First Metatarsophalangeal Joint Arthroscopy for Osteochondral Lesions.

Small-joint arthroscopy has supplanted open procedures because it offers the potential for improvement in joint visualization, reduced scarring, and accelerated recovery. Despite these advantages, arthroscopy of the first metatarsophalangeal joint is not commonly performed and reports of its use are lacking. The reason for this is not clear but may be because of perceived technical complexity and poorly defined indications. In our experience, however, arthroscopy of the first metatarsophalangeal joint is a versatile procedure that facilitates treatment of many different pathologic processes through a minimally invasive approach with few complications. We present our technique for arthroscopic management of osteochondral lesions of the hallux.

Suggested Guidelines for the Prescription of Orthotic Services, Device Delivery, Education, and Follow-up Care: A Multidisciplinary White Paper.

OBJECTIVES: This article establishes needed guidelines for determining orthotic prescriber authority, documenting medical necessity, and ensuring continuity of care for patients needing orthoses. It also identifies "off-the-shelf" (OTS) devices that can safely and appropriately be delivered to patients without professional adjustment as well as those that cannot. METHODS: A multidisciplinary task force made up of experts in orthopedics and physical medicine physicians, along with therapists and certified orthotists, applied a consensus approach to answer key questions: (i) When can a device be safely, effectively delivered to the patient OTS without professional guidance or education, and which caregivers have a role in that decision? (ii) What documentation is appropriate for physicians and other caregivers to determine medical necessity? (iii) What documentation/communication ensures continuity of care among physicians, therapists, and orthotists? RESULTS: Guidelines developed for consideration of OTS orthoses include accepting documentation from collaborating caregivers, including therapists and orthotists; keeping that documentation as part of the patient's total medical record for clinical, medical necessity determinations and reimbursement purposes; and using the physician's prescription for the device as the key determinant of whether a device is delivered OTS or as a custom-fitted device. CONCLUSION: This review provides expert guidance for patient safety, minimizing wasted expenditures, maximizing clinical outcomes, and providing efficient delivery of care for Medicare and other patients. Centers for Medicare and Medicaid Services guidelines should be directed toward recognizing the level of expertise of the orthotist, the value of their patient encounters, and their role in facilitating the timely, safe, and effective use of orthotic devices.

Ankle arthroscopy for ankle fractures.

In many patients who undergo open reduction-internal fixation of ankle fractures, there is a failure to achieve good clinical outcomes despite radiographic evidence of anatomic reduction. One possible reason for this is the high incidence of concomitant intra-articular pathology associated with ankle fractures that may go unrecognized using traditional open approaches. Arthroscopy in the setting of acute operative management of ankle fractures provides a means to completely assess intra-articular pathology, as well as provide direct therapeutic intervention in many instances. Arthroscopic management techniques include debridement of loose intra-articular fragments, assisted fracture reduction, microfracture of chondral injuries, and assessment of syndesmotic stability. The indications for arthroscopy in the setting of ankle fractures have not been fully defined; however, it is our practice to perform an arthroscopic assessment of all ankle fractures requiring surgical intervention. We present a sample of our experience using this technique that shows the severity of intra-articular pathology that is often found and occurs even in association with fracture patterns with seemingly innocuous radiographic appearances.

Use of universal split leg accessories for operating table setup in placement of circular external fixators.

This article describes a technique for the operating table setup for application of circular external fixation devices. This technique uses Universal Split Leg Accessories for the operating room table, which facilitates intraoperative fluoroscopy and makes the application of circular external fixation devices less cumbersome and more efficient.

A comparison of open versus arthroscopic harvesting of osteochondral autografts.

Osteochondral autograft transfer is a technique for treatment of traumatic and degenerative cartilage lesions. A graft in which the cartilage cap is oriented perpendicular to the long axis of the graft is ideal because it can both restore the cartilage tidemark and minimize articular step-off at the recipient site. This study determines if osteochondral harvest technique (arthroscopic versus mini-open) or donor site location affects suitable graft harvest. One hundred and twenty eight osteochondral grafts were harvested in 16 cadaver knees utilizing a 7 mm OATS chisel from four donor sites: lateral supracondylar ridge, lateral femoral condyle, lateral intercondylar notch and medial femoral condyle. Mini-open and arthroscopic harvesting techniques were equally employed. Radiographic methods were used to analyze graft perpendicularity. Statistical analysis comparing graft suitability based on technique and donor site location was performed. There were no statistically significant differences (p>0.05) in graft suitability regardless of the technique used or donor site location. 69% of arthroscopic and 56% of mini-open graft harvest were considered suitable, possessing a cartilage cap and graft axis angle that would create less than 1 mm of articular incongruity. Incongruity results when the angle between the subchondral bone plug long axis and cartilage interface is greater than 74 degrees . There is no difference in the quality of osteochondral grafts harvested from the knee regardless of technique or donor site used. Osteochondral graft diameter should be kept at or less than 7 mm because of the high percentage of unacceptable grafts with increasing chisel sizes.

Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation.

BACKGROUND: The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation. METHODS: A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed. RESULTS: A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days). CONCLUSIONS: Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

Perioperative differences between bone bridging and non-bone bridging transtibial amputations for wartime lower extremity trauma.

BACKGROUND: The distal bone bridge transtibial amputation technique requires additional intraoperative surgical steps when compared to the non-bone bridging technique. Comparative functional data is not available showing a clearly superior outcome from either technique. Identifying perioperative differences could influence a surgeon's decision regarding the technique of amputation to be performed. This study's purpose was to compare perioperative differences between bone bridging transtibial amputation and non-bone bridging amputation techniques. MATERIALS AND METHODS: A retrospective review from April 2004 to April 2007 identified 37 consecutive patients with 42 transtibial amputations as a result of wartime blast injuries. Twenty-two non-bone bridging and twenty bone bridging amputations were performed. Statistical comparisons of intraoperative time, tourniquet time, estimated blood loss, the need for postoperative transfusion and frequency of wound complications was performed. RESULTS: The bone bridging amputation technique had significantly longer operative times (178.5 vs. 112.2 minutes, p<0.0005) and tourniquet times (114.8 vs. 71.0 minutes, p<0.0005). Regardless of technique used, amputations performed within the zone of injury had a 66.7% wound complication rate (p<0.0005). There was not a statistically significant difference in reoperation for wound complications between groups when controlling for zone of injury: bone bridge (6.3%) and non-bone bridge (0.0%). Amputation closure performed within the zone of injury was a significant predictor for subsequent wound problems regardless of amputation technique. CONCLUSION: Longer operative and tourniquet times should not be considered a contraindication to utilizing the bone bridging amputation technique in younger and otherwise healthy patients. Both amputation techniques have comparable rates of short term wound complications and associated blood loss. Wound closure for traumatic amputations should not be performed through the zone of injury.

Long-term results after arthroscopic treatment of synovial chondromatosis of the shoulder.

PURPOSE: The purpose of this study was to document the results of arthroscopic treatment for synovial chondromatosis of the shoulder with loose body removal and partial synovectomy. METHODS: Five cases of shoulder arthroscopy performed for synovial chondromatosis were reviewed. Removal of loose bodies and partial synovectomy was performed in all cases. Follow-up of 4 to 9 years was obtained on these 5 patients. RESULTS: The clinical result was very good for all patients. Radiologic signs of chondroma were observed in two patients. Revision surgery was not necessary in either case. CONCLUSIONS: The clinical results referring to the Constant and Murley score and subjective assessment were very good at 4 to 9 years following surgery. However, in two out of five subjects, radiographs revealed evidence of persisting or recurrent synovial chondroma at follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Skin substitutes as alternatives to autografting in a wartime trauma setting.

Wartime injuries present extreme problems in wound management, with extensive skin degloving, deep tissue necrosis, and severe wound contamination. Several wound stabilization technologies, commonly used in burn and chronic wound treatment centers, have significantly advanced the treatment of wartime extremity trauma. Early skin coverage of these wounds is an ongoing challenge. Engineered skin substitutes offer advantages of expedited wound coverage and decreased donor site morbidity in the treatment of burns and chronic wounds. These substitutes, however, possess significant limitations when used in the presence of infection or full-thickness defects. Therefore, extrapolating the use of engineered skin substitutes to the coverage of acute war wounds is not clinically indicated. The timing and level of care in which skin substitutes could be applied for war wounds requires further clinical research.

Foot and ankle reconstruction after blast injuries.

Foot and ankle reconstruction following blast trauma is particularly challenging based on the devastating soft tissue injuries associated with open comminuted fractures. Considering the difficulties encountered in reconstruction, the functional limitations associated with many salvaged limbs, and the superior performance of contemporary prosthetics, many injured service members may benefit more from below knee amputation than from limb salvage. Limb salvage of blast-injured extremities is a multidisciplinary effort directed toward eradication of infection, treatment of soft tissue and bone defects, and management of late reconstructive procedures. External ring fixators have an important and expanding role in the treatment algorithm.

Intra-articular fluid volume and restricted motion in the elbow.

Eleven fresh-frozen cadaveric upper extremities were studied to determine the effect of intra-articular fluid volume on the range of motion of the elbow. The flexion arc of the cadaveric elbows was measured before and after incremental injections of saline solution. Linear regression analysis showed that the relationship between the flexion arc and intra-articular fluid volume is linear up to a total volume of 25 mL. The flexion arc of motion decreased by a mean of 2.1 degrees per milliliter of fluid injected. A mean volume of 10.8 mL of saline solution decreased the flexion arc to the point where surgery has traditionally been recommended for type II radial head fractures. On the basis of these findings, the use of post-aspiration range of motion should be reconsidered as a criterion for surgical treatment of radial head fractures.

Surgical treatment of intra-articular fractures of the trapezium.

Eleven patients with intra-articular fractures of the trapezium were evaluated after surgical treatment with a mean follow-up time of 47 months (range, 25-80 mo). There were 6 vertical split and 5 comminuted fractures. All fractures involved high-energy trauma in men. Five resulted from motorcycle accidents. An associated Bennett's fracture occurred in 4 patients. Three fractures went undiagnosed at the time of initial evaluation. At late follow-up evaluation, 8 of 11 patients experienced some pain, mainly at the trapeziometacarpal articulation. There was no statistical difference in thumb motion, wrist motion, or grip and pinch strength between the affected and unaffected extremity. Radiographs revealed degenerative changes at the trapeziometacarpal articulation in 5 of 11 fractures. No patient was disabled and no patient changed occupation as a result of the hand injury. Based on the good results obtained with surgical intervention we advocate open reduction and internal fixation for fractures with either articular displacement >2 mm or carpometacarpal subluxation.

Pedobarographic and musculoskeletal examination of collegiate dancers in relevé.

Twenty-one collegiate ballet pupils were evaluated via history/questionnaire, musculoskeletal assessment, and pedobarographs, focusing on factors (e.g., alignment of hip, knee, and foot) thought to affect the important and common second-position relevé in dance. In a blinded manner, three observers classified the pedobarographs (obtained by an independent examiner) according to force distribution through the foot. Most dancers bore weight through the toes and transmitted force on both the medial and central metatarsal heads, and some transmitted force through only one of these rays, but none transmitted force through the lateral ray alone. This analysis provides a baseline for future assessment of normal or abnormal dance maneuvers.