Faculty Bibliography

Traumatic injuries of the hand and fingers may be devastating and can result in irreversible functional and psychological problems in individuals who sustain them. They occur in all age groups, ranging from the elderly to young children. The management of these injuries can be challenging and onerous. As a result, it is imperative that the surgeon be both knowledgeable and meticulous in order to afford the best possible outcomes. This review focuses on the anatomy, initial evaluation, and acute management of these injuries. A variety of treatment algorithms are discussed as well, including primary closure, grafting, commonly utilized flaps, and replantation.

Aneurysmal bone cysts are rare skeletal tumors that most commonly occur in the first two decades of life. They primarily develop about the knee but may arise in any portion of the axial or appendicular skeleton. Pathogenesis of these tumors remains controversial and may be vascular, traumatic, or genetic. Radiographic features include a dilated, radiolucent lesion typically located within the metaphyseal portion of the bone, with fluid-fluid levels visible on MRI. Histologic features include blood-filled lakes interposed between fibrous stromata. Differential diagnosis includes conditions such as telangiectatic osteosarcoma and giant cell tumor. The mainstay of treatment is curettage and bone graft, with or without adjuvant treatment. Other management options include cryotherapy, sclerotherapy, radionuclide ablation, and en bloc resection. The recurrence rate is low after appropriate treatment; however, more than one procedure may be required to completely eradicate the lesion.

Since the 1980s, hip arthroscopy has become an accepted treatment modality for a variety of hip conditions. It is generally considered a low-risk procedure with a low rate of complications. The risk of developing a deep venous thrombosis (DVT) or venous thromboembolism following these procedures is also thought to be low, and most patients undergoing these procedures receive no pharmacologic prophylaxis postoperatively.This article presents a case of a 33-year-old woman with a history of oral contraceptive use who presented 13 days after a routine hip arthroscopy with pain and swelling in the contralateral thigh. Ultrasonography revealed acute DVTs in the left common femoral, superficial femoral, and popliteal veins. She was admitted to the hospital and treated accordingly. A workup for thrombophilic disorders was negative. We believe that her history of oral contraceptive use, the use of axial traction, and asymmetric forces about the pelvis during the procedure contributed to this postoperative complication.Although this complication is rare and the use of pharmacologic prophylaxis is not common, physicians must be aware of this potential complication following hip arthroscopy

Metal-on-metal bearing surfaces in total hip arthroplasty have been recently shown to have acceptable survivorship properties (J Bone Joint Surg Am. 2006;88:1183; J Bone Joint Surg Am. 2006;88:1173), and they have certain advantages and disadvantages when compared to conventional metal-on-polyethylene bearing surfaces. Like traditional metal-on-polyethylene bearings, these metal-on-metal implants may also suffer from catastrophic failure. This case report represents an unusual situation in a 57-year-old man in which dissociation of a metal inlay in a metal-on-metal total hip arthroplasty resulted in articulation of the inferior aspect of the inlay with the femoral neck, leading to femoral neck notching, extensive periprosthetic soft tissue metallosis, osteolysis, and subsequent prosthetic catastrophic failure

The pathology, assessment, and management of articular cartilage lesions of the hip and knee have been the subject of considerable attention in the recent orthopaedic literature. MRI has long been an important tool in the diagnosis and management of articular cartilage pathology, but detecting and interpreting early cartilaginous degeneration with this technology has been difficult. Biochemical-based MRI has been advocated to detect early cartilaginous degenerative changes and assess cartilage repair. Techniques such as T2 mapping, T1rho (ie, T1 in the rotating frame), sodium MRI, and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) take advantage of changes in the complex biochemical composition of articular cartilage and may help detect morphologic cartilaginous changes earlier than does conventional MRI. Although the newer modalities have been used primarily in the research setting, their ability to assess the microstructure of articular cartilage may eventually enhance the diagnosis and management of osteoarthritis

Group A streptococcus is responsible for a diverse range of soft tissue infections. Manifestations range from minor oropharyngeal and cellulitic skin infections to more severe conditions such as necrotizing fasciitis and septic shock. Troubling increases in the incidence and the severity of streptococcal infections have been reported over the past 25 years. Cases of streptococcal necrotizing fasciitis have received significant attention in the literature, with prompt surgical debridement being the mainstay of treatment. However, cases of rapidly progressing upper extremity streptococcal cellulitis leading to shock and a subsequent surgical intervention have not been well described.This article presents a case of an 85-year-old woman with a rapidly progressing, erythematous, painful, swollen hand associated with fever, hypotension, and mental status change. Due to a high clinical suspicion for necrotizing fasciitis, the patient was rapidly resuscitated and underwent immediate surgical irrigation and debridement. All intraoperative fascial pathology specimens were negative for necrotizing fasciitis, leading to a final diagnosis of Group A streptococcal cellulitis. Although surgical intervention is not commonly considered in patients with cellulitis, our patient benefited from irrigation and debridement with soft tissue decompression. In cases of necrotizing fasciitis as well as rapidly progressive cellulitis, prompt diagnosis and aggressive treatment may help patients avoid the catastrophic consequences of rapidly progressive group A streptococcal infections

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ

Although relatively uncommon, fractures of the distal humerus in the elderly patient population are significant injuries of which optimal management is a subject of debate in orthopaedic literature. The combination of complex anatomy, poor bone quality and extensive comminution often seen with these fractures makes successful treatment difficult. Currently, most surgeons support surgical fixation of distal humeral fractures with the belief that restoration of the patient's native elbow joint provides the best opportunity for a good functional outcome. Others have proposed the use of total elbow arthroplasty as a primary treatment method for geriatric distal humeral fractures based on the difficulties associated with ORIF and the relatively low demands of this patient population. To date, there have been no prospective randomised trials comparing these two treatment alternatives, and a comparison of available outcome data shows good functional outcome for both forms of fracture management. With the aging of the population and an associated increase in the incidence of distal humeral fractures, the debate over the optimal treatment regime will undoubtedly continue