Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system.

Computerized tomography was used to evaluate thirty intra-articular fractures of the calcaneus in twenty-seven patients. A classification of the fractures was devised on the basis of fracture patterns involving the posterior facet joint of the calcaneus. In Type I, the fracture fragments were small or not displaced; in Type II, they were displaced; and in Type III, they were comminuted. There were thirteen Type-I, ten Type-II, and seven Type-III fractures, all of which were treated with a variety of closed methods. The length of follow-up ranged from eighteen to fifty-two months (mean, thirty-six months). The results were graded by a predetermined point system that included the evaluation of motion of the subtalar joint. Of the thirteen Type-I fractures, eight had an excellent result; four, a good result; and one, a fair result. Of the ten Type-II fractures, two had a good result; four, a fair result; and four, a poor result. All of the seven Type-III fractures had a poor result. On the basis of our study of the fracture patterns as seen on the computerized tomography scans, we believe that it is possible to predict which fractures will do well with closed treatment and which will not. Type-I fractures did well with closed treatment. Type-II fractures can be treated closed but with a lower success rate than Type-I fractures. All of the Type-III fractures had a poor result after closed treatment.

Misrepresentation of research criteria by orthopaedic residency applicants.

BACKGROUND: Previous studies have shown that applicants for postgraduate training may misrepresent research citations. We evaluated the research citations that were identified in a review of the Publications and Work and Research sections from the Electronic Residency Application Service (ERAS) data for all applicants to our orthopaedic residency program for the 1998 to 1999 academic year. METHODS: The citations were searched for on Medline. We initially used the name of the first author, then the name of the applicant, the name of the journal, the volume number, the issue number, and the page numbers. When a journal was not listed in Medline, an interlibrary search was instituted with use of the same format. When no match was made for any category, the citation was defined as misrepresented. Point estimates are reported as percentages. RESULTS: Publications were listed on sixty-four (30.0 percent) of 213 applications. One hundred and thirty-eight publications were cited; there were fifteen citations (10.9 percent) to book chapters, twenty-six (18.8 percent) to journals not listed in Ulrich's International Periodicals Directory, and twenty-one (15.2 percent) to articles listed as in press, in print, or submitted for publication. Seventy-six articles that had been cited as appearing in journals listed in Ulrich's Directory were checked and verified. Fourteen (18 percent) of these seventy-six publications were misrepresented. Misrepresentations included citations of nonexistent articles in actual journals and nonauthorship of existing articles. CONCLUSIONS: We concluded that publications listed on postgraduate applications should be scrutinized carefully. Copies of cited publications should be required by residency programs before applications are considered complete. The importance of professionalism needs to be emphasized in the curricula of medical schools. Residency training programs should develop guidelines regarding misrepresentation.

Closed treatment of displaced middle-third fractures of the clavicle gives poor results.

We evaluated 242 consecutive fractures of the clavicle in adults which had been treated conservatively. Of these, 66 (27%) were originally in the middle third of the clavicle and had been completely displaced. We reviewed 52 of these patients at a mean of 38 months after injury. Eight of the 52 fractures (15%) had developed nonunion, and 16 patients (31%) reported unsatisfactory results. Thirteen patients had mild to moderate residual pain and 15 had some evidence of brachial plexus irritation. Of the 28 who had cosmetic complaints, only 11 considered accepting corrective surgery. No patient had significant impairment of range of movement or shoulder strength as a result of the injury. We found that initial shortening at the fracture of > or = 20 mm had a highly significant association with nonunion (p < 0.0001) and the chance of an unsatisfactory result. Final shortening of 20 mm or more was associated with an unsatisfactory result, but not with nonunion. No other patient variable, treatment factor, or fracture characteristic had a significant effect on outcome. We now recommend open reduction and internal fixation of severely displaced fractures of the middle third of the clavicle in adult patients.

Fixation comparison for chevron osteotomies.

A comparison study of temporary K-wire fixation, permanent Herbert Whipple screw fixation, versus no osteotomy fixation was performed on distal chevron osteotomies for hallux valgus deformities. Nineteen chevron osteotomies were performed on 17 patients. Six patients received a Herbert Whipple screw for fixation, seven patients received temporary K-wire fixation, and six patients received no fixation for the chevron osteotomy. The average postoperative hallux valgus (HV) angle improved by 7.1 degrees with no fixation, 6.3 degrees with temporary K-wire fixation, and 9.5 degrees with Herbert Whipple screw fixation. Comparison of the three groups using the Student's t-test revealed no statistical difference between the three groups (P = 0.6). The increased anesthesia time and operative costs for Herbert Whipple screw fixation was found to be statistically significant in comparison with the use of no fixation (P = <0.001). Time and cost studies were not significantly different for the K-wire and no fixation groups. Follow-up averaged 3.3 years. All patients reported satisfaction with the procedure and an improvement of their preoperative complaints. No significant difference in patient satisfaction was found to exist between the groups receiving fixation and those who did not have fixation. The results of this study can find no long-term benefit when comparing costs and patient satisfaction with the use of any temporary or permanent fixation of osteotomy sites when performing chevron osteotomies.

Open reduction and internal fixation of type II intra-articular calcaneus fractures.

Open reduction and internal fixation of 23 type II calcaneus fractures in 21 patients was performed using a standard extended lateral approach. Average follow-up was 26 months (range, 12-47 months). The Creighton-Nebraska Health Foundation Assessment Score for Fractures of the Calcaneus was used to evaluate fractures. The average score was 91.4 (range, 80-100), which represented an excellent result. A series of 10 type II fractures treated with closed methods was also evaluated using the same evaluation methods. The average score was 70 (range, 60-84), which represented a fair result. There was a clear statistically significant superiority with type II calcaneus fractures treated with open reduction and internal fixation (P < 0.0001). We recommend type I calcaneus fractures (nondisplaced) be treated with closed methods, and type II calcaneus fractures (displaced) be treated with open reduction and internal fixation.

Results of preprocedure and postprocedure toe cultures in orthopaedic surgery.

This study was to determine whether there is any benefit to wrapping the toes sterilely during orthopaedic procedures not involving the foot but performed on the lower extremity. The group studied consisted of 12 patients who had an orthopaedic procedure performed in which the foot and toes were included in the surgical prep, but not involved in the surgical procedure. Nine of the 12 patients (75%) had positive results from preprocedural aerobic cultures and two of the 12 (16.6%) had positive results from preprocedural fungal cultures. Recolonization of the bacteria between the toes was also demonstrated. Sterile draping of the toes would minimize the risk of infection and also protect against bacteria that recolonize during the procedure.

Irreducible dorsal dislocation of the great toe interphalangeal joint: case report and literature review.

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. Few case reports can be found in the literature. Most cases have been treated with operative exploration of the joint and reduction through a dorsal midline incision. We present a case where a medial approach was used under local block anesthesia to treat an irreducible complex dislocation of the interphalangeal joint of the great toe.

Complications following arthroscopic ankle arthrodesis.

Forty-two patients underwent an arthroscopic ankle arthrodesis utilizing a bi-framed distraction technique and demineralized bone matrix-bone marrow slurry as a graft substitute. The average follow-up was 27 months (range, 12-64 months). The overall complication rate was 55%, including three nonunions (7%), two fractures (4.8%), four pin site infections (9.5%), one deep infection, four hardware problems (9.5%), and four symptomatic painful subtalar joints (9.5%). Overall, 85% of patients were satisfied with their final result. The complication rate was high but most complications were minor and manageable. The demineralized bone matrix and bone marrow did not seem to increase the fusion rate over what has been documented previously for arthroscopic ankle fusions without the use of this graft substitute.

Humeral shaft nonunions treated with fibular allograft and compression plating.

The present study is a retrospective review of the treatment of 12 humeral shaft nonunions by using an intramedullary allograft with compression plating. The average age of the patients was 61 years (range, 36-82 years). Eight cases involved the proximal shaft, 3 cases were at the mid-diaphyseal level, and 1 case was at the distal one third. Follow-up averaged 30 months (range, 12-96 months). Ten patients (83%) went on to uneventful healing at an average of 3 months after surgery. Two failures involving patients with multiple medical conditions occurred secondary to reinjury. Two cases of postoperative radial nerve neuropraxia involved the posterior approach to the humerus. Each resolved with no long-term residual morbidity. One patient developed postoperative adhesive capsulitis of the shoulder that resolved with nonoperative treatment. We feel that a fibular allograft, along with compression plating, can give satisfactory results for humeral shaft nonunions. This technique can be especially helpful in proximal humeral nonunions and in nonunions involving osteoporotic bone. Patients with multiple medical problems at risk for refalls should be protected until complete healing has occurred.

Subtalar Dislocation in a Basketball Player.

In brief: Easily mistaken for an ankle fracture during the initial examination, medial subtalar dislocation-also known as 'basketball foot'-requires plaster immobilization for no more than 3 weeks. To extend immobilization beyond this time can lead to reduced range of motion in the subtalar joint, making it difficult for the athlete to resume sports activities. Encouraging toe motion while the patient is still in the cast prevents tendon adhesions. In this case report, the author discusses the importance of short-term immobilization and early rehabilitation for a 21-year-old basketball player recovering from medial subtalar dislocation.

Heel Pain in an Active Adolescent?

In brief Calcaneal apophysitis, a condition commonly seen in active adolescents, results in pain in the posterior aspect of the os calcis, or heel. Radiographic findings sometimes noted at the calcaneal apophysis, including fragmentation and increased density of the apophysis, were once thought to be evidence of osteochondrosis. These findings are now recognized as a normal stage of apophysis development and appear to be unrelated to the symptoms. Teatment, which generally produces excellent results, includes restriction of physical activity, nonsteroidal anti-inflammatory medication, icing, a heel lift, and a stretching program.

The potential value of the sedimentation rate in monitoring treatment outcome in puncture-wound-related Pseudomonas osteomyelitis.

Recently, a recommendation was made to treat Pseudomonas osteomyelitis in children with only ten to 14 days of postsurgical antibiotics. However, there were no clinical or laboratory measurements to monitor the response. Fourteen new cases of puncture-wound-related Pseudomonas osteomyelitis of the foot in children were investigated to examine the response of erythrocyte sedimentation rate (ESR) to treatment. The ESR was increased in 12/12 patients with a mean peak of 41 mm/hr and a mean duration of 30 days. After appropriate treatment was begun, the ESR decreased at a mean rate of 1.1 mm/day. In four of five patients with a poor treatment response, the ESR remained elevated until antibiotics were changed (in 3) or surgery performed (in 1). One patient with an abnormal ESR at completion of three weeks of postoperative antibiotics had a relapse after one year. These data suggest a need for careful assessment of treatment response, such as declining ESR, before antibiotics are discontinued at an arbitrary postoperative time period.

The history of the calcaneal fracture.

The treatment of intra-articular calcaneal fractures has been a source of controversy in the past century. Major shifts in emphasis among four broad categories of therapy--no reduction, closed reduction, open reduction, and primary arthrodesis have occurred. The historical foundations of each of these treatments are traced to the present and related to modern approaches. The evolution of classification systems and developments in understanding the pathomechanisms of these fractures are also reviewed. According to several authors, modern treatment is making increasing use of open reduction after appropriate analysis and classification by computed tomography.

Mycobacterium avium-intracellulare infection of the knee joint. Case report.

A 57-year-old white male with a history of scleroderma developed an osteoarticular infection of the right knee caused by Mycobacterium avium-intracellulare. The patient underwent arthroscopic synovectomy and was started on appropriate combination chemotherapy. The patient failed to improve clinically and developed osteomyelitis of the patella, distal femur, and proximal tibia. The patient refused further surgical intervention and subsequently developed a "Charcot-like" knee joint. This case report documents the failure of medical treatment alone for this infection, which must be combined with aggressive surgical intervention.

Basic rescue and resuscitation. Trauma system concept in the United States.

Trauma has become the most expensive health care problem in the United States. It is the leading cause of death in persons younger than 44 years old. In 1990, there were approximately 92,000 deaths from trauma, 50% of which were caused by automobile accidents. Before 1976, there was no systemized approach for care of the traumatized patient. The American College of Surgeons Committee on Trauma has developed guidelines covering the spectrum of care of the trauma patient from access and prehospital care to hospital treatment and rehabilitation. The effectiveness of trauma systems has been proven in many studies that show a significant decrease in the preventable death rate in traumatized patients receiving care at a trauma center. The implementation of a national trauma system has proven difficult because of expense, commitment, and effective legislation. Small strides continue to be made, but many hurdles remain.

Subperiosteal osteoid osteoma of the distal phalanx of the thumb.

Osteoid osteomas have been subgrouped into subperiosteal, cancellous, and cortical. The occurrence of subperiosteal osteoid osteoma of the hand is rare. The location in the distal phalanx of the thumb has not been described. The case reported illustrates the unusual presentation and radiographic features of subperiosteal osteoid osteoma.

Rotator cuff disorders.

The supraspinatus, infraspinatus, teres minor and subscapularis muscles form a musculotendinous rotator cuff that provides dynamic stability to the shoulder joint. Symptoms of rotator cuff injury include limitation of motion, weakness and pain that often radiates down the upper arm and is present at night. Examination may reveal deltoid and rotator cuff atrophy, tenderness, limited passive range of motion and weakness on abduction and external rotation. Radiographs may show degenerative changes of the acromion or acromioclavicular joint, cysts, sclerosis and spurs of the greater tuberosity, and calcific deposits within the supraspinatus tendon. In most patients with subacromial impingement, conservative management, including physical therapy, nonsteroidal anti-inflammatory drugs and subacromial injections, is successful. Failure of conservative therapy after six to 12 weeks merits further evaluation with magnetic resonance imaging or arthrography, and consideration of surgery.

Intraarticular calcaneal fractures. Results of closed treatment.

Thirty intraarticular calcaneal fractures were studied by computed tomography and then treated with a variety of closed methods. A classification of the fractures was devised according to the amount of displacement of the posterior facet. Follow-up evaluation showed that Type I fractures recovered function and healed extremely well. Closed treatment should be the treatment of choice for Type I fracture patterns. Type II and III fractures had unacceptable results with closed treatment. Alternate forms of treatment should be considered in dealing with more severely displaced fractures.