Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture.

Necrotizing soft tissue processes of the foot secondary to an acute stingray envenomation can be a challenge to manage. Very little is reported in the orthopaedic literature to aid the practicing surgeon faced with this problem. In this case report, we describe the wound management and team approach employed in this patient's care, including the indications for hyperbaric oxygen therapy, which, in this case, was ultimately successful.

Persistent postoperative pain after the Chrisman-Snook ankle reconstruction.

One complication of the Chrisman-Snook ankle reconstruction is persistent postoperative pain. The incidence of this complication ranges from 7% to 60%. We report 10 cases of surgical exploration for persistent pain after Chrisman-Snook reconstructions. In 6 of the 10 cases a surgically correctable cause was found for the pain. The identified pathologic lesions in these 6 patients could have been prevented by careful attention to detail in the index operation. Surgical exploration should be considered for any of the following findings: persistent point tenderness (especially at the graft tunnel sites), localized swelling, a painful mass, recurrent instability/laxity, a symptomatic neuroma, or painful inversion and dorsiflexion. To prevent the complication of persistent postoperative pain after the Chrisman-Snook ankle reconstruction, we recommend the following: 1) avoid forced eversion when tensioning the graft, excessive posterior placement of the calcaneal tunnel, casting in eversion, and the use of nonabsorbable suture; 2) resect the distal muscle belly of the peroneus brevis muscle distal to the superior peroneal retinaculum; 3) check for tears in the peroneus brevis; 4) respect the sural nerve; and 5) obtain a watertight closure of the joint capsule. Although the Chrisman-Snook ankle reconstruction is an excellent technique, numerous pitfalls in surgical technique must be avoided.

Crescentic osteotomy for hallux valgus: a biomechanical study of variables affecting the final position of the first metatarsal.

The position of the first metatarsal following a crescentic osteotomy for hallux valgus is a function of the size of the saw cut and orientation of the osteotomy. This study reports the effect of these variables, recommended technique, and potential pitfalls when using the crescent osteotomy. Using molded polyurethane foam metatarsals and a precision drill press which controlled the saw cuts, the following variables were studied: (1) orientation of the saw cut to the metatarsal, (2) the saw size (diameter of the saw relative to the shaft width of the osteotomy site), and (3) the direction toward which the crescent faces (proximal/distal). Best correction can be obtained if the saw diameter is larger than the diameter of the osteotomy site (allowing a greater degree of correction before impingement), the saw tip is tilted slightly toward the sesamoids (which ensures that the metatarsal does not rotate medially with correction), and the saw is rotated laterally to cause slight declination of the toe.

The generic shoe: a prescription tool.

A multiple-use testing shoe capable of various orthotic modifications has been developed. Its use in predicting prescription performance and patient compliance is presented. Patient compliance is enhanced by understanding gained through the testing procedure.

Professional behavior in the orthopedic resident. A method for evaluation and development.

The affective behavior of orthopedic residents may be the most important indicator of their ability to function as orthopedic surgeons. Seven years of personal observations were combined with the experience of more than 300 participants in the Basic Course for Orthopaedic Educators, and recorded from the results of a recent questionnaire answered by members of the Association of Orthopaedic Chairmen. The affective domain was found to supply the answers to most of the problems of orthopedic residents. An evaluation of affective behavior early in the residency program may help to determine residents' suitability for a career in orthopedic surgery.

The erythrocyte sedimentation rate in orthopaedic patients.

The ESR, a sensitive measure of the inflammatory response, is elevated in 90% of patients who have serious orthopedic infections, e.g., discitis, septic arthritis, and hematogenous osteomyelitis. In most cases, it is sufficient to distinguish these entities from the less serious disease states, i.e., transient synovitis. After major surgical operations or extensive trauma, the ESR often increases to high levels and, if sepsis does not supervene, it returns to normal within six months. Outpatient determination of the ESR, although useless in the early detection of malignancy, is valuable in detecting inflammatory arthridities and major sepsis.

A modification of the gravity method of reducing anterior shoulder dislocations.

A modification of the gravity method for reducing acute or recent anterior shoulder dislocation has the patient placed on a bed in a comfortable prone position. With the surgeon comfortably seated close to the patient's shoulder, he can talk to the patient, help him relax his deltoid muscle, watch the state of muscle relaxation, and adjust the traction force accordingly. Sustained traction of varying force is possible for long periods, and under a variety of field conditions has shown excellent results.

A comparison of convergent and bi-plane X-ray photogrammetry systems used to detect total joint loosening.

X-ray photogrammetry is an accurate method of measuring structural displacements within the musculoskeletal system. Total joint implant alignment, migration and loosening are important clinical parameters which can be measured by X-ray photogrammetry. The purpose of this paper is to compare two different X-ray photogrammetry systems which are being used to study total joint parameters. The Seattle system uses a convergent geometry and the Cleveland system a bi-plane geometry. The accuracy of the two systems was compared by individually measuring the relative motion produced in an articulated plastic model. The model was designed to simulate the relative motion which can take place between the bone and a loose implant. The displacements of the model components were determined physically and photogrammetrically, and the error in the measurements was calculated for several conditions. Both systems measured relative component motion in the model with a root mean square error of 0.1 mm or less. In clinical use stainless steel markers are implanted in human subjects, and both systems measure distances with a r.m.s. error of 0.2 mm or less. The ease of usage, efficiency and flexibility of the two systems based on actual clinical experience reveals strengths and weaknesses in each which should be recognized when selecting a particular system.

Avulsion of the triceps tendon.

Avulsion of the triceps tendon should be suspected in patients who have pain about the elbow following a deceleration stress to the upper extremity. In three cases, the avulsion occurred both with or without a concomitant blow to the posterior aspect of the arm. Examination revealed pain, swelling, and a palpable depression just proximal to the olecranon. Roentgenograms showed avulsed osseous material. In the evaluation and management of triceps avulsion, it was important to differentiate between complete and partial tears. Careful examination of active range of motion of the elbow was the most important factor in making this determination. An avulsion was considered partial only if normal elbow motion and extension against resistance were found on follow-up examination a few days postinjury. Nonoperative management was successful in one case of partial tear (Case 2). Surgical therapy was advisable for complete avulsions. Surgical repair was successful using heavy nonabsorbable suture through olecranon drill holes. Injuries of tendon avulsion and rupture are likely to become more common as the number of patients with chronic renal failure, on dialysis, increases. Tendo-osseous weakness and related musculoskeletal disorders in renal osteodystrophy patients are unsolved problems.

Valgus tibial osteotomy: avoiding the pitfalls.

Valgus tibial osteotomy is a well-accepted procedure for the treatment of unicompartmental degenerative joint disease of the knee. For a good result to be obtained, at least for degrees of valgus angulation with the leg in the weight-bearing position must be achieved. Experience with 20 procedures showed a tendency for undercorrection, which led to poor results. After analyzing the technical reasons for these poor results, we devised a detailed protocol that included patient selection, preoperative planning, and an operative technique that minimizes the chance of technical error.

Biomechanical study of the pitching elbow.

Medial-tension injuries of the pitching elbow are well recognized. One contributing factor is the extreme valgus which has been noted to occur during the acceleration phase of throwing. It is hypothesized that breaking pitches generate higher medial loading because of the pronation and supination required to impart spin to the ball. The pitching motion is a complex action of all body segments to produce maximum linear and angular acceleration of the ball. The purpose of this study was to correlate elbow loading with pitching style. We measured the forearm segment for axial and tangential (varus-valgus plane) acceleration using accelerometers attached to the forearm and hand. Muscle activity was measured by EMG. Forearm rotation was assessed by stroboscopic photography. Despite different delivery styles when throwing breaking pitches, each pitcher demonstrated patterns of muscle activity and acceleration which were similar. Deceleration forces were lower than acceleration forces. Pronation and supination were documented and contribute to the direction of ball spin. Accelerometers can be used to evaluate pitching mechanics. We suggest that the main factors causing an elbow injury are the amount of throwing and the force with which the ball is thrown.

Instability of the subtalar joint. Diagnosis by stress tomography in three cases.

Lateral instability in the subtalar joint was documented by a method of stress tomography in three patients. The subtalar inversion angle averaged 38 degrees +/- S.D. 6 degrees in asymptomatic feet and 57 degrees +/- S.D. 5 degrees in those with unstable subtalar joints . Review of the literature suggests that as many as 10 per cent of patients having the Watson-Jones procedure for abnormal talar tilt also have instability in the subtalar joint. It is felt that the subtalar joint should be evaluated in patients seen with the clinical symptom of lateral instability.

A jig for pin insertion in the performance of high tibial osteotomy.

The crucial step in high tibial osteotomy is to translate the computed angle of correction into a bone wedge outlined by 2 Kisrchner wires to guide the surgery. The wedge can be excised with precision in 2 planes. A jig facilitates accurate placement of the pins to correspond exactly to the predetermined angles.