Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 468 | Issue 4 | Apr, 2010

Compartment Syndrome of the Lower Leg and Foot

Michael Frink MD, Frank Hildebrand MD, Christian Krettek MD, Jurgen Brand MD, Stefan Hankemeier MD Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary.,[object Object]

The Scandinavian Total Ankle Replacement: Survivorship at 5 and 8 Years Comparable to Other Series

Alexia Karantana MD, Sally Hobson FRCS Orth, Sunil Dhar FRCS Ed Orth Ankle arthroplasty is increasingly used to treat advanced ankle arthritis. Earlier prostheses have given way to second-generation implants, on which we are accumulating medium-term data. The Scandinavian Total Ankle Replacement (STAR) is a three-component uncemented implant in wide use in Europe and the only mobile-bearing prosthesis with conditional approval in the United States. We retrospectively reviewed 45 patients (52 ankles) who had primary total ankle replacements using STAR prostheses, in order to assess survivorship and add to the pool of clinical data provided by independent practitioners required to establish this treatment as a viable alternative to arthrodesis. The minimum followup was 60 months (range, 60–110 months). Clinical outcome was determined using the AOFAS score. We determined the rate of radiographic loosening and recorded complications and the need for further surgery. Survival was 90% (95% CI 76.8 to 95.5) at 5 years and 84% (95% CI 68.9 to 92.2) at 8 years. Six of 52 ankles (11%) had component revision and two were converted to fusion. The mean postoperative AOFAS score was 78. The complication rate was 21%. Subsequent surgery, excluding component revision, was performed in nine of 52 (17%) ankles.,[object Object]

High Union Rates and Function Scores at Midterm Followup With Ankle Arthrodesis Using a Four Screw Technique

Hans Zwipp MD, PhD, Stefan Rammelt MD, PhD, Thomas Endres MD, Jan Heineck MD When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8–7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.,[object Object]

Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement?

Michel P. J. Bekerom MD, C. Niek Dijk MD, PhD We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.,[object Object]

Minimally Invasive Locked Plating of Distal Tibia Fractures is Safe and Effective

Mario Ronga MD, Umile Giuseppe Longo MD, Nicola Maffulli MD, PhD, MS, FRCS(Orth) Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2–4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7°. No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20° compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients.,[object Object]

Percutaneous Treatment of Less Severe Intraarticular Calcaneal Fractures

Stefan Rammelt MD, PhD, Michael Amlang MD, Sven Barthel MD, Johann-Marian Gavlik MD, Hans Zwipp MD, PhD Percutaneous treatment of calcaneal fractures is intended to reduce soft tissue complications and postoperative stiffness of the subtalar joint. We assessed the complications, clinical hindfoot alignment, motion, functional outcome scores, and radiographic correction of percutaneous arthroscopically assisted reduction and screw fixation of selected, less severe fractures. We performed percutaneous reduction and screw fixation in 61 patients with Type II (Sanders et al.) calcaneal fractures. In 33 of 61 patients with displaced intraarticular fractures (types IIA and IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically; these patients form the basis of this report. We observed no wound complications or infections. In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient, arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients (73%) were followed a minimum of 24 months (mean, 29 months; range, 24–67 months). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score at last followup was 92.1 (range, 80–100). Böhler’s angle and calcaneal width were reduced close to the values of the uninjured side. We believe percutaneous fixation is a reasonable alternative for moderately displaced Type II fractures provided adequate control over anatomic joint reduction with either subtalar arthroscopy or high-resolution (3-D) fluoroscopy.,[object Object]

Syndesmotic Stabilization in Pronation External Rotation Ankle Fractures

Michel P. J. den Bekerom MD, Daniel Haverkamp MD, PhD, Gino M. M. J. Kerkhoffs MD, PhD, C. Niek Dijk MD, PhD Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19–80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures.,[object Object]

Double Posteromedial Portals for Posterior Ankle Arthroscopy in Supine Position

Francesco Allegra MD, Nicola Maffulli MD, MS, PhD, FRCS(Orth) Both posterior and anterior arthroscopy of the ankle may be indicated in the same patient. With the patient supine, it is possible to reach most intraarticular structures of the ankle through the standard anterior portals, but difficult to examine the posterior compartments and to perform hindfoot endoscopy. In most patients following the anterior procedure the patient is positioned prone to operate on the posterior compartment. We describe a two-portal posteromedial hindfoot procedure that allows the surgeon to reach both the posterior joint space and the extraarticular compartment of the hindfoot with the scope and instruments, regardless of diagnosis, with the patient supine. After arthroscopy on the anterior portion of the foot using standard anterior portals, the two posteromedial portals allow endoscopic inspection and management of abnormalities in this region without repositioning the patient and without any remarkable local complication.,[object Object]

Should One Consider Primary Surgical Reconstruction in Charcot Arthropathy of the Feet?

Thomas Mittlmeier MD, K. Klaue MD, Patrick Haar MD, Markus Beck MD Charcot neuroosteoarthropathy of the feet can induce severe instability and deformity with subsequent plantar ulceration leading to substantial disability or even amputation. Traditionally, nonoperative treatment is regarded as the primary option of treatment while surgery is restricted to treating complications or failure of nonoperative treatment. Failed nonoperative treatment essentially prolongs treatment period. We retrospectively reviewed 22 patients (26 feet) with midfoot (n = 9) or hindfoot (n = 17) neuropathy who underwent primary surgical reconstruction and reorientation arthrodesis due to manifest instability, nonplantigrade foot position, and deformity with overt (n = 8) or what we judged was impending ulceration (n = 9). The minimum followup was 0.5 years (mean, 2.7 years; range 0.5–7 years). All eight ulcers healed without recurrence of ulceration or manifestation of new ulcers during the followup period. We observed complications leading to further surgery in nine patients: five with perioperative hematoma and four with instability. AOFAS scores rose from a preoperative mean of 39 to 70 points (hindfoot cases) and from 51 points to 84 (midfoot cases). Early surgical reconstruction in high-risk patients can provide timely restoration of a plantigrade and stable foot and improved quality of life of the patient at complication rates comparable to those after secondary surgery following failed nonoperative treatment; however we emphasize we had no control group in this small case series for which we could compare nonoperative treatment.,[object Object]

Lasso Stitch with Peroneal Retinaculoplasty for Repair of Fractured Os Peroneum: A Report of Two Cases

Vincent James Sammarco MD, Daniel J. Cuttica DO, G. James Sammarco MD Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon.,[object Object]

Modified Rerouting Procedure for Failed Peroneal Tendon Dislocation Surgery

R. Gaulke MD, F. Hildebrand MD, M. Panzica, T. Hüfner MD, C. Krettek MD, FRACS

Recurrent dislocation of the peroneal tendons following operative treatment is relatively uncommon, but can be difficult to treat. We asked whether subligamental transposition of the peroneus brevis tendon, fibular grooving, and reattachment of the superior peroneal retinaculum for failed peroneal tendon dislocation surgery would achieve a stable fixation of the peroneal tendons and whether there would be restrictions of ROM or instability of the hindfoot. We reviewed six female patients (mean age, 24.5 years) with general laxity of joints preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. Within 1 year postoperatively no recurrence was found. In two ankles the extension was restricted 5° to 10°. In another pronation and supination was restricted 5° each. Stability of the ankle increased in four patients and stayed unchanged in two. AOFAS score increased from a mean value of 36 ± 20.6 preoperatively to 90 ± 7 postoperatively at 1 year. We conclude transposition of the peroneus brevis tendon is a reasonable treatment for failed peroneal tendon dislocation surgery.,[object Object]

Correction and Prevention of Deformity in Type II Tibialis Posterior Dysfunction

Stephen Parsons FRCS, Soulat Naim MCh, FRCS, Paula J. Richards BSc (Hons), MRCP, FRCR, Donald McBride FRCS, FRCS(Orth) Cobb described a method of reconstruction in Johnson and Strom Type II tibialis posterior dysfunction (TPD) using a split tibialis anterior musculotendinous graft. We assessed patient function and satisfaction after a modified Cobb reconstruction in a group of patients with a narrow spectrum of dysfunction, examined a modification of the Johnson and Strom classification to emphasize severity of deformity, and assessed the ability of the technique to prevent subsequent fixed deformity. We prospectively followed 32 patients managed by this technique and a translational os calcis osteotomy with early flexible deformity after failed conservative treatment. There were 28 women and four men with unilateral disease. The average followup was 5.1 years. Staging was confirmed clinically and with imaging. The modified surgery involved a bone tunnel in the navicular rather than the medial cuneiform with plaster for 8 weeks followed by orthotics and physiotherapy. All of the osteotomies healed and 29 of the 32 patients could perform a single heel rise test at 12 months. The mean postoperative American Orthopaedic Foot and Ankle Society hindfoot score was 89. One patient had a superficial wound infection and one a temporary dysesthesia of the medial plantar nerve; both resolved. The observations suggest the technique is a comparable method of treating early Johnson and Strom Type II TPD.,[object Object]

Endoscopic Gastrocnemius Recession for Treating Equinus in Pediatric Patients

John F. Grady DPM, Carolyn Kelly BS Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2–5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15°; standard deviation, 4°). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment.,[object Object]

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly

Nicola Maffulli MD, MS, PhD, FRCS(Orth), Umile Giuseppe Longo MD, Mario Ronga MD, Anil Khanna MRCS, MS(Orth), Vincenzo Denaro MD Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 ± 8.7 years (range, 65–86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49–110 months). The ATRS had a postoperative average rating of 69.4 ± 14 (range, 56–93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports.,[object Object]

Volar Percutaneous Screw Fixation for Scaphoid Waist Delayed Union

Jae Kwang Kim MD, PhD, Jong Oh Kim MD, PhD, Seung Yup Lee MD Volar percutaneous cannulated screw fixation of acute scaphoid waist fractures reportedly produces high rates of healing and early return to work, but the method has not been reported for treating scaphoid waist delayed unions. We therefore report the surgical results of percutaneous screw fixation in scaphoid waist delayed union in 12 patients. All patients were male with an average age of 31.1 years. Duration of injury was 12 weeks (range, 6–20 weeks). However, no patient had carpal instability, scaphoid deformity, or avascular necrosis of the proximal fracture fragment. The minimal followup was 12 months (mean, 20 months; range, 12–24 months). Preoperative radiographs showed slight bone resorption at the fracture site in five patients and cyst formation in three patients. A cannulated screw was introduced volarly under image intensifier guidance in all patients. All fractures united uneventfully. At 12 month followups, the flexion and extension arcs of the injured wrist were 94% and 93% of the uninjured wrist. Grip strength averaged 34 ± 3 kg, which was 92% of the grip strength of the uninjured hand. The Mayo Modified Wrist Score was 94 ± 6 points and the Disabilities of the Arm, Shoulder, and Hand score was 9 ± 6 points. Our experience suggests volar percutaneous screw fixation is a reliable method to treat scaphoid waist delayed union.,[object Object]

A Comparison between Robotic-assisted and Manual Implantation of Cementless Total Hip Arthroplasty

Nobuo Nakamura MD, Nobuhiko Sugano MD, Takashi Nishii MD, Akihiro Kakimoto MD, Hidenobu Miki MD

The benefits of robotic techniques for implanting femoral components during THA are still controversial.

Lessons Learned with Extended-release Epidural Morphine after Total Hip Arthroplasty

Lauren Kahl BS, Javad Parvizi MD, FRCS, Eugene R. Viscusi MD, William J. Hozack MD, Peter F. Sharkey MD, Richard H. Rothman MD, PhD An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone.,[object Object]

Tailor-made Surgical Guide Reduces Incidence of Outliers of Cup Placement

Takehito Hananouchi MD, PhD, Masanobu Saito MD, PhD, Tsuyoshi Koyama MD, PhD, Nobuhiko Sugano MD, PhD, Hideki Yoshikawa MD, PhD Malalignment of the cup in total hip arthroplasty (THA) increases the risks of postoperative complications such as neck cup impingement, dislocation, and wear. We asked whether a tailor-made surgical guide based on CT images would reduce the incidence of outliers beyond 10° from preoperatively planned alignment of the cup compared with those without the surgical guide. We prospectively followed 38 patients (38 hips, Group 1) having primary THA with the conventional technique and 31 patients (31 hips, Group 2) using the surgical guide. We designed the guide for Group 2 based on CT images and fixed it to the acetabular edge with a Kirschner wire to indicate the planned cup direction. Postoperative CT images showed the guide reduced the number of outliers compared with the conventional method (Group 1, 23.7%; Group 2, 0%). The surgical guide provided more reliable cup insertion compared with conventional techniques.,[object Object]

How to Treat the Stiff Total Knee Arthroplasty?: A Systematic Review

Sean E. Fitzsimmons MD, Edward A. Vazquez BS, Michael J. Bronson MD, FACS

Multiple modalities have been used to treat the stiff TKA, including manipulation under anesthesia (MUA), arthroscopy, and open arthrolysis.

Posterior Displacement of the Tibia Increases in Deep Flexion of the Knee

Shingo Fukagawa MD, Shuichi Matsuda MD, PhD, Yasutaka Tashiro MD, PhD, Makoto Hashizume MD, PhD, Yukihide Iwamoto MD, PhD

Deep knee flexion is important to proper function for some activities and in some cultures, although there are large posterior forces during high knee flexion. Most of what we know about posterior restraint and stability, however, has not been determined from deep flexion and without distinguishing motion in the medial and lateral compartments.

Is MRI Adequate to Detect Lesions in Patients with Ankle Instability?

Patrick J. O’Neill MD, Scott E. Van Aman MD, Gregory P. Guyton MD

Chondral lesions, peroneal tendon tears, and other disorders in patients with chronic ankle instability may not be detected by preoperative MRI. Also, MRI often is obtained and interpreted at the referring institution, leading to variability in reading.

Fine Needle Aspiration for Clinical Triage of Extremity Soft Tissue Masses

Vincent Y. Ng MD, Kristen Thomas MD, Martha Crist RN, Paul E. Wakely MD, Joel Mayerson MD

Fine needle aspiration cytology (FNAC) is a rapid and low-morbid alternative to open biopsy or needle core biopsy for soft tissue masses. Numerous reports describe its use with metastatic or recurrent lesions, but FNAC is less accepted for primary lesions.

Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation

Anna N. Miller MD, Eben A. Carroll MD, Robert J. Parker BS, David L. Helfet MD, Dean G. Lorich MD

Fixation of unstable ankle fractures, including fixation of posterior malleolus fracture fragments with the attached, intact posteroinferior tibiofibular ligament (PITFL), reportedly provides more stable fixation than transsyndesmotic screws.

Does Severity or Specific Joint Laxity Influence Clinical Outcomes of Anterior Cruciate Ligament Reconstruction?

Sung-Jae Kim MD, Hong-Kyo Moon MD, Sul-Gee Kim MD, Yong-Min Chun MD, Kyung-Soo Oh MD It generally is believed generalized joint laxity is one of the risk factors for failure of anterior cruciate ligament (ACL) reconstruction. However, no consensus exists regarding whether adverse effects on ACL reconstruction are attributable to joint-specific laxity or are related to the severity of generalized joint laxity. We therefore asked whether knee stability and functional outcomes would be related to joint-specific laxity and would differ according to the severity of generalized joint laxity. The Beighton and Horan criteria were used to assess joint laxity in 272 subjects. All elements are added to give an overall joint laxity score ranging from 0 to 5. Knee translation did not increase in proportion to the severity of the generalized joint laxity. Patients with scores less than 4 showed similar knee stability. When all variables, including the severity of generalized joint laxity, were considered, only hyperextension of the knee independently predicted knee stability and function. In patients with knee hyperextension, a bone-patellar tendon-bone autograft provided superior stability and function compared with a hamstring tendon autograft. Our data suggest knee hyperextension predicts postoperative stability and function regardless whether patients have severe generalized joint laxity.,[object Object]

Longitudinal Shapes of the Tibia and Femur are Unrelated and Variable

Stephen M. Howell MD, Kyle Kuznik BS, Maury L. Hull PhD, Robert A. Siston PhD In general practice, short films of the knee are used to assess component position and define the entry point for intramedullary femoral alignment in TKAs; however, whether it is justified to use the short film commonly used in research settings and everyday practice as a substitute for the whole leg view is controversial and needs clarification. In 138 long leg CT scanograms we measured the angle formed by the anatomic axis of the proximal fourth of the tibia and the mechanical axis of the tibia, the angle formed by the anatomic axis of the distal fourth of the femur and the mechanical axis of the femur, the “bow” of the tibia (as reflected by the offset of the anatomic axis from the center of the talus), and the “bow” of the femur (as reflected by the offset of the anatomic axis from the center of the femoral head). Because the angle formed by these axes and the bow of the tibia and femur have wide variability in females and males, a short film of the knee should not be used in place of the whole leg view when accurate assessment of component position and limb alignment is essential. A previous study of normal limbs found that only 2% of subjects have a neutral hip-knee-ankle axis, which can be explained by the wide variability of the bow in the tibia and femur and the lack of correlation between the bow of the tibia and femur in a given limb as shown in the current study.

Low-intensity Ultrasound Increases FAK, ERK-1/2, and IRS-1 Expression of Intact Rat Bones in a Noncumulative Manner

Carlos Vinícius Buarque Gusmão MD, José Rodrigo Pauli PhD, Mario José Abdalla Saad PhD, José Marcos Alves PhD, William Dias Belangero PhD

Low-intensity pulsed ultrasound stimulation (LIPUS) reportedly increases osteogenesis in fracture models but fails in intact bone, suggesting LIPUS does not act on mechanotransduction and growth factor pathways of intact bone.

Radiofrequency Energy on Cortical Bone and Soft Tissue: A Pilot Study

Maria Menendez LMV, Akikazu Ishihara BVSc, Stephen Weisbrode VMD, PhD, Alicia Bertone DVM, PhD

Radiofrequency-generating energy devices have been used clinically in musculoskeletal procedures to provide hemostasis and capsular shrinkage (thermal capsulorrhaphy). However, the dose-effects are not well known.

Fine Wigns

Joseph Bernstein MD There are three categories of diagnostic data collected during the physical examination—sign, symptom, and that in between—but only two words to describe them. To fill that gap, I modestly propose here that examination responses that are vocalized (and thus symptomlike) yet thought to be specific (hence signifiers) be classified as wigns. I define a wign as the subjective reaction to a provocative examination maneuver deemed to have some valid relationship to the underlying pathology. This word is pronounced “whine” to remind us it is a spoken response, and its spelling echoes that of sign, reminding us likewise a wign is more definitive than a generalized complaint. The distinctions between sign, symptom, and wign are worthy of preservation, particularly regarding their probative value: treatments offered on the basis of signs can be said to be most rigorously indicated, as symptoms, unlike signs, pass through (and are affected by) the prism of patients’ perceptions. Remaining skeptical about the value of information provided by our patients is in the interest of these patients, as our skepticism might save them from unnecessary treatments and procedures.

Case Report: Primary Aneurysmal Bone Cyst of the Epiphysis

Gilbert Chan MD, Alexandre Arkader MD, Raymond Kleposki CRNP, John P. Dormans MD Aneurysmal bone cysts are benign active or aggressive bone tumors that commonly arise in the long bones, especially the femur, tibia, and humerus and the posterior elements of the spine. Aneurysmal bone cysts affect all age groups but are more common before skeletal maturity (first two decades of life). They usually involve the metaphysis or metadiaphyseal region of long bones. Although juxtaphyseal lesions abutting the growth plate and extending into the epiphysis have been described, there is no report of an aneurysmal bone cyst entirely and primarily located in the epiphysis. We report on a 3-year-old boy who presented with an entirely contained aneurysmal bone cyst to the proximal tibial epiphysis. We discuss the clinical presentation, diagnosis, including imaging and pathology, and treatment. A review of the pertinent literature also is presented.

Case Report: Psoriatic Erythroderma with Bilateral Osseous Bridge Across the Acetabulum

Shigeyoshi Tsuji MD, Tetsuya Tomita MD, Masahiro Inaoka MD, Mari Higashiyama MD Abnormal reactions accompanied by bone formation in the osteoarticular region induced by long-term administration of etretinate have been reported. We treated a patient who received continuous treatment of psoriatic erythroderma with etretinate for 7 years, and who had an osseous bridge that extended across the acetabulum over the femur on both sides. The patient experienced a major gait disturbance and eventually was unable to walk. Functional gait was restored by resecting the ossified regions and radiotherapy. Histologic sections of the ossified lesions showed enchondral ossification in the ligament attachment site in the joint margin, with advancing ossification along the articular capsule; the pattern was similar to that in diffuse idiopathic skeletal hyperostosis. This is the first report of an osseous bridge associated with long-term administration of etretinate extending across the acetabulum over the femur on both sides.

Erratum to: How Successful are Current Ankle Replacements?: A Systematic Review of the Literature

Nikolaos Gougoulias MD, PhD, Anil Khanna MD, Donald J. McBride FRCS(Orth), Nicola Maffulli MD, PhD

Erratum to: Resource Utilization in Clubfoot Management

Matthew A. Halanski MD, Jen-Chen Huang MBChB, Stewart J. Walsh FRACS, Haemish A. Crawford FRACS

Erratum to: The Ischial Spine Sign: Do Pelvic Tilt and Rotation Matter?

Diganta K. Kakaty MD, Andreas F. Fischer MD, Harish S. Hosalkar MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Klaus A. Siebenrock MD, Moritz Tannast MD

A 37-year-old Man with a Painless Growing Mass of the Thorax

Boris Michael Holzapfel MD, Christoph Schaeffeler MD, Ingo Jörg Banke MD, Simone Waldt MD
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