Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases.

Patellar tendon rupture after removal of the central third for ACL reconstruction is a rare complication. Only nine cases have been previously reported, and all of these occurred within the first 10 months after surgery. We report two cases of late patellar tendon ruptures occurring at more than 3 and 6 years, respectively, after surgery. A review of the literature has suggested but not conclusively supported that devascularization, an alteration in tendon healing and remodeling, or injury to the remaining tendon at the time of graft harvest may be possible causes of this rare complication. Biopsy tissue from any future patellar tendon ruptures after removal of its central third could contribute to a better understanding of this anomaly.

Allograft salvage of failed total elbow arthroplasty. A report of two cases.

Infection after total elbow arthroplasty (TEA) is a devastating complication. Current management options include (1) salvage of the implant with debridement and parenteral antibiotics, (2) resection arthroplasty, and (3) arthrodesis. Most infected TEA patients ultimately require resection arthroplasty. Inadequate bone may preclude both revision TEA and successful resection arthroplasty. It is in these cases that the patient may benefit from allograft reconstruction. Two patients with painful flail elbows secondary to previous resection arthroplasties were treated successfully with cadaver allograft augmented with in situ autograft. Use of the allograft resulted in improvement from failure to excellent in this patient with posttraumatic arthrosis at five years after operation and from failure to good in a rheumatoid patient at two years after operation. Autograft-augmented allografts in the resected failed-TEA patient are a valuable and bone-preserving option. This may be especially useful in patients with significant bone loss or young patients with posttraumatic arthrosis, for whom arthrodesis may be the only other surgical option. The method should not preclude further revision TEA.

Total sacrectomy for a giant sacral schwannoma. A case report.

Giant sacral schwannomas (GSS) are extremely rare. Complete resection of benign but neurologically devastating tumors has been recommended. A 48-year-old man with GSS had a tumor so large that a total sacrectomy was necessary. A special method of lumbar iliac fixation was devised. Two years and nine months after surgery, the patient was free of pain and ambulating with bilateral orthoses.

Intragluteal spindle cell hemangioendothelioma. An unusual presentation of a recently described vascular neoplasm.

A 40-year-old woman noted a large tumor mass in the left buttock that, on microscopic examination, proved to be a recently described, relatively uncommon spindle cell hemangioendothelioma. This particular neoplasm, which has some features of Kaposi's sarcoma, seems not to have been reported previously in a deep, intramuscular location.

The use of periosteally vascularized autografts to augment the fixation of large segmental allografts.

Large segmental bone grafts are a standard of reconstructing long bone defects. Nonunion or delayed union at the host-graft junction is a major complication of these procedures. In six patients, a nonunion was treated by locally available bone, vascularized by its periosteum as an onlay autograft to improve fixation and speed incorporation of the allograft into the host bone. At three months, all were pain free and using their allografts without limitation. By four months, all had roentgenographic evidence of allograft and autograft incorporation. During the follow-up period from two to four years, all have incorporated the allografts and are pain free.

Microscopically assisted posterior lumbar interbody fusion.

Microscopically assisted posterior lumbar interbody fusion was performed on 27 patients who had either spondylolisthesis or chronic lower back pain after previous lower back surgery. Overall improved satisfactory results occurred in 22 of 27 patients. Roentgenographic, stable, interbody fusion occurred in 22 of 27 patients. The poorest results and highest rate of pseudarthrosis occurred in patients with double-level fusions. Pseudarthrosis occurred in four of six patients with double-level fusions and unsatisfactory clinical results occurred in five of six patients with double-level fusions. Advantages of the microscopic technique are better examination of the surgical site, less blood loss, and less surgical dissection than other surgical salvage techniques. This procedure should be reserved for single-level pathology in the lumbosacral spine.

High radial nerve palsy following strenuous muscular activity. A case report.

A case of high radial nerve palsy occurred following muscular overexertion in a 20-year-old man. Late surgical exploration showed a nerve constricture from the lateral head of the triceps. A literature review showed that entrapment of the radial nerve following muscular overexertion can occur from a fibrous arch coming from the lateral head of the triceps or by the lateral head of the triceps muscle. The neuropathy can be irreversible, and early recognition of this syndrome is mandatory so that surgical decompression can be considered before permanent nerve damage occurs.

Thromboembolism after hip surgery. Comparison of screening methods.

Venous thromboembolism is a serious and, often, asymptomatic complication of hip surgery. A reliable screening test is needed to detect thrombi early to prevent death from pulmonary emboli. Noninvasive screening tests were ineffective in our study of 453 patients. We recommend early use of ventilation/perfusion lung scanning in all patients after hip surgery. In those who have positive results, ascending venography can be used to localize the thrombus and anticoagulation therapy can be started early.

Thromboembolism following hip fracture.

Two hundred forty-eight patients following hip fracture were studied for deep venous thrombosis and pulmonary embolus. Ventilation-perfusion lung scans and contrast ascending venography were performed on the sixth to eighth postoperative days. Low-dose intravenous heparin (3,000-5,000 units every 6 hours) was followed by a decreased incidence of pulmonary embolism more than twofold. Although heparin administration was not associated with a significantly decreased incidence of deep venous thrombosis as assessed by venographic studies, thrombi in the nonheparin-treated patients were more likely to occur above the knee and were at higher risk for pulmonary embolus. Pneumatic and mechanical compression devices alone did not protect patients from deep venous thrombosis above the knee, but were associated with a decreased incidence of pulmonary embolus compared to control.

Condylar nonunions of the elbow.

Between 1968 and 1978, 32 patients were seen with nonunion of distal humerus fractures in close proximity to the elbow: 25 were treated with open reduction and fixation of the nonunion, and seven patients were treated with excision of the distal fragments and total elbow arthroplasty. Of the 25 patients treated with open reduction and fixation, 22 had union at an average of 7.74 months. However, six of these patients needed secondary procedures for repeat bone grafting or revision of the fixation device. Two of the seven patients with total elbow arthroplasty needed reoperation for loose humeral components.

Osteochondritis dissecans of the capitellum.

A retrospective study was done of 84 patients with osteochondritis dissecans of the capitelum who were seen during a 43-year period; followup of 57 patients could be obtained, nine of whom had involvement in both elbows. Most of the osteochondral lesions could be classified either as those still attached to the capitellum (type 1) or as loosened fragments lying free and floating within the joint (type 2): 24 were of type 1 and 37 were of type 2. Residual limitations were highest in the type 2 lesions that were treated either nonsurgically or surgically after a long delay. The best surgical results occurred with excision of the osteochondral defect and drilling or curettage of subchondral bone.