Instability of shoulder arthroplasty: balancing mobility and stability.

Avoidance of instability after shoulder arthroplasty is based on an appreciation of normal articular anatomy and its restoration, as well as adequate soft tissue release and secure repair of subscapularis. Errors in restoration of articular anatomy, or disruption of soft tissues about the joint, are the principal reasons for instability. Revision in such cases can be challenging because of difficulties in restoring normal articular position and orientation, as well as reconstruction of deficient soft tissues.

Intermittent pneumatic pedal compression and edema resolution after acute ankle fracture: a prospective, randomized study.

Thirty patients with an acute Weber B or C ankle fracture were enrolled after signing an informed consent. Fifteen patients were randomized to a control group where they received a posterior splint, ice, and elevation before surgery. Fifteen patients were randomized to a pneumatic pedal compression group where they received the same treatment plus a pneumatic pedal compression device which was used full-time before surgery. Baseline volumetric measurements of the injured foot were obtained, followed by measurements at 24-hour increments until surgery. On average, the patients in the pneumatic pedal compression group had an 88 mL decrease in volume in the first 24 hours versus a 33 mL increase in the control group (P < 0.03) and a 31 mL decrease in the first 48 hours of treatment versus a 32 mL increase for the control group (P < 0.05). The pneumatic pedal compression was well tolerated by the majority of patients (only one did not tolerate its use because of pain) and, we believe, serves as a useful adjunct in preoperative edema resolution after ankle fracture.

Heterotopic ossification following operative treatment of acetabular fracture. An analysis of risk factors.

A total of 237 patients with surgically treated acetabular fractures were analyzed to identify the risk factors predisposing to development of heterotopic ossification (HO) following operative treatment, and to evaluate both clinical significance of HO and the clinical outcome of operative excision of ectopic bone. All patients had a minimum of 1 year followup time. The degree of HO was determined from anteroposterior radiographs of the pelvis at the 1 year followup and was classified as Grade 0 or Grade 1 according to the amount of ectopic bone present. Forty patients (17%) who developed a moderate to severe amount of ectopic bone were classified as Grade 1. Nine who developed significant ectopic bone resulting in 20% or greater loss of hip motion underwent excision of the ectopic bone; all six available for followup showed an improvement in range of motion. A significant correlation was found between poor clinical results at the 1 year followup and Grade 1 ectopic bone formation (p < 0.001). Four factors found to highly correlate with Grade 1 ectopic bone formation were: (1) the iliofemoral surgical approach; (2) multiple (2 or more) operative findings; (3) T type fractures; and (4) the presence of associated injuries to the abdomen and chest.

Examination of the patient with a knee dislocation. The case for selective arteriography.

One hundred fifteen patients with a unilateral knee dislocation underwent arteriography to examine the popliteal artery. The incidence of popliteal artery injury was 23% (27 patients). Clinically, 29 (25%) of the 115 patients had an abnormal ipsilateral pedal pulse and 23 (79%) of these 29 patients had an arteriographically identified popliteal artery injury. Twenty-two arteries were surgically repaired and one was treated without surgery. Eight-six patients had normal pulses; the arteriogram showed no abnormalities in 77, demonstrated spasm in five, and revealed an intimal flap in four. All 86 patients were treated without surgery and had no delayed vascular complications. This demonstrates that the vascular examination is an accurate predictor of major popliteal artery injury following knee dislocation. Patients with an abnormal pedal pulse warrant arteriography due to a high incidence (79%) of popliteal artery injury. Patients with normal pulses may be monitored by clinical examination only. Popliteal artery injuries in this group are minor and rarely require intervention.

Is arterial proximity a valid indication for arteriography in penetrating extremity trauma? A prospective analysis.

Three hundred seventy-three patients with a penetrating extremity injury were studied to assess the yield of arteriography. Patients underwent arteriography if any of the following was present: bruit, history of hemorrhage or hypotension, fracture, hematoma, decreased capillary refill, major soft-tissue injury, or nerve or pulse deficit. In the absence of these findings, arteriography was performed if the injury was in "proximity" to a major neurovascular bundle. In 216 patients, arteriography was performed when an abnormal finding was noted. Sixty-five injuries were identified, 19 requiring intervention. Proximity was the indication for arteriography in 157 patients. Seventeen injuries were identified, of which one required repair. In penetrating extremity trauma, the need for arteriography is based on clinical findings. The use of arteriography to screen for an arterial injury when proximity alone is the indication rarely identifies a significant injury and should be abandoned.