The results of vascularized-free fibular grafts in complex spinal reconstruction.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine outcomes after anterior or posterior placement of vascularized-free fibular grafts in complex spinal reconstruction for tumor resection and osteomyelitis and to evaluate the results with respect to bony fusion, time to union, and complications. SUMMARY OF BACKGROUND DATA: Biological reconstruction of segmental defects of the spinal column may be required when multiple vertebrae are resected for tumor or infection. Published series to date have not fully addressed surgical techniques or outcome and complications. METHODS: A retrospective, Institutional Review Board-approved review was performed on the medical records and neuroimaging of all patients who underwent a vascularized-free fibular graft for a multisegmental spine reconstruction at a single institution over the last 10 years. Details regarding indications, the levels spanned, the graft length, and the time to union were evaluated. RESULTS: Seven patients (mean age, 43 y) underwent surgery using this technique, with an average follow-up of 38 months. Surgical indications included oncologic resection associated with radiation therapy (n=3) and surgical treatment of vertebral osteomyelitis (n=4). An average of 2.7 (median, 2) levels was fused with an average of 2.1 (median, 2) vertebral body excisions performed. Mean fibular length was 19.1 cm. Six of 7 patients achieved union at mean of 3.2 months. Complications specific to the fibular grafting procedure included 1 nonunion associated with pedicle thrombosis. CONCLUSIONS: Vascularized-free fibular grafts are effective in the treatment of complex spinal reconstruction after surgery for spinal tumors or osteomyelitis. The vascularized-free fibular graft adds structural support as well as living bone to the fusion site and is a reasonable alternative to nonvascularized grafts in locally compromised surgical beds.

Arthrodesis as a salvage for failed proximal interphalangeal joint arthroplasty.

PURPOSE: To review the rate of fusion, complications, and subjective outcome measures of proximal interphalangeal joint arthrodesis after failed implant arthroplasty. METHODS: We conducted a retrospective review identifying patients from 1990 to 2009 who underwent proximal interphalangeal joint arthrodesis for implant arthroplasty failure. All types of implants were included. We reviewed clinical notes and radiographs identifying patient history, implant type, revisions before arthrodesis, method of arthrodesis, rate of union, time to union, and complications. We used the Michigan Hand Outcomes Questionnaire to assess patients' function and perceived clinical outcome. RESULTS: A total of 13 joints in 8 patients (6 female, 2 male) identified with an average clinical follow-up of 6.5 years (range, 1.0-12.3 y) were available for study. The average time from joint replacement to salvage for all implant types was 9.3 years (range, 1.6-32.2 y). Eight of the 13 fingers achieved union. The average time to union was 5.8 months (range, 1-11 mo). Eight of 13 fingers underwent removal of K-wires, tension band, or both. Excluding hardware-related problems, there were 4 additional complications in 4 patients. CONCLUSIONS: Salvage of failed proximal interphalangeal joint arthroplasty remains a challenging clinical problem. Although achieving solid fusion with arthrodesis is not completely reliable or without complication, patients' subjective and functional outcomes demonstrate fair to good results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Postoperative patient falls on an orthopedic inpatient unit.

We are not aware of any data looking specifically at inpatient falls in an orthopedic ward. We reviewed all postoperative orthopedic patients who fell during 2003 and 2005 on a single postoperative orthopedic unit. Seventy patients (1%) fell, resulting in 2.5 falls per 1000 musculoskeletal inpatient days. Most (n = 45, 64%) were bathroom related, were unassisted (n = 54, 77%), and occurred during the evening or night shift (n = 46, 66%). Thirteen (19%) patients acquired an injury as a consequence. Female sex (odds ratio [OR] = 1.9), patient age greater than 65 years (OR = 1.7), prolonged admission (OR = 1.7), and admission for primary or revision knee arthroplasty (OR = 5.0) were all significant risk factors for a postoperative inpatient fall. This information has provided us with some insight to direct the development of a fall prevention program specific to postoperative orthopedic patients.

Synovial chondromatosis of the foot and ankle.

BACKGROUND: Synovial chondromatosis (SC) is a benign condition where the synovial lining of joints, bursae, or tendon sheaths undergoes metaplasia and ultimately forms cartilaginous loose bodies. Synovial chondromatosis of the foot and ankle is exceedingly rare, and outcomes following surgical excision are largely unknown. MATERIALS AND METHODS: An Institutional Review Board-approved retrospective review of our institution's surgical database from 1970 to 2006 revealed 8 patients with SC of the foot and/or ankle confirmed by pathology. RESULTS: Eight patients (4 female and 4 male) presented with pain, locking, or stiffness. Average age at presentation was 37 (range, 19 to 60) years. Average followup was 9.5 (range, 1 to 31) years. Six patients had involvement of the ankle, and two, the midfoot. Four patients underwent ankle synovectomy with loose body removal, and were pain-free at last followup. One patient underwent excision and midfoot arthrodesis for severe midfoot destruction. Three patients ultimately underwent below knee amputation, one for multiple recurrences and two for malignant transformation to low-grade chondrosarcoma. CONCLUSION: To our knowledge, this is the largest reported series of patients with SC of the foot and ankle. In half the patients, synovectomy with excision of loose bodies resulted in pain free return to normal function, without recurrence, at last followup. However, recurrence occurred in 3 (37.5%) of 8 patients with subsequent malignant transformation to low-grade chondrosarcoma occurring in 2 patients.

Contemporary evaluation and treatment of distal radius fractures.

Distal radius fractures are among the most common fractures encountered by orthopedic surgeons. Because of many fracture patterns and types, it has been difficult to develop a comprehensive classification. Treatment options vary depending on injury severity and stability of the fracture reduction. Closed reduction and immobilization can be used for stable fractures. Common surgeries include pinning with and without external fixation and open reduction and internal fixation. Technological advances such as locking and fixed angle plates have made the volar approach feasible. Dorsal plating with low profile plates and fragment-specific techniques can be successful in treating distal radius fractures. Following fracture reduction and stabilization, assessment of distal radioulnar joint stability is essential and must be stabilized when necessary.

Triplanar trochanteric osteotomy: a modified anterior trochanteric slide osteotomy.

Current methods of trochanteric sliding osteotomy typically preserve the lateral aspect of the greater trochanter, the vastus lateralis, the abductors, posterior capsule, and the external rotators. Our modification to this technique includes leaving an anterior vertical ridge of bone that resists the anterior-directed forces acting on the osteotomy. Furthermore, a chevron-shaped osteotomy provides some additional stabilization to the proximally directed pull of the abductors. We believe these modifications improve the intrinsic stability of the osteotomy, theoretically decreasing the rate of nonunion.