Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study

OBJECTIVES

To compare three fluoroscopic methods for determining femoral rotation.

METHODS

Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur.

RESULTS

Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques ( p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference ( p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods ( p = 0.020).

CONCLUSIONS

The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Vascularized Medial Femoral Condyle Graft for Manubrium Nonunion: Case Report and Review of the Literature

Fractures of the sternum are rare. Persistent nonunions, however, can lead to chronic pain and significant functional limitations. The vascularized medial femoral condyle is a versatile tool in the surgeon's armamentarium. Traditionally, it has been used as a thin corticoperiosteal graft in the treatment of nonunion of tubular bones. Its use as a structural corticocancellous graft has also been expanding. This report presents a case of a patient with a recalcitrant symptomatic nonunion of the manubrium treated with the unique combined corticoperiosteal and corticocancellous vascularized bone graft from the medial femoral condyle and reviews the literature concerning these uncommon nonunions. (Journal of Surgical Orthopaedic Advances.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures

Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

Technical tips for fixation of proximal humeral fractures in elderly patients

Despite the application of modern locking plate technology, complications remain common after fixation of proximal humeral fractures in elderly patients. Varus deformity and intra-articular hardware are most often responsible; fortunately, both of these complications can be avoided. Recent advances in imaging, reduction techniques, fixation methods, and postoperative care have made surgical outcomes more reliable. Particular attention should be directed to obtaining high-quality fluoroscopic images, avoiding varus reductions, supporting the osteoporotic humeral head, using appropriate screw length, using tension band sutures liberally, and protecting the construct postoperatively. With these methods, many proximal humeral fractures in patients older than 75 years can be reliably fixed.

Complications and outcomes of functional free gracilis transfer in brachial plexus palsy

The purpose of this study was to evaluate the outcomes and complications following free functional gracilis transfer for restoration of elbow flexion and/or finger flexion in patients with acute or chronic brachial plexus injuries. A review of 130 free functioning gracilis muscles transferred for brachial plexus injuries was undertaken to evaluate the failure rate as well as late complications. The overall failure rate (defined as a non-function muscle or one that failed acutely) was 15.4%. The most common late complication was fracture of the clavicle (5.4%). A technical modification of the procedure resulted in a decrease in these complications from a early rate of 7.9% graft failures and 7.9% clavicle fractures to a 2.4% (n = 1) failure rate and zero clavicle fractures in the subsequent 41 consecutive cases. Observations made in this series lead to a technique change, which has thus far resulted in no clavicle fractures, no bowstringing, improved graft viability and function, and a statistically significant decrease in overall complications (p < 0.001) associated with use of functioning free gracilis transfer in brachial plexus reconstruction.

Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique

BACKGROUND

Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level.

METHODS

Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically.

RESULTS

Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirty-two fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99 degrees . The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three.

CONCLUSIONS

Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.

Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique

BACKGROUND

Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level.

METHODS

Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically.

RESULTS

Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirty-two fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99 degrees . The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three.

CONCLUSIONS

Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.

Locking plate fixation for proximal humeral fractures: initial results with a new implant

Treatment of proximal humeral fractures remains controversial, with multiple reported techniques and variable results. Recently, locking plates have become available for fixation of osteopenic and comminuted fractures. This study reports our initial experience with a new locking plate designed specifically for proximal humeral fractures. We observed 16 patients until union or revision with a mean of 12 months' follow-up. Of the 16 patients, 9 had high-energy injuries. There were nine 3-part, five 2-part, and two 4-part fractures. Twelve of sixteen patients healed without complications. There were 4 nonunions; all occurred in patients with 3-part fractures with metadiaphyseal comminution, 3 of whom were heavy smokers. In patients with united fractures, mean elevation was 132 degrees and mean external rotation was 43 degrees, with mean internal rotation to T11. Locking plate fixation achieved union in 75% of patients in this series. Risk factors for delayed union or nonunion included comminution, smoking, and 3-part fractures. These fractures remain challenging despite the availability of locked plating systems.

Bankart repair in patients aged fifty years or greater: results of arthroscopic and open repairs

Currently, there is little information on the results of Bankart repairs in older patients. Therefore, the purpose of this study was to determine the results, complications, and rates of revision among patients aged 50 years or greater undergoing Bankart repairs. Between 1992 and 1999, 12 Bankart repairs were performed on patients aged 50 years or greater (mean, 57 years) at our institution. Eleven patients with complete clinical records, operative reports, and minimum 3-year follow-up (mean, 6.5 years) were included in the study. All patients had shoulder instability as a result of specific trauma. Six patients underwent open repairs, and five underwent arthroscopic repairs. There were no patients with full-thickness rotator cuff tears. At the most recent follow-up, there were no shoulders with recurrent instability. The mean simple shoulder test score was 10.8 in the open group and 9.8 in the arthroscopic group. The mean American Shoulder and Elbow Surgeons score was 98 in the open group versus 87 in the arthroscopic group. At the most recent follow-up, mean elevation in the open group was 178 degrees versus 174 degrees in the arthroscopic group. Mean external rotation was 70 degrees in the open group and 72 degrees in the arthroscopic group. The data from this study suggest that Bankart repair in older patients is associated with a low recurrence rate, and similar results may be obtained with either open or arthroscopic procedures.

Neurovascular compression following isolated popliteus muscle rupture: a case report

This case report concerns an unusual complication of neurovascular compression following an isolated popliteus muscle rupture. A 59-year-old man, after a fall from a horse, gradually developed symptoms of a swollen leg, dysesthesias in the sole of his foot, and muscle weakness of his toe flexors. At presentation, he was found to have a complete tibial nerve injury at the level of the popliteal fossa and significant neuropathic pain. MRI demonstrated a rupture in the muscular portion of the popliteus muscle with extensive edema and hemorrhage compressing the tibial nerve in the popliteal fossa. The edema extended up to the distal part of sciatic nerve where there was evidence of intraneural hemorrhage. In the course of recovery, the patient additionally developed deep venous thrombosis in the ipsilateral popliteal vein. Spontaneous recovery was documented on serial clinical and electrodiagnostic examinations. The patient's neuropathic pain improved significantly within 6 months and his neurologic function recovered nearly fully by 2 years.

Radiographic analysis of polyethylene glenoid components using modern cementing techniques

The purpose of this study was to examine the initial radiographic appearance and changes occurring over time in patients who have undergone total shoulder arthroplasty by modern methods of bone preparation and current cement techniques. Sixty-five patients underwent seventy total shoulder arthroplasties by use of a cemented all-polyethylene, keeled glenoid component. The surface radius was equal to the radius of a one-piece humeral component. The mean clinical follow-up was 4.18 years (range, 2-8.6 years); radiographic follow-up averaged 3.9 years (range, 2-8.6 years). Three observers evaluated radiographs 1 to 2 months postoperatively and at final follow-up. The glenoid component was considered at risk for clinical problems if there was a complete lucent line surrounding the component and some part of the line was 1.5 mm or greater in width or two of three or all three observers identified a shift in component position. Similarly, a humeral component was judged to be at risk if three or more zones had lucent lines 2 mm or greater in width or a shift in component position had occurred. On the early radiographs, 10 glenoid components had incomplete lucencies behind the keel. On the most recent radiographs, 59 glenoid components had incomplete lucent lines and 3 had complete lucent lines. Eight components were judged to have shifted in position. When data for lucent lines and shifting were combined, 10 (14%) of the glenoid components were at risk. At follow-up, no cemented humeral components were at risk whereas 3 (6%) of the 54 tissue ingrowth components were at risk for clinical loosening. Given the number of shoulders in this study, there were no associations between radiographic changes and clinical results. Improvements have occurred in glenoid component fixation. However, additional advances are possible and may occur from improved surgical technique, decreased particle-related osteolysis, enhanced joint kinematics, or novel fixation methods.

Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years

BACKGROUND

There is a paucity of data on the treatment of femoral neck fractures in young patients. The purpose of the present study was to review the results and complications associated with the treatment of femoral neck fractures with internal fixation in a large consecutive series of young patients.

METHODS

Between 1975 and 2000, eighty-three femoral neck fractures in eighty-two consecutive patients who were between fifteen and fifty years old were treated with internal fixation at our institution. Two patients died, and eight were lost to follow-up. Seventy-three fractures were followed until union, until conversion to hip arthroplasty, or for a minimum of two years; the mean duration of follow-up was 6.6 years. Fifty-one of the seventy-three fractures were displaced, and twenty-two were nondisplaced. The results and complications of treatment were retrospectively reviewed, and the effects of fracture displacement, reduction quality, and capsular decompression on outcome were evaluated. Function was assessed by evaluating pain, walking capacity, and the need for gait aids. The mean duration of follow-up for the fifty-seven patients (fifty-eight fractures) who had not undergone early conversion to arthroplasty was 8.1 years.

RESULTS

Fifty-three (73%) of the seventy-three fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. Osteonecrosis developed in association with seventeen fractures (23%), and a nonunion developed in association with six (8%). Four of the six nonunions later healed after a secondary procedure. At the time of the final follow-up, thirteen patients had had a conversion to a total hip arthroplasty because of osteonecrosis (eleven), nonunion (one), or both (one). Five (9.8%) of the fifty-one displaced fractures were associated with the development of nonunion, and fourteen (27%) were associated with the development of osteonecrosis. Three (14%) of the twenty-two nondisplaced fractures were associated with the development of osteonecrosis, and one (4.5%) was associated with the development of nonunion. Eleven (24%) of the forty-six displaced fractures with a good to excellent reduction were associated with the development of osteonecrosis, and two (4%) were associated with the development of nonunion. Four of the five displaced fractures with a fair or poor reduction were associated with the development of osteonecrosis, nonunion, or both.

CONCLUSIONS

The ten-year survival rate of the native femoral head free of conversion to total hip arthroplasty was 85%. Osteonecrosis was the main reason for conversion to total hip arthroplasty, but not all patients with osteonecrosis required further surgery. The results of treatment were influenced by fracture displacement and the quality of reduction.

Treatment of supracondylar femur nonunions with open reduction and internal fixation

We reviewed a consecutive series of 22 adults with 22 supracondylar femoral nonunions treated with open reduction and internal fixation (ORIF) to determine the results and complications associated with the procedure. Twenty-one of 22 nonunions (95%) healed. Knee Society pain scores improved from 18 to 88 (P < 0.001). Mean Knee Society functional scores improved from 4 to 55 (P < 0.001). Mean range of motion at follow-up was 1 degree to 96 degrees. ORIF and bone grafting of properly selected patients with nonunions of the distal femur resulted in high rate of union with few associated complications. All patients had improvement in pain scores and the great majority had improvements in functional scores.

Infection after shoulder instability surgery

Currently, there are no reported series on the outcome of patients treated for infection after shoulder instability surgery. Therefore, the purpose of this study was to review patients who were treated for infection after shoulder instability surgery at our institution between 1980 and 2001 to determine the functional outcome and organisms responsible for infection. During this period, six patients were treated for infection after shoulder instability surgery. Three patients had an early postoperative infection, presenting 6 weeks or less from the time of instability surgery. Three patients had a late infection, presenting 8 months or greater from the time of surgery. Each of the three patients with a late infection had a sinus leading to a retained nonabsorbable suture. None of the six patients have had recurrent shoulder instability. Three patients had a polymicrobial infection and three patients had single organisms. Infection may be acute or significantly delayed from the time of the instability procedure. Additionally, among patients with late infection, there should be a high degree of suspicion for a nidus of infection surrounding nonabsorbable sutures.

Intramedullary fixation of diaphyseal femoral fractures in elderly patients: analysis of outcomes and complications

The efficacy of intramedullary fixation for diaphyseal femoral fractures in young patients has been well documented. There is a paucity of data, however, on the efficacy of intramedullary techniques used in the ever growing elderly population. The purpose of this study was to analyze the outcomes and rate of perioperative complications associated with using intramedullary fixation to treat diaphyseal femur fractures in patients older than 65 years. We retrospectively reviewed the medical records and radiographs of 21 patients (17 men, 4 women) with isolated diaphyseal femoral fractures treated with anterograde intramedullary nailing at our institution. All fractures united. Ten surgical complications occurred in 9 (43%) of the 21 patients, and 7 medical complications occurred in 4 patients (19%); overall, 17 medical or surgical complications occurred in 11 patients (52%). Although more than half of the patients had an intraoperative or postoperative complication, intramedullary fixation is an effective method for achieving union in elderly patients with diaphyseal femoral fractures.

Management of the smashed distal humerus

The purpose of this article is to present a principle-based approach to treating the smashed distal humerus. These injuries are challenging to even the most experienced surgeons. The four goals, in order of priority, are soft tissue healing without infection, restoration of diaphyseal bone stock, union between the distal fragments and the shaft, and a stable and mobile articulation.

Radiographic assessment of cemented humeral components in shoulder arthroplasty

Forty-three shoulder arthroplasties performed with the use of cemented Neer II humeral components and followed radiographically for a mean of 6.6 years (range, 2-20 years) were analyzed. A humeral component was considered radiographically "at risk" for clinical loosening when a radiolucent line 2 mm or greater in width was present in 3 or more zones or tilt or subsidence was identified on sequential radiographs by 2 or 3 of the 3 independent observers. None of the components was considered to have tilted or subsided. Radiolucent lines of any size were present in 16 shoulders and were wider than 2 mm in 9 shoulders. They were limited to 1 zone in 8 shoulders and to 2 zones in 7 shoulders. Only 1 component (2%) with a 2-mm radiolucent line in 3 zones was judged to be "at risk." The incidence, extent, and thickness of humeral radiolucent lines were significantly higher in total arthroplasties than in hemiarthroplasties (P <.05). Clinically important changes around cemented Neer II humeral components are uncommon. Humeral radiolucent lines develop more frequently in the presence of a glenoid component. Data from this study can be used as one benchmark to compare with alternate methods of humeral component fixation.

[Shoulder hemi-arthroplasty in proximal humeral fractures]

Most fractures of the proximal humerus with significant displacement are best treated surgically. The range of surgical treatment varies from closed reduction and pinning to hemiarthroplasty depending on the degree of displacement, age of the patient, and bone quality. Determining whether or not the individual fractured bone segments are displaced to a significant degree requires high quality x-rays which can be difficult to obtain from acutely injured patients. Indications for replacement of the humeral head in acute fractures include: head splitting fractures in elderly patients, Neer 4-part fracture dislocations, selected 3 part fractures and fracture dislocations in elderly patients with poor bone quality and a very small head fragment, selected severe impression fractures in elderly patients that involve more than 40% to 50% of the articular surface and selected anatomical neck fractures in which internal fixation is not possible. If a prosthetic replacement of the humeral head is chosen, secure repair of the tuberosities is essential to avoid tuberosity migration and malunion. The clinical results of prosthetic replacement of the proximal humerus for acute fractures are superior to those for late arthroplasty. This treatment modality has been proven to relieve pain. However, even for patients treated with primary arthroplasty, a restricted range of motion has to be expected postoperatively. Furthermore, several studies indicate that a significant number of complications can occur following early and late prosthetic replacement. Humeral head replacement as a salvage procedure after malunions or failed open reduction and internal fixation is technically demanding with a relatively high rate of complications. Newer implant designs and instruments may improve the clinical results.

Radiographic assessment of ingrowth total shoulder arthroplasty

Sixty-two primary ingrowth total shoulder arthroplasties, performed between 1989 and 1992 and with a minimum radiographic and clinical follow-up of 2 years or until the time of revision surgery (mean, 4.6 years), were reviewed. To combine data on both the distribution and the thickness of periprosthetic lucency and change in component position, criteria were used to determine whether a component was radiographically "at risk" for clinical component loosening. A glenoid component was "at risk" when a complete lucent line was present, some part of it being 1.5 mm or greater in width, or when 2 of 3 or 3 of 3 independent observers identified migration or tilt of the component. A humeral component was "at risk" when a lucent line 2 mm or greater in width was present in 3 or more of 8 zones or when at least 2 of 3 independent observers identified tilt or subsidence of the component. Four (6.5%) of the 62 glenoid components and 6 (9.7%) of the 62 humeral components were judged to be "at risk." There were no identifiable patient, disease, or surgical characteristics associated with the development of an "at risk" glenoid or humeral component. Currently, despite this very favorable radiographic assessment, we reserve the use of a tissue ingrowth glenoid component for those patients with bone loss precluding bone cement fixation with a keel type of implant. Because advantages exist for use of a tissue ingrowth humeral component, a press-fitted component with ingrowth surfaces is currently used unless bone deficiencies prevent secure fixation without cement.

Clinical consultations using store-and-forward telemedicine technology

OBJECTIVE

To investigate the potential role of a store-and-forward (SAF) telemedicine system in specialty consultations initiated by primary care physicians.

MATERIALS AND METHODS

In this pilot telemedicine study, patients needing consultations in cardiology, dermatology, endocrinology, and orthopedics had both standard face-to-face (FTF) consultations and SAF consultations.

RESULTS

Fifteen patients had both FTF and SAF consultations, 4 had echocardiograms transmitted for an SAF consultation only, and 1 had an SAF consultation but no FTF appointment. Of 19 diagnoses made, all were essentially the same in both types of consultations; 14 of 15 FTF consultations and 15 of 19 SAF consultations resulted in additional treatment recommendations.

CONCLUSIONS

While it was possible to develop a desktop system for SAF consultations, the equipment was not adequately integrated. Without total digital input, including electronic patient medical records, packaging of information is laborious and impractical. Seamlessly adapting to existing clinical practice is vital. Issues such as increasing work for the physicians or office staff, gathering adequate patient information, and designing a referral process were more difficult than we had anticipated. Patient acceptance was high, but the clinical pilot had very small numbers.

The spiral compression plate for proximal humeral shaft nonunion: a case report and description of a new technique

We present a case of humeral nonunion managed with a dynamic compression plate (DCP) contoured in a spiral fashion to preserve the deltoid muscle insertion. A forty-one-year-old woman sustained a closed proximal third humeral shaft fracture with an associated supraclavicular brachial plexus injury. She presented five months later with an atrophic nonunion of the proximal humeral shaft, inferior subluxation of the humeral head, and a resolving brachial plexopathy. Autogenous cancellous bone grafting and open reduction and internal fixation with a narrow DCP was performed. The deltoid muscle insertion was preserved by contouring the plate to fix the proximal humerus laterally over the greater tuberosity and anteriorly over the mid-humeral shaft. During the postoperative period, the humeral head reduced spontaneously. Five months after surgery, the fracture healed, and an excellent clinical result was achieved. We recommend the use of the spiral DCP for proximal shaft fractures and nonunions when preservation of the deltoid insertion is desirable.

Arthroscopically assisted percutaneous quadricepsplasty: a case report and description of a new technique

Restricted motion of the knee occurs frequently after an intra-articular fracture of the distal femur. Treatment of this complication typically requires open release of the quadriceps muscle. To our knowledge an arthroscopically assisted method of performing a quadricepsplasty has not been previously described. We present such a case and the details of the arthroscopically assisted method that may provide an alternative, minimally invasive means of restoring knee flexion in the setting of a post-traumatic extension contracture.

Total shoulder arthroplasty with the Neer prosthesis: long-term results

We determined the outcome of 113 total shoulder replacement arthroplasties performed with a Neer prosthesis between 1975 and 1981. The operations were performed for the treatment of osteoarthritis, rheumatoid arthritis, and old fractures or dislocations with traumatic arthritis. The probability of implant survival was 93% after 10 years and 87% after 15 years. Complications requiring reoperation developed in 14 shoulders. Seventy-nine patients with 89 replacements were available for follow-up a minimum of 5 years after the operation (mean 12.2 years, range 5 to 17 years). Relief from moderate or severe pain was achieved in 83% of shoulders. Active abduction improved by an average of 40 degrees to an average of 117 degrees. The amount of elevation that was regained was related to the amount of rotator cuff disease. Seventy-five glenoid components developed bone-cement radiolucencies, and 39 (44%) glenoid components had radiographic evidence of definite loosening. Glenoid loosening was associated with pain. A shift in position of the humeral component occurred in 49% of the press-fit stems and in none of the cemented stems. Humeral component loosening was not associated with pain.

Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders

One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).

Open fractures of the patella

We retrospectively reviewed 57 open patella fractures treated at our institution between 1976 and 1989. Forty-four patients with 47 fractures (cases) were available for follow-up a mean of 9.4 years after injury (range 2.2-15.7). High-energy vehicular trauma was the cause of injury in > 90% of cases. Treatment included osteosynthesis in 50% of cases and patellectomy (partial or total) in the remainder. At follow-up evaluation, results were excellent in 17% of cases, good in 60%, fair in 17%, and poor in 6%. Nonunion occurred in two cases in which nonrigid internal fixation was used. The incidence of deep infection was 10.7%, and the infection rate correlated with the magnitude of soft-tissue injury. Two of the seven fractures (29%) treated with cerclage wiring became infected. None of the open type I and II fractures treated with immediate internal fixation or primary wound closure (or both) became infected. Therefore, we recommend immediate rigid internal fixation (other than cerclage wiring) of types I and II open patella fractures. Partial patellectomy of highly comminuted fractures provided results similar to those of internal fixation of less comminuted fractures. Thus, when comminution precludes fixation, partial patellectomy can be performed without hesitation. The timing of wound closure should be individualized.

Total hip arthroplasty with cement in patients less than twenty years old. Long-term results

Sixty-three consecutive total hip arthroplasties were performed with cement in fifty adolescent patients from 1972 through 1980, and the results were determined after a minimum of ten years. A polyethylene cup without a metal backing and a non-modular femoral component with a collar and a fixed neck length were inserted, with use of so-called first-generation cementing techniques, in each hip. Kaplan-Meier survival analysis of all sixty-three hips demonstrated that the probability of failure (defined as revision or symptomatic loosening) increased steadily over time and reached 45 per cent after fifteen years. A number of specific variables were associated with a significantly higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0002), unilateral arthroplasty (p = 0.006), previous trauma involving the hip (p = 0.01), the absence of other disease that limited function of the ipsilateral lower extremity (p = 0.03), a high postoperative level of activity (involving moderate or strenuous manual labor) (p = 0.03), and a preoperative weight of more than sixty kilograms (p = 0.03). The probability of failure in the patients who had inflammatory arthritis (11 per cent) was significantly lower than that in those who had previous trauma involving the hip (47 per cent) (p = 0.0006). Fifty-two hips (forty patients) were followed for a minimum of ten years or until revision. The mean duration of follow-up for these fifty-two hips was 12.6 years (range, 1.6 to 18.6 years). The result was evaluated clinically and radiographically with use of the Mayo hip-scoring system and was graded as excellent in ten hips (19 per cent), good in sixteen (31 per cent), fair in one (2 per cent), and poor in twenty-five (48 per cent). Most of the poor results were due to symptomatic loosening of the acetabular component. The probability of radiographic loosening after fifteen years was 60 per cent for the acetabular component and 20 per cent for the femoral component. Radiographic evidence of polyethylene wear was associated with probable loosening of the acetabular component (p = 0.03). The findings of the present study suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. Fixation of the acetabular component with cement is not recommended in this setting.

Managing Posterior Shoulder Instability

In brief Posterior shoulder instability, a recently recognized source of pain in throwing, overhand, and contact sports, usually results from repetitive microtrauma or a single traumatic episode. Physical signs often are not obvious, so targeted physical tests, provocative maneuvers, and radiographic studies are needed to identify abnormal humeral head translation. Examination under anesthesia or arthroscopy may be required. The first line of treatment focuses on an intensive physical therapy protocol that strengthens the infraspinatus, teres minor, and posterior deltoid muscles. Surgery may be indicated, but ideal technique is a matter of debate.

A quantitative assessment of cross-sectional cortical bone remodeling in the femoral diaphysis following hip arthroplasty in elderly females

A quantitative assessment of cross-sectional cortical bone remodeling in the femoral diaphysis following hip arthroplasty was made by direct in vitro measurements of cross-sectional geometric properties. We obtained eight femora from four female cadavers ranging in age from 77 to 96 years. In three cases unilateral uncemented Austin Moore implants were used, and in one case a unilateral cemented Thompson prosthesis had been implanted. The time of implantation in the two specimens where this information could be obtained was greater than 40 months. Sections were made at 12 diaphyseal locations from the superior aspect of the lesser trochanter through the distal diaphysis. Section properties (areas and second moments of area, or area moments of inertia) were determined by tracing photographs of the cross-sections with a digitizer. In this sample of prosthetic femora, we found reductions in both total subperiosteal area (TA) and endosteal area (ENDA) relative to the contralateral unoperated side in most sections distal to the lesser trochanter. The average pairwise reduction in ENDA for this region was 21.1 mm2, reaching statistical significance in one distal diaphyseal section. The average decline in TA in this region was 10.2 mm2. Because the reduction in endosteal dimensions was generally greater than the reduction in subperiosteal dimensions, cortical area (CA) was maintained or increased throughout the distal 80% of this region in prosthetic femora with an average increase in CA of 9.3 mm2, reaching statistical significance in one mid-diaphyseal section. A completely different pattern of remodeling occurred in the two most proximal sections through the lesser trochanter and base of the femoral neck.(ABSTRACT TRUNCATED AT 250 WORDS)