Bulletin (Hospital for Joint Diseases (New York, N.Y.))最新文献

An anatomic study was conducted on 49 dried cadaveric humeri and 24 dried cadaveric scapula to ascertain the variability of the following parameters: humeral neck angle, humeral head retroversion, humeral head medial offset, humeral head posterior offset, humeral head diameter glenoid height, glenoid width, and the glenoid height to width ratio. For verification purposes, the results of this study were found to be within 1.5% to 14.3% of other anatomic studies published in the literature. This observed variability was then compared to that provided by an "anatomic" shoulder prosthesis (Equinoxe, Exactech, Inc.); viewed independently, this prosthesis can restore humeral neck angle in 94% of humeri, "secondary" retroversion in 92% of humeri, medial offset in 100% of humeri, posterior offset in 100% of humeri, and humeral head diameter in 96% of humeri. Additionally, the glenoid prosthesis height to width ratio was found to be within 5% and 10% of 71% and 96% of cadaveric glenoids, respectively. The results of this analysis indicate that a dual-offset "anatomic " shoulder prosthesis has the capability to successfully restore glenohumeral anatomy in this representative population.

The surgical treatment of recurrent posterior shoulder instability via a posterior approach has had a variable degree of success reported in the literature with recurrence rates ranging between 8% and 45%. The purpose of this study was to review the results of posterior capsulorrhaphy in a consecutive series of patients with recurrent posterior instability. Seventeen consecutive patients underwent operative management for posterior glenohumeral instability. The dominant shoulder was involved in ten patients. All patients were male with an average age of 28.1 years (range: 16 to 54 years). Ten patients had sustained a specific injury which precipitated the instability. Six patients reported dislocations requiring formal closed reduction maneuvers; the remainder described episodes of recurrent subluxation with spontaneous reduction. All patients underwent a posterior capsulorrhaphy using an infraspinatus splitting approach. Eight shoulders required repair of a posterior capsulolabral detachment. In addition, one patient required augmentation with a posterior bone block for significant glenoid rim deficiency. Outcome was assessed by personal interview, clinical assessment, and standardized radiographs. At an average follow-up of 3.9 years (range: 1.8 to 10.8 years) patients estimated their overall shoulder function to be 81% of the contralateral unaffected shoulder. The subjective result was excellent for eight patients, good for five patients, fair in two patients, and poor in two patients. One of the poor outcomes was in a patient with glenohumeral degenerative changes at the index procedure which progressed and eventually required a total shoulder arthroplasty. The other poor result was in a patient found to have a full-thickness rotator cuff tear 10.6 years after the index procedure. Two patients (12%) had recurrence of their instability. Both of these patients sustained a significant re-injury which precipitated their symptoms. Five patients complained of occasional night pain at the time of their last follow-up examination. Only one patient (who was re-injured) had to change professions as a result of shoulder symptoms. Posterior capsulorrhaphy for treatment of isolated posterior glenohumeral instability yields satisfactory clinical results. Recurrent instability in this series was associated with a specific re-injury and did not appear to increase with longer follow-up.

Following the tradition of the IDES European Hip Registry inaugurated by M. E. Müller in the 1960s, the Institute for Evaluative Research in Orthopaedic Surgery at the University of Bern started a new era of data collection using internet technology (www.memdoc.org). With support of the Swiss Orthopaedic Society, the pilot of the Swiss Orthopaedic Registry was conducted, and in cooperation with different academic and non-academic centers the practicability of integrating the various data collection instruments into the daily clinical workflow was evaluated. Three different sizes of hip and knee questionnaires were compiled, covering the individual demands of the participating hospitals whereby the smaller questionnaires always represent a subset of the next larger one. Different types of data collection instruments are available: the online interface, optical mark reader paper questionnaires, and barcode sheets. Precise implant tracking is implemented by scanning the implant barcodes directly in the operating theaters and linking them to the clinical data set via a central server. In addition, radiographic information can be linked with the clinical data set. The pilot clinics suggested enhancements to the user interface and additional features for data management. Also, recommendations were made to simplify content in some instances and diversify in others. With a new software release and adapted questionnaires the Swiss Orthopaedic Registry was officially launched in Summer 2005.

During exercise, muscular expansion and swelling occur. Chronic exertional compartment syndrome represents abnormally increased compartment pressures and pain in the involved extremity secondary to a noncompliant musculofascial compartment. Most commonly, it occurs in the lower leg, but has been reported in the thigh, foot, upper extremity, and erector spinae musculature. The diagnosis is obtained through a careful history and physical exam, reproduction of symptoms with exertion, and pre- and post-exercise muscle tissue compartment pressure recordings. It has been postulated that increased compartment pressures lead to transient ischemia and pain in the involved extremity. However; this is not universally accepted. Other than complete cessation of causative activities, nonoperative management of CECS is usually unsuccessful. Surgical release of the involved compartments is recommended for patients who wish to continue to exercise.

The successful treatment of chondral and osteochondral defects of the weightbearing surfaces is a challenge for orthopaedic surgeons. Autologous osteochondral transplantation is one method that can be used to create a hyaline or hyaline-like repair in the defect area. Ten years of clinical experience with autologous osteochondral mosaicplasty are described. Clinical scores, imaging techniques, arthroscopy, histological examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage in a total of 831 patients who underwent mosaicplasty. According to our investigations, good-to-excellent results were achieved in 92% of the patients treated with femoral condylar implantations, in 87% of those treated with tibial resurfacing, in 79% of those treated with patellar and/or trochlear mosaicplasties, and in 94% of those treated with talarprocedures. Long-term donor-site disturbances, which were assessed using the Bandi score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 83 patients who were followed arthroscopically showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. Four deep infections and 36 painful postoperative hemarthroses were experienced as complications arising from the surgical procedures. On the basis of both these promising results and also those of other similar studies, autologous osteochondral mosaicplasty would appears to be an alternative for the treatment of small and medium-sized focal chondral and osteochondral defects of the weightbearing surfaces of the knee and other weightbearing synovial joints.

Segmental fractures of the radius and ulna are relatively common in adults, often occurring after high energy trauma. Segmental forearm fractures in children have not previously been reported, and their optimal management is unclear. We report a child of eight years of age who underwent fixation of these injuries with a good outcome.

Fractures of irradiated bones present special challenges to healing. Nonunions are very common and are challenging surgical problems. We report three radiated nonunions of the clavicle successfully treated with modifications of standard internal fixation techniques.

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilateral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis experienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: I to 4). A mean arc of wrist extension and flexion of 53 degrees on the right and 49 of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed partial arthrodesis at rest and by 46% at stress on the visual analog scale andfrom intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain activities, 55%felt considerably and 15% strongly limited in daily life. However, all but two patients were satisfied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and preserved valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.

Recurrent instability in patients over forty years of age is felt to occur primarily as a result of an associated rotator cuff tear. This is often referred to as the "posterior mechanism." We reviewed our patients over the age of forty who underwent an anterior shoulder repair to identify the incidence of capsulolabral detachments and the role of an "anterior mechanism" in this patient population. A retrospective review of all patients from 1985 to 2000 was performed to identify patients who had surgery for recurrent instability that began after forty years of age. Of the 265 patients records reviewed, 11 patients were identified who fulfilled the inclusion criteria. Of the 11 patients identified, 9 patients underwent anterior capsulolabral reconstruction for recurrent instability; the remaining two patients underwent repair of large rotator cuff tears. All 9 patients had a capsulolabral detachment, 4 had a rotator interval defect, 2 had anterior and inferior capsular redundancy, 1 had a small rotator cuff tear and 1 had an anterior capsular avulsion from the humeral head. At minimum follow-up of 32 months none of the patients reported episodes of instability. The reported incidence of rotator cuff tears in patients over the age of forty following an initial traumatic anterior glenohumeral dislocation ranges from 35% to 100%. When recurrent instability occurs, it is postulated to occur via a "posterior mechanism" (i.e., secondary to a significant full-thickness rotator cuff tear). However, all of our patients had an anterior capsulolabral detachment as the "common lesion" associated with recurrent instability. Although small, this series emphasizes the role of the "anterior mechanism" in patients who develop recurrent instability after the age of forty. A high rate of success was achieved by addressing the pathoanatomic changes identified.