Journal of the Southern Orthopaedic Association最新文献

Forefoot ulcers are a common complication of neuropathy. Trans-tibial amputation too often becomes necessary when progressive infection develops secondary to ulcers of the forefoot. Tendon lengthening appears to be an effective treatment for plantar forefoot ulcers in patients with neuropathy and forefoot ulceration.

Total hip arthroplasty is characterized by significant blood loss. The principal aim of blood management in joint replacement surgery is to minimize both the risks associated with surgical blood loss and the risks associated with allogenic blood transfusion. In the 1980s, the AIDS epidemic triggered the development of a variety of innovative approaches to conserving blood and reducing the need for allogenic transfusion to replace surgical blood loss. Subsequently, the safety of the blood supply was dramatically improved, changes in surgical technique led to decreased surgical blood loss, and changes in transfusion thresholds made the need for transfusion less common. The review re-examines the options available for the management of blood loss in total joint replacement and defines parameters that can be used preoperatively to predict which patients are likely to benefit from these interventions, given the clinical realities of the 21st century.

Thromboembolic disorders are worrisome complications following total hip arthroplasty, and the best way to address such complications is by prevention. Several regimens have been advocated to decrease the risk of thromboembolic disorders. A combination of pharmacologic and nonpharmacologic measures helps reduce the incidence of deep venous thrombosis and, hence, pulmonary embolization.

The occurrence of deep vein thrombosis (DVT) following cases of major trauma, in particular pelvic and hip fracture, has ranged from 36% to 60%, depending on the study quoted and the method of detection. The frequency of fatal pulmonary embolism (PE) has been reported as 0.5%-12.9% of the cases. A retrospective study of 1000 consecutive hip fracture patients in a community hospital setting reveals that 95% received a combination of mechanical and pharmacologic prophylaxis for prevention of DVT. Sixty-one patients were excluded for insufficient data, leaving 939 for analysis. There were 724 female patients with an average age of 83 years and 215 male patients with an average age of 78 years. Fifty-one patients (18.4%) received no prophylaxis in the eligible population. Three hundred eighty-seven patients (41.2%) received only aspirin as the pharmacologic agent for anticoagulation. Four hundred twenty-nine patients (45.6%) were treated with the low-molecular-weight heparin (LMWH), enoxaparin. Ten patients (1.1%) received heparin for anticoagulation and 17 patients (1.8%) were treated with warfarin. A total of 43 patients received a combination of therapies. Four hundred ninety-five of the patients used concomitant intermittent pneumatic compression in addition to pharmacologic prophylaxis. There were 15 perioperative deaths from all causes, including five cases of DVT two distal and three proximal). One distal DVT occurred prior to surgery. A second distal DVT and one fatal PE occurred in the aspirin group. The rates of minor bleeding complications in the aspirin group, the < 12-hour postoperative dosing of the enoxaparin group, and the 12 to 24-hour postoperative dosing of the enoxaparin group were 3.1%, 5.7%, and 2.8%, respectively. There were no major bleeds in the aspirin group and 0.9% in the enoxaparin group. The LMWH group also had two proximal DVTs but no PEs. The combination of a relatively short half-life, predictable pharmacokinetics, and favorable safety profile makes enoxaparin an excellent drug for use in hip fracture patients. Additional trials will be necessary to establish an optimal duration of prophylaxis in this population.

Hip fractures are associated with significant morbidity and mortality. Most of these fractures are preventable late manifestations of osteoporosis. The authors examined incidence and medical costs associated with hip fractures among 34,363 veterans by gender and race for fiscal years 1996-2000. Data were obtained from the Patient Treatment File administrative database. The frequencies of seven known risk factors were quantified. White veterans hospitalized for hip fracture were 69% more likely to be given the diagnosis of osteoporosis, when compared to black veterans. Male gender was associated with lower percentage of osteoporosis diagnoses (2.2%) than female gender (11.9%). The authors estimate that hip fractures result in 43 million dollars of excess cost to veterans and the Veterans Health Administration annually. Greater use of diagnostic and preventive measures represents an excellent opportunity for improvement of care, as well as substantial cost savings for at risk populations.

Cannulated screws are utilized widely in the management of periarticular fractures and osteotomies. Reports of complications related to these screws have increased as use has become more commonplace. A novel mode of mechanical failure of 4.0-mm and 4.5-mm A-O cannulated screws is described in three patients, as well as hypotheses regarding possible causes of the failure. It may be prudent to predrill and tap dense cortical bone when such devices are used in teenagers and young adults patients in an attempt to avoid similar damage to the screw during insertion.

Polyethylene wear and extension of indications of total hip arthroplasty into younger and younger age groups have pushed manufacturers to develop more durable bearing surfaces. Standard polyethylene, the plastic used for the first 3 decades of hip replacement, virtually ceases to exist in its original form. Modifications of the processing, including sterlization in an inert environment and cross-linking, have demonstrated some improvements in wear. Hard-on-hard bearings such as ceramic-on-ceramic and metal-on-metal also have demonstrated extremely low wear. This article reviews the pros and cons of the alternative bearing options available to assist in the proper bearing selection for a particular patient.

Concomitant nonunion of an operatively treated fracture of the distal humerus and the olecranon osteotomy used for exposure is an unusual and complex situation which compromises ulnohumeral function on both sides of the joint. Operative treatment restored good elbow function in a series of six patients with this problem. An average of 110 degrees of ulnohumeral motion was restored, arthrosis was none (four patients) or mild (two patients) at an average follow-up of 50 months, and outcome measures documented good upper extremity specific (DASH) and general (SF-36) health status.

A case report is presented of a patient with acetabular protrusio 2 years following hemiresurfacing of the femoral head for osteonecrosis associated with sickle cell disease. Renewed interest in bone-preserving hip arthroplasty has led to increased use of hemiarthroplasty and femoral resurfacing in young patients with arthritis. In cases of osteonecrosis, especially that associated with sickle cell disease, awareness of this potential complication is important.

Lipoma arborescens (LA) (diffuse articular lipomatosis, synovial lipomatosis, Hoffa disease) is a rare intra-articular lesion of unknown etiology. This article presents three patients who had LA, which was diagnosed in the knee in two patients and in the wrist of the third patient. Details of the clinical and histomorphological examination and treatment, in addition to a review of the literature, are discussed. The article concludes that in patients with a slow increase in painless swelling of the joints, unresolving articular pain with or without limited motion, or intermittent effusions following a minor trauma, LA should be considered in the differential diagnosis. It should be remembered that LA occurs in joints other than the knee, such as the elbow, shoulder, and wrist. Although recommended surgery involves arthrotomy and synovectomy, arthroscopic synovectomy may be a useful treatment modality, particularly in the larger joints as the recurrence rate is low.