Faculty Bibliography

UNLABELLED:Interposition arthroplasty reportedly improves outcomes after traditional salvage procedures for advanced hallux rigidus. We hypothesized this procedure can provide pain relief and satisfactory function with few complications. We examined 18 patients with severe articular cartilage loss who received 21 interposition arthroplasties. The patients a mean age was 56 years. They had a mean followup of 38 months. All patients had substantial loss of articular cartilage when examined intraoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society and Short Form-36 scores. All 18 patients had pain relief, and 17 of 18 patients said they would have the procedure again. The mean postoperative increase in range of motion of the first meta-tarsophalangeal joint was 37 degrees . The mean American Orthopaedic Foot and Ankle Society and Short Form-36 scores were 78.4 and 96.3, respectively. The complication rate was 6%. Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint. LEVEL OF EVIDENCE/METHODS:Therapeutic study, Level IV (case series).

Metatarsalgia of the central ray is a major surgical challenge. Without precise correction, transfer lesions may occur at an adjacent metatarsal or patients may have inadequate pain relief. Current surgical treatment strategies do not facilitate precise positioning in different planes, resulting in disappointing outcomes. To achieve better outcomes we used an oblique sliding osteotomy to facilitate precise correction. We hypothesized the procedure would reduce pain in patients with prominent second and/or third metatarsal heads, with few complications. We retrospectively reviewed 32 consecutive patients with 42 osteotomies of the lesser metatarsal bones. The mean and median ages at the time of surgery were 49 and 54 years, respectively, with a minimum followup of 26 months. Thirty-one patients (97%) had relief of plantar pain. The mean American Orthopaedic Foot and Ankle Society score was 82.4 points. We identified no transfer lesions. The median time to radiographic union was 10 weeks. Although time to bony union can be extended, the oblique sliding osteotomy facilitates intraoperative adjustment to provide the precise positioning critical to eliminating plantar pain.

Isolated carpal scaphoid dislocations are rare. Because of this, treatment strategies can be conflicting and vague. The current authors present a case of isolated scaphoid dislocation that was treated initially with closed reduction and percutaneous pinning. Failure of this index treatment necessitated open reduction and internal fixation providing an adequate short-term outcome. Current treatment strategies now advocate ligament reconstruction as a first-line treatment to restore normal anatomy and preserve function.

BACKGROUND:Patellar complications following endoprosthetic reconstruction can occur as a result of anatomic, physiologic, and surgical reasons. Patellar impingement on tibial polyethylene is a complication of distal femoral replacement, and it is frequently related to inaccurate restoration of the joint line and to soft-tissue contracture. The purpose of our study was to determine the prevalence and type of patellar complications following distal femoral replacements after excisions of bone tumors. METHODS:The results of reconstruction with use of a rotating-hinge endoprosthesis following excision of a distal femoral tumor in forty-three patients were retrospectively reviewed. Patients were followed clinically and radiographically for a minimum of forty-eight months or until death. Pain status, functional scores, and the range of motion were determined from a prospectively maintained database. The ratio of the patellar tendon length to the height of the patellar tendon insertion, as described by Insall and Salvati, was calculated. In addition, we attempted to determine whether the position of the patella was associated with anterior knee pain or with the functional scores derived with use of the International Society of Limb Salvage (ISOLS) scoring system. RESULTS:Thirty-five patellar complications, including eleven cases of impingement, occurred in twenty-seven patients (63%). We found no difference, on the basis of our sample size, with regard to the presence of patellar pain, the range of motion, or the Insall-Salvati ratio between the patients with and those without impingement. The ratio of the patellar tendon length to the height of the patellar tendon insertion averaged 0.9 in the group with impingement and 1.4 in the group without impingement (p = 0.07). The ISOLS score averaged 21.2 points in the group with impingement compared with 24.2 points in the group without impingement (p = 0.01). Patella baja occurred in nine patients. The average ISOLS score (and standard deviation) was 20.1 +/- 4.4 points for the patients with patella baja compared with 24.8 +/- 3.9 points in the group with a normal patellar position (p = 0.004). Patellar fracture occurred in two patients, and osteonecrosis occurred in two patients. These patients were treated nonoperatively. CONCLUSIONS:Patellar complications are common after distal femoral resection and endoprosthetic reconstruction. Patellar impingement on the polyethylene tibial bearing surface is a more common and important complication of distal femoral replacement than has been reported to date. Patella baja is also a relatively common complication, which has a negative impact on knee function.

BACKGROUND:Operative strategies used in resecting the digital nerve in Morton neuroma emphasize retaining the digital artery. Concern over inadvertent resection of the digital vessel has prompted many surgeons to avoid adjacent interdigital neurectomies when more than one nerve is affected. METHODS:The current study examined 674 consecutive pathologic specimens obtained after neurectomy. RESULTS:The digital vessel was identified along with the resected nerve in 39% of specimens. No adverse effect was recorded from these arterial resections. CONCLUSION/CONCLUSIONS:Extensive collateralization of digital vessels is hypothesized to account for the lack of adverse sequelae.

Calcaneal ostectomy is the benchmark for definitive surgical treatment in patients with Haglund's syndrome, despite conflicting and unpredictable study results. The current study's hypothesis is that when adequate bone is resected and outcomes are evaluated using validated scores, calcaneal ostectomy can give reliable and predictable results. Thirty six consecutive patients (39 feet) underwent calcaneal ostectomy for Haglund's deformity between 1998 and 2002. All patients were evaluated with the AOFAS score and SF-36v2 questionnaire. The mean time to follow-up was 51 months. The mean AOFAS score following surgery was 86/100 points; the mean SF-36v2 score following surgery was 144/152. Six of the 36 patients interviewed, however, would not recommend the procedure to others, citing mainly prolonged recovery time. Calcaneal ostectomy achieves good-to-excellent results in the treatment of Haglund's deformity when appropriate amounts of bone are excised. However, patients must be made aware of the necessary time to recovery, between 6 months and 2 years.

PURPOSE OF REVIEW/OBJECTIVE:To evaluate the increase in overuse injuries in the adolescent athlete, specifically sports-related injuries to the foot and ankle of the adolescent runner. Factors affecting these injuries include anatomic considerations, gender, rate of development, growth, training errors, shoe wear, and running surface. RECENT FINDINGS/RESULTS:Most injuries in adolescent runners are overuse injuries rather than sudden traumatic events. Adolescent athletes are as prone as adults to poor form, poor habits, and poor training patterns. In addition, anatomic variants in the hindfoot, midfoot, and forefoot may predispose an athlete to specific injury. SUMMARY/CONCLUSIONS:Adolescent running injuries are common and becoming more frequent as trainers and athletes place increasing demands on the growing body. There is no evidence that this increased demand produces long-term adverse effects; however, a significant amount of time can be lost to injuries unless training patterns are constructed to allow for repair of the adolescent athlete.

As health care costs increase, evaluating treatment methods in femoral neck fractures to determine the most effective treatment paradigm will become increasingly important. The current study compared two methods of treatment in similar cohorts of displaced femoral neck fractures. One hundred and twenty two patients were randomly assigned to two groups: In Group A, 62 patients were treated with a hemiarthroplasty. In group B, 60 patients were treated with dynamic screw fixation. Patients were evaluated at a minimum 3 year follow-up. Using the Matta functional hip score, 42% of group A and 70% of group B had good to excellent results. This difference was significant (p = 0.004). A significant agreement between physician assessment using the Matta score, and patient perception of outcome using the SF-36 scale was demonstrated (r = 0.64). No statistical difference between groups for revision surgery existed. Both physician based and patient based outcome scores favour retention and internal fixation of the femoral head in this cohort of patients at a short-term follow-up.

BACKGROUND:The Broström-Gould procedure is a commonly recommended operative treatment for chronic ankle instability. Using standardized physician-based outcome scores, the results of this procedure have been uniformly excellent. Current scoring systems, however, do not adequately evaluate mechanical or functional instability. Therefore, outcome data may suggest greater success than is justified. METHODS:A retrospective review was done of 73 patients who had isolated Broström-Gould repairs of the lateral ankle ligaments. The mean time to followup was 64 months. Both the AOFAS ankle-hindfoot score and the Short Form 36 (SF-36) were used to evaluate outcome. RESULTS:The overall American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 95 of 100 points. Despite that, 17% of patients in the study had functional instability of the ankle that was not reflected in the AOFAS score. The mean physical component score of the SF-36 was 84% and reflected the presence of functional instability. Low correlations were found between the AOFAS ankle-hindfoot score and the SF-36 score. CONCLUSIONS:The current study identified a deficiency in the AOFAS score in evaluating functional ankle stability after the Broström-Gould procedure. A more meaningful analysis of outcomes can be expected using the SF-36 score. The data suggest that greater attention must be paid to functional rehabilitation after ankle stabilization surgery to obtain optimal outcome.

UNLABELLED:To date the principal focus of the mechanism of cervical spine fracture has been directed towards head/neck circumference and vertebral geometric dimensions. However the role of other measurements, including chest circumference and neck length, in a standard cervical fracture population has not yet been studied in detail. Cervical fractures often involve flexion/extension type mechanisms of injury, with the head and cervical spine flexing/extending, using the thorax as an end point of contact. Thus, the thorax may play an important role in neck injuries. STUDY DESIGN/METHODS:We prospectively studied all patients with cervical spine fractures who were admitted to the National Spinal Injuries Unit from 1 July 2000 to 1 March 2001. Anthropometrical measurement of head circumference, neck circumference, chest circumference, and neck length were analysed. Ages ranged from 18 to 55 years, and all patients with concomitant cervical pathology were excluded from the study. Mechanism of injury involved flexion/extension type injuries in all cases; those with direct axial loading were excluded. A control group of 40 patients (age 18-50 years) involved in high velocity trauma with associated long bone fractures, in whom cervical injury was suspected, but who were without any cervical fracture, or associated pathology, were similarly measured. RESULTS:Our analysis revealed a statistically significant increase in chest size in the male control group versus the male fracture group (97.89 cm versus 94.19 cm, P < 0.05, Student's t-test). There was a correspondingly significant increase in chest circumference between the female controls versus the female fracture group (92.33 cm versus 88.88 cm, P < 0.05, Student's t-test). Our results revealed no statistical difference in head circumference, neck circumference, or neck length between each of the groupings. These results indicate a proportionately larger chest may be a protective factor in cervical spine fractures.