NOVEMBER 2009 VOLUME XXXVIII NUMBER 11 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

170	Intraosseous and Extraosseous Attachments of Flexor Tendon to Bone: A Biomechanical In Vivo Study in Rabbits Steven M. Green, MD, and Martin A. Posner, MD Dr. Green is Clinical Associate Professor of Orthopaedic Surgery, New York University Medical School, New York, New York, and Associate Chief, Hand Service, New York University Hospital for Joint Diseases, New York, New York. There are 2 popular methods of repairing flexor tendons to the distal phalanx and attaching a free tendon graft to bone: intraosseous, by implanting the tendon into a bony tunnel, and extraosseous, by suturing the tendon to the cortical surface after elevating the periosteum. An in vivo study was designed to determine whether one method is stronger than the other. The profundus flexor of the third and fourth toes of the hind paw of adult rabbits was divided and reattached to the middle phalanx using either an intraosseous tunnel or an extraosseous suture. Half the rabbits were killed after 3 weeks, the other half after 8 weeks. Repairs were then tested to failure, using an Instron device, and compared with the same tendons in the nonoperated limbs. The repaired tendons demonstrated similar strength 3 weeks and 8 weeks after surgery but were significantly weaker than the nonoperated tendons. The importance of this study is that it gives equal credence to these usual methods of tendon attachment. Am J Orthop. 2009;38(11):E170-E172.
173	Concomitant Fractures of Capitellum and Radial Neck in an Adolescent Faizal Rayan, MRCSEd, Trichy S. Rajagopal, MRCSEd, and Mike Uglow, FRCS Tr & Orth Mr. Rayan is Clinical Research Fellow, University College Hospital, London, England. Abstract not available. Introduction provided instead. Fractures of the capitellum in association with fractures of the radial head have been described in adults, but to our knowledge this is the first reported case of concomitant fractures of the capitellum and radial neck in an adolescent. The authors have obtained written informed consent from the patient’s guardian for print and electronic publication of the case report. Am J Orthop. 2009;38(11):E173-E174.
175	Calf Endometriosis: A Case Report and Review of Musculoskeletal Involvement Sadegh Saberi, MD, Amir Reza Farhoud, MD, and Ali Radmehr, MD Dr. Saberi is Assistant Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran. Abstract not available. Introduction provided instead. It is not uncommon for women of childbearing age to have ectopic endometrial tissue (includes endometrial glands and stroma) in the pelvic genital organs. Less often, this versatile condition has been reported in many other unrelated extrapelvic sites. The extreme variability in presentation of endometriosis, in addition to the unusual location of extrapelvic endometriosis, can create a significant diagnostic challenge before definitive histologic examination. Even with high-technology magnetic resonance imaging (MRI) showing several radiopathologic aspects of endometriosis, differential diagnoses with similar radiologic presentations can result in an inaccurate diagnosis if precise attention is not given to helpful clues in the patient’s history and clinicoradiologic correlation. A few cases of endometriosis of the musculoskeletal system have been reported. In the present case report, we describe an endometriosis of the leg, presenting as a soft-tissue mass, and emphasize the importance of patient history and clinicoradiologic correlation for easier diagnosis. The authors have obtained the patient’s written informed consent for print and electronic publication of the case report. Am J Orthop. 2009;38(11):E175-E178.

549	Health Care Reform—Let the Right Voices Be Heard Peter D. McCann, MD Dr. McCann is Editor-in-Chief of this journal and Chair, Department of Orthopaedic Surgery at Beth Israel Medical Center, New York, New York. Abstract not available. Am J Orthop. 2009;38(11):549.
550	Acetabular Component Revision in Total Hip Arthroplasty. Part II: Management of Major Bone Loss and Pelvic Discontinuity Paul S. Issack, MD, PhD, Markku Nousiainen, MS, MD, FRCS(C), Burak Beksac, MD, David L. Helfet, MD, Thomas P. Sculco, MD, and Robert L. Buly, MD Dr. Issack is Fellow, Orthopaedic Trauma and Adult Reconstructive Surgery, Hospital for Special Surgery, New York, New York. Use of structural bone graft and/or reconstruction cage devices in acetabular revisions with major bone loss has the advantages of providing a stable construct at the anatomical hip center of rotation and, theoretically, reconstituting bone stock. When the structural graft supports more than 50% of the acetabular component, a reconstruction cage device spanning ilium to ischium should be used to protect the graft and provide structural stability. Recent introduction of trabecular metal cups and augments and custom triflanged acetabular components has increased the potential for biological fixation and long-term stability of revision constructs. Longer follow-up of these reconstructions is needed. Revisions with pelvic discontinuity and major bone loss have a high failure rate and require techniques either to reduce and plate the discontinuity or to distract the discontinuity to achieve long-term stability. Am J Orthop. 2009;38(11):550-556.
559	Wound Management for Severe Open Fractures: Use of Antibiotic Bead Pouches and Vacuum-Assisted Closure Mark L. Prasarn, MD, Gregory Zych, DO, and Peter A. W. Ostermann, MD, PhD Dr. Prasarn is Orthopaedic Trauma Attending, University of Rochester, Rochester, New York. Open fractures complicated by infection, or those requiring extensive soft-tissue procedures, are disabling problems for patients and result in significant costs for the health care system. As an adjuvant to current protocols involving open fractures, antibiotic bead pouches (ABPs) provide high concentrations of local antibiotics and can help reduce infection rates. Vacuum-assisted closure (VAC) has been shown to decrease the need for, and enhance the success of, free-flap coverage for traumatic wounds that are significant enough to preclude primary closure, delayed primary closure, or healing by secondary intention. These 2 modalities may help decrease the complications and costs involved in the management of severe open fractures. In this article, we review the theory, technique, and efficacy of ABPs and VAC in the management of severe open fractures. Am J Orthop. 2009;38(11):559-563.
567	Atrophic Nonunion of Humeral Diaphysis Treated With Locking Plate and Recombinant Bone Morphogenetic Protein: Nine Cases Charles H. Crawford III, MD, and David Seligson, MD Dr. Crawford is Assistant Professor, Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky. Nonunions of the humerus are debilitating for patients and challenging for surgeons. We retrospectively reviewed our first 9 humeral nonunions treated with a locking plate and commercially available recombinant bone morphogenetic protein. At latest follow-up, 8 patients showed clinical and radiographic signs of union. One patient had a persistent (11-year) nonunion that failed to unite at 1 year, despite new bone formation, and underwent revision with the same technique. The reported technique is a useful part of the surgeon’s armamentarium in treating difficult humeral nonunions. We found a high union rate with an acceptably low complication rate in this difficult population. Am J Orthop. 2009;38(11):567-570.
572	Porcine Small Intestine Submucosa Xenograft Augmentation in Repair of Massive Rotator Cuff Tears Wesley P. Phipatanakul, MD, and Steve A. Petersen, MD Dr. Phipatanakul is Assistant Professor, Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California. In this prospective study, we evaluated the efficacy of using porcine small intestine submucosa (SIS) xenograft to augment the repair of massive rotator cuff tears. Our hypothesis was that SIS xenograft would help restore tendon tissue in the human model, as has been shown in several animal studies. Eleven patients were followed clinically for a mean of 26 months (range, 14-38 months). Mean University of California Los Angeles end-result scores improved from 13.9 before surgery to 25.7 after surgery, American Shoulder and Elbow Surgeons scores improved from 36.3 to 71.8, and the visual analog scale pain score decreased from 6.6 to 2.0. All findings were statistically significant (P<.01). At a mean of 25 months after surgery, magnetic resonance arthrography (MRA) showed the repairs partially or completely intact in 44% of shoulders. Intact repairs were thin and wispy. There were 3 complications, which included 1 infection and 2 localized skin reactions that resolved spontaneously. SIS xenograft did not reconstitute rotator cuff tissue or add to the quality of the rotator cuff repair. Given clinical concerns about localized reactions in this series and suboptimal MRA findings, use of SIS xenograft to augment rotator cuff repairs is not recommended. Am J Orthop. 2009;38(11):572-575.
578	Effects of Recombinant Human Bone Morphogenetic Protein 2 on Surgical Infections in a Rabbit Posterolateral Lumbar Fusion Model Christopher P. Miller, BA, Andrew K. Simpson, MD, Peter G. Whang, MD, Benjamin P. Erickson, BA, Walid R. Waked, MD, James P. Lawrence, MD, and Jonathan N. Grauer, MD Mr. Miller is Medical Student, Yale University School of Medicine, New Haven, Connecticut. Recombinant human bone morphogenetic proteins (rhBMPs) are often used during spine surgery, but their effects on postoperative infections have not been well elucidated. Long-bone studies suggest that BMPs may limit local infection and facilitate bone formation. Until now, rhBMP-2 had not been evaluated in the setting of infected spinal arthrodesis. In the study reported here, we evaluated the safety and efficacy of rhBMP-2 and autograft in inducing fusion in the setting of surgically acquired infection. Sixty rabbits underwent fusion with autograft or rhBMP-2 with coadministration of Staphylococcus aureus or sterile saline. In the noninoculated groups, 4/15 autograft and 13/13 rhBMP-2 rabbits fused (P<.001). In the inoculated groups, 0/14 autograft and 3/12 rhBMP-2 rabbits fused (P = .085). There were 4/14 early deaths caused by infection in the autograft group and 0/12 in the rhBMP-2 group (P = .1). Although the difference in fusion rates and early deaths from infection for rhBMP-2 and autograft did not reach our predetermined α error threshold, the data were trending toward significance. Our results demonstrated no increase in morbidity or mortality associated with use of rhBMP-2 in the setting of local infection. Although BMP use with infections remains controversial, these results indicate that rhBMP-2 could be used in a contaminated environment. Am J Orthop. 2009;38(11):578-584.
588	Obturator Internus Strain in the Hip of an Adolescent Athlete Benjamin T. Busfield, MD, and Denise M. Romero, MD Dr. Busfield is Orthopedic Surgeon, Sutter East Bay Medical Group, Antioch, California. A male 13-year-old presented with acute onset of right hip pain as he prepared to kick a soccer ball. A case of acute strain of the obturator internus is reported. The strain resolved completely after a period of activity modification and physical therapy. Am J Orthop. 2009;38(11):588-589.

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