A biomechanical comparison of periprosthetic femoral fracture fixation in normal and osteoporotic cadaveric bone.

Several techniques are described for fixation of Vancouver B1 femoral shaft fractures after total hip arthroplasty. Twenty-four femurs were scanned by dual x-ray absorptiometry scanned and matched for bone mineral density. Femurs were implanted with a cemented simulated total hip prosthesis with a simulated periprosthetic femur fracture distal to the stem. Fractures were fixed with Synthes (Paoli, Pa) 12-hole curved plates and 4 different constructs proximally. Each construct was loaded to failure in axial compression. Constructs with locking and nonlocking screws demonstrated equivalent loads at failure and were superior in load at failure compared with cables. Cable constructs failed proximally. No proximal failures occurred in specimens fixed with screws and cables. A combination of locked or nonlocked screws and supplemental cable fixation is recommended for the treatment of Vancouver B1 periprosthetic femur fractures.

Subtrochanteric valgus osteotomy for chronically dislocated, painful spastic hips. Surgical technique.

BACKGROUND: Many treatments have been proposed for a painful chronically dislocated hip in a child with spasticity who is unable to walk. The valgus subtrochanteric femoral osteotomy was originally described as a treatment for a missed congenital hip dislocation in a young adult who was able to walk. The purpose of this study was to investigate the outcomes of a modified Hass subtrochanteric valgus osteotomy for the treatment of symptomatic chronic hip dislocations in patients with spasticity due to neuromuscular disorders. METHODS: Patients were identified by surgical codes. Medical records were reviewed for surgical indications, complications, and results. Preoperative and postoperative radiographs were assessed. Caregivers were contacted and asked to complete a brief survey detailing the pain that the patient experienced with daily activities before and after surgery as well as other information. RESULTS: Thirty-one Hass osteotomies in twenty-four consecutive patients were performed by one surgeon between 1995 and 2005. Although fifteen patients (63%) had at least one complication (including urinary tract infection, pneumonia, hardware failure, and heterotopic bone formation), the majority of the patients were doing well at an average of forty-four months postoperatively. The duration for which the patient could sit, ease of transfers, and ease of diaper changes had all improved according to the caregivers. Fourteen of fifteen caregivers who replied to the question stated that they were satisfied with the operative results and would have the procedure done again if they had the decision to make. CONCLUSIONS: The modified Hass osteotomy provides children who have symptomatic hip dislocations due to neuromuscular disorders with reproducible pain relief and improves ease of positioning by their caregivers. The complication rate, although high, was comparable with that of similar surgical procedures in this patient population. Concurrent femoral head resection at the time of the proximal femoral osteotomy was not necessary in this group of patients.

Subtrochanteric valgus osteotomy for chronically dislocated, painful spastic hips.

BACKGROUND: Many treatments have been proposed for a painful chronically dislocated hip in a child with spasticity who is unable to walk. The valgus subtrochanteric femoral osteotomy was originally described as a treatment for a missed congenital hip dislocation in a young adult who was able to walk. The purpose of this study was to investigate the outcomes of a modified Hass subtrochanteric valgus osteotomy for the treatment of symptomatic chronic hip dislocations in patients with spasticity due to neuromuscular disorders. METHODS: Patients were identified by surgical codes. Medical records were reviewed for surgical indications, complications, and results. Preoperative and postoperative radiographs were assessed. Caregivers were contacted and asked to complete a brief survey detailing the pain that the patient experienced with daily activities before and after surgery as well as other information. RESULTS: Thirty-one Hass osteotomies in twenty-four consecutive patients were performed by one surgeon between 1995 and 2005. Although fifteen patients (63%) had at least one complication (including urinary tract infection, pneumonia, hardware failure, and heterotopic bone formation), the majority of the patients were doing well at an average of forty-four months postoperatively. The duration for which the patient could sit, ease of transfers, and ease of diaper changes had all improved according to the caregivers. Fourteen of fifteen caregivers who replied to the question stated that they were satisfied with the operative results and would have the procedure done again if they had the decision to make. CONCLUSIONS: The modified Hass osteotomy provides children who have symptomatic hip dislocations due to neuromuscular disorders with reproducible pain relief and improves ease of positioning by their caregivers. The complication rate, although high, was comparable with that of similar surgical procedures in this patient population. Concurrent femoral head resection at the time of the proximal femoral osteotomy was not necessary in this group of patients.

Progressive cervical kyphosis associated with botulinum toxin injection.

Weakness of the neck extensors can lead to "dropped head syndrome", a condition of progressive cervical kyphosis in which a patient is unable to hold their head up against the force of gravity. This condition can be associated with structural abnormalities of the spine as found in ankylosing spondylitis and vertebral fractures. Neuromuscular disorders, such as myasthenia gravis, muscular dystrophies, inflammatory myopathies, and motor neuron disorders such as amyotrophic lateral sclerosis (ALS) have also been reported as etiologies of dropped head syndrome. In this article, we describe an elderly woman with rapidly progressive cervical kyphosis following an injection of botulinum toxin A into her neck extensor musculature.

Domestic violence: no place for a smile.

Because dentists routinely assess a patient's head, neck and mouth, they have a unique and excellent opportunity to recognize whether or not a patient is being abused. This article seeks to enlist the collaboration of the dental community in the effort to prevent domestic/intimate partner violence and provide more information about the signs and symptoms of domestic violence injuries, including strangulation, which is often overlooked by medical and dental professionals. Strangulation has only been identified in recent years as one of the most lethal forms of domestic violence. Unconsciousness may occur within seconds and death within minutes. It is known that victims may have no visible injuries whatsoever yet because of underlying brain damage by a lack of oxygen from being strangled, victims may have many serious internal injuries or die days or several weeks later. Strangulation is often indicative of a high level of domestic violence in a relationship. Attempted strangulation may cause physiological changes evident in the course of a dental examination. For these reasons, dentists should be vigilant in looking for its symptoms.

Endoscopic plantar fascia release.

BACKGROUND: Endoscopic release of the plantar fascia is becoming an increasingly popular alternative to open procedures for the treatment of chronic plantar fasciitis. Although most patients can be successfully treated with Achilles tendon stretching, orthoses, physical therapy and corticosteroid injections, a small percentage of patients will have symptoms that are refractory to such treatments. METHODS: This is a retrospective review, analyzing the clinical outcome of 22 consecutive patients treated for chronic plantar fasciitis with endoscopic plantar fascia release by a single orthopaedic foot and ankle surgeon. RESULTS: These patients complained of symptoms for an average of 7.43 months before referral to the senior author (MS); 11 patients had chronic symptoms for 12 months or more. The ages at surgery ranged from 30 to 73 years. Followup averaged 8.48 (range 6 to 20) months. Satisfaction rate with this procedure was 97.7% and all patients reported at least a 50% improvement in pain after surgery. Twenty-two patients completed a modified Mayo Foot and Ankle Score: 15 of 22 (68%) were judged to have good or excellent results. Bilateral symptoms and prior ankle trauma or surgery were significantly correlated with less favorable results. CONCLUSIONS: Patients who had no previous foot trauma and had unilateral symptoms obtained the best results from this procedure. Even patients who had some residual pain in their foot were satisfied with the procedure and with the level of pain relief that had been achieved. Endoscopic plantar fascia release does appear to benefit selected patients who fail to respond to conservative therapy.

When life is on the line: orthopaedic trauma care in South Carolina.

There are approximately 300 orthopaedic surgeons in South Carolina, a state with a population of approximately four million. There is one orthopaedic surgeon per approximately 13,000 people, which should be adequate to meet the demand for orthopaedic care. The problem is not the quantity of orthopaedic surgeons. The problem is staffing our trauma centers with orthopaedic surgeons who are enthusiastic, have an interest in trauma care, and maintain high levels of CME and technical expertise. They need to be supported with appropriate medical liability reform, such as has been adopted in other states, and methods should be put into place to compensate surgeons for expensive, time consuming, and potentially risky procedures performed on uninsured and under insured patients. The number of patients with extremity trauma in South Carolina increased 25.6 percent during a five-year time period and is expected to continue to increase. It is estimated that 40 percent of all surgical charges generated for orthopaedic surgeons staffing trauma centers are for self-pay patients. Given the higher liability cost and lower reimbursement from other payer sources for elective procedures, it will soon become impossible for orthopaedic surgeons to continue to provide services at trauma centers without support from hospitals or government agencies.

Overuse injuries in pediatric athletes.

Children can be seemingly invincible, with inexhaustible energy. Even the elite young athlete, however, may lack the experience to realize when his or her level of activity is increasing the risk of sustaining injuries related to overuse. Coaches, trainers, parents, and physicians need to monitor the activities of young athletes, modify factors that may place them at increased risk of injury, and enforce periods of "relative rest" when necessary. Factors that can increase the risk of overuse injuries can be identified and modified if possible. Environmental factors include the use of sport-specific equipment (ie, running shoes instead of cleats for running activities) and properly sized equipment. Children of the same age will be of different sizes; "one size fits all" is not a good enough policy in this diverse population. Training factors include magnitude, frequency, and intensity. Children should be asked if they are participating in more than one team or sport simultaneously. Also, because the child's interest may exceed his or her skill level, young athletes optimally should be taught sport-specific skills to prevent injuries related to improper biomechanics. Finally, anatomic factors should be assessed, including alignment, laxity, flexibility, and muscle balance. These factors cannot always be changed, but coaches can modify training regimens and suggest strength and flexibility training to counteract specific weaknesses. Young athletes have a long future of activity ahead of them. Even if they never reach the Olympics or compete in the National Basketball Association (NBA), the injuries that occur in young athletes can have significant repercussions long after they leave the competitive arena.

Effect of low-intensity ultrasound stimulation on consolidation of the regenerate zone in a rat model of distraction osteogenesis.

This study was performed to explore the tissue-level changes in mineralization caused by low-intensity ultrasound stimulation after distraction osteogenesis. Unilateral femoral lengthenings (7 mm) were performed on 34 male Sprague-Dawley rats. Half of the animals received daily ultrasound stimulation for 5 weeks; the remaining animals received sham treatments. Healing was assessed with serial radiographs, quantitative micro-computed tomography, and biomechanical testing. Twenty-one animals were evaluated at the conclusion of the study (9 experimental, 12 control). Radiographically, healing of the ultrasound-treated bones preceded that of the sham-treated bones by approximately 1 week. Bone volume fraction and trabecular bone pattern factor were significantly higher in the ultrasound-treated animals, but there were no significant differences in bone mineral content or bone mineral density. The ultrasound-treated femurs were 20% stiffer and 33% stronger than the control femurs, but the differences were not statistically significant. These findings suggest that pulsed, low-intensity ultrasound matures the regenerate by altering the microarchitecture of the newly formed bone.

Three-dimensional in vivo kinematics of the distal radioulnar joint in malunited distal radius fractures.

How malunion of the distal radius affects the kinematics of the distal radioulnar joint in vivo was evaluated. A novel computed tomography image-based technique was used to quantify radioulnar motion in both wrists of 9 patients who had unilateral malunited distal radius fractures. In the injured wrists dorsal angulation averaged 21 degrees +/- 6 degrees, radial inclination averaged 18 degrees +/- 5 degrees, and radial shortening averaged 21 +/- 3 mm. Clinically, the average range of motion of the injured wrists was 75 degrees +/- 25 degrees pronation and 73 degrees +/- 23 degrees supination. Kinematics of the radius during pronation and supination in the malunited forearms was indistinguishable from that in the uninjured forearms. In both the axis of rotation of the radius passed through the center of the ulnar head, although it shifted slightly ulnar and volar in supination and radial and dorsal during pronation. In contrast to previous in vitro biomechanical findings, there was no dorsovolar radial translation at the extremes of pronation or supination and no translation of the radius along the rotation axis. Soft tissues may play a larger role in limiting function than previously appreciated, and treatment may require correction of altered soft tissue structures as well as any abnormal bone anatomy.