APRIL 2009 VOLUME XXXVIII NUMBER 4 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

71	Radiographic Assessment of Sternal Notch Level and Its Significance in Approaching the Upper Thoracic Spine Palaniappan Lakshmanan, MS (Orth), AFRCS, FRCS (Orth), Kathleen Lyons, FRCR, Paul Rhys Davies, FRCS, FRCS (Orth), John P. Howes, FRCS, FRCS (Orth), and Sashin Ahuja, MS (Orth), FRCS, FRCS (Orth) Dr. Lakshmanan is Specialist Registrar, Trauma and Orthopaedics, Newcastle General Hospital, Newcastle-Upon-Tyne, United Kingdom. In this retrospective study, we used anteroposterior plain radiographs of the neck to analyze sternal notch level in relation to the upper thoracic spine and to assess the usefulness of this relation in deciding how to approach the upper thoracic spine. We reviewed 53 patients’ anteroposterior plain radiographs of the cervicothoracic spine and thoracic magnetic resonance imaging (MRI) scans. On the plain radiographs, we drew a horizontal line joining the lower-fifth edge of the medial end of the 2 clavicles; on the midsagittal thoracic MRI scans, we drew a tangential line to the sternal notch. Then we noted the vertebral level of the 2 lines. In all cases, the horizontal line on the plain radiographs and the tangential line on the MRI scans corresponded to each other without discrepancy. We evaluated this method in a patient with a fractured T3 vertebral body, in whom a satisfactory procedure was performed using low anterior cervical spine approach. As the level of sternal notch is found to be present below the level of T2 and T3 radiologically in most cases, a low cervical approach can be contemplated in most patients with upper thoracic spine pathology depending on their sternal level as determined by preoperative radiographs. MRI scans are not needed to decide the approach, as it can be assessed with plain radiographs alone, as shown in this study. Am J Orthop. 2009;38(4):E71-E74.
75	Ankle Clonus and Wakeup Tests During Posterior Spinal Fusion: Correlation With Bispectral Index Joseph D. Tobias, MD, Daniel G. Hoernschemeyer, MD, and John T. Anderson, MD Dr. Tobias is Professor of Anesthesiology and Pediatrics, University of Missouri, Columbia, Missouri. Abstract not available. Introduction provided instead. Spinal cord injury and its resultant neurologic deficits are recognized complications of posterior spinal fusion (PSF) for correction of scoliosis. Spinal cord injuries are identified with various methods, including intraoperative monitoring using somatosensory evoked potentials (SSEPs) and/or motor evoked potentials (MEPs), intraoperative wakeup test, and demonstration of ankle clonus.1-4 The wakeup test, originally reported (in the 1970s) to be a means of monitoring spinal cord integrity, involves gradually decreasing anesthesia depth until the patient is able to follow commands and voluntarily move the lower extremities5,6; then anesthesia is returned to its previous level, and the surgery is completed. Although this test and potential intraoperative awareness are discussed with the patient before surgery, recall may occur during the test. In addition, as anesthesia lightens, hemodynamic changes may cause bleeding, and excessive patient movement may cause bodily harm or dislodge intravascular catheters or even the endotracheal tube. Given these issues, alternative means of monitoring spinal cord integrity are desirable. The ankle clonus test was the first test to be used to assess spinal cord integrity during surgery. Ankle clonus is a neurologic sign that is usually considered pathologic but can normally appear during emergence from general anesthesia.7,8 During the normal awake state, descending inhibitory fibers prevent clonus in response to an ankle stretch. As the patient emerges from general anesthesia, lower motor neuron function returns before descending inhibitory cortical fibers regain their normal function, thereby disinhibiting the lower motor neurons and resulting in the ability to elicit clonus. If the spinal cord has been damaged, flaccid paralysis will be present, thereby preventing spinal reflexes, including ankle clonus.3 The ankle clonus reflex is elicited by rapid dorsiflexion of the foot followed by continued application of pressure to hold the foot in slight dorsiflexion. Rhythmic contractions of the gastrocnemius muscle result in repetitive plantar flexion of the foot. Compared with the wakeup test, the ankle clonus test can usually be elicited before the patient regains consciousness, at a deeper level of anesthesia.9 In this article, we describe the cases of 3 adolescents whose SSEPs or MEPs changed during intraoperative monitoring for PSF. In these cases, the Bispectral Index (BIS) monitor (Aspect Medical Systems, Inc., Newton, Mass) was used to judge the depth of anesthesia and to provide numeric data regarding the anesthesia level at which ankle clonus can be elicited, versus the point at which the patient is able to voluntarily move the lower extremities. Am J Orthop. 2009;38(4):E75-E77.
78	Use of C1 Lateral Mass and C2 Intralaminar Fixation to Stabilize a 30-Year-Old Odontoid Fracture That Was Causing Myelopathy Ehsan Tabaraee, MS, Joseph R. O’Brien, MD, MPH, and Warren D. Yu, MD Mr. Tabaraee is fourth-year medical student, George Washington University School of Medicine and Health Sciences, Washington, DC. Abstract not available. Introduction provided instead. Odontoid fractures occur with a bimodal incidence. They are usually seen after a fall in the elderly or a motor vehicle accident in the young.1,2 Their sensitive location and potential to destabilize the craniocervical junction can result in neurologic compression. Despite extensive discussions in the literature regarding the epidemiology, imaging, and classifications of odontoid fractures, there has been no consensus on the best treatment options for the type II fracture across various age groups.3-5 In this article, we present the case of a patient in whom myelopathy developed more than 30 years after he sustained a type II odontoid fracture in a motor vehicle accident. This case is unique for 2 reasons. First, the prolonged asymptomatic period between initial injury and symptom onset is rare.6-8 Second, the surgical technique used was a unique modification of prior C1–C2 fixation techniques. C1 lateral mass fixation was initially described by Goel and Laheri9 in 1994 and then popularized by Harms and Melcher10 in 2001. Initially, C1 fixation was paired with C2 pars (pedicle) fixation. However, up to 20% of patients may have vertebral artery anatomy that precludes safe C2 pedicular fixation.11 In 2004, Wright12 described intralaminar fixation of C2 as a potential solution for patients with medialized vertebral arteries that make C2 pedicle screw placement dangerous. The present case of late myelopathy caused by odontoid nonunion was successfully treated with instrumentation and fusion using C1 lateral mass and C2 intralaminar fixation. We have obtained the patient’s informed written consent to publish his case report. Am J Orthop. 2009;38(4):E78-E81.

170	GUEST EDITORIAL—Fads and Fashion in Orthopedic Surgery Melvin P. Rosenwasser, MD Dr. Rosenwasser, this journal’s Associate Editor for Hand and Wrist, is Robert E. Carroll Professor of Orthopedic Surgery, Columbia University College of Physicians and Surgeons, and Chief of Hand and Microvascular Surgery, and Chief of Orthopedic Trauma Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York. Abstract not available. Am J Orthop. 2009;38(4):170, 193.
172	Salvage Procedures for the Distal End of the Ulna: There Is No Magic William B. Kleinman, MD Dr. Kleinman is Senior Attending Surgeon at The Indiana Hand Center, and Clinical Professor of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, IN. Resection of the distal end of the ulna is not a benign procedure; nor is it a panacean surgical treatment of disorders at the distal radioulnar and ulnocarpal joints. Over the past 96 years, since Darrach first described his classic procedure, many authors have warned surgeons of the consequences of the Darrach resection. For salvaging the persistently painful distal forearm after Darrach resection, researchers have recommended a spectrum of possible surgical options. Each has its advantages and disadvantages; none substitutes completely for the painless, load-bearing capacity of a healthy distal radioulnar joint. Resection of the seat of the distal ulna eliminates the fulcrum of the ulna through which load is transferred from the hand to the forearm. At this time, there is still no surgical “magic” available to the reconstructive surgeon for salvaging normal use of the upper limb after failed Darrach resection. Am J Orthop. 2009;38(4):172-180.
181	A Reliable and Simple Solution for Recalcitrant Carpal Tunnel Syndrome: The Hypothenar Fat Pad Flap Cesare Fusetti, MD, Guido Garavaglia, MD, Christophe Mathoulin, MD, John Gianfranco Petri, MD, and Stefano Lucchina, MD Dr. Fusetti is Consultant, Hand Surgery Unit, Department of Orthopaedics and Traumatology, Ospedale San Giovanni, Bellinzona, Switzerland. The incidence of failure in open carpal canal tunnel decompression is underestimated. Recurrence is often the result of scarring of the median nerve. Conservative treatment or careful neurolysis is usually insufficient. The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence and could offer a solution for patients with recalcitrant carpal tunnel syndrome. We reviewed the results of using this procedure in 20 patients with recalcitrant carpal tunnel syndrome and analyzed subjective and objective results, complications, and pitfalls. For 18 patients, pain disappeared completely. Two-point discrimination improved from an expanded range to normal in 16 of the 20 patients. Quick DASH (Disabilities of the Arm, Shoulder, and Hand) scores improved significantly. The hypothenar fat pad flap, a technically simple procedure, prevents median nerve readherence, produces excellent results, and should be included among the tools any surgeon uses for carpal tunnel surgery. Am J Orthop. 2009;38(4):181-186.
187	The Effects of Blood and Fat on Morse Taper Disassembly Forces Carlos J. Lavernia, MD, Luis Baerga, BS, Robert L. Barrack, MD, Evangelos Tozakoglou, PhD, Stephen D. Cook, PhD, Loren Lata, PhD, and Mark D. Rossi, PhD, PT, CSCS Dr. Lavernia is Chief of Orthopedics and Director of the Orthopaedic Institute at Mercy Hospital, Miami, Florida, and Adjunct Professor of Biomedical Engineering, Florida International University, Miami, Florida. Biological debris between modular components using Morse tapers in hip arthroplasty can lead to weakening of the implant construct. We conducted a study to determine the effect of blood and fat within the taper interface. Tapers were divided into groups 1 (clean), 2 (surface covered with blood and fat), and 3 (blood and fat wiped off). Each taper was impacted and disassembled 5 times. There was a difference in mean disassembly force between pulls within group 2. Thus, blood and fat contamination can have a significant effect on the potential for disassembly. Am J Orthop. 2009;38(4):187-190.
191	Closed-Reduction Percutaneous Pinning of a Complex Divergent Carpometacarpal Fracture-Dislocation Involving the 4 Ulnar Carpometacarpal Joints Yuri M. Lewicky, MD, and Joseph E. Sheppard, MD Dr. Lewicky is an Orthopaedic Surgeon specializing in arthroscopy and reconstruction of the shoulder and knee at Summit Center Sports Medicine and Northern Arizona Orthopaedics, Flagstaff, Arizona. Abstract not available. Am J Orthop. 2009;38(4):191-193.
194	Bilateral Comminuted Radial Shaft Fractures From a Single Gunshot: Fixation With Alternative Techniques John T. Capo, MD, Frank Liporace, MD, Damon Ng, MD, and Steve Caruso, MD Dr. Capo is Chief, Division of Hand and Microvascular Surgery, and Associate Professor, Department of Orthopaedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey. Acute bilateral radial shaft fractures are an unusual entity that has not been previously reported in the literature. Given its bilaterality, this rare clinical entity is best treated with stable internal fixation. Here we report the case of an 18-year- old right-hand–dominant man who sustained a low-caliber gunshot injury. He had been driving with both hands on the steering wheel when he was struck by a single bullet. The bullet caused displaced fractures of the left proximal radial shaft and the right distal radial shaft. Each fracture had extension outside the mid- diaphysis. The patient underwent operative fixation with plating of the right upper extremity and intramedullary nailing on the left side. Both fractures healed, and range of motion was functional. Am J Orthop. 2009;38(4):194-198.
199	The “Bluie,” a Simplified Method for Applying a Vacuum-Assisted Closure Dressing in Residual Limbs and Complex War Wounds Daniel B. Judd, MD, Winston Warme, MD, and Christopher E. White, MD MAJ Judd, MC, USA, is Staff Orthopaedic Surgeon, Tripler Army Medical Center, Honolulu, Hawaii. An impervious plastic stockinet can facilitate application of a vacuum-assisted closure dressing in complex, traumatic wounds. This article reviews our technique. Am J Orthop. 2009;38(4):199-200.

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