MARCH 2008 VOLUME XXXVII NUMBER 3 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

46	Guest Editorial—Orthopedic Surgeon in the ER: The Importance of Remembering the Basics Howard S. An, MD Howard S. An, MD, this journal’s Associate Editor for Spine, is the Morton International Endowed Chair, Professor of Orthopaedic Surgery, and Director, Division of Spine Surgery and Spine Fellowship Program, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Abstract not available. Am J Orthop. 2008;37(3):E46.
47	Gunshot Wounds to the Spine: Literature Review and Report on a Migratory Intrathecal Bullet Edward Moon, MD, Dimitriy Kondrashov, MD, Matthew Hannibal, MD, Ken Hsu, MD, and Jim Zucherman, MD Edward Moon, MD, is Orthopaedic Surgery Resident, University of Washington, Seattle, Washington. Treatment of the complex injury to the spine produced by a gunshot wound remains controversial. Treatment depends on the physician’s ability to understand mechanism of injury, principles of medical management, diagnostic imaging, and surgical options. Antibiotics are an important component of treatment and should be continued for a minimum of 7 days in cases of wounds that both perforate the colon and injure the spine. Corticosteroids do not affect neurologic outcome and therefore should not be used. Decompression and removal of intracanal bullets at T12 and below may improve motor function. In select cases of cervical injuries, removal of intracanal bullet fragments may be justified, particularly with incomplete lesions. Regardless of injury level, new-onset or progressive neurologic deterioration is an indication for urgent decompression. Optimal surgical timing remains a controversial issue, and more study is needed to develop treatment guidelines. Intrathecal migratory missiles represent a very rare subset of the gunshot wounds to the spine, and their treatment should be individualized. In this article, we review the literature and then describe the case of a migratory intrathecal bullet in the lumbar spine of a patient who presented with cauda equina–type symptoms. Am J Orthop. 2008;37(3):E47-E51.
52	Intraosseous Stab Wound to the Arm Joseph A. Abboud, MD, Brent Wiesel, MD, Daniel Tomlinson, MD, and Matthew Ramsey, MD Joseph A. Abboud, MD, is Clinical Assistant Professor of Orthopaedic Surgery, University of Pennsylvania Health System, Pennsylvania Hospital, Philadelphia, Pennsylvania. Abstract not available. Introduction provided instead. Although stab wounds are common in metropolitan settings, involvement or injury to the bone is seldom reported.1-4 We report on a patient who presented with a knife retained in the humerus after a stab wound to the arm. To our knowledge, this is the first documented case of a patient who presented for treatment after receiving an intraosseous stab wound to the upper extremity with the foreign body still lodged in the bone. Our patient was informed that data concerning this case would be submitted for publication. Am J Orthop. 2008;37(3):E52-E54.
55	Small-Caliber Gunshot Wound With Fragment Lodged in Thoracic Foramen in a Patient With Partial Brown-Sequard Syndrome Douglas G. Orndorff, MD, and Francis H. Shen, MD Douglas G. Orndorff, MD, is Chief Resident, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia. Abstract not available. Introduction provided instead. Unfortunately, our society is marked by continued violence, including a high rate of gunshot injuries. Gunshot wounds to the spine account for 13% to 17% of all gunshot wounds.1 Gunshot injuries to the spine occur mostly in the thoracic spine but inflict the most devastation and functional impairment when they involve the cervical spine.2,3 Spinal cord gunshot wounds most often occur in minorities between ages 15 and 34. Spinal cord damage after gunshot wounds is more likely than blunt trauma to result in complete injury.3-5 Am J Orthop. 2008;37(3):E55-E58.

129	Sacrifice and the Afghan/Iraq Conflict 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. 2008;37(3):129.
130	Treatment of Open Periarticular Shoulder Fractures Sustained in Combat-Related Injuries Andrew W. Mack, MD, Adam T. Groth, MD, H. Michael Frisch, MD, and William C. Doukas, MD CPT Andrew W. Mack, MD, MC, USA, is Resident, Orthopaedic Surgery Service, National Naval Medical Center, Walter Reed Army Medical Center, Washington, DC. Open periarticular shoulder fractures present a tremendous challenge for orthopedic surgeons. These injuries, albeit rare, are typically caused by high-energy mechanisms and are associated with insult to multiple organ systems resulting in high morbidity and mortality. Although the civilian trauma literature includes several articles on outcomes of closed periarticular shoulder fractures, only 1 peer-reviewed article has focused on this specific open injury pattern. No standard management technique has been adopted for these injuries, and treatment patterns have anecdotally evolved from war to war. In this article, we review evacuation of patients, management of combat-related open periarticular shoulder injuries, and the pertinent literature; we supplement this review with a description of the recent experience of Drs. HMF and WCD. All cases of combat-related open fractures treated at our institution between March 2003 and January 2007 were reviewed. We identified 44 patients with open periarticular shoulder fractures (33 IIIA, 1 IIIB, 10 IIIC). Inpatient and outpatient medical records, x-rays, laboratory culture data, and photographic documentation records were reviewed. Mean follow-up was 34 months (range, 12-49 months). Rates of associated neurologic and vascular injury were 41% (18/44 patients), and 23% (10/44 patients), respectively. Other associated significant injuries occurred in 38/44 patients (86%). Internal fixation was used as definitive treatment in 26/44 patients (59%). Radiographic union occurred by a mean of 4.5 months (range, 3-9 months) after surgery. Postoperative deep infection/osteomyelitis occurred in 5/35 patients (14%) with more than 1-year follow-up data available. The overall amputation rate was 9%. Open combat-related periarticular shoulder fractures are complicated injuries, often associated with several traumatic comorbidities that together present difficult challenges to treatment. Meticulous surgical débridement is essential in managing these severely comminuted and contaminated open fractures. In cases in which internal fixation is used, careful timing and patient selection are required to minimize risk for osteomyelitis. Data collection is being continued in this patient cohort to allow for eventual reporting of functional outcomes. Am J Orthop. 2008;37(3):130-135.
136	Orthopedic Manifestations and Management of Psoriatic Arthritis Eric J. Strauss, MD, Daniel Alfonso, MD, Gurpinder Baidwan, MD, and Paul E. Di Cesare, MD Eric J. Strauss, MD, is an Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York. Psoriatic arthritis is a complex, chronic inflammatory disease with both skin and joint involvement. Clinical presentation varies considerably among patients and during the course of the disease. Assessment of patients for psoriatic arthritis requires careful attention to patient history, a focused physical examination, and inspection for characteristic radiographic changes. Although this disease was once thought to be a rare and mild form of arthritis, recent studies have shown that patients with psoriatic arthritis may develop significant disability, with up to 20% of cases demonstrating a rapidly progressive, debilitating clinical course. Orthopedic manifestations of the disease can be severe and can cause significant physical disability. Although surgical intervention for psoriatic arthritis is relatively uncommon, having an understanding of the assessment, available treatment options, and surgical considerations allows for improved outcome in the management of this complex patient population. Am J Orthop. 2008;37(3):138-147.
148	Obesity and Osteoarthritis Peter W. Lementowski, MD, and Stephen B. Zelicof, MD, PhD Peter W. Lementowski, MD, is Full-time Academic Faculty, Department of Orthopaedics, Long Island Jewish Hospital, New Hyde Park, New York. Osteoarthritis (OA) has become one of the leading causes of disability in the United States. Mechanical forces exerted on the joints are a significant cause of OA and one of the most modifiable risk factors. As determined by body mass index (BMI), 34 million US adults are obese, and 13 million of these are morbidly obese. Female sex, lower educational levels, obesity, and poor muscular strength are associated with symptomatic disease and subsequent disability. Recently, genetics has been shown to be a significant factor in the disease process. March and Bagga (Med J Aust. 2004; 180 (5 suppl): S6-S10) showed that the risk for knee OA increased by 36% for every 2 units of BMI (5 kg) of weight gain. Bariatric surgery results in a mean weight loss of 44 kg (97 lb). Eighty-nine percent of patients had complete relief of pain caused by OA in at least one joint after undergoing bariatric surgery. Am J Orthop. 2008;37(3):148-151.
153	Sequelae of Pediatric Hip Disorders: Survey Responses From Experts in Adult Hip Reconstruction Gregory A. Lundeen, MD, John L. Masonis, MD, and Steven L. Frick, MD Gregory A. Lundeen, MD, is Orthopedic Resident, Department of Orthopedics, Carolinas Medical Center, Charlotte, North Carolina. Questions persist concerning the incidence of total hip arthroplasties (THAs) attributable to secondary osteoarthrosis and the impact of corrective pediatric hip surgeries and retained internal fixation on subsequent THAs. Hip reconstruction fellowship directors (N = 72) were mailed a survey of multiple-choice questions about pediatric hip disorders (PHDs) in their THA populations, the influence of hip osteotomies on subsequent THAs, and the recommendation to routinely remove pediatric hip internal fixation. Forty-five surgeons (62.5%) responded. The majority reported that a small proportion of hip arthrosis in their practice was attributable to PHDs (10-30 cases per 100-200 annual cases). Fifty-seven percent indicated that hip surgery performed during skeletal immaturity made THA more difficult. Twenty-eight surgeons (62% of respondents) said that they remove implants from fewer than 10% of cases with previous pediatric surgery. Sixty- eight percent felt that removal of pediatric hip implants, particularly those in the proximal femur (83% of respondents), should be routine. Survey results showed that the majority of experts in adult hip reconstruction (a) do not identify PHDs as a significant factor in most of their patients with end-stage hip arthrosis and (b) believe in routine removal of pediatric hip implants, particularly those in the proximal femur. The impact of performing corrective hip surgery during skeletal immaturity—whether such surgery increases the difficulty of or diminishes the effectiveness of subsequent THA—remains controversial. Am J Orthop. 2008;37(3):153-156.
157	Prediction of Hamstring Tendon Autograft Diameter and Length for Anterior Cruciate Ligament Reconstruction Randy Schwartzberg, MD, Bradd Burkhart, MD, and Christopher Lariviere, PA-C, ATC Randy Schwartzberg, MD, is Sports Medicine Director, Orlando Regional Orthopaedic Surgery Residency Program, Orlando, Florida. The purpose of this study was to determine whether common physical measurements in patients undergoing anterior cruciate ligament (ACL) reconstruction with autologous hamstring tendon could be used to predict autograft length and diameter. One hundred nineteen consecutive patients undergoing hamstring autograft ACL reconstruction had these preoperative measurements taken: age, height, weight, bilateral leg length, and bilateral thigh girth 5 and 10 cm proximal to the superior pole of the patella. Correlations between these measurements and graft length and diameter were evaluated. There was a strong correlation between leg length and hamstring autograft length (r = .73, P<.001). Weight (r = .51, P<.001) and leg length (r = .42, P<.001) had only moderate correlations with graft diameter. All other correlations were weak. Regression analysis demonstrated that leg length can be used to predict hamstring autograft tendon length to within 20 mm and that weight can be used to predict graft diameter to within 1.2 mm using regression equations. In conclusion, several simple measurements correlate with doubled semitendinosus and gracilis tendon autograft length and diameter. This new information may prove useful to surgeons who want hamstring autografts of a certain diameter or of a long length. Am J Ortho. 2008;37(3):157-159.
160	The Power of Paying Attention Karen Zupko, BSJ Karen Zupko, BSJ, is President of KarenZupko & Associates, Inc., a consulting firm that works with orthopedic surgeons on practice management, personnel, and reimbursement issues. Web site: www.karenzupko.com. Abstract not available. Am J Orthop. 2008;37(3):160-161.
162	Using an External Fixation “Kickstand” to Prevent Soft-Tissue Complications and Facilitate Wound Management in Traumatized Extremities MAJ Mark J. Berkowitz, MD, and David H. Kim, MD MAJ Mark J. Berkowitz, MD, is Chief, Foot and Ankle Section, Orthopaedic Surgery Service, Tripler Army Medical Center, Honolulu, Hawaii. External fixation represents an extremely effective and versatile means of treating severe musculoskeletal injuries of both upper and lower extremities, particularly in austere environments. A relatively simple modification of standard external fixation techniques can facilitate the care of complex soft-tissue wounds and prevent unnecessary wound complications. Additional carbon bars can be attached to the primary construct to create a “kickstand” that can effectively support the extremity and eliminate the risk for pressure ulcers. This kickstand modification, which also allows improved access for wound care and dressing changes, has proved to be an effective adjunct in the treatment of high-energy extremity trauma. Am J Orthop. 2008;37(3):162-164.
165	Osteopetrosis: “Sandwich Vertebrae” Francis H. Shen, MD, Dino Samartzis, DSc, and Cree M. Gaskin, MD Francis H. Shen, MD, is Assistant Professor, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia. Abstract not available. Am J Orthop. 2008;37(3):165-166.

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