David E. Ruchelsman

Open Reduction and Internal Fixation of Capitellar Fractures with Headless Screws

BACKGROUND The outcome of operatively treated capitellar fractures has not been reported frequently. The purpose of the present study was to evaluate the clinical, radiographic, and functional outcomes following open reduction and internal fixation of capitellar fractures that were treated with a uniform surgical approach in order to further define the impact on the outcome of fracture type and concomitant lateral column osseous and/or ligamentous injuries. METHODS A retrospective evaluation of the upper extremity database at our institution identified sixteen skeletally mature patients (mean age, 40 +/- 17 years) with a closed capitellar fracture. In all cases, an extensile lateral exposure and articular fixation with buried cannulated variable-pitch headless compression screws was performed at a mean of ten days after the injury. Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated at a mean of 27 +/- 19 months postoperatively. RESULTS Six Type-I, two Type-III, and eight Type-IV fractures were identified with use of the Bryan and Morrey classification system. Four of five ipsilateral radial head fractures occurred in association with a Type-IV fracture. The lateral collateral ligament was intact in fifteen of the sixteen elbows. Metaphyseal comminution was observed in association with five fractures (including four Type-IV fractures and one Type-III fracture). Supplemental mini-fragment screws were used for four of eight Type-IV fractures and one of two Type-III fractures. All fractures healed, and no elbow had instability or weakness. Overall, the mean ulnohumeral motion was 123 degrees (range, 70 degrees to 150 degrees). Fourteen of the sixteen patients achieved a functional arc of elbow motion, and all patients had full forearm rotation. The mean Mayo Elbow Performance Index score was 92 +/- 10 points, with nine excellent results, six good results, and one fair result. Patients with a Type-IV fracture had a greater magnitude of flexion contracture (p = 0.04), reduced terminal flexion (p = 0.02), and a reduced net ulnohumeral arc (p = 0.01). An ipsilateral radial head fracture did not appear to affect ulnohumeral motion or the functional outcome. CONCLUSIONS Despite the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV fractures or fractures with an ipsilateral radial head fracture, good to excellent outcomes with functional ulnohumeral motion can be achieved following internal fixation of these complex fractures. Type-IV injuries may be more common than previously thought; such fractures often are associated with metaphyseal comminution or a radial head fracture and may require supplemental fixation.

Isolated tuberosity fractures of the proximal humerus: Current concepts

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.

Accuracy of correction of tibia vara: acute versus gradual correction.

The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction.

Operative Experience in an Orthopaedic Surgery Residency Program: The Effect of Work-Hour Restrictions

BACKGROUND The implementation of Section 405 of the New York State Public Health Code and the adoption of similar policies by the Accreditation Council for Graduate Medical Education in 2002 restricted resident work hours to eighty hours per week. The effect of these policies on operative volume in an orthopaedic surgery residency training program is a topic of concern. The purpose of this study was to evaluate the effect of the work-hour restrictions on the operative experiences of residents in a large university-based orthopaedic surgery residency training program in an urban setting. METHODS We analyzed the operative logs of 109 consecutive orthopaedic surgery residents (postgraduate years 2 through 5) from 2000 through 2006, representing a consecutive interval of years before and after the adoption of the work-hour restrictions. RESULTS Following the implementation of the new work-hour policies, there was no significant difference in the operative volume for postgraduate year-2, 3, or 4 residents. However, the average operative volume for a postgraduate year-5 resident increased from 274.8 to 348.4 cases (p = 0.001). In addition, on analysis of all residents as two cohorts (before 2002 and after 2002), the operative volume for residents increased by an average of 46.6 cases per year (p = 0.02). CONCLUSIONS On the basis of the findings of this study, concerns over the potential adverse effects of the resident work-hour polices on operative volume for orthopaedic surgery residents appear to be unfounded.

Osteochondritis dissecans of the capitellum: current concepts.

Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. Unlike Panner disease, a self‐limiting condition of the immature capitellum, OCD is multifactorial and likely results from microtrauma in the setting of cartilage mismatch and vascular susceptibility. The natural history of OCD is poorly understood, and degenerative joint disease may develop over time. Multiple modalities aid in diagnosis, including radiography, MRI, and magnetic resonance arthrography. Lesion size, location, and grade determine management, which should attempt to address subchondral bone loss and articular cartilage damage. Early, stable lesions are managed with rest. Surgery should be considered for unstable lesions. Most investigators advocate arthroscopic débridement with marrow stimulation. Fragment fixation and bone grafting also have provided good short‐term results, but concerns persist regarding the healing potential of advanced lesions. Osteochondral autograft transplantation appears to be promising and should be reserved for larger, higher grade lesions. Clinical outcomes and return to sport are variable. Longer‐term follow‐up studies are necessary to fully assess surgical management, and patients must be counseled appropriately.

Subacromial corticosteroid injections

The use of subacromial injections to treat shoulder pain has remained one of the most common procedures for the practicing orthopedist, rheumatologist, and general practitioner. Despite this, many prospective studies have questioned the efficacy of corticosteroid injections compared with nonsteroidal anti-inflammatory drugs or injections of local anesthetics alone, or both, when used for the treatment of symptomatic rotator cuff disease. Accurate diagnosis of the etiology of a patients shoulder pain and proper injection technique are important in achieving satisfactory clinical outcomes. Both extrinsic as well as intrinsic etiologies for rotator cuff disease should be considered and must be elucidated with appropriate physical examination techniques. Although subacromial injections appear straightforward, more recent cadaveric, radiographic, and clinical studies have demonstrated variable accuracy rates using the two common techniques. In addition, absolute sterile technique must be used because infections of the subacromial space after injections, although uncommon, have generally led to debilitating conditions. This article reviews the etiology and pathophysiology of rotator cuff disease and the indications and techniques for subacromial corticosteroid injections.

Fractures of the Radial Head and Neck

The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.

Coronal plane partial articular fractures of the distal humerus: current concepts in management.

&NA; Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow‐up.

Total Hip Arthroplasty in Sickle Cell Hemoglobinopathies

Abstract Advances in medical treatment have led to improved life expectancy in patients with sickle cell hemoglobinopathies. Improved life expectancy has, in turn, led to an increasing number of patients with osteonecrosis requiring total hip arthroplasty. Patient evaluation begins with understanding the extent of the disease process and the patients musculoskeletal manifestations (ie, pyogenic infection, marrow hyperplasia, osteonecrosis). A multidisciplinary approach to implementing effective preoperative treatment strategies increases the likelihood of a successful surgical outcome. Intraoperatively, consideration of bone stock, bone quality, and method of component fixation may help minimize the risk of eccentric reaming, perforation or fracture of either the acetabulum or the femur, and loosening. The optimal mode of acetabular and femoral fixation in these patients has not been conclusively determined, but recent results of cementless total hip arthroplasty have been encouraging. Although patients with sickle cell disease are at increased risk of medical and surgical complications, total hip arthroplasty in the appropriately selected patient can provide significant pain relief, restoration of function, and patient satisfaction.

Avulsion injuries of the flexor digitorum profundus tendon.

Abstract Avulsions of the flexor digitorum profundus tendon may involve tendon retraction into the palm and fractures of the distal phalanx. Although various repair techniques have been described, none has emerged as superior to others. Review of the literature does provide evidence‐based premises for treatment: multi‐strand repairs perform better, gapping may be seen with pullout suture‐dorsal button repairs, and failure because of bone pullout remains a concern with suture anchor methods. Clinical prognostic factors include the extent of proximal tendon retraction, chronicity of the avulsion, and the presence and size of associated osseous fragments. Patients must be counseled appropriately regarding anticipated outcomes, the importance of postoperative rehabilitation, and potential complications. Treatment alternatives for the chronic avulsion injury remain patient‐specific and include nonsurgical management, distal interphalangeal joint arthrodesis, and staged reconstruction.