November 2007  Volume XXXVI No. 11 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

E-FOCUS ON THE PREGNANT PATIENT

153	Management of Pelvic Fractures During Pregnancy Gil Almog, MD, Meir Liebergall, MD, Avi Tsafrir, MD, Yair Barzilay, MD, and Rami Mosheiff, MD Rami Mosheiff, MD, Department of Orthopedic Surgery, Hadassah Medical Center, PO Box 12000, Jerusalem il-91120 (tel, +972-2-6778611; fax, +972-2- 6423074; e-mail, ramim@cc.huji.ac.il). Pelvic or acetabular fractures during pregnancy are rare, and information on managing such complex incidents has been limited. Over several years, we have gained significant experience in handling such cases. Of the 1345 pelvic and acetabular fractures treated at our level I trauma center between 1987 and 2002, 15 (1.1%) occurred in pregnant women. Eleven women received conservative treatment, and 4 were treated surgically. Of the 16 fetuses, 12 survived, and 4 pregnant women had nonviable pregnancies. One of the 15 pregnant women died. We describe our cases and propose treatment guidelines. The dilemma presented in a multitrauma situation at various stages of pregnancy necessitates making management modifications involving timing of surgery and delivery, use of radiation for imaging, and choice of appropriate surgical procedure. Am J Orthop . 2007;36(11):E153-E159.
160	Orthopedic Trauma in Pregnancy Pratik Desai, MD, and Michael Suk, MD, JD, MPH Pratik Desai, MD, Department of Orthopaedics and Rehabilitation, 655 W 8th St, ACC Building, 2nd Floor, University of Florida Health Science Center, Jacksonville, FL 32209 (tel, 904-244-7757; fax, 904-244-3457; e-mail, pratik.desai@jax.ufl.edu). Trauma sustained during pregnancy can trigger uncertainty and anxiety for patient and orthopedic surgeon alike. In particular, orthopedic-related injuries raise concerns about preoperative, intraoperative, and postoperative care. In this article, we review common concerns about radiation exposure, leukemia, pain management, anticoagulation, and anesthesia. One finding is that radiation risk is minimal when obtaining x-rays for operative planning, provided that the cumulative dose is within 5 rad. We also address safety concerns about patient positioning and staff radiation exposure. In addition, we found that most anesthetics used in pregnancy are category C (ie, safe). Perioperative opioid use for pain management is recommended with little risk. Regarding anticoagulation, low-molecular-weight heparin and fondaparinux are the safest choices. Last, pregnancy is not a contraindication to operative management of pelvic and acetabular fractures. Am J Orthop. 2007;36(11):E160-E166.
167	Traumatic Disruption of Pubis Symphysis With Accompanying Posterior Pelvic Injury After Natural Childbirth Christian Hierholzer, MD, Arif Ali, MD, Jose B. Toro-Arbelaez, MD, Michael Suk, MD, JD, MPH, and David L. Helfet, MD David L. Helfet, MD, Department of Orthopaedic Surgery, Weill Medical College of Cornell University/Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 (tel, 212-606-1888; fax, 212-628-4473; e-mail, helfetd@hss.edu). Abstract not available. Introduction provided instead. Parturition-induced pelvic instability is a rare pathogenetic entity. Reports of the incidence of symphyseal rupture after vaginal delivery have varied from 1 in 300 to 1 in 30,000 deliveries.1-6 The extent of symphyseal changes during pregnancy and delivery may vary significantly. Peripartum ligamentous relaxation with moderate widening of symphysis pubis and sacroiliac (SI) joints is physiologic and occurs regularly.7,8 Anterior separation of the pubic symphysis of more than 2.5 cm progressively causes injury to the posterior pelvic ring, including disruption of the SI joint or sacral fractures.9 When symphyseal rupture does occur, it typically happens during delivery or shortly after labor and is characterized by a sharp and immediate onset of severe pain over the pubic symphysis and may extend posteriorly into the SI joint region accompanied by an audible crack. Treatment of a ruptured pubic symphysis is predominately nonoperative and consists of pelvic binder application, immobilization and bed rest, analgesia, and physical therapy.10 Operative treatment has been described in selected cases, particularly when nonoperative treatment is unsuccessful.1,11,12 Symphyseal rupture that may indicate posterior pelvic arch instability requires reduction and stable fixation. These injuries result in an unstable pelvic disruption and may correspond to traumatic anteroposterior compression (APC) II or III or Tile type B or C pelvic injuries.9,13 These women should be managed as one would a trauma patient with a pelvic fracture—including vigilant monitoring of hemodynamic status and aggressive resuscitation, appropriate diagnostic imaging studies, and timely operative reduction and fixation of the pelvis. In this report, we present the case of a woman in her early 30s suffering from traumatic symphysis diastasis with accompanying disruption of left and right SI joints after natural childbirth. The patient, who was successfully treated with open reduction and internal fixation (ORIF) of the symphysis and percutaneous screw fixation of the SI joints, recovered from this disabling injury. Am J Orthop. 2007;36(11):E167-E170.

580	A Conversation with AAOS President James H. Beaty, MD Peter D. McCann, MD Peter D. McCann, MD, is Chair, Department of Orthopaedic Surgery at Beth Israel Medical Center, New York, New York. Abstract not available. Am J Orthop. 2007;36(11):580-581.
582	Computerized Fluoroscopic-Based Navigation-Assisted Intramedullary Nailing Amal Khoury, MD, Meir Liebergall, MD, Yoram Weil, MD, and Rami Mosheiff, MD Rami Mosheiff, MD, Department of Orthopedic Surgery, Hadassah Medical Center, PO Box 12000, Jerusalem il-91120 (tel, +972-2-6778611; fax, +972-2- 6423074; e-mail, ramim@cc.huji.ac.il). Intramedullary nailing, a fixation method commonly used for most diaphyseal fractures, relies heavily on fluoroscopy and delivers a significant amount of radiation to both patient and surgical team. Fluoroscopy-based computerized navigation enables accuracy in implant placement and minimizes soft-tissue dissection while reducing radiation. Navigation facilitates intramedullary nailing in determining entry-point location, insertion of locking and blocking screws, and nail and screw length measurement. We refer to our preliminary experience with 150+ cases to describe the technique of navigation-based intramedullary nailing and its various applications. Am J Orthop. 2007;36(11):582-585.
586	Infantile Idiopathic Scoliosis Todd L. Lincoln, MD Todd L. Lincoln, MD, Department of Orthopaedic Surgery, Kaiser Permanente, 280 West MacArthur Blvd, Oakland, CA 94611 (phone, 510-752-6446; fax, 510-752-6674; e-mail, t3lincoln@yahoo.com). This review of infantile idiopathic scoliosis highlights the clinical features, etiology, epidemiology, and treatment considerations that clearly distinguish this entity from the more common diagnosis of juvenile and adolescent idiopathic scoliosis. A comprehensive understanding of infantile idiopathic scoliosis provides the basis for reliable prediction of those curves that are likely to spontaneously resolve and those that will relentlessly progress if left untreated. Am J Orthop. 2007;36(11):586-590.
591	Use of Fluoroscopically Guided Intra-articular Hip Injection in Differentiating the Pain Source in Concomitant Hip and Lumbar Spine Arthritis Dhruv B. Pateder, MD, and Marc W. Hungerford, MD Dhruv B. Pateder, MD, Steadman Hawkins Spine Surgery, P.O. Box 4815, 360 Peak One Drive, Suite 340, Frisco, CO 80443 (tel, 970-668-6760; fax, 970-668- 6761; e-mail, drpateder@steadman-hawkins.com). We retrospectively tested the effectiveness of fluoroscopically guided intra- articular hip injection in differentiating the pain generator in patients with atypical lower extremity pain and concomitant radiographic hip and spine arthritis. After the hip injection, 74 of 83 patients had pain relief (pain score improvement, 7.2 to 2.7) and functional improvement (Harris hip score [HHS] improvement, 54.3 to 80.4). Of those 74 patients, 50 (mean preoperative HHS, 60.3) went on to hip arthroplasty (for 48 of these 50, mean HHS increased to 84.4); the other 24 patients are being treated nonoperatively so far. The 11 patients who did not experience pain relief (9 after initial injection plus 2 after total hip arthroplasty) were found to have spinal pathology and were treated accordingly. Statistics: sensitivity, 100%; specificity, 81%; positive predictive value, 97%; negative predictive value, 100%. Am J Orthop. 2007;36(11):591-593.
596	Minimal-Incision Total Shoulder Arthroplasty: A Cadaveric Study Jason A. Schneider, MD, J. David Hill, MD, Frances Cuomo, MD, and Peter D. McCann, MD Peter D. McCann, MD, Department of Orthopaedic Surgery, Beth Israel Medical Center, 10 Union Sq E, Suite 3K, New York, NY 10003 (tel, 212-844-6735; fax, 212-535-2703; e-mail, PMcCann@BethIsraelNY.org). Traditional exposure for total shoulder arthroplasty (TSA) is a deltopectoral incision of approximately 17 cm. Recent literature suggests that minimally invasive surgery for knee and hip arthroplasties may be successful in reducing perioperative morbidity and improving patient satisfaction. In the study reported here, we evaluated a minimal-incision approach to TSA. Using 10 fresh-frozen cadaveric shoulders, we performed TSAs through a 6-cm incision originating at the center of the coracoid process and extending distally along the deltopectoral interval. Soft-tissue releases, humeral osteotomy, and glenoid resurfacing were performed in all 10 cadaver shoulders using standard TSA retractors and guides. No skin or soft-tissue complications were observed. We conclude that it is technically possible to perform TSA through an appropriately placed minimal (6-cm) incision. Am J Orthop. 2007;36(11):596-599.
600	Impact of Erythropoietin on Allogenic Blood Exposure in Orthopedic Surgery Jennifer E. Santoro, PharmD, Robert K. Eastlack, MD, James M. Mirocha, PhD, and William D. Bugbee, MD William D. Bugbee, MD, Division of Orthopaedic Surgery, Scripps Clinic, 10666 N Torrey Pines Rd, MS116, La Jolla, CA 92037 (e-mail, Bugbee.William@scrippshealth.org). Joint reconstruction surgery is associated with significant blood loss, and patients often require perioperative transfusions. Recombinant human erythropoietin (epoetin) can be used in anemic patients scheduled for elective, noncardiac, nonvascular surgery to reduce the need for transfusions. In the study reported here, patients with a preoperative hemoglobin level of 10 to 13 g/dL were treated with epoetin. Our analysis showed that transfusions were given to 3 (8%) of the 38 patients who received epoetin before surgery and 20 (57%) of the 35 historical controls (P<.001) and that length of hospital stay did not differ significantly between the 2 groups. Our results provide further support for use of epoetin as an effective strategy for reducing exposure to allogenic blood in orthopedic surgery. Am J Orthop. 2007;36(11):600-604.
605	Acute Calcific Tendinitis of the Hand: 2 Case Reports Involving the Abductor Pollicis Brevis John S. Shields, MD, A. Bobby Chhabra, MD, and Michael E. Pannunzio, MD Michael E. Pannunzio, MD, Reconstructive Hand Surgeons of Indiana, 13421 Old Meridian Street, Suite 200, Carmel, IN 46032 (tel, 317-249-2616; fax, 317-249- 2618; e-mail, mpannunzio@indianahandsurgeons.com). Abstract not available. Am J Orthop. 2007;36(11):605-607.
611	Bilateral Luxatio Erecta Humeri and Bilateral Knee Dislocations in the Same Patient Abdul Foad, MD, and Robert F. LaPrade, MD, PhD Robert F. LaPrade, MD, PhD, Sports Medicine and Shoulder Divisions, Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Ave, R200, Minneapolis, MN 55454 (tel, 612-273-8000; fax, 612-263- 7959; e-mail, lapra001@umn.edu). Bilateral knee dislocations seldom occur, and fewer than a dozen cases of bilateral luxatio erecta humeri (erect dislocation of the shoulder) have been reported. Here we present the case of a patient who sustained bilateral knee dislocations and bilateral luxatio erecta humeri in a motorcycle accident. Transient neurologic compromise resolved with closed reduction of the bilateral shoulder and left knee dislocations. To our knowledge, this is the first case report of a patient with this combination of injuries. Am J Orthop. 2007;36(11):611-613.
614	Tissue-Engineered Meniscal Constructs Andrew J. Schoenfeld, MD, William J. Landis, PhD, and David B. Kay, MD Andrew J. Schoenfeld, MD, Department of Orthopaedic Surgery, Akron General Medical Center, 510 Crossings Cir, Tallmadge, OH 44278 (tel, 330-945-9734; fax, 330-996-2973; e-mail, ajschoen@neoucom.edu). The medial and lateral menisci play important roles in knee biomechanics, kinematics, and stability. Unfortunately, these structures are prone to damage and, because of a tenuous blood supply, have great difficulty healing. Many interventions have been proposed for treatment of damaged meniscal tissue, but most surgical options are fraught with difficulties, from continued osteoarthritic degeneration to potential for disease transmission. The field of tissue engineering has made wide inroads into constructing meniscal tissue. Investigations involving collagenous tissue, meniscal fibrochondrocytes, chondrocytes, synthetic scaffolds, and gene therapy have all been reported in the literature. Despite these advances, however, more work needs to be done, including incorporating concepts and applications from other engineering disciplines, to potentiate the possibility of a tissue-engineered meniscus that approximates native tissue. In particular, the histologic, morphologic, and biomechanical properties of tissue-engineered meniscal constructs must be better understood to facilitate this goal. Am J Orthop. 2007;36(11):614-620.
622	Connecting Multiple Open Wounds to a Single Negative-Pressure Dressing Richard White, MD, Allison Wade, MD, Jason Calhoun, MD, and Ann Gietler, MD Richard White, MD, Department of Orthopaedic Surgery, University of Missouri­ Columbia, 213 McHaney Hall, One Hospital Drive, Columbia, MO 65212 (tel, 573-882-3106; fax, 573-882-1760; e-mail, whitera@health.missouri.edu). We present a new technique for connecting open wounds to a negative-pressure device. In this technique, a flexible, small-diameter intravenous tube is used to bridge the gap between open wounds on the same extremity. After these connections are made, the first layer of plastic is placed, and only 1 fenestrated connection is made to the device. This technique allows use of multiple sponges with only 1 fenestrated cap and 1 connection to the device. The smaller intravenous tube must not be placed directly on skin, as it may cause a pressure ulcer underneath. Am J Orthop. 2007;36(11):622-623.

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