Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures.

BACKGROUND: We compare the use of plate and screws versus intramedullary nails in the operative management of patients with displaced midclavicular fractures. METHODS: Between March 2006 and June 2007, we performed a retrospective comparison of a demographically balanced sample of 110 patients (aged 16-65 years) who had received either plates or nails for completely displaced midshaft clavicular fractures. RESULTS: We selected 59 plate-fixed and 51 nail-fixed patients. There was no significant difference between the groups with respect to age, gender, height, dominant arm, fracture angulation, fracture shortening, total fracture displacement, or mechanism of injury. Outcomes were significantly higher in the plate group compared with the nail group for the length of hospital stay (4.6 days ± 2.1 days vs. 5.9 days ± 2.6 days, p = 0.006), operative blood loss (67.5 mL ± 36.2 mL vs. 127.9 mL ± 48.8 mL, p < 0.0001), and size of surgical wound (11.9 cm ± 4.4 cm vs. 22.3 cm ± 4.5 cm, p < 0.0001). There was no significant difference in operative time, time to union, restoration of mobility (forward flexion, abduction, external rotation, and internal rotation), number of nonunions, number of malunions, infection, need for hardware removal, early mechanical failure, time to return to work, and Constant Shoulder and Disabilities of the Arm, Shoulder, and Hand functional scores. CONCLUSION: Our results demonstrate no significant differences in functional outcome and nonunion rates between nails and plates fixation for displaced midshaft clavicular fractures.

Responsiveness and minimal important differences after revision total hip arthroplasty.

BACKGROUND: The health-related quality of life (HRQoL) is currently weighted more heavily when evaluating health status, particularly regarding medical treatments and interventions. However, it is rarely used by physicians to compare responsiveness. Additionally, responsiveness estimates derived by the Harris Hip Score (HHS) and the Short Form 36 (SF-36) before and after revision total hip arthroplasty (THA) have not been clinically compared. This study compared responsiveness and minimal important differences (MID) between HHS and SF-36. METHODS: All revision THA patients completed the disease-specific HHS and the generic SF-36 before and 6 months after surgery. Scores using these instruments were interpreted by generalized estimating equation (GEE) before and after revision THA. The bootstrap estimation and modified Jacknife test were used to derive 95% confidence intervals for differences in the responsiveness estimates. RESULTS: Comparisons of effect size (ES), standardized response means (SRM), relative efficiency (RE) (>1) and MID indicated that the responsiveness of HHS was superior to that of SF-36. The ES and SRM for pain and physical functions in the HHS were significantly larger than those of the SF-36 (p < 0.001). CONCLUSION: The data in this study indicated that clinicians and health researchers should weight disease-specific measures more heavily than generic measures when evaluating treatment outcomes.

Measurement of spinal range of motion in healthy individuals using an electromagnetic tracking device.

OBJECT: The authors measured the range of motion (ROM) of the spine in healthy individuals by using an electromagnetic tracking device to evaluate the functional performance of the spine. METHODS: The authors used the Flock of Birds electromagnetic tracking device with 4 receiver units attached to C-7, T-12, S-1, and the midthigh region. Forward/backward bending, bilateral side bending, and axial rotation of the trunk were performed in 18 healthy individuals. RESULTS: The average ROM was calculated after 3 consecutive measurements. The thoracic spine generated the greatest angle in axial rotation and smallest angle in backward bending. The lumbar spine generated the greatest angle in forward bending and smallest angle in axial rotation. The hip joints generated the greatest angle in forward bending and smallest angle in backward bending. Additionally, 40% of forward-bending motion occurred in the lumbar spine and 40% occurred in the hip joints. Approximately 60% of backward bending occurred in the lumbar spine; 60% of axial rotation occurred in the thoracic spine; and 45% of side bending occurred in the thoracic spine. CONCLUSIONS: The Flock of Birds electromagnetic tracking device cannot only measure the ROM of spine but also easily differentiate the 6-degree contributions by different segments.

Giant cell tumor of the EDL tendon sheath: an unusual cause of hallux valgus.

Hallux valgus is a lateral deviation of the proximal phalanx of the first metatarsophalangeal joint. It is a common disorder in adults. The etiologic factors include modern shoes, rheumatoid arthritis, pes planus, metatarsus primus varus, and trauma. Tumors causing hallux valgus deformities are unusual. We report a 50-year-old female with a hallux valgus deformity caused by a giant cell tumor of the second EDL tendon sheath. Surgical excision of the tumor and corrective osteotomy produced a permanent cure. This unusual cause of a hallux valgus deformity should increase awareness of tumors as a possible cause of foot deformities.

Clinical follow up after instrumentation-augmented lumbar spinal surgery in patients with unsatisfactory outcomes.

OBJECT: The authors investigated the causes of unsatisfactory outcomes in patients who had undergone instrumentation-assisted lumbar surgery and followed the clinical and imaging results of the revision surgery. METHODS: Myelography and postmyelography computed tomography (CT) scanning were successfully conducted in 103 patients. In nearly 80% of these patients, the main symptom was back pain, with or without leg pain. Additional electromyography and nerve conduction velocity studies were also conducted in 22 patients in whom CT myelography could not help to establish the definitive cause of surgical failure. There were 26 cases of spinal stenosis, 13 of adjacent-segment instability, 15 of pseudarthrosis, 11 of screw misplacement, four of epidural fibrosis, five of arachnoiditis, seven of disc disruption, and 22 miscellaneous. When conservative treatment failed to relieve symptoms, surgery was suggested whenever an operable lesion was found. Revision surgery was performed in 48 patients, and these cases form the basis of this retrospective cohort study. All patients underwent clinical and imaging follow up for a minimum of 2 years. Two-year clinical outcomes were assessed using the 36-Item Short Form Health Survey questionnaire and compared with earlier scores using the Student t-test. Fusion status was evaluated by two orthopedic surgeons, who examined flexion-extension x-ray films or CT studies. The greatest improvement after revision surgery was documented in patients with symptoms related to spinal stenosis or disc disruption. Little improvement was observed in patients with misplaced pedicle screws causing nerve injury and those with epidural fibrosis or arachnoiditis. CONCLUSIONS: Adequate decompression at the initial operation and prevention of restenosis or accelerated adjacent-segment degeneration yielded the most favorable prognosis in the present cases. Successful posterolateral arthrodesis combined with supplemental interbody fusion improved the surgical outcomes in cases involving disc disruption or degeneration.

Relationship of chondrocyte apoptosis to matrix degradation and swelling potential of osteoarthritic cartilage.

BACKGROUND AND PURPOSE: Softening of cartilage is the initial degenerative step of osteoarthritic cartilage by matrix degradation and corruption of interconnection of the collagen fibrillar network. The purpose of this study was to investigate the correlation of chondrocyte apoptosis, matrix degradation, and the corruption of collagen architecture in the development of severe swelling of osteoarthritic cartilage. METHODS: Twenty osteoarthritic and 7 normal femoral neck fractured cartilage samples were obtained from patients with knee osteoarthritis and normal patients with femoral neck fracture at the time of total hip joint replacement surgery. Apoptosis was verified by TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick end-labeling) staining and structural changes were observed under phase-contrast microscopy. Matrix degradation was evaluated by histochemical analysis of proteoglycans. Swelling tests were performed by immersing the cartilage slices in hypotonic solution. The results of ultrastructural study of collagen architecture of osteoarthritic cartilage performed by scanning electron microscopy before and after swelling were compared. RESULTS: Matrix degradation was most prominent in the middle zone of osteoarthritic cartilage. The percentage of chondrocytes in osteoarthritic cartilage showing apoptosis ranged from 15 to 20% (average, 18%; standard deviation (SD) = 3.2%) and was correlated with the extent of structural changes and matrix degradation. The swelling strain of the osteoarthritic cartilage varied from 120 to 200% (average, 160%; SD = 40%) depending on the degree of matrix degradation and structural changes. The loss of interconnectivity of collagen fibrillar architecture was correlated with the increased swelling potential of osteoarthritic cartilage. CONCLUSION: This study demonstrated that chondrocyte apoptosis was correlated with matrix degradation and the corruption of fibrillar architecture and that the extent of these manifestations correlated with the swelling potential of osteoarthritic cartilage. These findings also emphasize the importance of the fibrillar architecture in maintaining the mechanical properties of cartilage.

Arthroscopy following total knee arthroplasty.

Conservative treatment had previously been used in our institution to treat the painful stiff knee joint following total knee arthroplasty (TKA). However, the result was not satisfactory. Arthroscopic surgery was then performed in 11 patients with painful knee joints with limited motion who had previously undergone TKA. Good results were achieved in eight patients. An average improvement of 56.3 degrees was achieved for knee range of motion. Flexion improved up to 90 degrees in all patients in the early postoperative period following arthroscopy. However, the benefits declined with time. To avoid the potential complications of manipulation and open arthrotomy, arthroscopic surgery is an option for treating the painful stiff knee joint.

Salvage procedures for failed compression hip screw fixation of intertrochanteric femoral fractures: analysis of 50 cases.

We retrospectively studied 50 patients who underwent salvage procedures for failed compression hip screw (CHS) fixation of intertrochanteric fractures from January 1991 to July 2000. Among these patients, seven underwent revision fixed angle plate surgery; 16 patients underwent bipolar hemiarthroplasty; five patients underwent Austin-Moore hemiarthroplasty; another nine patients underwent total hip arthroplasty; and 13 patients underwent removal of the implant. The age, gender, type of falling accident, osteoporosis status and post-operative ambulation status were recorded. The incidence of failed fixation of CHS was estimated at around 9.7%. A fall was recorded in 52% of cases. There was a significant difference in osteoporosis grade between the failed and successful CHS groups (p < 0.005). There was also better postoperative ambulation in the total hip replacement group compared to the other groups (p = 0.03). Surgical management of nonhealed intertrochanteric fractures is a challenge to orthopedic surgeons. The authors suggest multiple factors, such as fracture geometry, bone quality, preservation of acetabulum cartilage and individual patient factors, be considered when performing salvage procedures for failed CHS.

The benefit of arthroscopy for symptomatic total knee arthroplasty.

Thirty-one knees with symptomatic total knee arthroplasty were diagnosed and treated arthroscopically. There were 18 knees with soft tissue impingement and 13 knees without. There were 16 knees with painful arthroplasty and range of motion (ROM) greater than 90 degrees. Hypertrophied synovitis with or without impingement was more easily found by arthroscopy in this group than in the other 15 knees with the chief complaint of limited ROM, where more remarkable fibrotic tissue with intra-articular adhesion was found. Overall, the average improvement in ROM was 43.1 degrees immediately after arthroscopy, and 20 degrees at the final follow-up. Symptoms improved in 90.3% of patients, and 58.1% were satisfied with the outcome of their surgery. Arthroscopy is helpful for intra-articular diagnosis, obtaining a specimen for histopathologic analysis, culture for subclinical infection, and better improvement in ROM. In our experience, arthroscopy for symptomatic knee arthroplasty is reliable, safe and effective.

Surgical treatment of acute acromioclavicular joint injuries using a modified Weaver-Dunn procedure and clavicular hook plate.

Various surgical procedures have been described for the treatment of complete acromioclavicular joint dislocation, but no consensus exists on the optimal therapy. The aim of each type of procedure is to stabilize the clavicle by substitution of the ruptured coracoclavicular ligaments. Treatment modalities have changed with increasing understanding of the nature of the problem and the biomechanics of the joint. This article presents a method consisting of a modified Weaver-Dunn procedure and a clavicular hook plate for the operative management of acute acromioclavicular joint injuries.We performed a retrospective study of 46 patients who had undergone a modified Weaver-Dunn procedure with a clavicular hook plate for acute acromioclavicular joint injuries between July 2002 and December 2006. Average follow-up was 36.6 months (range, 24-46 months). There was 1 skin-deep infection, 1 dislocation of the hook, and 2 redislocations of the acromioclavicular joint. Thirteen patients had some calcification between the clavicle and the coracoid process, which did not cause loss of motion or other symptoms. All but 1 patient returned to work, and all but 1 returned to their preoperative activity level. The mean Constant score was 88.2 points. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 12.2 points.Treatment of acute acromioclavicular joint injuries using a modified Weaver-Dunn procedure and a clavicular hook plate showed good short-term clinical results with a low complication rate. Further investigation and long-term results are needed to confirm these preliminary findings.

The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children.

OBJECTIVES: To investigate the time required for elbow range of motion (ROM) recovery after supracondylar and lateral condylar fractures in children and to analyze the relationship between the ROM recovery and the related factors. DESIGN: Retrospective study. SETTING: Tertiary pediatric orthopaedic care unit at a general hospital. PATIENTS/PARTICIPANTS: Forty-five children with distal humerus supracondylar fractures and 16 children with lateral condylar fractures were followed. Twenty-seven children with distal forearm fractures, which were immobilized with long arm casts, were used as a control group to study elbow flexion-extension recovery after immobilization without elbow fracture. MAIN OUTCOME MEASUREMENTS: Elbow ROM was measured with a goniometer in a series of follow-up visits after cast removal until 90% ROM of the uninjured side had been reached. Morrey's definition was used to define ROM required for functional activity of daily living. RESULTS: The supracondylar fracture group took 29.5, 39.0, 6.1, and 11.0 days to achieve 90% ROM in extension, flexion, supination, and pronation directions. The lateral condylar fracture group needed 30.2, 35.6, 2.3, and 8.9 days, respectively, in 4 directions. In the distal forearm fracture group, the elbow total flexion-extension angle required less than 2 weeks to reach a total arc of 135 degrees. The supination range was easier to recover than the pronation motion. The flexion recovered last among 4 directions in supra- and lateral condylar fractures. CONCLUSIONS: In the uncomplicated distal humerus supracondylar and lateral condylar fractures, it takes 5 weeks to restore original elbow ROM after removal of long arm cast without physical therapy. This information could be applied in the education material to caregivers of children with elbow injuries.

Hemi-arthroplasty with supplemental fixation of greater trochanter to treat failed hip screws of femoral intertrochanteric fracture.

INTRODUCTION: Management for failed hip screw after femoral intertrochanteric fracture is a challenge for orthopaedic surgeons. The unfavorable factors include severe osteoporosis, unstable fracture geometry, improper placement of hip screw, and repeated trauma. Except revision fixation of the fractures, arthroplasty may be indicated in case of destructed femoral head. In this study, we reported the surgical outcomes of patients with concomitant failed hip screws and fractures of greater trochanter operated by hemi-arthroplasties. MATERIALS AND METHODS: We treated 16 patients of failed hip screws with concomitant fracture of greater trochanter surgically by hemi-arthroplasty and cable-grip system from January 2001 to December 2004. The reattachment of greater trochanter by cable-grip system enhanced abductor mechanism to reduce the dislocation rate of hip arthroplasty. The hemi-arthroplasties eliminated the pain from the destructed femoral head. Partial weight bearing was allowed postoperatively. The patients were followed every 6 weeks clinically and radiologically. Full weight bearing was not allowed until solid bony union was seen on the plain radiographs. RESULTS: Among these 16 patients, all patients achieved solid union of greater trochanter except one by 24 weeks postoperatively. No postoperative wound infection was found. No dislocation of hemi-arthroplasty occurred during the postoperative follow-up. The clinical assessment based on SF-36 questionnaire improved from 41.9 to 82.7. CONCLUSION: Hemi-arthroplasty with supplemental fixation of greater trochanter is a rational option to treat failed hip screws with fracture of greater trochanter in case of destructed femoral head.

Treatment of distal tibial metaphyseal fractures: Plating versus shortened intramedullary nailing.

BACKGROUND: Fractures in the distal tibial metaphysis are more complicated to treat than diaphyseal fractures. We compared treatment with plating to treatment with shorted intramedullary (IM) nailing. METHODS: Patients with AO type 43A fractures were treated with plate fixation (group A, n=14) or shortened IM nailing (group B, n = 13). We compared postoperative radiographic deformities, functional results (Iowa ankle scores), and symptoms (Olerud and Molander ankle scores). RESULTS: All fractures had healed at final follow-up (mean, 33 month). Mean union times were 27.8 week (range, 18-36 week) in group A and 22.6 week (range, 18-30 week) in group B (P<0.05). Mean postoperative valgus angulations were larger in group B (3.7 degrees ) than in group A (0.5 degrees ) (P<0.05). However, malunions did not differ between groups (P<0.05). Functional results and postoperative symptoms were similar. CONCLUSIONS: Both plate fixation and shortened IM nailing were effective for treating distal tibial metaphyseal fractures.

Arthroscopic reduction and suture fixation of displaced tibial intercondylar eminence fractures in adults.

INTRODUCTION: Tibial intercondylar eminence fractures are uncommon. In a review of the literature, most authors agreed that conservative treatment was suggested for non-displaced fractures. Displaced fractures were considered an indication for surgery. MATERIALS AND METHODS: Between April 2000 and November 2001, five adult displaced tibial eminence fractures were treated by arthroscopic reduction and non-absorbable suture fixation. Postoperatively, the knee was immobilized in a hinged knee brace locked in full extension with non-weight bearing for 4 weeks. Range of motion and quadriceps-strengthening exercises were started 4 weeks later. Partial weight-bearing was allowed in the following 4 weeks. RESULTS: The average follow-up was 24.6 months (range 18-36 months). Subjectively, there was no instability or residual pain in the knee. The patients were able to resume their normal activities. Objectively, the average Lysholm Score was 95.6 (range 93-98). The average knee range of motion was 2 degrees to 135 degrees (range 0 degree-140 degrees). All patients had a negative Lachman's test and no pivot shift phenomenon. All fractures showed good union according to radiological evaluation. CONCLUSION: Arthroscopy-assisted screw fixation is more stable, and it allows early exercise. However, the fragment must be large enough to be fixed with a screw. Comminuted or small fragments present limitations for screw fixation techniques. We used the non-absorbable intraligmentous suture to pull down the fragment regardless of small size or comminuted status. The technique is simple and provided secure fixation without damage to the ACL insertion. A second operation is not required to remove the hardware.

Adjacent segment degeneration after lumbar spinal posterolateral fusion with instrumentation in elderly patients.

This retrospective study investigated adjacent segments radiologically and clinically after posterolateral fusion of the lumbar spine with instrumentation. Thirty-two patients over 60 years old with a postoperative follow-up of at least 4 years were included. These patients all met the criteria of a postoperative symptom-free period of over 2 years, evident fusion mass seen on plain radiographs, and no implant breakage or loosening. There was 81.3% excellent and good clinical results (26/32). For all patients, flexion and extension views of the lumbar spine were done preoperatively and postoperatively. Adjacent segments below the fusion, above the fusion, and cranial to the above adjacent segment were examined. Three patients each with translation > 4 mm in adjacent segments were found in both the short and long (> or = 3 segments) fusion groups. The incidence was 16.7% (3/18) in the short fusion group and 21.4% (3/14) in the long fusion group. However, no statistically significant difference (p = 0.7878) was found according to the Fisher exact test. Comparing the effect of different types of instruments, there still was no statistically significant difference (p = 0.1161) between the VSP plate and Isola rod groups in inducing degeneration of adjacent segments after posterolateral fusion of the lumbar spine. After measuring the mobility of degenerated adjacent segments, relative hypermobility was more likely responsible for the accelerated degeneration rather than the absolute increase of mobility.