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

A 46-year-old female presented a six-month history of posterior heel pain. Clinical and radiographical examination revealed a nodular calcified mass into the subcutaneous tissue of the Achilles tendon bursa. Following excision, histopathology showed an extraskeletal soft-tissue chondroma. Follow up at 24 months showed no recurrence. To our knowledge, this is the first description of a soft tissue chondroma at this site: some soft tissue tumors develop at unusual anatomic location.

Union of the greater tuberosity to the humeral shaft after hemiarthroplasty for acute fractures of the proximal humerus is a critical factor in the restoration of glenohumeral function. A retrospective review was undertaken to examine 23 consecutive patients who underwent hemiarthroplasty for the treatment of acute three- and four-part fractures of the proximal humerus. The study was conducted to examine the relationship between the position of the healed greater tuberosity and postoperative range of motion. The average age of the patients was 66.5 years. The average follow up was 3.8 years with a range of 24 to 108 months. Active range of motion was measured in forward elevation, external rotation, and internal rotation. Postoperative radiographs were examined to determine the position of the united greater tuberosity in relation to the top of the replaced humeral head. The tuberosity was fixed at an average of 15.4 mm below the top of the humeral head (range: 3 to 26 mm). A radiographic assessment of a control population of 50 normal proximal humeri demonstrated an average tuberosity position of 6.7 mm (range: 2 to 12 mm) below the superior aspect of the humeral head. Polynomial regression analysis demonstrated a polynomial relationship for active range of motion and tuberosity height. ANOVA testing demonstrated statistically significant differences in all ranges of motion. Active forward elevation for Group I (3 to 9 mm) was 88 degrees, Group 11 (10 to 16 mm) was 126 degrees, and Group III (17 to 26 mm) was 85 degrees (p = 0.04). Active external rotation for Group I was 19 degrees, Group II was 48 degrees, and Group III was 29 degrees (p = 0.01). Active internal rotation for Group I was to L2, Group II was to T10, and Group III was to L2 (p = 0.01). Although many factors affect the final ranges of motion in patients who undergo prosthetic replacement for acute proximal humeral fractures we believe that placement of the greater tuberosity 10 to 16 mm below the humeral head will assist in the maximum recovery of glenohumeral motion.

The anterior capsulolabral reconstruction (ACLR) has been shown to yield satisfactory results predominantly in overhead athletes with atraumatic anterior shoulder instability. The purpose of this study was to assess the clinical results of patients who underwent ACLR for recurrent traumatic anterior shoulder dislocation. A retrospective review of 41 patients, mean age 29 (range: 16 to 55 years) who underwent ACLR for traumatic recurrent anterior shoulder dislocation was performed. All patients reported a traumatic anterior shoulder dislocation with subsequent recurrent instability. Seven patients had undergone previous shoulder stabilization surgery which had failed. The mean number of previous dislocations was 4.5 (range: 1 to 15). There were 31 males and 10 females, and the dominant arm was involved in 24 patients. In all cases, the capsulolabral complex was detached from the glenoid rim. The mean follow-up was 3.6 years (range: 15 to 80 months). All patients were evaluated by physical examination. The mean modified Rowe score was 93.6 (range: 65 to 100). There were 32 excellent, 5 good, 1 fair, and 2 poor results. Instability was eliminated in 38 patients (93%). Of 25 patients who engaged in recreational sports, all were able to return to their previous level of participation. One patient sustained a traumatic redislocation and underwent revision surgery. Two patients reported atraumatic recurrent subluxation with one requiring revision surgery due to persistent symptoms of instability. There was no loss of range of motion in comparison to preoperative values. Of the seven shoulders that had undergone previous surgery, all remain stable. These results indicate that a glenoid-sided capsulolabral reconstruction can restore shoulder stability in patients with recurrent traumatic anterior shoulder dislocation. Success rates comparable to those of other open anterior shoulder repair procedures can be achieved.

Although the operative management of recurrent anterior glenohumeral instability has received significant attention in literature, the outcome of revision anterior shoulder repair is much less frequently reported. We report the results of our experience with this challenging problem. Retrospective chart review identified 29 patients who underwent revision anterior shoulder repair. Prior procedures included eight Bankart repairs, seven capsular shifts, 10 combined Bankart and capsular shift procedures, three Putti-Platt procedures, two staple capsulorrhaphies, two Bristow procedures, seven arthroscopie procedures, and one Magnuson-Stack. The average age of the patients was 31.6 years (range: 18 to 52 years) and the dominant extremity was involved in 69%. Findings at the time of revision anterior shoulder repair included 22 patients with capsulolabral detachment, 24 with capsular redundancy, and 14 with rotator interval defects. Twenty-three of the 29 patients were available for at least a two-year follow-up. Twenty-one (91%) remain stable. One patient was non-compliant with the postoperative immobilization and re-dislocated within the first month. The second patient, who had a prior Bankart procedure followed by a capsular shift two years later, underwent a capsular shift for significant capsular laxity. He re-dislocated approximately 15 months postoperatively. Our success rate of 91% in this small series approaches the results of primary open repair for recurrent glenohumeral instability. To achieve a successful outcome, it is essential to address all pathology at the time of revision repair.

A prospective study was conducted to determine the efficacy of using recombinant BMP-7 (rhOP-1) as an adjuvant in the treatment of diaphyseal humeral nonunions. Twenty-three consecutive patients with atrophic humeral diaphyseal nonunions were treated at seven separate institutions. All nonunions were fixed with either a compression plate or an intramedullary nail in conjunction with various bone grafting techniques. Recombinant OP-1 was delivered to the fracture site in a Type I collagen carrier at the time of fixation. All fractures went on to eventual union. There were no serious complications and no adverse reactions to the rhOP-I implant. Our study suggests that rhOP-1 may be a safe and effective adjuvant for the treatment of humeral diaphyseal nonunions.

We performed a retrospective study of pelvic radiographs of children between August 2003 and January 2004 to determine whether gonadal shields effectively protected the gonads during pelvic radiographs in pediatric patients. We considered 1,047 radiographs of 111 children under the age of 16 years who were examined by the orthopaedic department at the University Hospital of North Staffordshire. The presence and absence of gonadal shields in all the pelvic radiographs was recorded. If the shields were present, then whether the gonads were effectively protected was recorded. An average of 9.4 radiographs were taken per patient. The gonadal shields effectively protected the gonads in 466 (49.2%) radiographs and were completely omitted in 270 (28.5%) radiographs. In the remaining 212 (22.3%) radiographs, the shields did not adequately protect the gonads, which were therefore exposed to radiation in 482 (50.8%) of all the eligible pelvic radiographs. Children receive many radiographs with avoidable excess radiation from inadequate positioning or complete omission of gonadal shields. This may increase the potential for disease in the future offspring of these patients. Strict adherence to guidelines is required to decrease radiation exposure.

Computer assisted fluoroscopic surgery is at the forefront of the ability to continue and pursue minimally invasive surgical options in orthopaedic surgery. Many systems afford the surgeon three-dimensional views and biplanar imaging for placement of orthopaedic implants in difficult areas. The current literature regarding these techniques is limited. The indications are poorly defined. The common thread of all techniques, however, is the preservation of the soft tissue attachments and the biology of the fracture hematoma. Currently we are using first generation implants. It appears that malalignment is the biggest problem with any of these techniques and long-term prospective studies will be required to evaluate whether or not these theoretical advantages become clinically viable and functional for patient care.

"Osteobiologics" is the term that has been introduced to refer to the class of engineered materials that have been created and which promote healing of fractures and bone defects. The list of osteobiologics is rapidly expanding as new products incorporating osteoconductive materials are mixed with a variety of osteoinductive proteins, demineralized bone, and preparations of osteogenic cells. The growth in osteobiologics has been stimulated by the early success of osteoconductive materials as graft substitutes in the repair of fractures and by the increasing demand for grafts in all areas of orthopaedics. Although allografts have historically been employed with success, the number of donors has grown much slower than demand leading to the development of artificial materials. Manufactured bone graft substitutes, or osteobiologics, attempt to mimic the components of an autogeneous bone graft by reproducing the bone matrix, which is osteoconductive and osteoinductive. Other products aim to introduce osteogenic cells by concentrating bone marrow while others introduce differing growth factors from platelets in peripheral blood. Very few of these products have been supported by appropriate clinical studies and as such their value is unknown. Orthopaedic surgeons employing these products must understand the basic science principles behind their development in order to understand the indications and limitations of their application. Properly designed clinical studies should be performed to determine the usefulness and cost-effectiveness of both current and future products.

The use of intramedullary rods is accepted as the gold standard for treatment of closed femur fractures. Early fixation of these fractures has been shown to be beneficial in the multiply-injured patient. This retrospective review was undertaken to examine the isolated femur fractures in an urban trauma center over a six-year period. Of the 76 patients included in the study, 42 underwent early fixation (less than 48 hours after injury) and 34 had delayed fixation (more than 48 hours after injury). There was no statistical difference in postoperative complications between the two groups. Fixation performed within 48 hours did not seem to decrease morbidity when compared to fixation performed after 48 hours. Length of stay and hospital costs were increased with delayed fixation.