Contemporary total hip replacement with metal on metal articulation

Between 1991 and 1994, 74 patients received total hip replacements with metal on metal articulation. The results of these patients with 74 hips who had a 6-month to 4-year (average, 2.2 years average) followup are reported. Patients were prospectively evaluated by the Harris hip score, a patient self assessment form, and radiographs. The average postoperative Harris hip score was 91. Patient self assessment forms showed that 95% of the patients scored their results as excellent or good. No patient had revision for loosening, but 1 underwent revision surgery for recurrent dislocation. Serial radiographs have not revealed loosening or osteolysis. Wear could not be measured radiographically. Twenty-seven of the patients had bilateral total hip replacements with 1 hip being metal on polyethylene; the patients could not detect any difference between the 2 hips. The satisfactory short term results from the contemporary metal on metal articulation investigated in this study are encouraging and warrant continued study.

Distribution of cobalt chromium wear and corrosion products and biologic reactions

Replacement hip arthroplasty with the use of ultrahigh molecular weight polyethylene for the cup articulating with a metal head has provided a low friction arthroplasty with years of success. However, the search for improved materials and designs for articulating surfaces continues. The use of metallic heads articulating with metallic cups is now being reconsidered for total hip replacements. Success will be enhanced if wear and corrosion of the articulating surfaces can be kept below that of the metal on ultrahigh molecular weight polyethylene couple. Concern has been raised about the release, and biologic fate, of metal species from corrosion and wear. Titanium alloys have been shown to have limitations as an articulating surface showing significant wear, and the alloy per se should not be considered for wear couples in total hip replacements. The cobalt chromium alloys are known to have reasonable wear and corrosion properties and continue to be evaluated. The issue of cobalt chromium wear and corrosion products and how this relates to the biologic performance of total hip replacement devices is reviewed. Under the condition of wear as currently experienced at the articulating surfaces of cobalt chromium alloys and ultrahigh molecular weight polyethylene, the amount of metallic products transferred to the tissues is sufficiently low to be well tolerated by the biologic system. Nickel and cobalt ions arc, rapidly transported from the implant site and eliminated in the urine. Chromium is stored in the tissue and eliminated more slowly. The issue of host hypersensitivity to these elements remains of concern. All 3 elements, in ionic form, are known to cause contact dermatitis. Untoward biologic reactions, including hypersensitivity, should be minimized if wear and corrosion phenomena are minimized.

The management of complex orthopedic injuries

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.

Neurologic injuries in pelvic ring fractures

Unstable fractures of the pelvic ring are an increasingly frequent outcome of motor vehicle trauma. Neurologic injury after such injuries can be a cause of significant morbidity. The available literature on neurologic injuries was reviewed and compared with a clinical review of 90 unstable pelvic injuries treated during a 3-year period. Eighty-three patients were available for followup examination. Neurologic injuries were seen in 21 % of the patients. Thirty-seven percent of patients had sensory deficits alone whereas the remaining 63% had motor and sensory findings. All patients showed some evidence of neurologic recovery at an average or 24-months followup. At least 1 grade of muscle function improvement was consistently seen and 53% of patients had complete neurologic recovery. Improvement in function was seen as many as 24 months postinjury, but L5 function was least likely to progress to full recovery. The incidence of neurologic injuries and their distribution was similar to that reported in the literature, whereas the prognosis for neurologic recovery was significantly better. This may be related to techniques of early anatomic reduction and stabilization of unstable pelvic ring injuries.

A tapered titanium femoral stem inserted without cement in a total hip arthroplasty. Radiographic evaluation and stability

The results of 416 total hip arthroplasties performed in 372 patients with insertion of a Mallory-Head titanium femoral component without cement were reviewed retrospectively, to determine the stability and the radiographic parameters of stability for this type of stem. The average duration of clinical and radiographic follow-up was 3.7 years (range, 2.0 to 6.5 years). No revisions were performed to treat instability of the stem, pain, or osteolysis by the time of the latest follow-up examination. Although the clinical results were excellent, the radiographic signs of fixation that have been well described for chromium-cobalt stems were frequently absent. So-called endosteal spot welds, commonly seen in association with long, extensively coated stems, were seen infrequently. Resorptive bone-remodeling rarely extended beyond zones 1 and 7 of Gruen et al. Both endosteal and periosteal distal cortical hypertrophy was common, but the cause was unknown. Osteolysis of the distal aspect of the femur, shedding of the porous coating, and breakage of the stem were not seen. Forty-four stems (11 per cent) had initial subsidence; however, it nearly always stabilized within six months postoperatively and did not affect the eventual stability at the time of the short-term follow-up. The short-term clinical outcome confirmed the stability of these stems that had been determined from the radiographic findings and the lack of revisions. At the latest follow-up examination, 323 (87 per cent) of the patients (362 [87 per cent] of the hips) had no or slight pain in the lower limb over-all and only twenty-two (6 per cent) of the patients (twenty-seven [6 per cent] of the hips) had pain in the thigh. This tapered titanium femoral component appears to provide excellent short-term stability, without resorptive bone-remodeling, osteolysis, or a high prevalence of pain in the thigh. Radiographic evaluation of stability of this stem is clearly different from that of chromium-cobalt stems-particularly extensively coated anatomic medullary locking stems-in that so-called spot welds and severe resorptive bone changes were uncommon and distal cortical hypertrophy was common.

Hybrid external fixation in tibial plafond fractures

Fourteen patients with Ruedi/Allgower types II and III distal tibia fractures received indirect reduction followed by application of a Monticelli-Spinelli hybrid external fixation system. All 14 patients were available for followup. A stability similar to that of an open reduction and internal Fixation was noted. The mean time to union was 13 weeks. There were no nonunions. One patient experienced malunion in 7 degrees varus. Superficial pin tract infections occurred in 8 pins (3 patients), and all resolved with aggressive pin care and a short course of orally administered antibiotics. Through postoperative tomography, 1 pin was found to be within the ankle joint and was removed. There were no deep infections. The subjective and objective results were classified according to Ovadia and Beals. On the basis of these early results, by limiting additional trauma to the soft and bony tissues and allowing early ankle range of motion, indirect reduction and application of a hybrid external fixator is useful, particularly if the fracture fragments are so comminuted that anatomic reduction cannot be expected despite surgical intervention.

Operative stabilization of fracture dislocations of the sacroiliac joint

Posterior fracture dislocations of the sacroiliac joint (crescent fracture) represent a subset of lateral compression pelvic fractures. The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the inferior 1/2 of the sacroiliac joint. The posterior superior iliac spine remains firmly attached to the sacrum by the strong posterior ligaments. As a result of this combination of bony and soft tissue injury, the hemipelvis is rotationally unstable, but because the sacrospinous and sacrotuberous ligaments remain intact the involved hemipelvis is stable to vertically applied forces. Operative stabilization is necessary to restore articular congruity of the sacroiliac joint, pelvic stability, and to allow early mobilization of the patient. Stabilization of the pelvis may be achieved through either an anterior or a posterior approach with or without transarticular fixation. A posterolateral approach to the crescent fracture and a method of stabilization using extraarticular fixation, intertable lag screws and outer table antiglide plates are described. The results of using this technique in 22 patients are reviewed.

Patellar tilt and subluxation following subvastus and parapatellar approach in total knee arthroplasty. Implication for surgical technique

Eighty-nine posterior-stabilized total knee arthroplasties (TKAs) were studied using a Merchant view to assess patellar tilt or subluxation. Forty TKAs were performed via the subvastus approach (SVA) and 49 via the standard parapatellar approach (PPA). Intraoperative tracking was assessed using a "no thumbs" test, and a lateral release was performed if necessary. Following the SVA, 40.0% of patellas tracked centrally compared to 44.9% for the PPA. With the SVA, a lateral release was necessary in 27.5% of procedures compared to 51.0% for the PPA. The data suggest that the no thumbs test may overestimate the need for lateral release following the PPA. Since there are fewer lateral releases following the SVA, reapproximation of the medial retinaculum to assess intraoperative tracking may result in fewer lateral release being performed without adversely affecting patellar position. Medial tilting of the patella is also found to be common; 29.7% of the patellas tilted this way, including 40.0% of knees operated via the SVA. Why this occurs is unclear, but the incidence of medial tilting increased after posterior-stabilized TKA.

Surgical management of soft tissue lesions associated with pelvic ring injury

Mortality rates associated with pelvic ring injury combined with open wounds have decreased considerably during the past 2 decades. Consequently, increased survivability has heightened the demand for definitive stabilization techniques to address pelvic ring instability. Control of hemorrhage and avoidance of sepsis remain paramount concerns in the initial and later stages of management, respectively. Exclusion of occult and readily apparent perforations of the genital urinary and gastrointestinal tracts is essential when using a multidisciplinary approach. Recognition of open and closed degloving injury patterns and appropriate adherence to treatment guidelines will optimize outcome and avoid catastrophic complication.

Strength of the glenoid labrum and adjacent shoulder capsule

This study evaluates the role of the glenoid labrum and capsule in the prevention of shoulder dislocation. Fifteen shoulder joints from nine fresh cadavers were used. The labrum and capsule were cut into sections 5 mm wide, and the strength of each slice to rupture was measured. The rupture site was observed microscopically. The anterior-inferior portion was the weakest, with a mean force necessary to cause rupture of 3.84 +/- 1.00 kg/5 mm. The rupture site was the portion of the labrum close to the cartilage of the glenoid. Histologic structure and degenerative changes of the labrum did not differ in the anterior to posterior portions. These results show that the anterior-inferior portion of the labrum is relatively weak. This finding may explain the lesion commonly identified in anterior shoulder dislocation.

Use of Orthofix T-Garche fixator in late-onset tibia vara

The treatment of late-onset tibia vara has not been well described. High tibial corticotomies and use of the Orthofix T-Garche fixator were performed on 11 children (14 knees) with late-onset tibia vara. The average age at surgery was 12 years, and follow-up was 2 years. Minimum follow-up was until completion of growth. Angular deformities were measured by using the tibiofemoral angle, metaphyseal-diaphyseal angle, and the mechanical axis both preoperatively and on removal of the fixation device. Union was accomplished in 7-12 weeks, and the total time with the appliance averaged 9 weeks. Complications included superficial pin-tract infections (two) and a transient nerve palsy (one). High tibial corticotomy followed by corrective gradual distraction osteosynthesis by using the Orthofix T-Garche fixator is effective in correcting angular deformity and alleviating knee pain. Advantages of this technique include ease of application, immediate weight bearing, and minimal discomfort with hardware removal. Disadvantages include difficulty in obtaining adequate radiographs with the anteriorly based fixation device, pin-tract infections, and the high degree of patient compliance needed.

Coronal plane geometry of the proximal humerus relevant to prosthetic arthroplasty

Most prosthetic designs for the replacement of the proximal humerus have one head shaft angle and several head sizes allowing limited replication of the anatomy. The necessity for press fit designs to follow the reamed canal adds an additional constraint. To better understand these limitations, this study measures proximal humeral anatomy in relationship to the surgically reamed canal. Measurements were made from radiographs of 21 humeri. Radius of curvature averaged 25.3 mm, head height 18.5 mm, head-shaft angle 40.7 degrees, and offset 9.7 mm. Longer humeri had proportionally larger shafts and larger heads (r = 0.7, p < 0.0005). Proximal humeral anatomy is extremely variable. The relatively fixed geometry of most prosthetic systems limits the surgeon's ability to replicate the original anatomy. As a generalization for existing press fit, modular systems, the surgeon must either position a similarly sized prosthetic articular surface superomedial to that of the original anatomy or use one with less articular surface area.

Dynamic condylar screw for subtrochanteric femur fractures with greater trochanteric extension

Sixteen cases of subtrochanteric femur fractures with greater trochanteric extension were treated using the AO dynamic condylar screw (DCS). All cases were treated using the principles of strict indirect reduction to achieve anatomic alignment rather than anatomic reduction, with no bone grafting, and delayed weight bearing. The overall union rate was 93.7% (15 of 16). One unique case of implant failure with varus nonunion was encountered following repeat trauma. The advantages of the implant and technique are a simplified procedure, shorter operative time, and rapid union. Using the DCS with the indirect reduction method and delayed weight bearing is an acceptable choice in subtrochanteric femur fractures with greater trochanteric involvement when other adequate implants are not available for stable fixation.

Combined injuries--soft tissue management

The combination of severe bone and soft tissue injuries challenges all hand surgeons. Immediate restoration of all damaged structures is the goal whenever possible, integrating soft tissue techniques with principles of internal fixation. Debridement must be radical and resulting defects in bone, vessel, nerve, tendon and skin must be reconstituted with the combination of free and vascularized grafts. Rigid internal fixation is mandatory to allow functional restoration of the hand to begin with a stable platform against which motor tendon units and gliding structures to move. The timing of subsequent reconstruction is based on the prerequisites of adequate vascularity and soft tissue coverage. Understanding the reconstructive ladder and the nuances of techniques regarding skin grafting, local and distant flaps and microsurgical reconstruction is necessary to complete reconstruction in a timely and appropriate fashion. Various soft tissue techniques are described; from simple skin grafting to the use of toe to hand transfers. The decision to amputate versus reconstruct is also important, particularly in today's cost conscious health care environment. Finally, a well thought out and directed rehabilitation program will allow patients to ultimately return to functional status after mutilating injuries of the hand. This article provides a comprehensive review of the combined injury.

Complications of a cable grip system

From a group of 643 total hip arthroplasties, 98 patients required trochanteric osteotomies, and in 68 the trochanteric osteotomies were repaired with the Dall-Miles cable grip system (Howmedica, Rutherford, NJ). Trochanteric nonunion occurred in 17 of these patients (25%), with fraying and fragmentation of the cable present in 15 (88%). Of the 51 patients with radiographic union, 18 (35%) also had signs of fraying and fragmentation. Bone destruction around the cable in the area of the lesser trochanter was seen in seven patients (10%). Large deposits of metal debris at the inferior border of the acetabulum were seen in eight hips (12%). Multifilament cable did not appear to offer significant advantages over standard monofilament wire, and the potential problems of fraying, fragmentation, and free-floating metallic debris must be considered.

The location of the vertebral artery foramen and its relation to posterior lateral mass screw fixation

STUDY DESIGN

This study evaluated the anatomic relationship between the vertebral artery foramen and the posterior midpoint of the cervical lateral mass using cervical spine specimens.

OBJECTIVES

To determine quantitatively the location of the vertebral artery foramens from C3 to C6 and their relationship to the posterior midpoints of the lateral masses.

SUMMARY OF BACKGROUND DATA

Anatomic studies of the cervical nerve root and facet relative to lateral mass screw placement have been addressed. It is necessary to know the correct location of the vertebral artery foramen during lateral mass screw placement to minimize the risk of injury to the vertebral artery.

METHODS

Forty-three cervical spines from C3 to C6 were directly evaluated for this study. Anatomic evaluation included the dimension of the vertebral artery foramen and its projection on the posterior aspect of the lateral mass. The vertical distance from the posterior midpoint of the lateral mass to the posterior border of the vertebral artery foramen, and the angle between the parasagittal plane and the line connecting the posterior midpoint of the lateral mass with the lateral limit of the vertebral artery foramen, were also measured.

RESULTS

The vertical distances from the posterior midpoint of the lateral mass to the vertebral artery foramens at C3-C6 averaged from 9.3 to 12.2 mm for male and female specimens. The average angles medial to the sagittal plane, between the parasagittal plane and the line connecting the posterior midpoint of the lateral mass with the lateral limit of the vertebral artery foramen, from C3 to C5, were found to range from 6.0 degrees to 6.3 degrees for male specimens and from 5.3 degrees to 5.5 degrees for female specimens. At C6, the average angles lateral to the sagittal plane, between the parasagittal plane and the line connecting the posterior midpoint of the lateral mass with the lateral limit of the vertebral artery foramen, were 6.4 degrees for male specimens and 5.4 degrees for female specimens.

CONCLUSIONS

The present study indicated that there is no risk of damaging the vertebral artery if a screw is directed perpendicular to the posterior aspect of the lateral mass at C3-C5 and 10 degrees lateral to the sagittal plane at C6 starting at the midpoint of the lateral mass.

The antero-inferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: an anatomic and clinical study

In order to find a direct approach to the antero-inferior third of the glenoid rim, an anatomic study was performed on a total of 89 shoulders (48 cadavers). To obtain defined reference points for the anterior inferior third of the glenoid cavity, it was compared with the hour markings on a clock face. The 4:30 position on the right shoulder and the 7:30 position on the left shoulder were defined as the relevant reference points. The average distance between the palpable end of the coracoid process and the 4:30 and 7:30 positions was 19 mm. The average distance to the point of intersection of the musculocutaneous nerve with the medial margin of the conjoined tendon was more than 5 cm, and was never less than 2 cm. The average distance of the axillary nerve from the 4:30 position was 2.5 cm in the horizontal plane, with a minimum of 1.5 cm. Radially, the average distance of the axillary nerve was 1.7 cm, with a minimum of 1.3 cm. The anatomic study was followed by a clinical study of 264 patients. An antero-inferior portal located maximum 2 cm distal from the palpable coracoid tip was selected for the introduction of a trocar sheath and blunt trocar, passing through the subscapularis muscle to access the antero-inferior area of the glenoid rim. As additional protection for the musculocutaneous nerve, the direction of the trocar was adjusted during introduction. Reattachment of the labrum-capsule complex was performed extra-articularly. In all cases, at least one implant was located inferior to the 4:30 or 7:30 position. No neurovascular complications arose out of the choice of portal. Out of the 264 patients, the first 100 shoulders (98 patients) were followed-up after an average time of 35 months (18 to 62 months). The recurrence rate was 9%. Excluding the first 30 shoulders (30 patients) from the development phase of the technique, the recurrence rate is only 5.7%. The rate of return to overhead sports activities was 62% and to collision sports activities 70%.

Nontraumatic glenohumeral instability and coracoacromial impingement in swimmers

Competitive swimming is one of the most demanding and time-consuming sports. Swimmers at elite level practice 20-30 h per week. During 1 year's practice, the average top level swimmer performs more than 500,000 stroke revolutions per arm. These innumerable repetitions over many years of hard training together with an increasing muscular imbalance around the shoulder girdle seem to be the main etiological factors in the development of the over-use syndrome swimmer's shoulder. Shoulder pain in swimmers has in general been regarded as synonymous with coracoacromial impingement, i.e. anterior shoulder pain due to rotator cuff tendinitis, but new knowledge suggests that a concomitant glenohumeral instability plays an additional role. The diagnostic complexity of the problem is as challenging as the search for the gold standard of treatment. The condition should ideally be diagnosed as early as possible, and intensive functional rehabilitation of the shoulder girdle including the scapular muscles should be started in order to restore muscle balance. The surgical possibilities include subacromial decompression in cases of purely mechanical impingement. If a painful glenohumeral instability persists after intensive functional rehabilitation, anterior capsulolabral reconstruction can be performed. Still, however, short- and long-term results show that surgery is less successful in elite athletes involved in overhead sports. Prevention protocols include education of coaches in primary injury prophylaxis and the institution of resistance strength training in prepubescent swimmers. Emphasis should be made to improve muscular balance around the glenohumeral and scapulothoracic joints.

Comparative results of a distal modular sleeve, circumferential coating, and stiffness relief using the Anatomic Porous Replacement II

One hundred forty-eight primary Anatomic Porous Replacement II (APR-II, Intermedics Orthopaedics, Austin, TX) noncemented total hip arthroplasties were studied at follow-up periods of 2 to 5 years. Because the stem geometry has not changed since 1988, it was possible to study three adjunctive criteria for porous-coated hip arthroplasties. The APR-II stem geometry was used in three groups: APR-II stem in 56 hips, APR-IIS stem with distal sleeve in 44 hips, and APR-IIT stem with circumferential coating and hollow stem in 48 hips. The APR-IIT was followed 2 years; the APR-II and APR-IIS were followed an average of 3.4 years (range, 2-5 years). For comparison of the results within these three groups 2-year results were compared. The results of the APR-II and APR-IIS at the last follow-up examination are also reported. There was no statistical difference within the three groups for any clinical comparison: 82% had excellent results, 14% good, 2% fair, and 2% poor. At the 2-year follow-up examination, radiographic fixation of the APR-IIS was worse than that of the APR-II and APR-IIT (P < .0005). The APR-IIS uses a distal sleeve, which results in an adverse stiffness ratio between bone and stem. Fixation of the APR-IIT was better than that of the APR-II (P < .0005), probably because the APR-IIT had an increased volume and circumferential level of porous coating and was hollowed for stiffness relief. At final follow-up examination, fixation of the APR-IIS was still worse than that of the APR-II (P < .0005). There was no progressive loss of fixation for either the APR-II or APR-IIS between 2 and 5 years. Only 1 of 148 patients was revised for osteolysis. No other stem or acetabular component is loose. The adjunctive use of a modular sleeve seems to have little advantage, whereas stiffness relief of the stem seems to be beneficial. Circumferential porous coating seems the most important factor for durable fixation.

Surgical treatment of complex fracture of the proximal humerus

Sixteen patients aged 19 to 63 years (average, 52 years) were observed from 1.8 to 5.6 years (average, 3.8 years) after open reduction and internal fixation with or without external fixation of 3- and 4-part displaced fractures of the proximal humerus. There were 12, 3-part displaced greater tuberosity and surgical neck fractures with 6 concomitant dislocations. Four cases were 4-part fractures with 3 concomitant dislocations. Fixation was achieved with heavy sutures or wire that incorporated the rotator cuff tendon, tuberosities, and shaft combined with threaded pins or Hoffmann external fixation to enhanced stability for early rehabilitation. According to Neer's criteria, 14 (87%) of the 16 patients had satisfactory or excellent results. Two (13%) of the 16 had unsatisfactory results. The use of a technique of limited soft tissue dissection and internal fixation with or without external fixation achieved good fracture stability and a high percentage of satisfactory results. The limitations of the procedure include (1) patients who could not tolerate anesthesia, (2) complex displaced fractures in older patients with osteoporotic bone that cannot hold pins or external fixation, (3) older patients with 4-part fracture dislocations in which avascular necrosis of the humeral head occurs frequently and in which a subsequent endoprosthesis insertion is inappropriate if osteosynthesis fails, and (4) head splitting fractures. The described approach provides an alternative method for the treatment of complex displaced fractures of the proximal humerus.

A simple and secure anchoring system for Caspari's transglenoid multiple suture technique using a biodegradable poly-l-lactic acid button

To manage a difficulty in tying sutures over the infraspinatus fascia when using Caspari's transglenoid multiple suture technique, we developed a new anchoring system using a biodegradable poly-L-lactic acid (PLLA) button and investigated its clinical efficacy in 28 patients who were followed-up for more than 2 years postoperatively (mean, 26.5 months). Twenty-four patients had Bankart lesions and 4 had detachment of the superior glenoid labrum. The mean age at operation was 22.1 years. The PLLA button measured 8 x 8 x 1.2 mm and had two holes. After multiple sutures were inserted by the routine Caspari technique (mean, 7.3 sutures), the sutures were divided into 2 bundles, passed through the holes in the button, and tied over it on the posterior scapular neck under traction. The arm was immobilized in a Velpeau bandage for 3 weeks after Bankart repair and for 1 to 2 weeks after superior labral repair. The results of Bankart repair were excellent in 13 patients, good in 7, and poor in 4 according to Rowe's rating scale (success rate, 83%), while the outcome of superior labral repair was excellent in 3 and good in 1 according to our own criteria. All 4 patients who showed a poor outcome were contact athletes who developed resubluxation postoperatively. There were no complications, but transient damages to the suprascapular nerve occurred in 2 patients. In conclusion, the PLLA button provided simple and secure suture fixation for the Caspari technique.

Bone graft in hindfoot arthrodesis: allograft vs autograft

From 1990 to 1992, all arthrodeses of the so-called triple joints, combined or isolated and performed by one surgeon, were reviewed to allow a minimum follow up of 18 months from the time of the index procedure. Type of bone graft was selected based on the patients' decision after the risks of each were explained by the surgeon. There were 37 patients undergoing 41 procedures (4 bilateral) including double and triple arthrodesis, as well as isolated subtalar fusions. Twenty-nine of these were performed for either degenerative or posttraumatic arthritis. Ten others were performed for joint incongruity resulting from posterior tibial tendon insufficiency, and the rest for hemiparesis or residual clubfoot. All patients were placed into a routine postoperative regimen of casting, bracing, weight bearing, and therapy. They were evaluated based on subjective complaints, physical examination, and postoperative radiographs. Any patient suspected of having a nonunion underwent a computed tomography scan for confirmation. Overall, 24 patients received allografts and 17 iliac crest grafts. There were four nonunions, three of which utilized banked bone graft, with the only nonunion in the autograft group occurring in a patient following open calcaneus fracture. Of the four nonunions, three opted for revision surgery and the only one to choose allograft again incurred the only recurrent nonunion. There were two infections, one in each group, resulting in prolonged intravenous antibiotic therapy.

Treatment of a bone defect of the forearm by bone transport. A case report

The technique of bone transport has been used in the lower extremities to treat acute and chronic bone defect. It has not been applied to the upper extremities. An 8.0-cm defect of the ulna was treated with this technique, using a unilateral bone transport system. At completion of the transport, bone graft was brought to the docking site. A 4.0-cm radius defect was treated with free fibula graft and intramedullary nailing. Treatment was completed with removal of the external fixator at 10 months. Complication was limited to transient superficial pin site infection.

The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction

To correlate clinical results after anterior cruciate ligament reconstruction with tunnel placement measured radiographically, we prospectively studied 128 patients who had arthroscopically assisted bone-patellar tendon-bone reconstructions. Patients with bilateral anterior cruciate ligament reconstructions, other significant knee ligament injuries, or those undergoing chondroplasty or meniscal repairs were excluded, leaving 42 patients. The relationship between radiographic tunnel position and clinical results was determined using the Lysholm score, KT-1000 arthrometer testing, the Tegner activity level, and the pivot shift and Lachman tests. Clinical results correlated positively with posterior femoral tunnel placement on lateral radiographs and negatively with excessive anterior tibial tunnel placement. Specifically, when femoral tunnels were placed at least 60% posterior along Blumensaat's line and tibial tunnels were at least 20% posterior along the tibial plateau, 69% of patients had good or excellent Lysholm scores and 79% had KT-1000 arthrometer maximum manual side-to-side differences of 3 mm or less. When the above criteria were not met, 50% of patients had good or excellent Lysholm scores and 22% had KT-1000 arthrometer maximum manual side-to-side differences of 3 mm or less. This close correlation indicates that satisfactory radiographic tunnel position influences outcome after anterior cruciate ligament reconstruction.

Kinematic and Kinetic Comparison between Baseball Pitching and Football Passing

Kinematic and kinetic aspects of baseball pitching and football passing were compared. Twenty-six high school and collegiate pitchers and 26 high school and collegiate quarterbacks were analyzed using three-dimensional high-speed motion analysis. Although maximum shoulder external rotation occurred earlier for quarterbacks, maximum angular velocity of pelvis rotation, upper torso rotation, elbow extension, and shoulder internal rotation occurred earlier and achieved greater magnitude for pitchers. Quarterbacks had shorter strides and stood more erect at ball release. During arm cocking, quarterbacks demonstrated greater elbow flexion and shoulder horizontal adduction. To decelerate the arm, pitchers generated greater compressive force at the elbow and greater compressive force and adduction torque at the shoulder. These results may help explain differences in performance and injury rates between the two sports.

Arthroscopic anterior labral reconstruction using a transglenoid suture technique. Results in active-duty military patients

We report the clinical outcome of arthroscopic labral reconstruction using a transglenoid suture technique in a young, active-duty military population. Forty-eight patients (49 shoulders) with varying degrees of glenohumeral instability underwent arthroscopic labral reconstruction using a transglenoid suture technique. All patients had traumatic injuries to their shoulders and all patients had magnetic resonance imaging scans demonstrating anterior labral tears. Postoperatively, the patients' shoulders were immobilized for up to 6 weeks. At a mean followup of 30 months (range, 12 to 49), 17 of the 41 patients (41%) with preoperative dislocation or subluxation had recurrent instability. Nine of these patients subsequently underwent open reconstruction procedures for recurrent instability. On the basis of the Rowe rating system, 53% had excellent or good results and 47% had fair or poor results. The overall perioperative complication rate was 14%. Suprascapular nerve palsy occurred in three cases (6%). Using the Fisher exact test, we determined that immobilization for 6 weeks postoperatively correlated with a lower recurrence rate in the patients with a history of glenohumeral dislocation (P = 0.007). The results of arthroscopic labral reconstruction using transglenoid sutures in the military patient are inferior to the reported 3% to 5% recurrence rate with open Bankart procedures, and the transglenoid pin technique jeopardizes the suprascapular nerve.

Neurohistology of the subacromial space

Subacromial decompression is one of the most commonly performed shoulder procedures. Debridement of the subacromial soft tissues is a critical part of the procedure. However, the extent of soft tissue debridement is not well defined. The purpose of this study was to identify neural elements within the soft tissues composing the subacromial space. Using special immunohistochemical stains and electron microscopy, neural elements were identified within the subacromial bursa, rotator cuff tendon, biceps tendon and tendon sheath, and transverse humeral ligament. There was a significantly richer supply of free nerve fibers in the bursa compared with the other tissues. The nociceptive information relayed by these fibers may be responsible for the pain associated with impingement syndrome.

Arthroscopic management of recurrent anterior dislocation of the shoulder: analysis of technical modifications on the Caspari procedure

Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations; all of the patients had monoplanar anterior instability attributable to arthroscopically diagnosed Bankart lesion. Of the 71 operations, 29 were performed using the original Caspari technique (follow-up, 59 months), and 42 were performed after modifications made in the original technique (follow-up, 38 months), notably improved preparation of the capsular reinsertion zone and increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. We compared the results obtained in these two differently treated groups, taking into account several factors in the patient's history and clinical condition. These included the number of dislocation episodes before the operation, as well as clinical findings regarding stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, level of preoperative versus postoperative athletic activity, and postoperative recurrence rate. In the Caspari-treated group, we obtained 66% satisfactory results compared with the 90% obtained in the second group. The recurrence rate was 27% in the first group compared with 4.8% in the second group. These data were statistically significant. No correlation was found between preoperative number of dislocations and recurrence rate, nor for contralateral shoulder laxity. No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that, with accuracy in patient selection and effective surgical technique, the recurrence rate can be reduced, and results similar to those of the arthrotomic technique may be obtained.

Revision anterior cruciate ligament surgery: experience from Cincinnati

Prospective studies were done to determine the outcome of allografts and autografts used for revision anterior cruciate ligament reconstruction. The allograft group was comprised of 65 patients observed for a mean of 42 months postoperatively; the autograft (bone-patellar ligament-bone) group contained 20 patients observed for a mean of 27 months postoperatively. KT-2000 testing and a comprehensive knee examination were done on all the patients. The Cincinnati Knee Rating System was used for assessment. Significant improvements were noted in all patients for symptoms, functional limitations, anteroposterior displacements, pivot shift tests, and overall rating scores. KT-2000 results showed 53% of the allograft group and 67% of the autograft group had less than 3 mm increased displacement (not statistically significant). The overall failure rates were 33% for the allografts and 27% for the autografts. Preoperative planning and technical aspects of anterior cruciate ligament revision procedures are described. The authors prefer bone-patellar ligament-bone autografts for anterior cruciate ligament revision, although the data presented were considered preliminary. Bone-patellar ligament-bone allografts may be used when autogenous tissues are not available, because they offer reasonable success rates for patients who are symptomatic with daily activities.

Revision anterior cruciate ligament surgery: experience from Miami

Failed anterior cruciate ligament reconstruction as defined by recurrent patholaxity is increasingly commonplace. This report presents the findings of 54 patients who had unsuccessful intraarticular anterior cruciate ligament reconstruction to correct persistent instability and who subsequently underwent revision anterior cruciate ligament surgery. Before revision, patients were evaluated by clinical examination, KT-1000 arthrometer, radiographs, Lysholm knee score, Tegner activity scale, and subjective questionnaire. The results were compared at a mean of 32 months following revision surgery. There was an average of 16 months from index procedure to the time of revision. Autogenous patellar tendon grafts were used in 61% of the cases with 30% of these harvested from the contralateral knee. Fresh frozen patellar tendon was used in 35% and autogenous hamstring tendons in 4%. Revision was successful in objectively improving stability in all patients with an average KT-000 of 2.8 mm. Autogenous tissue grafts provided greater objective stability when compared with allograft tissue with average KT-1000 of 2.2 and 3.3, respectively. Functionally, however, there was no significant difference in outcome between the 2 groups. Harvesting of the contralateral patellar tendon was found to have no adverse long term effect. Subjectively, the results were significantly worse depending on the degree of articular cartilage degeneration. Only 54% of patients returned to their preanterior cruciate ligament injury activity level. Competence in various anterior cruciate ligament reconstruction techniques will facilitate revision surgery especially in avoiding preexisting tunnels and hardware. Correct graft placement and addressing the secondary restraints are critical to successful revision surgery.

Posterior instrumentation of the unstable cervicothoracic spine

Fractures, tumors, and other causes of instability at the cervicothoracic junction pose diagnostic and treatment challenges. The authors report on 23 patients with instability of the cervicothoracic region, which was treated with posterior plate fixation and fusion between the lower cervical and upper thoracic spine. During operation AO reconstruction plates with 8- or 12-mm hole spacing were affixed to the spine using screws in the cervical lateral masses and the thoracic pedicles. Postoperative immobilization consisted of the patient's wearing a simple external brace for 2 months. The following parameters were analyzed during the pre- and postoperative treatment period: neurological status, spine anatomy and reconstruction, and complications. Follow up consisted of clinical and radiographic examinations (mean duration of follow up, 15.4 months; range, 6-41 months). No neurovascular or pulmonary complications arose from surgery. All patients achieved a solid arthrodesis based on flexion-extension radiographs. There was no significant change in angulation during the postoperative period, but one patient had an increase in translation that was not clinically significant. There were no hardware complications that required reoperation. One patient requested hardware removal in hopes of reducing postoperative pain in the cervicothoracic region. One postoperative wound infection required debridement but not hardware removal. The authors conclude that posterior plate fixation is a satisfactory method of treatment of cervicothoracic instability.

Management of the chronic irreducible patellar dislocation in total knee arthroplasty

Neglected dislocation of the patella with gonarthrosis, genu valgum, flexion, and external rotation deformity is rarely encountered. Experience with five total knee arthroplasties in three patients with chronic patellar dislocation and gonarthrosis is reported. All knees had a modified proximal patellar realignment and arthroplasty with a constrained prosthesis. Preoperative Hospital for Special Surgery knee scores averaged 55. Average follow-up period was 40 months. At latest follow-up examination, the average Hospital for Special Surgery knee score was 83, the Knee Society knee score was 95, and the functional score averaged 50. There was one complication: a full-thickness lateral skin necrosis requiring flap coverage. The patellar score was zero in all knees. Four knees had mild quadriceps weakness. Three knees rated as excellent and two as good on both The Hospital for Special Surgery and Knee Society rating systems. Radiographic analysis revealed no radiolucent lines or osteolysis. The patellas were centralized in the trochlear groove in all patients. Patellar height averaged 14 mm (range, 12-17 mm). In conclusion, satisfactory results were obtained by restoring axial alignment with a constrained implant and realigning the patella with an extensive proximal realignment.

The crescent fracture: a posterior fracture dislocation of the sacroiliac joint

Between October 1987 and August 1992, 22 patients with crescent fractures, a posterior fracture-dislocation of the sacroiliac joint, were admitted, treated, and available for review at Tampa General Hospital and The Hospital for Special Surgery. The purpose of the study was twofold: (a) to evaluate the incidence, severity, and pattern of associated injuries, and (b) to determine the efficacy of a treatment protocol using a posterior extrapelvic approach and extraarticular internal fixation. The study population was composed of 13 females and nine males; the average age was 25 years (range 10-52). Despite the fracture pattern resulting in a rotationally unstable hemipelvis, all patients were hemodynamically stable at the time of presentation. Fourteen patients (64%) had other associated injuries, including five (23%) with closed head injury. In all cases a posterior extrapelvic approach was used with an anatomic reduction of the fractured iliac wing and the sacroiliac joint dislocation. Stable extraarticular internal fixation was obtained using intertable lag screws and outer-table neutralization plates. All the fractures were clinically and radiographically healed within 8-10 weeks postoperatively, and there were no acute wound, neurologic, or vascular complications. One patient developed osteomyelitis of the iliac crest 6 months postoperatively.

Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric and clinical study

In the course of ilioinguinal exposure, significant bleeding can occur from anastomotic vascular channels along the posterior aspect of the superior public ramus. A cadaveric study was undertaken to quantify and qualify these communicating vascular systems. We made bilateral ilioinguinal exposures on 40 cadavers. All vessels > 2 mm in diameter, connecting the obturator system with a more superficial system, were singled out and their courses recorded. Fifty-eight of 79 sides (73%) had at least one large-diameter communicating vascular channel along the posterior aspect of the superior pubic ramus. In 47 of the 79 exposures (59%) communicating veins were noted. Arterial channels were identified in 34 exposures (43%). A prospective clinical study was also performed. Thirty-eight consecutive patients with displaced acetabular fractures were treated surgically using ilioinguinal exposures. Fourteen of the patients (37%) had anastomotic vessels. This study confirms the variability of the retropubic vascular system.

Radiographic appearance and structural properties of proximal femoral bone in total hip arthroplasty patients

The relationship between the morphology of the proximal femur and the physical properties of intertrochanteric trabecular bone was assessed in 26 patients undergoing total hip arthroplasty. Significant correlations were found between ash density and (1) Singh index, (2) "calcar-to-canal isthmus ratio," and (3) a modified "morphologic cortical index." Despite this, these radiographic indices accounted for only 30% of the variability in bone density and are therefore of limited predictive value in this context. Two indices of cortical morphology were at least as effective as the Singh index in predicting cancellous bone density. Surgeons using these indices to quantify the morphology and structure of proximal femoral bone should be aware of their limitations when selecting patients for cementless arthroplasty.

Tibial component in total knee arthroplasty: To cement or not to cement?

Loosening of the tibial component is a major cause of failure in total knee arthroplasty. Implant stability is a key element for achieving long term successful results and relies on the interplay of several factors which include the method of fixation, prosthesis design, surgical technique, bone quality and patient characteristics.The analysis of these aspects may provide some guidelines for the choice of fixation, but an ultimate solution of the problem can not be found in the past experience with total knee replacement. A better understanding of the biological and mechanical changes induced in bone tissue by the joint disease as well as by the prosthesis, will probably allow us to adopt the most appropriate solution for every patient.

Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study

The reasons why many patients seemingly benefit from arthroscopic treatment of osteoarthritis of the knee remain obscure. The purpose of this pilot study was to determine if a placebo effect might play a role in arthroscopic treatment of this condition. After giving full informed consent, including full knowledge of the possibility and nature of a placebo surgery, five subjects were randomized to a placebo arthroscopy group, three subjects were randomized to an arthroscopic lavage group, and two subjects were randomized to a standard arthroscopic debridement group. The physicians performing the postoperative assessment and the patients remained blinded as to treatment. Patients who received the placebo surgery reported decreased frequency, intensity, and duration of knee pain. They also thought that the procedure was worthwhile and would recommend it to family and friends. Thus, there may be a significant placebo effect for arthroscopic treatment of osteoarthritis of the knee. The small numbers in this preliminary study preclude a valid statistical analysis, and no conclusions can be drawn regarding the superiority of one treatment over another. A larger study is needed to evaluate fully the efficacy of an arthroscopic procedure for this condition and to decide if it is reasonable to expend health care resources for this treatment; the larger study should include a placebo control group.

Treatment of Kienböck's disease with scaphotrapezio-trapezoid arthrodesis

The long-term results of 28 cases of Kienböck's disease treated with scaphotrapezio-trapezoid arthrodesis between 1980 and 1990 are presented. The average follow-up period was 51 months. Of these wrists, nine required late lunate excision for pain and limited motion; however, only three patients in the entire series required further wrist salvage procedures (wrist arthrodesis, proximal row carpectomy). At late follow-up examination, range of motion averaged 48 degrees in extension, 52 degrees in flexion, 11 degrees in radial deviation, and 27 degrees in ulnar deviation. Using a subjective pain relief rating scale, patients reported excellent results in 12 cases, good results in 9, fair results in 4, and poor results in 2 (1 case was omitted because of a coexisting different disease).

A differential scanning calorimetry study of retrieved orthopedic implants made of ultrahigh molecular weight polyethylene

Differential scanning calorimetry (DSC) was used to examine thermal and thermooxidative properties of ultrahigh molecular weight polyethylene (UHMW-PE) of five acetabular components of failed orthopedic implants retrieved at revision of total hip arthoplasty. The results were compared with controls (unimplanted acetabular cups, a 20-year-old slab of UHMW-PE, and raw material). Profiles of exothermic peaks indicated increased levels of oxidation in all retrieved cups. In three retrieved cups, DSC revealed an additional peak of endotherm that was not seen in control samples. The additional endotherm peaks were not artifacts due to oxidation during scanning, heat buildup during cutting of the samples, or the sterilization method after retrieval. The additional peak was associated with the bulk of the polymer that was extracted with hexane. It varied in relative area, depending on its original location of the sample in a cup, implicating local variability in the extent of changes in material property. The distribution of the changes suggests that, during implantation, tissue exposure and friction affected the level of oxidation and degree of crystallinity in the UHMW-PE to a greater degree than did loading alone. Overall results showed that DSC may be a useful tool in evaluating changes in the properties of UHMW-PE orthopedic components in vivo.

Developments in Bankart repair for treatment of anterior instability of the shoulder

In the past 10 years, Bankart repair for operative treatment of recurrent luxation of the shoulder has become well established. Recently, the arthroscopic Bankart procedure has been developed. Since 1991, cannulated, bioabsorbable plugs are being used (Suretac; Acufex Microsurgical, Mansfield, Ma., USA). This investigation examines what the advantages of this micro-invasive technique are compared with the open Bankart procedure. From 1986 to 1995, 120 patients underwent Bankart repair of the shoulder in our hospital. Since 1993 we have preferred using arthroscopy, and since 1994 with Suretac. We were able to follow-up 93 patients. The results were assessed using the criteria of stability, range of motion, pain and functional results. The patients were evaluated using the Rowe score. The mean follow-up time was much shorter in the arthroscopic group. Nevertheless, we registered a higher reluxation rate (2 patients, 8%) in comparison with the group that underwent open surgery (3 patients, 4%). As postoperative pain and deterioration of range of motion are less, however, the mean Rowe score shows no significant difference. In conclusion, proper selection of patients has to be performed: arthroscopic Bankart repair is recommended for refixation of a detached anterior labrum. It is disadvantageous when the labrum is degenerated or the capsular tissue is attenuated. That is why, in our opinion, the open Bankart procedure with its capsulorrhaphy cannot be renounced completely.

Direct reduction with indirect fixation of distal tibial physeal fractures: a report of a technique

Displaced intraarticular fractures of the distal tibia in children often require open reduction and internal fixation. Displaced epiphyseal fractures in the sagittal plane may be difficult directly to visualize from a standard medial malleolar incision, so accurate reduction may be impossible. Approaching the ankle joint by anterior arthrotomy, the fracture line can be directly visualized and accurately manipulated and reduced. However, access to the medial malleolus for insertion of internal fixation devices may be difficult from an anterior incision. We have found that after anterior arthrotomy and open reduction, rigid fixation can be placed percutaneously from medially or, in exceptional cases, from laterally under fluoroscopic control. The physis and talocrural joint can be seen and avoided in the growing child. Thirteen cases fixed by this method are reported. At 12.2-month average follow-up, clinical results were excellent. There were no instances of joint degenerative changes but one growth derangement.

Failure of intraoperatively customized non-porous femoral components inserted without cement in total hip arthroplasty

Seventy-four primary total hip arthroplasties were performed in sixty-eight patients between August 1990 and September 1991. Clinical assessments were made with use of the Harris hip score and, specifically, the pain component of that score. The preoperative radiographs were digitally quantified for calculation of the so-called canal-to-calcar ratio and the so-called cortical index. The postoperative radiographs were evaluated for the percentage of the cross-sectional area of the femoral canal that was occupied by the prosthesis; subsidence of the prosthesis; and adaptive osseous changes, including hypertrophic cortical remodeling, osteolysis, formation of sclerotic radiolucent lines around the prosthesis, and formation of a pedestal at the tip of the prosthesis. The indication for the arthroplasty was osteoarthrosis in fifty hips (68 per cent), avascular necrosis in fourteen (19 per cent), congenital dysplasia in six (8 per cent), and another diagnosis in four (5 per cent). The average duration of follow-up was thirty-one months (range, eleven to forty-six months). The average Harris hip score (and standard deviation) was 75 +/- 16.8 points (range, 29 to 100 points), and the average score for the pain component was 37 +/- 7.5 points (range, 0 to 44 points). The average canal-to-calcar ratio of the hips was 0.44 (range, 0.32 to 0.74), and the average cortical index was 0.54 (range, 0.33 to 0.66). The average subsidence of the component was 0.6 centimeter (range, 0.0 to 2.3 centimeters). The average fill of the canal was 100 per cent proximally, 97 per cent at the middle of the stem, and 92 per cent distally as measured on the anteroposterior radiographs made immediately postoperatively and 100, 95, and 90 per cent, respectively, as measured on the lateral radiographs. A failure occurred in twenty-one hips (28 per cent) in twenty-one patients, with an average time to failure of 21 +/- 13 months (range, one to forty-four months). The Kaplan-Meier survival estimate (and standard error) for this population was 0.45 +/- 0.11 (confidence interval, 0.67 to 0.23) at forty-four months. The average subsidence of the components that failed was 0.7 centimeter (range, 0.1 to 2.3 centimeters). There was no significant relationship between failure of the component and the age or sex of the patient, the diagnosis, or the side of the operation. Postoperative severity of pain (p = 0.09) or subsidence (p = 0.08) alone did not reach significance for predicting outcome. The Harris hip score alone (p = 0.05), the Harris hip score in combination with subsidence of the femoral component (p = 0.01), and the pain component of the Harris hip score in combination with subsidence of the femoral component (p = 0.01) were all significant for predicting outcome. No other measured radiographic variable was predictive of failure. Despite optimization of the fit of the component within the femoral canal and the percentage of the cross-sectional area of the femoral canal occupied by the component, the clinical results indicated a high rate of failure. Thus, these criteria are not the only requisites for stabilization of these femoral components without cement. On the basis of these data, we have discontinued the use of these intraoperatively customized, non-porous, smooth femoral prosthesis.