Nebraska Orthopaedic Hospital

The system of grading presented here more nearly meets the requirements set forth than have others presented in the literature. This system attempts to standardize all important findings, so that various observers can arrive at the same grade for any given hip. It makes possible a comparison of the same hip at various ages which, as will be shown in Part II, gives valuable information. Those findings of least accuracy are grouped together and do not lessen the accuracy of the whole. The physical findings are more accurate than the symptomatic observations, but they too will not be graded by two observers exactly alike, since an estimate of the degree of limp and of hip motion will vary even between two careful observers. The roentgenographic grade depends for the most part on actual measurements which can be checked by more than one observer and, although these measuremensts admittedly vary somewhat with changes in projection of the roentgenograms, it is believed that this variation can be minimized by attention to details. The same plan of grading results, with some modification of the basic roentgenographic factors, can be used in evaluating the long-term results of therapy in other hip conditions.

BACKGROUND: Patients with surgical site infections (SSIs) require a longer time in the hospital, more nursing care, additional dressings, and, possibly, readmission to the hospital and further surgery. The combined direct and indirect costs of treating SSIs may be extremely high. METHODS: Review of current practice and guidelines. RESULTS: The direct costs of SSI include a longer hospital stay, readmission, outpatient and emergency visits, further surgery, and prolonged antibiotic treatment. Other direct costs arise from radiologic procedures, laboratory tests, home health visits and other ancillary services, drugs, and professional fees. Indirect costs, which are difficult to quantify, include lost productivity of the patient and family and a temporary or permanent decline in functional or mental capacity. The cost of SSIs increases with the depth of the infection. That is, the costs associated with superficial incisional SSIs are relatively low, but increase with deep SSI, and especially when organ or space infection is present. The estimated costs of managing SSI differ widely, from less than dollar 400 per case for superficial SSI to more than dollar 30,000 per case for serious organ or space infections. CONCLUSIONS: The need to treat SSIs places a severe financial strain on health care resources. It is possible that treating high-risk surgical patients medically will prove to be more cost-effective than repeated operations.

The role of the posterior tibial muscle in producing foot deformities has been stressed in the literature. The importance of releasing the posterior tibial tendon in correcting an equinovarus deformity has been well recognized. A review of the literature, however, reveals that transplantation of the posterior tibial tendon through the interosseous space is not a well known operative procedure. Transplantation of the posterior tibial muscle and tendon through the interosseous space is a valuable operative procedure and can be relied upon to restore active dorsiflexion of the foot. The operation is applicable to a wide variety of conditions in which the posterior tibial muscle has good power and there is a need for an additional dorsiflexor of the foot.

UNLABELLED: Elite overhead throwing athletes with rotator cuff tears represent a unique group of patients with an ultimate goal of returning to their previous level of competition. We hypothesized débridement of small partial-thickness rotator cuff tears would return the majority of elite overhead throwing athletes to their previous level of competition. Preoperative and intraoperative findings on 82 professional pitchers who had undergone débridement of partial-thickness rotator cuff tears were evaluated using our database. We obtained return to play data on 67 of the 82 players (82%); 51 (76%) were able to return to competitive pitching at the professional level and 37 (55%) were able to return to the same or higher level of competition. Of the 67 patients, 34 pitchers returned a questionnaire with a minimum followup of 18 months (mean 38 months; range 18 to 59 months). SF-12 scores were above average with a mean PSF-12 and MSF-12 of 55.04 and 56.49 respectively. An Athletic Shoulder Outcome Rating Scale score of greater than 60 was found in 76.5% of pitchers. Débridement of small partial-thickness rotator cuff tears allowed a majority of elite overhead throwing athletes to return to competitive pitching, however, returning to their previous level of competition remains a challenge for many of these players. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Magnetic resonance imaging (MRI) and clinical examination are tools commonly used in the diagnosis of meniscus tears. It has been suggested routine MRI before therapeutic arthroscopy for clinically diagnosed meniscus tears will reduce the number and cost of unnecessary invasive procedures. We designed a systematic review of prospective cohort studies comparing MRI and clinical examination to arthroscopy to diagnosis meniscus tears. Thirty-two relevant studies were identified by a literature review. Careful evaluation by an experienced examiner identifies patients with surgically treatable meniscus lesions with equal or better reliability than MRI. MRI is superior when indications for arthroscopy are solely diagnostic. However, the methods by which such a clinician arrives at a conclusion have not been identified. To create an evidence-based algorithm for the diagnosis of a meniscus tear future investigations should prospectively assess the value of commonly used aspects of the patient history and meniscus tests. MRI is useful, but should be reserved for situations in which an experienced clinician requires further information before arriving at a diagnosis. Indications for arthroscopy should be therapeutic, not diagnostic in nature.

The hip should never he held in a position of tension, especially extension, abduction, and internal rotation, as this wrings out the blood vessels along the neck and still further embarrasses the circulation. No operation should be done when acute pain and spasm are present, at least until after two or three weeks of bed rest. The treatment of choice is pegging of the epiphysis in the preslipping stage or before much slipping has occurred. The results of this operation have been excellent, and far better than with any of the other methods of treatment. Drilling without pegging has little or no effect on the course of the disease. Even the slipped epiphysis can be pegged, and the deformity can be corrected later by subtrochanteric osteotomy.

The acromioclavicular (AC) joint enjoys the dubious distinction of being one of the few joints in the body whose total dislocation is routinely treated by simply leaving the joint dislocated. Adherents of both conservative and operative treatment have presented reasons for their viewpoints. Residual shoulder weakness has been offered as a sequela of untreated acromioclavicular injury and a reason for repairing the joint. An objective evaluation of shoulder strength would be valuable in determining the optimum treatment for this injury. The purpose of our study was to quantitate, using the Cybex II, the residual shoulder weakness following various modes of treatment. Seventeen patients with Grade III AC separations and eight patients with Grade II AC sprains were reviewed. Nine of the Grade III injuries were treated and eight nonoperatively. All Grade II injuries were treated nonsurgically. All patients were tested on the Cybex II isokinetic dynamometer at both slow and fast speeds through various ranges of motion. Grade III injuries treated nonoperatively showed no significant strength deficits. Surgically treated Grade III injuries had a significant strength deficit in vertical abduction at fast speeds (19.8%) when compared to the uninjured shoulder. Interestingly, the Grade II injuries led to a significant weakness in horizontal abduction (24.3%) at fast velocity. Evaluation of subjective results showed that Grade III injuries treated conservatively had the most pain and stiffness, despite their strong shoulders. Patients with Grade III injuries treated operatively rated their overall outcome below that of those treated conservatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Despite the lack of consensus guidelines and randomized control trials, the use of arthroscopy for the treatment of osteoarthritis of the knee has increased over the last decade. Techniques used for the arthroscopic treatment of osteoarthritis of the knee include joint lavage, joint débridement, meniscectomy, abrasion arthroplasty, and microfracture. We performed a retrospective, evidence-based review of the current literature on the arthroscopic treatment of osteoarthritis of the knee and provide insight into the study design flaws and difficulties associated with the current research on this controversial topic. Our literature search yielded 18 relevant studies. Of these, one was Level I evidence, five were Level II, six were Level III, and six were Level IV. We found limited evidence-based research to support the use of arthroscopy as a treatment method for osteoarthritis of the knee. Arthroscopic débridement of meniscus tears and knees with low-grade osteoarthritis may have some utility, but it should not be used as a routine treatment for all patients with knee osteoarthritis.

Current indications for shoulder arthrodesis include posttraumatic brachial plexus injuries, paralysis of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. The trapezius, levator scapulae, serratus anterior, and rhomboid muscles must be functional to optimize the functional result following shoulder arthrodesis. A consensus has not been reached concerning the ideal position of the shoulder arthrodesis, although excessive abduction or flexion has been associated with chronic postoperative pain. Decortication of both the acromiohumeral and the glenohumeral surfaces to increase the surface area available for arthrodesis is the most common means for obtaining successful fusion. Although there are numerous methods for stabilization of a shoulder arthrodesis, the most popular method today is probably the AO technique with either a single plate or double plates.

Osteochondral defects in the distal femoral condyles of rabbits exposed to a pulsing direct current exhibits an enhanced quality of repair. The signal, with a peak value of 2 microA repeating at 100 Hz, imposed an electric field in the tissue of 20-60 mV/cm2. Maximum efficacy was seen with a shorter period of exposure (40 vs. 160 h) initiated 48 h after surgery for 4 h/day. Repair tissue originated primarily from metaplasia of subchondral elements although hyperplasia of pre-existing chondrocytes at the margins of the defect could be detected. Defects in treated joints contained Safranin O staining material that was histologically similar to a disorganized hyaline cartilage. Central areas of the defects in control animals contained Safranin O-negative material that generally extruded over the surface as a pannus. The edges of nontreated defects also had characteristics of cartilaginous healing, stressing the importance of using serial sectioning techniques in this model of cartilage repair.

Concerns about the transmission of the human immunodeficiency virus (HIV) have driven the evolution of surgical transfusion practices including the use of preoperative erythropoietin (rhEPO). Although there is significant experience documenting the efficacy of preoperative rhEPO in reducing transfusion requirements for adult patients, there is little experience in the pediatric population. With 178 pediatric patients who underwent surgery for spinal deformity, a retrospective cohort study was performed using patient charts, administrative records, and blood bank computer data. Of these patients, 44% received erythropoietin and 55% did not. From the entire population, 17.5% were in the rhEPO treatment group that received homologous blood transfusion compared with 30.6% in the untreated group (p < 0.05). Among the children with idiopathic scoliosis, this effect was more pronounced, with 3.9% of rhEPO patients receiving blood transfusion compared with 23.5% of nontreated patients (p = 0.006). Additionally, rhEPO treatment was associated with a significantly decreased length of stay only for patients in the idiopathic group (9.3 vs. 6.7, p = 0.02). Use of preoperative erythropoietin in pediatric patients undergoing scoliosis surgery resulted in higher preoperative hematocrit levels. Significantly lower rates of transfusion were noted only in the idiopathic group, however. Although there is a possibility of erythropoietin "resistance" in the neuromuscular and congenital patients, alternative explanations for the lack of effect on transfusion rates may include underdosing and biases existent in this nonrandomized retrospective study.

1. The results eighteen years after open reduction of the fitty-eight hips are as follows: [see pdf for table] 2. The optimum roentgenographic grade was attained two years after reduction in 66 per cent. of the hips, and by puberty in 85 per cent. Hips followed roentgenographically in children between the ages of five and eight years show definite trends toward the eventual adult result, a fact which is of practical value in determining further treatment. 3. Vascular changes were seen in 41 per cent. of the femoral heads In 81 per cent. of the hips so involved, the roentgenographic rating was below 70 per cent. of normal 4. It is again proposed that an initial capsular relaxation is the primary abnormality in congenital dislocation of the hip. Subluxation and dislocation are the result of the mechanical forces applied to the hip with a relaxed capsule. The acetabular changes are secondary. 5. Any degree of post-reduction subluxation seriously jeopardizes the development of a normal adult hip. Increase of the subluxation ensures an unsatisfactory result. On the other hand, the obtaining and maintaining of perfect reduction ensure an excellent result if no vascular change affects the epiphysis.

Management of nonunions requires careful and critical assessment of the true biologic status of the fracture. The mere radiographic persistence of a fracture line does not invariably indicate nonunion. Ten percent of fractures considered initially to be ununited in this series healed spontaneously without further treatment. The patient who has no pain with weight-bearing and no demonstrable motion on careful stress studies does not usually require further treatment, except for protection against reinjury. Intraosseous venography may be useful to distinguish the delayed from the nonunion in order to institute appropriate and early treatment. Percutaneous direct-current electrostimulation is proving to be a reliable and effective method of managing the most common nonunion of the tibia or distal femur. It appears less satisfactory for the more proximal femoral fractures and for fractures of the humerus. Electrical stimulation does not eliminate the need to stabilize the nonunion of either the femur or the upper limb. Electrical stimulation also does not eliminate the need for bone grafting in approximately 15% to 20% of nonunions. The fractures' biologic inability to respond may be identifiable by 99MTc diphosphonate bone scan. The implantable direct-current electrical stimulatory device proved ineffective in this series. Hopefully, further development of this technology may produce more consistent results in the future. The electromagnetic noninvasive stimulator appears to be a useful alternative method to the semi-invasive system. This, of course, should depend on the individual needs of the patient and the nature and location of the fracture. Continued technologic improvement in all electrical stimulatory methods should broaden their usefulness and applicability. However, the healing status of the fracture and the processes by which each fracture responds must be carefully assessed to appreciate what is being effected by electrical stimulation. Critical evaluation and clarification of indications are essential if the patient is to be offered the most effective therapy available.

The cases of three brothers with similar lesions of osteochondritis dissecans in the knee joint are reported. The theories of the etiology and pathogenesis of this condition are reviewed and discussed. It is suggested that there are two distinct groups or types of cases. One is the type in which trauma is the cause. The second type, which occurs in children and in which the lesions are often multiple, sometimes is familial and is occasionally associated with osteochondritis in other joints, probably due to some systemic condition. It is further postulated that this may well be a metabolic disturbance. The treatment of osteochondritis dissecans in the knee is also discussed.

1. Clinical evidence in support of Wolff's law as originally propounded has been cited. 2. Jansen's contention that tension always produces bone atrophy is not substantiated, and his proposal that Wolff's law be modified accordingly is unwarranted. 3. A bone graft will survive and will continue to hypertrophy, although under constant tension.

In a canine model with a transepiphyseal distal femoral fracture, varus deformity was corrected and the arrested limb was lengthened using transphyseal traction (turnbuckle). Correction was possible without removing the transphyseal bone bridge operatively. Subsequent growth was not adversely affected in most animals. Based on this study, two patients with significant growth deformities secondary to an enchondroma were treated by epiphyseal traction. Although correction was achieved initially, both lost the length previously gained because of premature removal of the external fixator and/or subsequent early growth plate closure.

This study was to determine whether there is any benefit to wrapping the toes sterilely during orthopaedic procedures not involving the foot but performed on the lower extremity. The group studied consisted of 12 patients who had an orthopaedic procedure performed in which the foot and toes were included in the surgical prep, but not involved in the surgical procedure. Nine of the 12 patients (75%) had positive results from preprocedural aerobic cultures and two of the 12 (16.6%) had positive results from preprocedural fungal cultures. Recolonization of the bacteria between the toes was also demonstrated. Sterile draping of the toes would minimize the risk of infection and also protect against bacteria that recolonize during the procedure.

Total hip arthroplasty was performed in 13 hips with acetabular bone grafts for secure component fixation. The incorporation and healing of acetabular bone grafts were investigated with the aid of roentgenograms, planar bone scans, and a newer scintigraphic technique, three-dimensional single photon emission computed tomography (SPECT). Conventional roentgenograms proved unreliable in evaluating bone graft reconstitution because of overlapping trabecular bone patterns of the graft and iliac wing. There was no evidence of graft failure or acetabular loosening. Bone grafts in the late follow-up group (four to seven years postoperation) exhibited normal radionuclide activity, whereas grafts less than one year postsurgery demonstrated patterns of increased activity. SPECT was helpful in producing an anatomic reconstruction of the acetabulum. The observation that bone grafts exhibited normal biological viability is crucial for ensuring secure acetabular component fixation on a long-term basis.

Monteggia fractures represent approximately 1 to 2 percent of forearm fractures, whereas Galeazzi fractures represent 3 to 6 percent. The combination of these injuries in the same extremity is an exceedingly rare occurrence. We report a case of ipsilateral combination Monteggia and Galeazzi fractures in an adult patient. The patient was treated with anatomic reduction and rigid internal fixation. The radius was stabilized with a 3.5-millimeter dynamic compression plate (Synthes USA, Paoli, PA, U.S.A.) and the olecranon with tension band fixation. The radiocapitellar and distal radioulnar joint relationships were restored; the fractures healed; and the patient proceeded to obtain a satisfactory functional result at one year.

Normal fracture healing in long bones is a poorly defined process which to a great extent is dependent on periosteal response to injury. When this normally effective mechanism fails, electrical enhancement may prove an effective adjunct and less morbid solution than standard bone grafting procedures for periosteal reactivation.