The American Journal of Orthopedics

APRIL 2007 Volume XXXVI No. 4 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

46
Biomechanical Stability of a Volar Locking-Screw Plate Versus Fragment-Specific Fixation in a Distal Radius Fracture Model
Ellis O. Cooper, MD, Keith A. Segalman, MD, Brent G. Parks, MSc, Krishna M. Sharma, MD, and Augustine Nguyen, BSc
Anne Mattson, Curtis National Hand Center, Union Memorial Hospital, 3333 N Calvert St, Mezzanine, Baltimore, MD 21218 (tel, 410-261-8413; fax, 410-554-4363; e-mail, anne.mattson@medstar.net).
Eight matched pairs of cadaveric radii were osteotomized by removing a 4-mm dorsal wedge of bone at the level of the sigmoid notch designed to simulate dorsal comminution. They were then fixed with either a volar locking-screw plate or fragment-specific fixation. All constructs underwent biomechanical testing in a custom-designed, custom-fabricated 4-point bending device. No statistically significant difference in stiffness was noted between the groups. Linear displacement and angulation at the osteotomy site were significantly less in the group with fragment-specific fixation at loads expected to be encountered during postoperative rehabilitation. Angulation at the osteotomy site was significantly less in the locking-screw plate group at higher loads.
Am J Orthop. 2007;36(4):E-46-49.

50
Vitallium^® Cup Arthroplasty: Case Report of a 57-Year Follow-Up
John T. Anderson, MD, and James L. Gluck, MD
John T. Anderson, MD, University of Missouri School of Medicine-Columbia, Department of Orthopaedic Surgery; One Hospital Drive, MC 213, Columbia, MO 54212 (tel, 573-884-2522; e-mail, andersonjo@health.missouri.edu).
Abstract not available. Introduction provided instead.
During the first half of the 20th century, interpositional/mold-cup arthroplasty of the femoral head was a popular form of treatment for afflictions of the hip joint. However, the technique lost favor after the introduction of total hip arthroplasty (THA). Interestingly, the concept of hemiresurfacing of the femoral head has gained momentum recently as a response to the lower success rate of THA for young persons with osteonecrosis. Here we report the case of a 57-year follow-up on a Vitallium<R> cup arthroplasty performed to treat the resultant deformity of Legg-Calvé-Perthes disease. This case represents a unique opportunity to view the results of a procedure that was one of the progenitors of modern hemiresurfacing arthroplasty.
Am J Orthop. 2007;36(4):E50-E52.

53
Ipsilateral Intertrochanteric and Pipkin Fractures: An Unusual Case
Mustafa H. Khan, MD, Vonda J. Wright, MD, and Michael J. Prayson, MD
Mustafa H. Khan, MD, 5471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213 (tel, 412-605-3262; fax, 412-687-3724; e-mail, khanm2@upmc.edu).
Abstract not available. Introduction provided instead.
We report the case of an ipsilateral femoral head fracture and an associated intertrochanteric fracture sustained in a motor vehicle accident. This extremely rare injury pattern presents a unique diagnostic and therapeutic challenge for the treating surgeon. Open reduction and internal fixation of the femoral head fracture and intramedullary nailing of the intertrochanteric femur fracture resulted in a successful clinical outcome.
Am J Orthop. 2007;36(4):E53-E55.

56
Treatment of Radiation-Induced Soft-Tissue Fibrosis and Concomitant Acetabular Osteonecrosis: A Case Report
Robert J. Goitz, MD, Matthew M. Tomaino, MD, Patrick Smith, MD, David Hannallah, MD, MSc, and Raj Sinha, MD
Robert J. Goitz, MD, Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA 15213 (tel, 412-605-3324; fax, 412-687-3724; e-mail, goitzrj@upmc.edu).
Abstract not available. Introduction provided instead.
Radiation-induced changes to bone and to soft tissues have been described independently. In this report, we report the case of combined joint-and-soft-tissue reconstruction of radiation-induced osteonecrosis and concomitant soft-tissue necrosis in a 61-year-old man. A latissimus dorsi muscle flap was used to reconstruct the soft tissues. When an orthopedic surgeon and a microvascular surgeon coordinate their efforts, treatment of a patient with radiation-induced changes to both bone and soft tissues can be successful.
Am J Orthop. 2007;36(4):E56-E58.

59
Carpal Tunnel Syndrome: Using Self-Report Measures of Disease to Predict Treatment Response
Jefferson J. Kaye, MD, and John M. Reynolds, MD
Jefferson J. Kaye, MD, Ochsner Clinic Foundation, 1514 Jefferson Hwy, New Orleans, LA, 70121 (tel, 504-842-3970; fax, 504-842-6784; e-mail, jkaye@ochsner.org).
Initial self-report assessments of symptom severity in patients with carpal tunnel syndrome was retrospectively examined. At initial evaluation, 86 patients completed a self-administered questionnaire previously shown to be reproducible, internally consistent, and responsive to clinical change. Within the next 2 years, 50 patients underwent carpal tunnel release; of the other 36 patients, 23 were managed adequately with conservative treatment alone, and 13 were lost to follow-up. Initial mean symptom severity scores were statistically significantly higher for the surgery group (P = .000012). Significantly higher symptom severity scores on self-administered questionnaires at initial evaluation from patients who eventually undergo carpal tunnel release may be of value in treatment planning.
Am J Orthop. 2007;36(4):E59-E62.

63
Workers’ Compensation, Return to Work, and Patient Satisfaction After Carpal Tunnel Decompression
Ramsey A. Ellis, MD, Christine B. Novak, PT, MS, Susan E. Mackinnon, MD, and Christine J. Cheng, MD
Susan E. Mackinnon, MD, Division of Plastic and Reconstructive Surgery, 660 South Euclid, Campus Box 8238, St. Louis, MO 63110 (tel, 314-362-4586; fax, 314-362-4536; e-mail, mackinnons@wustl.edu).
In the study reported here, we assessed satisfaction and return to work in workers’ compensation (WC) patients after carpal tunnel decompression. Eighty of the 362 patients who underwent surgery met the study criteria; 42 of the 80 were found for follow-up; 40 of the 42 participated in the telephone questionnaire; 15 (38%) of the 40 received WC; and 39 (98%) of the 40 returned to work. Mean age of the 40 respondents was 47 years, and mean follow-up was 29 months. WC involvement was not related to return to work and did not affect satisfaction with overall outcome but was related to dissatisfaction with job factors and timing of return to work.
Am J Orthop. 2007;36(4):E63-E66.

PRINT PUBLISHING

188
Editorial
Price Orthopedic Implants “I’ll Take the Mink…”
Peter D. McCann, MD
Abstract not available.
Am J Orthop.2007; 36(4):188.

193 Factors Associated With Thromboprophylaxis for Orthopedic Patients and Their Impact on Outcome
James E. Muntz, MD, Paul J. O’Connor, RPh, MBA, Hongjun Yin, PhD, and F. Randy Vogenberg, RPh, PhD
F. Randy Vogenberg, RPh, PhD, Aon Consulting, Health & Benefits, 50 Kennedy Plaza, 10th Floor, Providence, RI 02903-2392 (tel, 401-553-6609; e-fax, 847-953-4155).
We conducted a study to identify the factors affecting inpatient thromboprophylaxis use and to assess the impact of pharmacologic prophylaxis on the incidence of postsurgical venous thromboembolism (VTE). Our ultimate goal was to close the gap in knowledge about the need for thromboprophylaxis, including aspirin use. Although prophylaxis was effective in reducing VTE risk in orthopedic patients, it seemed to be underused at some hospitals, and use of aspirin alone in these patients continues despite guidelines recommending otherwise.
Am J Orthop. 2007; 36(4):193-197.

200 The Glenoid Center Point: A Magnetic Resonance Imaging Study of Normal Scapular Anatomy
Nicholas J. Meyer, MD, William T. Pennington, MD, and Dean W. Ziegler, MD
Nicholas J. Meyer, MD, St. Croix Orthopaedics, 1991 Northwestern Ave, Stillwater, MN 55082 (tel, 651-439-8807; fax, 651-439-0232; e-mail, nmeyer@stcroixortho.com).
Using 10 normal cadaveric glenoids, Matsen and colleagues described the anatomic concept and clinical use of the glenoid centering point during shoulder arthroplasty. In the study reported here, we used magnetic resonance imaging scans of 50 patients with nonarthritic conditions of the glenohumeral joint to evaluate the relationship between the glenoid center line and the scapular neck. Results from this larger group of patients confirmed that a reproducible anatomic relationship of the glenoid centering line and the centering point on the anterior glenoid neck exists and can be used to restore normal anatomy in cases of posterior glenoid wear. An understanding of this anatomic relationship vis-à-vis shoulder arthroplasty may aid in recreating a normal glenoid version.
Am J Orthop.2007; 36(4):200-202.

204 Accuracy of Injection Into the Basal Joint of the Thumb
Mark A. Pollard, MD, Mary Beth Cermak, MD, Walter R. Buck, PhD, and D. Patrick Williams, MD
Mark A. Pollard, MD, 3 Cooper Plaza, Suite 411, Camden, NJ 08103 (tel, 856-968-7486; fax, 856-968-8313; email; pollard-mark@cooperhleath.edu).
To investigate the accuracy of intra-articular injection of the basal joint and to determine the rate of soft-tissue extravasation of injected material in successful intra-articular injection, we injected the basal joint of 30 hands with radiopaque dye (with fluoroscopy guiding needle placement in 8 cases) and then used fluoroscopy to check injection accuracy. Results were recorded depending on the location of the injected dye on fluoroscopic examination. Rates of intra-articular accuracy and soft-tissue extravasation for successful intra-articular injections were 100% and 25% for the fluoroscopyguided group and 81.8% and 25% for the “blind” group. This study’s accuracy rate for intra-articular injection of the basal joint is comparable to the rates reported for injection of larger joints. There is a relatively high soft-tissue extravasation rate for successful intra-articular injection.
Am J Orthop. 2007; 36(4):204-206.

207 Osseous Healing With a Composite of Allograft and Demineralized Bone Matrix: Adverse Effects of Smoking
Bruce H. Ziran, MD, Pooneh Hendi, MD, Wade R. Smith, MD, Kenneth Westerheide, MD, and Juan F. Agudelo, MD
Bruce H. Ziran, MD, St. Elizabeth’s Health System, 1044 Belmont Ave, Youngstown, OH 44501 (tel, 330-480-3027; fax, 330-480-3522; e-mail, bruce_ziran@hmis.org).
We report on our use of a composite graft of lyophilized cancellous allogenic chips and demineralized bone matrix (DBM; Grafton^®; Osteotech, Eatontown, NJ) to manage traumatic osseous defects and nonunions. Data were prospectively collected from all patients who received this composite bone graft between 1996 and 2000. Only acute fractures with bone loss resulting in a uncontained defect and atrophic non-unions were included in the present study. Demographic data and complications related to composite use, tobacco use, and other comorbidities that could affect healing were evaluated. One hundred seven patients (112 bone graft sites) were followed up for a mean of 32 months (range, 12–60 months). Graft sites included the forearm, femur and tibia. Of the 112 patients, there were 56 smokers (25 non-unions and 31 fractures) and 56 non-smokers (28 fractures and 28 non-unions). Healing occurred in 38/56 smokers compared with 49/56 non-smokers. In failed cases, smoking was characteristic in 7/9 non-unions and 11/16 fractures. There were 26 acute uncontained injuries, 29 acute contained defects, and 67 nonunions. Grafting sites were radius/ulna (13 cases), humerus (17), femur (31), and tibia/fibula (51). Significant comorbidities were diabetes mellitus (4 cases), fungal osteomyelitis (1), and pulmonary alveolar proteinosis (1). Eight (73%) of the 11 patients with graft failure had a significant smoking history. This composite graft is an option for managing osseous defects and nonunions traditionally treated with autologous bone grafting but should be used with caution when treating patients who are smokers.
Am J Orthop. 2007; 36(4):207-209.

213 High-Pressure Water Injection Causing an Isolated Tendon Laceration: A Case Report
John C. Austin, MD, and Fred M. Hankin, MD
High-pressure injection of water frequently elicits a minimal inflammatory response. However, the mechanical force of the stream can cause significant soft-tissue injuries, including tendon lacerations.
Am J Orthop. 2007; 36(4):213-214

215 Effect of Delayed Treatment on Open Tibial Shaft Fractures
Bryan L. Reuss, MD, and J. Dean Cole, MD
Bryan L. Reuss, MD, 100 West Gore Street, Suite 500, Orlando, FL 32806 (tel, 407-254-2500; fax, 407-423-9512; e-mail, breuss@mac.com).
Open tibial shaft fractures were analyzed retrospectively to determine the effect of treatment timing on infection and nonunion rates. The cases of 77 patients with 81 open tibial shaft fractures were reviewed. Patients were treated with initial wound cleansing and splinting in the emergency department and then formally with operative irrigation and débridement and stabilization, which included intramedullary (IM) nailing, external fixation, open reduction and internal fixation, or splinting. All tibial shaft components ultimately were treated with IM nailing. Mean time to operative treatment was 12.97 hours (SD, 10.8 hours). There were 7 infections (8.6%) and 3 nonunions (3.7%). Time was found not to be a significant factor in predicting either infection or nonunion. Increased severity of fracture was a significant factor in predicting infection rate. The infection rate for fractures treated first with external fixation and then with IM nailing was significantly higher than that for fractures treated with IM nailing alone. In addition, a relation was found between patients who received multiple débridements and development of infection. These results show that infection and nonunion rates were not adversely affected by longer time to operative treatment (up to 48 hours) when adequate trauma department open fracture care and early initiation of antibiotics were coupled with standardized and thorough débridement in the operative theater.
Am J Orthop. 2007; 36(4):215-220.

221 Kirschner-Wire Fixation of Small Bones
Vincent D. Waldron, MD, FACS, Brian Tsholl, MD, Brian Blake, MD, Jason Levine, MD, Martin Skie, MD, and Nabil Ebraheim, MD
Vincent D. Waldron, MD, VA Medical Center, Huntington, West Virginia 25401 (tel, 304-263-0811; fax, 304-262-1397; e-mail, vincent.waldron@med.va.gov).
A simple technique for Kirschner wire placement in small bones is to place the wire over the to-be-pinned bones, push the wire out through the skin, and run the wire back across the bones.
Am J Orthop. 2007; 36(4):221.

SUPPLEMENT

3
Best of Times
Robert F. Ostrum, MD
Robert F. Ostrum, MD, Cooper University Hospital, Camden, New Jersey.
Abstract not available.
Am J Orthop. 2007;36(4S)3

4
Intramedullary Nailing of Proximal Femur Fractures
Kenneth J. Koval, MDD
Kenneth J. Koval, MD, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Despite the general success of the sliding hip screw for stabilization of intertrochanteric fractures, there is dissatisfaction with the resultant deformity associated with its use, particularly in unstable fracture patterns. These concerns have resulted in increasing use of intramedullary devices for treatment of peritrochanteric fractures. Use of an intramedullary device for peritrochanteric fracture stabilization limits the amount of lag screw sliding and resultant limb deformity, particularly shortening, since the fracture can settle only until the proximal fragment abuts against the nail. This article describes some of the advances in intramedullary nails used to stabilize peritrochanteric fractures.
Am J Orthop. 2007;36(4S)4-7

8
Osteobiologics
Bharat M. Desai, MD
Bharat M. Desai, MD, St Anthony’s Central Hospital, Panorama Orthopedic Clinic and Spine Center, Denver, Colorado.
Osteobiologic adjuvants that aid in bone grafting have recently been popularized. Current osteobiologic technologies can be organized into 3 main categories: osteoconductive, osteogenic, and osteoinductive. Appropriate use of osteobiologic agents mimics autograft. Compared with autograft , synthetic adjuvants minimize donor morbidity. Understanding how synthetic agents can enhance bone formation and their appropriate use can aid the orthopedic surgeon in delivering optimal care in these difficult cases. The understanding of how synthetic grafts can enhance the normal bone healing cascade defines their role and use in treating fracture gaps.
Am J Orthop. 2007;36(4S):8-11

12
Staged Management of Tibial Plateau Fractures
Douglas R. Dirschl, MD, and Daniel Del Gaizo, MD
Douglas R. Dirschl, MD, Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina.
Careful and thorough assessment of injury severity, with particular attention paid to identifying high-energy injuries, is critical to achieving optimal outcomes and avoiding complications following tibial plateau fractures. Staged management of tibial plateau fractures refers to the use of temporizing methods of care (often spanning external fixation) in high-energy injuries, as well as delaying definitive fracture surgery until such a time as the risk of soft tissue complications is decreased. This article discusses the principles and techniques of staged management, including the use of less invasive methods for definitive stabilization.
Am J Orthop. 2007;36(4S)12-17