Ulnar focal cortical indentation: a progressive, deforming variant of focal fibrocartilaginous dysplasia.

BACKGROUND: Focal fibrocartilaginous dysplasia is a rare growth disturbance of bone resulting in deformity. In the ulna, focal fibrocartilaginous dysplasia is particularly rare, and the characteristic fibroligamentous tether can result in progressive deformity with progressive dislocation of the radial head. The fibroligamentous tether is similar in appearance and function to the Vickers ligament seen in Madelung deformity. The imaging features of ulnar focal fibrocartilaginous dysplasia include a unilateral angular deformity in the ulna with a radiolucent cortical defect and surrounding sclerosis, with secondary radial bowing or radial head dislocation. Focal fibrocartilaginous dysplasia of the ulna has been described using the term ulnar focal cortical indentation. OBJECTIVE: To review the clinical and radiologic features of four cases of ulnar focal cortical indentation occurring in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed picture archiving and communication system and electronic medical record imaging findings with surgical correlation of ulnar focal cortical indentation at two large specialty pediatric hospitals. RESULTS: Ulnar focal cortical indentation lesions typically arise in the ulnar metaphysis and result in angular forearm deformities with progressive radial deformity including radial head dislocation. Early surgical intervention prevents progression of the deformity and retains range of motion. CONCLUSION: Ulnar focal cortical indentation, although rare, is likely a progressive form of focal fibrocartilaginous dysplasia resulting in significant deformity and disability. Early recognition of the characteristic imaging features is important for early surgical intervention to preserve range of motion and prevent radial head dislocation.

Outcomes in Early Versus Late Presentation of Focal Fibrocartilaginous Dysplasia Affecting the Upper Extremity: A Review of 4 Cases.

BACKGROUND: Focal fibrocartilaginous dysplasia (FFCD) is a rare disorder of the upper and lower extremities. In the distal ulna, a ligamentous tether emerging from the metaphysis crosses the physis and restricts growth, leading to deformity. Lesion excision before radiocapitellar subluxation has been shown to restore growth and allow remodeling. We review the outcomes of 4 patients with FFCD of the distal ulna after the occurrence of radiocapitellar incongruity. METHODS: This retrospective review examined 4 patients diagnosed with FFCD of the distal ulna from 2007 to 2015. Diagnosis was based on radiographic parameters and pathology when available. The radiographic and functional outcomes are reported. RESULTS: Three males and 1 female patient presented at an average of 37.5 months (range, 22 to 48 mo) with ulnar FFCD and radiocapitellar joint incongruity. The first patient had progressive radiocapitellar dislocation, poor motion, pain, and deformity. The second patient presented for a third opinion after previous surgery secondary to deformity progression and radial head dislocation. These patients required salvage procedures with creation of a 1-bone forearm. Patient 3 had frank dislocation of the radiocapitellar joint, yet maintained functional motion. This family elected for continued observation. Patient 4 had a 50% subluxation of the radiocapitellar joint and underwent tether excision and ulnar lengthening with an external fixator. Both joint congruity and deformity improved with functional forearm and elbow motion. CONCLUSIONS: Delayed treatment of ulnar FFCD may require salvage procedures to maximize function and provide pain relief.

Polyethylene glycol improves elution properties of polymethyl methacrylate bone cements.

BACKGROUND: Bone cements are used as adjuncts to fracture fixation methods and can also function as a local drug delivery system. The ability to elute drugs makes bone cement a promising and powerful chemotherapy treatment modality for osseous tumors. However, because of poor elution rates, the clinical application of this drug delivery mode remains challenging. Soluble fillers, such as sugars, salts, or biocompatible polymers, offer a solution to improve elution rates. This study quantified the effect of polyethylene glycol (PEG) on the elution properties of three commercially available bone cements. METHODS: Two grams of Vertebroplastic, Palacos, and Confidence bone cement powder containing three concentrations (0%, 20%, or 50%) of PEG filler were hand mixed with 10 mg of methotrexate. This powder mixture was then polymerized with 1.0 mL of the cement specific liquid monomer. The cylindrical elution samples were placed in saline solution and methotrexate elution was recorded for 720 h. RESULTS: The cumulative and daily elution rate increased as the concentration of PEG increased for each bone cement. However, the percent of increase depended on the bone cement used. Cumulative methotrexate elution increased by 40%-54% in case of the highest PEG filler concentration when compared with controls. CONCLUSIONS: PEG soluble filler offers a promising method for improving methotrexate drug elution in bone cement. Future studies need to optimize the PEG and bone cement ratio that produces the greatest drug elution profile without sacrificing the biomechanical properties of bone cement.

The Effect of Image-Guided Corticosteroid Injections on Thumb Carpometacarpal Arthritis.

Background: Arthritis involving the thumb carpometacarpal (CMC) joint is common in the adult population. Initial treatment includes corticosteroid injections. Injections can be performed with image guidance to assist with placement; however, the clinical benefits are unclear. Methods: This retrospective study used Truven Health Marketscan Research Databases to identify patients from 2003 to 2014 with common International Classification of Diseases, Ninth Revision (ICD-9) codes for osteoarthritis of the CMC joint, Common Procedural Terminology (CPT) codes for image and non-image-guided injections, and codes for surgical interventions. Length of time from injection until subsequent injection(s) and/or surgery was extrapolated for identified patients. Analysis of variance and binomial logistic regression were used to compare continuous variables and calculate odds ratios, respectively. Results: We identified 62 333 patients (68% women, 32% men), average age 59.7, with common ICD-9 diagnostic codes for CMC arthritis with respective injection CPT codes. The average number of days between the first and second injection for patients treated with non-guided injection was 237.3 versus 266.7 for image-guided injections. Of the 62333 patients, 8107 went on to operative treatment. Among operative patients, the average number of days to surgery following non-guided injection was 317.7 versus 333.7 days in the image-guided group. The average cost of performing non-image-guided injections was $203 less than using ultrasound. Conclusions: Image-guided thumb CMC injections do not result in significant increases in time between injections and do not lead to a meaningful delay to surgery. Future research needs to clarify the value of image-guided CMC injections in an increasingly economically conscientious health care environment.

Use of high-speed burr and water-based lubricant in the partial removal of surgical plates: A technique Guide.

Implant removal comprises 5% of all orthopaedic surgery procedures performed annually. Surgical indications range from implant failure, infection, non-union, and symptomatic hardware. Intra-operatively, surgeons need to prepare for complications including bony overgrowth, cold-welding, broken screws, and stripped screw heads. Large anatomic dissections required for complete hardware removal place the patient at increased risk of complications due to increased operating time and larger dissections. The authors present a safe and effective technique for the partial removal of surgical implants. The technique utilizes a high-speed burr to cut surgical plates, minimizing the total dissection and operative time. Sterile surgical laps covered in water-based lubricant capture metal debris to reduce tissue contamination as well as surgeon exposure to metal particles.

Bilateral Hemiarthroplasty in a Patient with Below-Knee and Above-Knee Amputations: A Case Report.

CASE: This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. CONCLUSION: This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

A Comparison of Three C-Arm Draping Techniques to Minimize Contamination of the Surgical Field.

The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior-posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.