Gregory T. Altman

Functional Outcome After Acute Compartment Syndrome of the Thigh

BACKGROUND Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result. METHODS Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores. RESULTS Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores. CONCLUSIONS Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

The Effect of Interference Screw Diameter on Fixation of Soft-Tissue Grafts in Anterior Cruciate Ligament Reconstruction

PURPOSE The purpose of this study was to evaluate the effect that interference screw diameter has on fixation strength of a soft-tissue anterior cruciate ligament (ACL) graft. METHODS We prepared 32 fresh-frozen bovine tibiae with 9-mm ACL tibial tunnels. Accompanying 9-mm soft-tissue bovine Achilles grafts were also prepared. Bioabsorbable interference screws of increasing diameters were used for tibial fixation. There were 4 groups, consisting of 8-, 9-, 10-, and 11-mm screws for fixation of the 9-mm graft in the 9-mm tunnel. Tensile testing and cyclic loading from 50 to 250 N at 2 Hz for a total of 1,500 cycles were performed with a hydraulic biaxial materials testing machine. Graft slippage was measured with a video analysis technique with photo-reflective markers. At the end of cyclic testing, the grafts were loaded to failure, and the ultimate strength was recorded. RESULTS All grafts failed at the tendon-bone-screw interface. The ultimate strength (+/- SD) was greatest for the 11-mm screw (624 +/- 133 N), with slightly decreased strength for the 10-mm (601 +/- 54 N), 9-mm (576 +/- 85 N), and 8-mm (532 +/- 185 N) screws. Graft slippage (+/- SD) was least for the 9-mm screw (2.65 +/- 2.38 mm). There were no statistically significant differences in ultimate strength and graft slippage between screws (P = .45 and P = .34, respectively). CONCLUSIONS All interference screws tested provided adequate fixation strength. The results of this study show no statistical significance for ultimate strength or graft slippage with variable screw diameter. CLINICAL RELEVANCE Aperture fixation with the interference screw technique provides adequate stability for soft-tissue grafts in ACL reconstruction. Although no statistical significance was found, there was a trend toward less graft-site motion when we used a screw diameter equal to tunnel size.

Femoral bone strains during antegrade nailing: A comparison of two entry points with identical nails using finite element analysis

BACKGROUND Antegrade femoral nailing has become the standard treatment for diaphyseal femoral shaft fractures. Concerns linger that improper location of the nail entry point may lead to iatrogenic fracture and further complications. This study used finite element analysis to compare the strain magnitude and distribution resulting from each of two entry points in the proximal femur during antegrade nailing. METHODS A finite element model was created from a CT scan of a 37 year old male femur and of a standard antegrade nail. Using implicit time-stepping, the nail was inserted through piriformis and trochanteric entry points and strain was computed at 9 anatomic locations. FINDINGS The strain levels were higher overall when inserting a nail through the trochanteric starting point. The highest strain occurred immediately medial and lateral to the trochanteric entry point. The posterior greater trochanter also showed very high strain levels during nail insertion. All strain values for nail insertion through the piriformis entry point were less than 2000 μm/m. INTERPRETATION The trochanteric entry will have a much greater potential of iatrogenic fracture of the proximal femur during insertion of a nail. Strains with this entry point exceed the yield level of bone and the repeated loading with the progression of the nail could cause fissures or fractures. Caution should be taken during insertion of an antegrade nail when utilizing a lateral trochanteric starting point secondary to an increased risk of trochanteric fracture and lateral cortex fracture.

Effects of Radiofrequency Probe Application on Irrigation Fluid Temperature in the Wrist Joint

PURPOSE Radiofrequency (RF) probes used in wrist arthroscopy may raise joint fluid temperature, increasing the risk of capsular and ligamentous damage. The purposes of the current study were to measure joint fluid temperature during wrist arthroscopy with the use of RF probes, and to determine whether using an outlet portal will reduce the maximum temperature. METHODS We performed wrist arthroscopy on 8 cadaveric arms. Ablation and coagulation cycles using RF probe were performed at documented locations within the joint. This was done for 60-second intervals on both the radial and ulnar side of the wrist, to mimic clinical practice. We used 4 fiberoptic phosphorescent probes to measure temperature (radial, ulnar, inflow-tube, and outflow-tube probes) and measured joint fluid temperature with and without outflow. RESULTS There was a significant difference between wrists with and without outflow when examining maximum ablation temperatures (p < .002). All specimens showed higher maximum and average ablation temperatures without outflow. Maximum joint temperatures, greater than 60 degrees C, were observed in only no-outflow conditions. CONCLUSIONS In performing RF ablation during wrist arthroscopy, the use of an outlet portal reduces the joint fluid temperature. Without an outlet portal, maximum temperatures can exceed desirable levels when using ablation; such temperatures have the potential to damage adjacent tissues. It is useful to maintain adequate outflow when using the radiofrequency probes during wrist arthroscopy.

Presence of bacteria in failed anterior cruciate ligament reconstructions.

AbstractBackgroundNovel microbial detection technologies have revealed that chronic bacterial biofilms, which are recalcitrant to antibiotic treatment, are common in failed orthopedic procedures.QuestionsAre bacteria present on failed anterior cruciate ligament (ACL) reconstructions? Is there a difference in the presence or nature of bacteria in failed ACL reconstructions relative to a control set of healthy ACL’s?MethodsWe used a case–control study design, where we analyzed the bacterial composition of 10 failed ACL reconstructions and compared it to 10 native ACL’s harvested during total knee arthroplasty. The IBIS Universal Biosensor was used to determine the nature of bacteria on ACL specimens, and fluorescent in situ hybridization (FISH) was used to visualize bacteria in a subset of cases.ResultsBacteria are present in failed ACL reconstructions. Bacteria are present in ACL’s harvested during total knee arthroplasty, but the nature of the species differs significantly between experimental and control sets. Twelve genera were detected in the experimental set (in both allografts and autografts), and in four samples multiple species were detected. In contrast, the control group was characterized by presence of Propionibacterium acnes.ConclusionsWe demonstrate the presence of bacteria on failed ACLs surgeries, and open the door to investigate whether and how bacteria and the associated immune responses could possibly contribute to graft failure.Clinical relevanceIf microbial pathogens can be linked to failed grafts, it could provide: (1) markers for early diagnosis of abnormal healing in ACL surgeries, and (2) targets for early treatment to prevent additional reconstruction surgeries.

Osteonecrosis of the femoral head after retrograde intramedullary nailing of a femoral shaft fracture in an adolescent. A case report.

O steonecrosis of the capital femoral epiphysis following antegrade intramedullary nailing of femoral shaft fractures has been generally described as occurring in adolescent and pediatric patients1-10. However, a limited number of cases have been reported in adults11,12. The condition appears to represent an iatrogenic injury resulting from the proximity of the medial femoral circumflex artery to the piriformis fossa, which is the typical starting point for intramedullary nailing13. To our knowledge, there have been no previously published reports of osteonecrosis of the femoral head following retrograde intramedullary nailing of a femoral shaft fracture. Retrograde insertion techniques are applicable to adults and older adolescents, after closure of the distal femoral physis. We present the case of an adolescent male with osteonecrosis of the femoral head following retrograde femoral intramedullary nailing, and we review the osteonecrosis risk factors that may be present in patients who sustain polytrauma. Our patient and his legal guardian were informed that data concerning the case would be submitted for publication. Fig. 1-A Initial anteroposterior radiograph showing an open comminuted fracture of the right femoral shaft. There is no apparent associated fracture of the femoral neck. A seventeen-year-old boy was involved as an unrestrained, front-seat passenger in a high-energy, head-on motor-vehicle collision. Paramedics found the boy trapped under the dashboard and required more than thirty minutes to extricate him. On arrival at our institution, the patient was tachypneic (respiratory rate, 33 breaths/min), tachycardic (heart rate, 105 beats/min), and hypotensive (blood pressure, 76 mm Hg) but was alert and oriented and had a Glasgow Coma Scale score of 15. Radiographs revealed multiple long-bone fractures, including a type-I open comminuted fracture of the right femoral shaft (Fig. 1-A), according to the system of Gustilo and Anderson14, and closed diaphyseal fractures …

Lateral clavicle fractures.

THE PATIENT A 41-year-old, right hand–dominant, active man presents for treatment of a right shoulder injury after a motor vehicle crash. Evaluation in the emergency room identifies slight swelling, no ecchymosis, no skin tenting, tenderness over the lateral one third of the right clavicle, neurovascular examination within normal limits, and limitation of shoulder motion resulting from pain. Radiographs of the shoulder and clavicle reveal a fracture of the clavicle between the conoid and trapezoid ligaments with 14-mm superior displacement (Neer type IIB). The patient is placed in a sling and referred to follow up with you. He presents 1 week after the injury inquiring about surgery. He states he plays racquetball on the weekends and wonders about the long-term consequences of the injury.

Towards a New Paradigm in the Diagnosis and Treatment of Orthopedic Infections

Imagine an office visit of an older, but still poised, oncologist with her orthopedic surgeon. The surgeon must somehow break the news that a prosthetic knee, installed some 10 months previously, must be removed in a two-stage procedure that will leave the lady immobile while an infection is brought under control, and a new knee can be implanted in 3 months. If this frightening specter was an ovarian cancer, the oncologist would ask if the genome of her cancer had been sequenced and whether estrogen receptors were present on her malignant cells, so that a rational treatment strategy could be devised. The surgeon would say that the aspirate he took on the previous visit had grown “Staphylococcus epidermidis,” in small numbers that might be contaminants from the technician’s hands, and that most strains of Staphylococcus epidermidis these days were resistant to methicillin so she had better go on an aminoglycoside until her surgery early next week. And the twenty-first century would have ground to a sickening halt, on the residue of nineteenth century techniques, right there in the surgeons’ office.