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2003 Board of Directors
President: Champ L. Baker, Jr.,
MD
President Elect: Craig T. Kerins,
MD
Past President: Charles N. Hubbard,
MD
Secretary-Treasurer: Stephen M.
McCollam, MD
Secretary-Treas Elect: Waldo E.
Floyd, III, MD
Board Of Councilors: Frank B. Kelly,
MD and Peter L. Meehan, MD
Mag Legislative Council: C. Thomas
Hopkins, MD
Legislative Chairman: James W. Scott,
MD
Membership Chairman: Charles E.
Hancock, MD
Executive Director: Sherri Hill
EDUCATIONAL OBJECTIVES
FRIDAY, OCTOBER 10, 2003
Distal Phalangeal Fractures
in Pediatric Patients:
A Retrospective Review
J. David Hill, M.D.
A series of 79 distal phalangeal fractures
is presented. The age, fracture pattern, mechanism, nature,
location and delay of treatment were identified. Treatment
outcomes were evaluated. Treatment should be initiated
expediently as these fractures are unstable and can displace
even when immobilized appropriately. Reducing time from
injury to treatment is critical to preventing malunion. When
non-displaced, this fracture pattern may be successfully treated
with casting or splinting provided there is a close follow-up. When
displaced, operative intervention is recommended to optimize
join function. Stiffness is the most common adverse outcome
and is associated with the degree of initial displacement
and involvement of the proximal phalangeal head. Secondary
surgery may be required in some children.
Fixed-Angle Volar Plate Fixation
for Dorsally Displaced Distal Radius Fractures: Technique
and Early Results
J. Kevin Brooks, M.D.
Distal radius fractures comprise almost 40%
of fractures of the upper extremity. With the predicted
increase in the elderly population, expert knowledge and treatment
of these fractures is paramount to ensure successful outcomes. The
goal of treatment, whether nonsurgical or surgical, is to
achieve restoration of the disrupted anatomy and allow quick
return of hand function, while preventing secondary fracture
displacement. The surgical treatment of dorsally displaced,
unstable distal radius fractures has been debated over the
years. Surgical options included closed reduction
with external fixation, closed reduction with percutaneous
pinning, closed reduction with percutaneous bridge plate fixation
(i.e. Becton plate), and formal open reduction and internal
fixation, typically through a dorsal approach.
Though dorsal plating techniques can achieve
successful outcomes, extensor tendon complications, ranging
from irritation tendonitis to frank rupture, approach 12-20%
in some series. Furthermore, the need for secondary bone
grafting has also been reported with doral techniques possibly
due to the disruption of the dorsal soft tissue blood supply.
Over the past year, a volar approach with fixed-angle
plate fixation has been instituted for dorsally angulated,
unstable distal radius fractures. The incision is centered
over the FCR tendon, and dissection is performed on the radial
side of the FCR tendon sheath just ulnar to the radial artery. The
contents of the carpal canal are retracted ulnarly. The
pronator quadratus is incised radially and reflected from
the volar distal radius. Next, the fracture is reduced
typically with longitudinal traction and volar flexion. In
some instances, the dissection is extended distally while
pronating the radial shaft away from the distal fracture fragment(s)
to allow direct visualization of the articular surface. Once
reduction is obtained the periarticular, locking plate is
aligned and confirmed with fluoroscopy. The plate design
allows placement of distal, locking screws (2.0 or 2.5mm)
in the subchondal bone which supports the articular surface,
even in severely osteopenic bone. The plate is secured
to the diaphysis with 3.5mm bicortical screws. The pronator
quadratus is reattached and the incision is closed. Postoperatively
the patient is immobilized for 4 weeks in a removable, short-arm
splint; active range of motion exercises out of the brace
are initiated at the first postoperative appointment (typically
10-14 days).
As of September 1, 2003, thirty two cases (on
29 patients) have been performed. The average patient
age was 59.3 years (range 21-86). The average pre-operative
dorsal angulation was 14 degrees. Of these patients,
19 have at least 4 months of follow-up. Of these, all
19 fractures have healed. The final volar tilt averaged
2 degrees, radial inclination averaged 20 degrees, with 1
mm of radial shortening. Wrist motion was also evaluated
at four month follow-up and averaged 55 degrees extension,
63 degrees flexion, 32 degrees ulnar deviation, 9 degrees
radial deviation, 78 degrees pronation, and 81 degrees supination. Subjectively,
13 patients reported excellent results, 4 with good results,
and 2 fair results. Both of the patients with fair results
developed early post-op wound infections; one resolved with
oral antibiotics, and the other required formal I&D.
Though not the universal solution, fixed-angle
volar plate fixation can be a useful tool for the orthopaedic
surgeon in the treatment of dorsally angulated distal radius
fractures. Further studies with longer follow-up, including
comparison with other techniques, are needed to
determine the true extent of success with this type of treatment.
Occult Lesions of the Brachial Plexus
Waldo E. Floyd, III, MD
There are a number of common etiologies for
upper extremity paralysis including central nervous system
disturbances, spinal cord injury or nerve root dysfunction,
peripheral compression neuropathy, and muscle trauma. Though
uncommon, tumors about the brachial plexus may masquerade
as another problem. Lesions of the brachial plexus are
difficult to diagnosis and a misdiagnosed condition may be
pursued before the correct diagnosis is made. Occult
lesions of the brachial plexus are frequently not considered
as a cause for upper extremity paralysis.
Four patients are included in this report
with diagnoses including a posterior cord schwannoma, a neuro
fibrosarcoma, a lipoma, and a Pancoast tumor. The patient
with a neuro fibrosarcoma of the brachial plexus underwent
an initial anterior cervical discectomy and fusion and
subsequent tendon transfers for radial paralysis before the
correct diagnosis was made. The patient with the Pancoast
tumor underwent two ulnar nerve decompressions at the elbow
before the correct diagnosis was made. The Schwannoma of the
posterior cord was felt to be an isolated radial paralysis.
The lipoma presented as ulnar paralysis.
The treating physician must rely upon his own
knowledge of neuro anatomy to make the correct diagnosis and
order the appropriate tests. Consultants may point the surgeon
towards an incorrect diagnosis. The surgeons must carefully
review electodiagnostic studies and ensure that they jibe
with the patient's physical examination. An atypical
clinical course may be due to an alternative diagnosis.
This paper is presented to increase the awareness
of frequently occult tumors about the brachial plexus as an
etiology for upper extremity paralysis.
Periarticular Osteomyelitis
of the Distal Tibia: comparative outcomes using the SF-36
questionnaire.
George Cierny, III, MD
Questions: What are the appropriate patient
selection criteria for joint salvage, ankle fusion and/or
amputation when treating periarticular infections of the distal
tibia and talus?
Methods: 64 consecutive patients with periarticular
infections of the distal tibia and talus were prospectively
treated between l996 and l999. Etiologies included 11
septic joints and 53 infected non-unions.The SF-36 outcomes
questionnaire was administered to all patients before the
first office visit and one year after completing treatment.
Treatment options included an ankle joint salvage, ankle fusion
or below-knee amputation. Our recommendations were based
on a projected functional capacity, the morbidity of treatment
and the overall prognosis. There were 8 amputations and
56 limb-salvage attempts (32 joint-sparing; 24 fusions). 42%
of the salvage protocols utilized small-wire fixation and
distraction methodologies; eight patients underwent reconstructions
utilizing micro-vascular bone and soft tissue flaps.
Results: The 1st treatment success
rates for joint salvage and fusion were 91% and 78% for A-hosts
and B-hosts, respectively. All the amputations were in B-hosts. The
overall, 2-yr success rate was 95%: 97% joint salvage;
91% ankle fusion. Total disability times were 5.8mos
for amputees, 7.5mos for ankle fusions and 11mos for patients
undergoing joint salvage. Physical and emotional domains were
impaired in patients undergoing joint salvage and fusions;
significant physical role dysfunction (RP) was prevalent in
joint-salvage patients. A successful below-knee amputation
was the most restorative procedure in this study. The SF-36
questionnaire is a quick and ease measure of patient-based
outcomes.
Treatment of Osteochondral Lesions
of the Talus with Arthroscopic Drilling and Osteochondral
Autograft Transplantation.
Alonzo Sexton, MD
The purpose of this study is to report the preliminary
outcomes of patients with Osteochondral Lesions of the Talus
(OLT). These lesions may represent a diagnostic dilemma
often reported by patient as an ankle injury that was initially
treated as a sprain, but has failed to improve. This
is a prospective study of 10 consecutive patients treated
between 1998 and 2002. These patients received either
arthroscopic drilling of the talar defect or Osteochondral
Autograft Transplantation (OATS). The size of defect
was used as the primary determining factor of the treatment
patients received. Frank defects measuring 10 mm or greater
received OATS (n = 4), while smaller defects had arthroscopic
drilling performed (n = 6). Both a preoperative and postoperative
AOFAS hindfoot scoring was completed. The average follow-up
was 20.1 months. According to the hindfoot scoring system
9/10 patients had significant improvement of their hindfoot
score, with an increase average score of 23.8%. All 6 patients
undergoing arthroscopic drilling showed improvement in their
hindfoot score whereas only 1 patient out of 4 from the OATS
group showed score improvement. In addition, 1 patient
(25%) had a decrease in score and the only patients in the
study with scores less than 65 (n = 3) belong to the OATS
group. Both patients that were over the age of 50 had
scores less than 65. 2 of the 3 patients with low postoperative
scores reported duration of symptoms of greater than 4 years. These
findings suggest that arthroscopic drilling is effective in
increasing the postoperative hindfoot score in patients with
OLT. While 10 mm has been suggested previously as a cutoff
guide for performing osteochondral transfer, size of lesion
may not be the only factor responsible for patient outcome,
both patient age and duration of symptoms may have a role. Further
study is clearly needed with longer follow up, but we feel
that arthroscopic drilling may be an excellent choice for
initial procedure for this problem, reserving OATS for refractory
cases.
Management of the adult acquired
flatfoot deformity: How to avoid arthrodesis
Mark S. Myerson, MD
Georgia Foot & Ankle Guest
Speaker
Traditional methods of treatment of the adult
flatfoot have involved arthrodesis, whether performed as an
isolated or more extensive procedure. The flatfoot deformity
has been classified into 4 stages, based upon rigidity of
the hindfoot, and while the more severe stages can only be
corrected with arthrodesis, any foot which is even fairly
flexible should not be treated with arthrodesis. There is
significant structural and biomechanical stress transferred
to the ankle joint following hindfoot arthrodesis, and the
long term studies following triple arthrodesis indicate a
high incidence of ankle arthritis. In addition to the deleterious
effects of arthrodesis on the ankle, the foot is stiff, and
from a functional standpoint, patient outcome and satisfaction
is never quite adequate.
This presentation will cover the stages of the
adult flatfoot deformity, and present a treatment algorithm
based upon hindfoot flexibility. It is critical to understand
the concept of forefoot supination in planning treatment.
As the hindfoot drifts into valgus, the forefoot remains plantigrade
by a process of supination. This may become fixed, and referred
to as "fixed forefoot supination". This deformity was traditionally
corrected using a triple arthrodesis, since it was believed
that the only way that the medial column of the foot could
be plantarflexed was with arthrodesis, in this instance of
the talonavicular joint when combined with the triple arthrodesis.
It is the premise of this presentation, that
wherever possible, arthrodesis of the hindfoot should be avoided.
For the majority of patients with a flexible hindfoot in valgus,
a reconstruction which involves a flexor digitorum longus
tendon transfer combined with a medial translational osteotomy
of the calcaneus is sufficient. If the hindfoot is abducted
across the transverse tarsal joint, then a medial translational
osteotomy of the calcaneus is not sufficient, and lengthening
of the lateral column is performed. While this may be done
using an arthrodesis of the calcaneocuboid joint with interposition
bone graft, the complication rate, particularly arthrodesis
of this procedure is unacceptably high. Instead, the lateral
column lengthening is performed as an osteotomy through the
neck of the calcaneus. If there is a fixed forefoot supination
deformity, arthrodesis may be considered, but again, can be
avoided by plantarflexion of the medial column of the foot
using an opening wedge osteotomy of the medial cuneiform.
The algorithm of correction is presented along
with video demonstration.
Cubital Tunnel Syndrome - Fact
or Fiction?
James R. Doyle, MD
Georgia Hand Society Guest Speaker
The term cubital tunnel syndrome was proposed
by Feindel and Stratford in 1958 to identify a specific
site of entrapment of the ulnar nerve and to distinguish it
from tardy ulnar nerve palsy associated with post traumatic
cubitus valgus. Its more ubiquitous cousin, the carpal
tunnel syndrome, although first noted at autopsy in 1913 by
Marie and Foix was launched by Tanzer in 1959. These
two conditions have provided a diagnostic reservoir that seems
to never run dry. Both diagnostic entities have provided
patients, doctors and attorneys with endless options for debate! While
the carpal tunnel syndrome has fewer surgical options, open
decompression versus a variety of single or double portal
"mini" approaches with or without the assistance of the "wonder
wand" (the arthroscope), the cubital tunnel surgical treatments
range from decompression in the tunnel with or without neurolysis
and with or without medial epicondylectomy; and subcutaneous
or submuscular transposition. The extent of decompression
varies with the surgeon. Various anatomic points of interest
have been identified and incriminated as culprits of causation
that must be dealt with at the time of surgery if one is to
effect a cure. If nothing more, these anatomic features
enlarge the Resident's and Fellow's "must know" list. The
perfect and best operation for cubital tunnel syndrome will
be revealed based on audience participation that will conclude
the presentation.
Articular Cartilage Repair: Is
It Really Possible?
Steven P. Arnoczky, DVM
Presidential Guest Speaker
This lecture will discuss the basic science
rationale for the various surgical procedures that have been
developed to stimulate the repair of articular cartilage. The
presentation will also explore new technologies that are currently
being advocated for cartilage repair.
Dr. Arnoczky has an affiliation/financial
arrangement with Depuy, Wright Medical and Smith & Nephew.
EDUCATIONAL OBJECTIVES
SATURDAY, OCTOBER 11, 2003
Closed Treatment of Acute Locked
Posterior
Fracture-Dislocations of the
Shoulder
Xavier A. Duralde, M.D.
We retrospectively reviewed the results of closed
treatment in seven patients who sustained acute locked posterior
fracture-dislocations of the shoulder. Treatment consisted
of closed reduction under general anesthesia and splinting
in neutral rotation for six weeks followed by a supervised
physical therapy program. Six men and one woman of average
age 52 years (range 32-74) were followed an average of 42
months (range 12-88 months). All shoulders were reduced
within 14 days. Humeral head defects varied from 20 to
33 percent of the articular surface. All patients had
at least one co-morbidity. Seizure was the cause in five
cases and motor vehicle accident in two. One patient
who had had a previous Magnuson Stack procedure redislocated
and required open treatment. There were no other failures
or complications. Two patients died of unrelated causes
in the follow up period. Patients were assessed using
ASES scale and had an average shoulder score of 94 out of
100 (range 73-100). Average postoperative motion was
forward elevation to 161 degrees, external rotation to 66
degrees, and internal rotation to T11. All patients without
preexisting shoulder instability were treated successfully
in a closed fashion despite significant humeral head defects. Significant
spontaneous filling in of the defect was noted on serial X-rays
following relocation. Closed management of acute posterior
fracture-dislocations is highly successful and avoids the
stress of open surgery in this population with multiple medical
problems.
Locking-Screw Compression Hip
Screw for use with Retrograde Intramedullary Nailing in the
Treatment of Ipsilateral Femoral Neck and Shaft Fractures
Mark W. Hanna, MD
Background: The treatment of combined
fractures of the proximal femur (base of neck) and femoral
shaft remains controversial. The combination of a dynamic
hip screw (DHS) and retrograde femoral nail can be used for
fixation in patients with injuries which preclude the use
of a fracture table or the lateral position. However,
the intersection between the DHS side plate screws and femoral
nail presents a problem. Unicortical locking side plate
screws (designed by Synthes) offer a solution by allowing
the use of a longer retrograde nail than conventional bicortical
screws. This increases the overlap between the devices
and theoretically the stability of the construct. A biomechanical
study was performed comparing DHS side plates fixed with four
unicortical locking screws versus two conventional bicortical
screws.
Methods: The study was divided into
two parts. In each part two groups (standard vs. locked)
of composite sawbone femurs with base of neck osteotomies
were instrumented with a retrograde femoral nail and either
a standard DHS with two conventional bicortical side plate
screws or a newly designed locked DHS with four unicortical
locking side plate screws. The nail measured 36 cm in
the locked group and 30 cm in the standard group. In
part I, a displacement control protocol measured the peak
load to failure. In both parts the mode of failure was
recorded.
Results: In part I, the average peak
load for the standard and locked groups was 3112.82+/-244.15
N and 3358.38+/-151.07 N, respectively. The locked group
withstood 245 N greater average peak load than the standard
group (p=0.03). Fractures occurred in 8/8 standard femurs
and 2/8 locked femurs. In part II, the average number
of cycles for the standard and locked groups was 114201+/-129838
and 692353+/-376330, respectively. The locked group withstood
average 578152 more cycles than the standard group (p=0.02). Fractures
occurred in 6/6 standard femurs and 4/6 locked femurs.
Discussion and Conclusion: Compression
hip screws with four unicortical locking side plate screws
provided improved resistance to ramp loading and cyclic loading
compared to those with standard side plates and two bicortical
screws. Because of greater overlap between the nail and
side plate, the locked group also provided improved resistance
to femoral fracture. The combination of a DHS with four
unicortical locking side plate screws and retrodgrade femoral
nail is a potential alternative in the difficult fixation
of ipsilateral femoral base of neck and shaft fractures.
Spondylotic Spondylolisthesis:
An Archeological Study of Pelvic and Lumbosacral Parameters
of Possible Etiologic Effect in Two Distinct Racial Groups
of High Occurrence
Thomas E. Whitesides, Jr., MD
A study in archeologic remains of anatomic
parameters in two racial groups with high occurrence rates
of spondylolytic spondylolysthesis was done to determine their
significance to occurrence and etiology. Sacral Table
Angle is associated with the occurrence of pars defects while
Pelvic Incidence is not. The increasing Pelvic Incidence in
Spondylolisthesis appears to be secondary to the occurrence
of upper sacral deformity. Sacral Table Angle appears possibly
racially determined.
Posterior Soft Tissue Closure
Following Total Hip Arthroplasty: A Clinical and Biomechanical
Analysis
Scott Olvey, MD
Dislocation remains a frequent complication
of total hip replacement using the posterior approach. Enhanced
posterior closures of the soft tissue with trans-osseous sutures
have been reported with decreased rates of dislocation. While
this closure imparts some improved stability, a significant
posterior dead space remains. In this paper we report
clinical and biomechanical results for a two part enhanced
repair for posterior closure after primary total hip arthroplasty. A
retrospective chart review of 544 cases revealed a dislocation
rate of 0.37%. A biomechanical study of 11 cadaveric
hips comparing no closure to both the enhanced and two part
enhanced closures showed an increase in internal rotation
and torque to dislocation of 21 degrees and 4 N/m respectively
which were both statistically significant. From this
data we believe that a two part enhanced posterior closure
reduces the rate of postoperative dislocation after primary
total hip arthroplasty.
Total Knee Arthroplasty - Mini
Incision -
Does Size Matter?
James W. Scott, M.D.
Mini incision is the new buzz word in total
joint arthroplasty. Surgeons must consider the benefit
or risks of the smaller incision.
Who benefits from smaller incisions? Surgeons
or patients?
What are potential benefits?
1. Cosmetics
2. Faster rehab? This is not yet proven.
3. Less complictions - which is doubtful.
4. Better patella tracking - no change
our cases
What are potential risks?
1. Skin trauma 2º pins, saw blade, traction
2. Component malposition
3. Third body wear - bone on cement left
in wound
4. Added operating room time
5. In inflammatory arthritis, less complete
synovectomy.
6. Patella tendon avulsion - a disaster
What is required?
1. Small instruments - cannot be
performed with standard instruments
2. Additional assistants (skilled)
3. Laminar spreader to allow access to
posterolateral and posteromedial
compartments.
4. Careful care and planning to balance
ligaments, select component size and
position.
Patient Selection -
This approach can be difficult or not
appropriate in:
1. Multiple prior skin incisions
2. Limited pre-op ROM
3. Post HTO 2º scarring of patellar tendon
4. Post distal femur fracture with suprapatellar
adhesions
5. Severe patellofemoral erosion - difficult
to dislocate patella
6. Osteopenia - because of added risk to
patellar tendon insertion, additional traction to expose posterolateral
corner of tibia.
7. Severe valgus - may be more difficult
to do lateral soft tissue release if patella is not everted.
8. Patella baja - less mobile extensor
mechanism than patella alta.
9. It is not adequate for revision. Despite
the difficulties, 4 or 5 incisions can be done safely, in
most cases.
TECHNICAL TIPS -
A video demonstration will be used to
show the technique.
It is useful to make bone cuts in the
following sequence:
1. Patella cuts - then lateral femoral
condyle osteophytes are removed to allow the patella to be
dislocated, not always everted.
2. Distal femoral cut - works better to
extend knee at this stage.
3. Proximal tibia - can be done prior to
distal femoral cut (if necessary to increase flexion.)
4. Distal femoral AP & chamber cuts.
5. Posterior femur - osteophytes, loose
bodies, etc.
We have gone from 8" to 6" to 4" successfully
with smaller instruments. Less than 4" is extremely challenging
and with standard TKA implants the added risk outweighs possible
benefits.
TECHNICAL PITFALLS -
1. Without very small femoral cutting guides
the patella - if not everted tends to displace cutting guides
and subsequently the femoral component medially - resulting
in abnormal patella tracking..
2. The posterolateral exposure of the tibial
plateau can be difficult and may result in tibial component
internal rotation and/or the tendency to downsize the tibial
component.
3. Difficulty removing cement from posterolateral
tibia and around posterior femur - 3rd body wear.
4. The patellar tendon is at risk from
traction as well as the saw blade.
5. Pins to affix cutting guides must not
go through skin - pits or rough edges can carry bits of skin,
drape, etc. into bone.
CLOSURE -
In conclusion, we can perform TKA through
smaller incisions. Should we??? Component position and
function are more important than incision size. It is acceptable
to attempt the mini incision. If we begin to struggle
the incision should be extended without hesitation. Few
patients complain about TKA incisions when they have good
function and pain relief.
Dr. Scott has an affiliation/financial arrangement
with Biomet,
E-Trauma and Merck.
Dr. Scott intends to discuss an unapproved/investigative
use of a commercial product device.
Extensor Mechanism Disruption in Total Knee
Arthroplasty
Carlton G. Savory, MD
The facts are inescapable. As the world population
ages, more patients seek and receive total knee arthroplasty
(TKA). Patients' and surgeons' demands are greater. More surgeons
are performing TKAs, and as a result, more failures will occur.
Extensor mechanism complications are often cited as the single
most common reason for reoperation after TKA.
Extensor mechanism disruption (patellar fracture,
quadriceps tendon or patellar tendon rupture) occurs either
immediately (intraoperatively) or is delayed. Immediate disruptions
can be addressed using the "VY" turn-down (Coonse-Adams) approach,
a tibial tubercle osteotomy, or a rectus "snip." Delayed disruptions
can be early or late but are equally difficult to treat.
Surgeons at the Mayo Clinic found the prevalence
of patellar fractures after 12,464 TKAs to be 0.68% and developed
a classification system based on implant stability, integrity
of the extensor mechanism, and quality of the bone stock.
In 1987, Lynch et al noted extensor mechanism complications
in 10% of 281 TKAs. Emerson et al reported on 15 knees with
extensor mechanism allograft used to treat patellar tendon
rupture after TKA and noted generally beneficial results despite
some complications. In 1999, Aracil et al described reasonable
long-term results in extensor mechanism reconstruction with
the Leeds-Keio ligament, although the numbers were small and
complications significant.
The authors' personal series of 10extensor mechanism
disruptions will be presented.
The old axiom prevails: "the best treatment
is prevention." Most extensor mechanism complications are
avoidable, probably iatrogenic, and technique dependent. It
is important to recognize red-flag situations (eg, obesity,
ankylosis in extension, limited flexion, increased postoperative
flexion, increased postoperative activity, and rheumatoid
arthritis) and to choose the surgical technique accordingly,
based on sound anatomic principles and with respect for the
blood supply.
Dr. Savory is a consultant for Stryker Howmedica
Osteonics.
Injuries to the Posteromedial Corner of
the Knee
Kurt E. Jacobson, MD
Background: Medial-sided knee injury
patterns have been poorly defined in the available literature.
In part, the lack of definition of can be attributed to the
differing anatomic perspectives of physician authors and the
functional significance they assigned to the posteromedial
structures of the knee.
Hypothesis: Many so-called medial collateral
ligament injuries can involve significant damage to the posteromedial
corner structures that may not be appreciated.
Study Design: Retrospective cohort study.
Methods: We reviewed the charts of 93
patients (93 knees) with operatively treated isolated and
combined medial-sided knee injuries and described the associated
medial injury patterns.
Results: Ninety-nine percent of the knees
were found to have an injury of the posterior oblique ligament.
In our series, 70% of the knees also had an injury of the
semimembranosus capsular attachment, and 30% were found to
have complete peripheral detachment of the meniscus. Injury
to the posterior oblique ligament was the common injury, but
other sites of disruption capable of disabling this dynamic
meniscocapsular complex were present.
Conclusions: Before assigning function
to the various posteromedial structures of the knee, we must
better define medial sided injury patterns, which is the
purpose of the current work. From our review
of medial-sided injuries in this series of patients, we have
come to realize that a subgroup of these knee injuries involve
injuries to the posteromedial structures that are under appreciated.
THOMAS E. WHITESIDES, MD, RESIDENT'S
AWARD
A Biomechanical Comparison of
Fixation Methods of Proximal Humerus Fractures: Is Locking
Plate Technology An Option?
Brett Sanders, MD
Emory University
Introduction: The three part proximal humerus
fracture still offers a challenging clinical dilemma in modern
Orthopaedics. Fixation problems arise from osteoporotic
bone stock, impaction, and comminution which are often associated
with this fracture pattern. Loss of fixation, pain, osteonecrosis,
and nonunion may occur as a result of this confluence of difficulties. Multiple
methods have been espoused for operative treatment including
conventional plating, IM nails, percutaneous pins, and combinations
of sutures and nails. However, no clear concensus is
evident as to which method is superior. The relatively
new concept of Locked plating offers a potential biomechanical
solution to this problem. To date, there are no studies evaluating
this form of fixation in the proximal humerus. This study
evaluates the biomechanical performance of the Synthes Locking
Proximal Humerus Plate versus a well studied alternative,
the Polaris Nail.
Methods: Three part osteotomies were created
in paired fresh frozen cadaver specimens (n=5 pair) obtained
from females over the age of 65 (mean =82). The specimens
were instrumented with either a Synthes locking proximal humeral
plate or a Polaris nail. A Bionix MTS machine was used
to obtain multi-plane load deformation data, followed by cyclic
loading and load to failure data on the specimens. A
quantitative method was used to evaluate absolute versus relative
stability.
Results: The Synthes Locking plate had
significantly greater stiffness in valgus compared to the
IM nail. All other loading vectors showed no statistical significance,
including the cyclic loading protocol. Load to failure
data for both devices was supraphysiologic at approximately
1000 Newtons. The Locked plate demonstrated absolute
stability behavior, whereas the IM nail demonstrated relative
stability.
Discussion: Our study demonstrated that
in a cadaver model, the Polaris Nail and Synthes Locking Plate
perform in a similar manner biomechanically and both can withstand
supraphysiologic loads. The locking plate may provide
rigid stability behavior in the setting of poor bone stock,
which could be advantageous in rehabilitation of a periarticular
fracture. Locking plate technology appears to be a viable
option in the treatment of these fractures.
Thermal Modification of Connective
Tissues: Basic Science Considerations and Clinical Implications
Steven P. Arnoczky, DVM
Presidential Guest Speaker
This lecture will explore the basic science
mechanisms behind the thermal modification (shrinkage) of
connective tissues. The role of thermal modification
as a clinical tool will also be discussed.
Dr. Arnoczky has an affiliation/financial
arrangement with Depuy, Wright Medical and Smith & Nephew.
ROTATOR CUFF SYMPOSIUM
Mini-Open Assisted Arthroscopic
Rotator Cuff Repair in Patients with Large and Massive Tears
Using a Double Row Fixation Technique
George M. McCluskey III, M.D.
Introduction
This prospective study evaluates the clinical
outcome of the mini-open assisted arthroscopic rotator cuff
repair utilizing a double row fixation technique in patients
with large and massive rotator cuff tears.
Methods
27 patients underwent mini-open assisted arthroscopic
rotator cuff repair for large and massive tears utilizing
a double row fixation technique. A medial row of suture
anchors were placed at the lateral humeral articular margin
and a lateral row of suture anchors or transosseous sutures
were placed at the greater tuberosity cuff insertion site. The
mean age was 61 years and the average follow up was 31 months. Functional
outcome was assessed utilizing the ASES score. Pre and
postoperative pain, strength, range of motion, and patient
satisfaction were also evaluated.
Concurrent procedures included subacromial decompression
(25), distal clavicle excision (10), biceps tenotomy (4),
biceps tenodesis (14), and SLAP repair (3).
Results
Active forward elevation improved an average
of 37°; external rotation 13°; and, internal rotation by four
spine segments. 94% of patients were satisfied with their
results. The average visual analog pain scale improved
from 8.5 pre-op to 1.2 post-op. The average ASES score
improved from 37 pre-op to 89 post-op. Two patients with
massive tears had symptomatic retears diagnosed at 3 months
and 20 months that were re-repaired. Two additional patients
developed postoperative adhesive capsulitis that required
synovectomy and capsular release.
Conclusion
This study provides evidence that a primarily
arthroscopic rotator cuff repair assisted by a small deltoid
split mini-incision can assist in providing secure fixation
in patients with large to massive rotator cuff tears, sometimes
involving multiple tendons.
Dr. McCluskey has an affiliation/financial
arrangement with Zimmer.
Tissue Engineered Augmentation
of Rotator Cuff Repair
Steven P. Arnoczky, DVM
This lecture will examine the potential use
of two commercially available tissue-engineered products (ReStore
Patch and Graftjacket) for augmentation of rotator cuff repair.
Dr. Arnoczky has an affiliation/financial
arrangement with Depuy, Wright Medical and Smith & Nephew.
Arthroscopic Repair of Partial Thickness
Rotator Cuff Tears
Xavier A. Duralde, M.D.
The treatment of partial thickness articular
side rotator cuff tears remains controversial with recommendations
ranging from debridement with or without acromioplasty to
mini-open repair following completion of the tear. We
report the results of a prospective nonrandomized series of
26 patients treated with arthroscopic acromioplasty and anatomic
arthroscopic repair of articular sided rotator cuff tears
(Ellman Grade III) without take down of the intact bursal
surface of the rotator cuff. There were 14 men and 12
women with an average age of 49 (range 28-67). All patients
were treated with a minimum of six months of conservative
management preoperatively. MRI preoperatively reported
a full thickness rotator cuff tear in 2 (8 percent), deep
partial thickness rotator cuff tear in 12 (46 percent), tendinosis
in 5 (19 percent), and no evidence of tear in 7 (27 percent). Additional
procedures included distal clavicle resection in 12 (46 percent),
biceps tenotomy in 2 (8 percent), and SLAP repair in 1 (4
percent). Follow-up averaged 18 months (range 12-28 months). American
Shoulder and Elbow Surgeons scores improved from 47.9 (range
15-71.75) preoperatively to 91.2 (range 38.4-100) postoperatively. Good
or excellent results were seen in 25 (96 percent) all of whom
were satisfied with the result of surgery. This reproducible
arthroscopic technique results in greater success than debridement
alone while avoiding the increased morbidity associated with
mini-open repair and take down of intact cuff tissue.
Open Rotator Cuff Repair Using
Minimally Invasive Surgery (MIS): A New Technique
Timothy R. Stapleton, MD
The concept of Minimally Invasive Surgery
(MIS) is currently a trend in orthopedics. This is not
really a new concept in shoulder surgery since we have been
using "mini-open" techniques for many years. However,
a somewhat new twist on this approach to the shoulder has
proven to be very effective in our hands. It has been
stated that the difference between an "open" and a "mini-open/arthroscopic-assisted"
rotator cuff repair is that the deltoid and CA ligament are
NOT detached from the acromion in a truly arthroscopic-assisted
mini-open repair while they are detached in an open repair.
We described a technique to perform an open
rotator cuff repair using a "mini-open" (3cm) incision that
has given us superior results, far more comparable to mini-open
than the traditional open results. The incision was first
taught to this author by Dr. John Waldrop of Columbus,
GA, while at the Hughston Clinic. He has been doing the
incision for over twenty years, although we have now made
it somewhat smaller. It starts at the tip of the acromion
and runs almost 90 degress to the traditional open rotator
cuff "saber"incision. While this breaks the "rule" of
Langer's lines, we have seen no more cosmetic problems than
with the traditional incision and it provides better exposure
to the rotator cuff. The deltoid and CA ligament are
detached but are meticulously repaired. Post-op failure
of either the rotator cuff repair of the deltoid repair has
been below most reported series.
We have performed over 1000 of these procedures
over the last seven years and now report on 630 that have
a minimum followup of 2 years. Arthroscopy was often
used in conjunction with the procedure, either for diagnosis
or to correct intra-articular pathology, but the entire decompression/rotator
cuff portion was done open. We report range of motion,
outcome results and complications, along with a detailed discussion
of the procedure itself. Patient satisfaction has been
superlative. We feel the technique is easily learned
and may assist the general orthopaedist in performing rotator
cuff surgery.
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