruction and reattachment of injured ligaments at the same time as joint stabilization with a Steinmann pin. If arterial injury is present it must be repaired first.