American journal of orthopedics (Belle Mead, N.J.)最新文献

Nonunion after a proximal tibia fracture is often associated with poor bone stock, (previous) infection, and compromised soft tissues. These conditions make revision internal fixation with double plating difficult. Combining a plate and contralateral 2-pin external fixator, coined composite fixation, can provide an alternative means of obtaining stability without further compromising soft tissues. Three patients with a proximal tibia nonunion precluding standard internal fixation with double plating were treated with composite fixation. All 3 patients achieved union with deformity correction at a mean of 5.2 months (range, 5-5.5 months). The average range of motion (ROM) arc was 100° (range, 100°-115°) and postoperative ROM returned to pre-injury levels.Composite fixation can be a helpful adjunct in the treatment of this challenging problem.

The ulnar nerve is most commonly compressed at the elbow in the cubital tunnel. Conservative and operative treatments have been applied for cubital tunnel syndrome. Surgical management options include decompression, medial epicondylectomy, and various anterior transposition techniques. We describe a novel technique of anterior transposition of the ulnar nerve by using Osborne's ligament as a sling to avoid subluxation. Osborne's ligament is incised posteriorly and medially on the olecranon to create a sling with 2 to 3 cm width. The sling is tailored to wrap around the ulnar nerve and attached to the flexor-pronator fascia or dermis to create a smooth gliding surface without causing compression. Ten patients with cubital tunnel syndrome, established by physical examination findings and electromyography/nerve conduction studies underwent ulnar nerve transposition using this technique and were able to participate in a phone survey. The average follow-up was 15.6 months (range, 4-28 months). The average time to become subjectively "better" after surgery was 4.2 weeks. The pain intensity was reduced from an average of 7.5 preoperatively to <1, on a 10-point scale, at the time of the survey. All patients had symptomatic relief without any complication. The proposed technique using Osborne's ligament as a ligamentofascial or ligamentodermal sling offers a unique way of creating a non-compressive sling with the component of the cubital tunnel itself and has an additional benefit of creating a smooth gliding surface for early return of function.

The morbidity and mortality after hip fracture in the elderly are influenced by non-modifiable comorbidities. Time-to-surgery is a modifiable factor that may play a role in postoperative morbidity. This study investigates the outcomes and complications in the elderly hip fracture surgery as a function of time-to-surgery. Using the American College of Surgeons-National Surgical Quality Improvement Program data from 2011 to 2012, a study population was generated using the Current Procedural Terminology codes for percutaneous or open treatment of femoral neck fractures (27235, 27236) and fixation with a screw and side plate or intramedullary fixation (27244, 27245) for peritrochanteric fractures. Three time-to-surgery groups (<24 hours to surgical intervention, 24-48 hours, and >48 hours) were created and matched for surgery type, sex, age, and American Society of Anesthesiologists class. Time-to-surgery was then studied for its effect on the post-surgical outcomes using the adjusted regression modeling. A study population of 6036 hip fractures was created, and 2012 patients were assigned to each matched time-to-surgery group. The unadjusted models showed that the earlier surgical intervention groups (<24 hours and 24-48 hours) exhibited a lower overall complication rate (P = .034) compared with the group waiting for surgery >48 hours. The unadjusted mortality rates increased with delay to surgical intervention (P = .039). Time-to-surgery caused no effect on the return to the operating room rate (P = .554) nor readmission rate (P = .285). Compared with other time-to-surgeries, the time-to-surgery of >48 hours was associated with prolonged total hospital length of stay (10.9 days) (P < .001) and a longer surgery-to-discharge time (hazard ratio, 95% confidence interval: 0.74, 0.69-0.79) (P < .001). Adjusted analyses showed no time-to-surgery related difference in complications (P = .143) but presented an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001). Timeliness of surgical intervention in a comorbidity-adjusted population of elderly hip fracture patients causes no effect on the overall complications, readmissions, nor 30-day mortality. However, time-to-surgery of >48 hours is associated with costly increase in the total length of stay, including an increased post-surgery-to-discharge time.

Cryotherapy is the use of the anti-inflammatory and analgesic properties of ice to facilitate healing. Cryotherapy mediates these salutatory effects by reducing blood flow to the site of injury, down-regulating the production of inflammatory and pain-inducing prostaglandins, and diminishing the conductive ability of nerve endings. It is commonly used postoperatively in orthopedics to decrease analgesic requirements and blood loss as well as to increase range of motion, despite limited literature on its ability to produce such therapeutic effects in clinical practice. This article examines the available literature and the scientific evidence for the use and efficacy of cryotherapy in post-surgical orthopedic patients. It also reviews the potential pitfalls associated with improper use. Overall, this review seeks to provide insight into when, or whether, cryotherapy is appropriate for orthopedic patients during surgical recovery.

Meniscus allograft transplantation (MAT) has yielded excellent long-term functional outcomes when performed in properly indicated patients. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency. Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure. Once an ideal candidate is identified, graft selection and preparation are critical steps to ensure a proper fit and long-term viability of the meniscus. When selecting the graft, accurate measurements must be taken, and this is most commonly performed using plain radiographs for this. Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.

Cervical myelopathy is the most common cause of acquired spinal cord dysfunction in people aged >55 years. Advanced age and duration of symptoms have been implicated in the literature as negative prognostic indicators for postoperative functional improvement, but very few studies have evaluated the interaction of these factors. We retrospectively reviewed 125 patients who underwent surgery for cervical myelopathy. Patients were stratified according to age greater or less than 65 years and duration of symptoms of greater or less than 12 and 24 months. Functional outcomes were assessed using the Nurick score. Simple regression and multiple regression analyses were done, controlling for sex, preoperative Nurick score, surgical approach, smoking status, diabetes status, prior surgery, number of levels fused, ethanol use, and signal change on preoperative magnetic resonance imaging. The average change in Nurick score in all patients was 1.36, with a significant difference between patients with symptoms for <24 months and those with symptoms for >24 months (1.54 vs 0.98, P = .03). Multiple regression analysis revealed that older patients had a significant difference at 24 months (1.69 vs 1.25, P = .01), whereas younger patients showed slightly lower improvement overall and a change in Nurick score at both thresholds that was statistically nonsignificant.

Surgical reconstruction of the ankle and hindfoot in patients with diabetes, Charcot neuroarthropathy, osteomyelitis, deformity, and/or bone loss can be challenging and often results in amputation. In these patients, conventional internal fixation with plates, screws, and intramedullary nails is often not feasible because of ongoing infection or poor bone stock and soft tissue quality. The Ilizarov method of ankle and hindfoot arthrodesis is a well-established technique for limb reconstruction that uses circular external fixation to achieve solid bony fusion, optimal leg length, and eradication of infection in cases of complex pathology. This article discusses indications, contraindications, pearls, and pitfalls of performing ankle and hindfoot arthrodesis using the Ilizarov technique.

The incidence of acetabular fractures and associated in-hospital complication rates in the United States are poorly defined. Studies evaluating predictors of outcome for isolated acetabular fractures are weakly generalizable due to small sample sizes or the inclusion of all types of pelvic fractures. This study sought to analyze trends in acetabular fractures and associated complications in the US using the largest and most recent national dataset available. The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with acetabular fractures between 1990 and 2010. A representative cohort of 497,389 patients was identified, and multivariable logistic regression was used to identify independent predictors of mortality, adverse events, requirement of blood transfusion, and operative treatment with open reduction and internal fixation (ORIF). Between 1990 and 2010, the population-adjusted incidence of acetabular fractures increased from 7.8 to 9.5/100,000 capita (P < .001). Mortality declined from 5.9% to 0.4% (P < .001), paralleling an increase in the proportion of patients treated with ORIF (12.6%-20.4%, P < .001), which was the variable associated with the lowest odds of mortality. Surgical intervention was associated with higher odds of adverse events and a requirement for blood transfusion. The average in-hospital length of stay decreased from 17.0 days to 10.3 days (P < .001). This study provides the largest and most comprehensive epidemiologic analysis of acetabular fractures in the US. Knowledge of the increasing incidence of acetabular fractures and prognostic factors associated with poor outcomes may improve outcomes.

Conventional interrupted sutures are traditionally used in extensor mechanism closure during total knee arthroplasty (TKA). In recent years, barbed suture has been introduced with the proposed benefits of decreased closure time and a watertight seal that is superior to interrupted sutures. Complication rates using barbed sutures and conventional interrupted sutures are similar. We propose a novel closure technique known as the Flint Lock, which is a double continuous interlocking stitch. The Flint Lock provides a quick and efficient closure to the extensor mechanism in TKA. In addition, similar to barbed suture, the Flint Lock should provide a superior watertight seal. It utilizes relatively inexpensive and readily available materials.

A 61-year-old woman with a periprosthetic knee joint infection caused by Mycobacterium abscessus was successfully treated with surgical débridement, multidrug antimicrobial therapy, and staged reimplantation. To the authors' knowledge, this represents the first report of successfully treating this organism after knee arthroplasty. M. abscessus knee infections are rare, and there are no specific guidelines to inform treatment or successful treatment regimens for periprosthetic knee infections. Medical management alone was not successful in this case and hence cannot be recommended. Using a collaborative multidisciplinary approach, including surgical débridement, staged reimplantation, and multidrug antimicrobials, successful eradication of the periprosthetic joint infection caused by M. abscessus was achieved.