J. Mack Aldridge

Free Vascularized Fibular Grafting for the Treatment of Postcollapse Osteonecrosis of the Femoral Head

Background: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with collapse of the articular surface and subsequent arthrosis. Free vascularized fibular grafting has been reported to be successful for patients with early stages of osteonecrosis, but little is known about its efficacy after the femoral head has collapsed.Methods: We retrospectively reviewed the results in a consecutive series of 188 patients (224 hips) who had undergone free vascularized fibular grafting, between 1989 and 1999, for the treatment of osteonecrosis of the hip that had led to collapse of the femoral head but not to arthrosis. The average duration of follow-up was 4.3 years (range, two to twelve years). We defined conversion to total hip arthroplasty as the failure end point, and we analyzed the contribution, to failure, of the size of the lesion, amount of preoperative collapse of the femoral head, etiology of the osteonecrosis, age of the patient, and bilaterality of the lesion. We used the Harris hip score to evaluate clinical status preoperatively and at the time of the most recent follow-up.Results: The overall rate of survival was 67.4% for the hips followed for a minimum of two years and 64.5% for those followed for a minimum of five years. The mean preoperative Harris hip score was 54.5 points, and it increased to 81 points for the patients in whom the surgery succeeded; 63% of the patients in that group had a good or excellent result. There was a significant relationship between the outcome of the grafting procedure and the etiology of the osteonecrosis (p = 0.017). Patients in whom the osteonecrosis was idiopathic, associated with alcohol abuse, or posttraumatic fared worse than did those with other causes, including steroid use. Survival of the joint was not significantly related to the size of the femoral head lesion, but there was an increased relative risk of conversion to total hip arthroplasty with increasing lesion size and amount of collapse. Neither patient age nor bilaterality significantly affected outcome.Conclusions: Patients with postcollapse, predegenerative osteonecrosis of the femoral head appear to benefit from free vascularized fibular grafting, with good overall survival of the joint and significant improvement in the Harris hip score. The results of this femoral head-preserving procedure in patients with postcollapse osteonecrosis are superior to those of core decompression and nonoperative treatment, as reported in the literature. Patients with larger lesions and certain diagnoses, such as idiopathic and alcohol-related osteonecrosis, have worse outcomes.Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Free Vascularized Fibular Transfer for Femoral Head Osteonecrosis: Donor and Graft Site Morbidity

BACKGROUND Autogenous vascularized fibular transfer is used effectively for a variety of complex reconstructive procedures. Published series demonstrating the morbidity associated with its harvest have, understandably, been relatively small, and graft site (hip) complications have not been reported. This report describes both the donor and the graft site morbidity associated with use of vascularized fibular transfer to treat osteonecrosis of the femoral head. METHODS Between 1990 and 2006, 1270 free vascularized fibular grafts were used to treat osteonecrosis of the femoral head in 946 consecutive patients. All procedures and follow-up examinations were performed by one of two surgeons. Subjective and objective findings were recorded on standardized examination sheets at routine postoperative intervals. Data were analyzed to determine the morbidity associated with donor and graft sites. RESULTS There were 215 complications (a 16.9% rate) at the time of follow-up, at an average of 8.3 years, after the 1270 procedures. Of these complications, 146 (11.5%) and sixty-nine (5.4%) were referable to the donor and graft sites, respectively. A major complication requiring an additional surgical procedure or chronic pain management occurred after fifty-four (4.3%) of the 1270 procedures. CONCLUSIONS A measurable but acceptable morbidity risk is associated with vascularized fibular transfer for the treatment of osteonecrosis of the hip. Major complications are not frequent, and many minor complications are transient and improve over time. Risks can be minimized when specific technical principles are followed.

Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair.

BACKGROUND The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair. METHODS Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS Full active range of motion was achieved in ten patients; the remaining patient had a 20 degrees flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6. CONCLUSIONS Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement

Total elbow replacement is a well-recognized surgical treatment for patients with advanced rheumatoid arthritis (RA) of the elbow. At present, there is minimal literature outlining the perioperative complications associated with total elbow replacement. We endeavored to identify complication rates and hospital disposition differences between patients with and without RA who received a total elbow replacement. Data from the Nationwide Inpatient Sample was used to capture 3,617 patients who received a total elbow arthroplasty between 1988-2005. Of these, 888 had a primary diagnosis of RA and were compared against patients without RA. Analyses addressed perioperative complications and hospital disposition factors, such as charges and length of stay. Overall complication rates were very low with only 2 variables, respiratory complications (P = .01) and renal failure (P = .04) demonstrating significantly worse outcomes in patients without RA (P = .01). Patients without RA had also had longer lengths of stay (P < 0.01). There were 9 reported perioperative deaths. The findings suggest that the perioperative complications of a total elbow replacement for all patients studied are few and that outcomes in patients with RA are nearly equivalent to those in patients without RA.

Free Vascularized Fibular Grafting for treatment of osteonecrosis of the femoral head secondary to hip dislocation.

Traumatic dislocation of the hip results in osteonecrosis of the femoral head (ONFH) or avascular necrosis (AVN) in ∼40% of patients. This high‐energy event causes an ischemic insult to the femoral head that may lead to ONFH. Here, we investigate use of Free‐Vascularized Fibular Grafting (FVFG) in patients with ONFH after traumatic hip dislocation. Thirty‐five patients with FVFG for this indication were reviewed (average follow‐up 3.3 years, range 1–21). We reviewed patient injury statistics, demographics, preoperative radiographs, pre‐ and postoperative Harris Hip scores, complications, and rate of conversion to total hip arthroplasty (THA). The majority (81%) of our patients were young males (22 years) with ONFH diagnosed an average of 2 years after injury. The average preoperative Harris Hip score was 64.9 which improved by over 10 points to 76.1 at 1‐year follow‐up. Seven of 35 patients required conversion to THA at an average of 45 (13–86) months postoperation. After a maximum follow up of 21 years, the remainder of the patients retained their native hips and Harris Hip scores tended to show improved hip function.

Acute Irreducible Distal Radioulnar Joint Dislocation: A Case Report

Dislocation of the distal radioulnar joint is a rare injury pattern. There is little in the English literature describing this injury and even less to direct treatment. We present the case of a patient with an irreducible dislocation of the distal radioulnar joint and discuss the pathoanatomy and operative treatment. In addition, we describe a novel radiographic and clinical finding of an ulnar impaction fracture, which we equate to the Hill-Sachs lesion noted in the humeral head following dislocation of the shoulder. Our patient was informed that data concerning the case would be submitted for publication. Aforty-year-old, right-hand dominant man presented to the emergency department immediately following a work-related injury. The patient had pain in the right wrist and lack of forearm rotation. In an attempt to catch a bag of cement that was thrown down from a truck, he struck the dorsum of the right wrist, which was supporting the 50-lb bag, against the right knee. The patient had no medical or surgical history that was relevant to the injury, nor had he sustained any previous injuries to the right forearm, wrist, or hand. On physical examination, the patient was only able to rotate the forearm between 30° and 80° with the right wrist held in a position of supination. There was loss of the dorsal prominence of the ulnar head, which was instead palpable on the volar side. The wrist was moderately swollen, tender to palpation, and painful with attempted pronation. The patient had no elbow or forearm pain. The skin and the neurovascular function, specifically including ulnar nerve function, were intact. Initial radiographs were made. The posteroanterior radiograph demonstrated an overlap of the radius and ulna at the distal radioulnar joint (Fig. 1-A), and a true lateral radiograph demonstrated volar displacement of the ulna with respect to …

Nontuberculous mycobacterial olecranon bursitis: Case reports and literature review

Olecranon bursitis is most frequently caused by Staphylococcus aureus (80-100% of cases). 20 Patients usually present with bursal pain, fluctuant swelling, overlying cellulitis, and occasionally fevers. However, when more unusual pathogens infect the olecranon bursa, the clinical course is often more subtle and insidious, delaying the diagnosis and leading to inappropriate treatment. We report on three cases of olecranon bursitis caused by nontuberculous mycobacteria in healthy patients with no medical comorbidities or systemic immunosuppresion.

Open Reduction Internal Fixation With Transverse Volar Plating for Unstable Proximal Interphalangeal Fracture-Dislocation: The Seatbelt Procedure

Background: Unstable intra-articular proximal interphalangeal (PIP) joint fracture-dislocations present a difficult problem that requires congruous joint reduction and stable internal fixation or distraction. Though fractures with limited articular involvement may be treated successfully with less invasive procedures, fracture-dislocations with a volar shear component may benefit from joint reduction with subchondral support for maintenance of stability. The purpose of this article is to describe a volar transverse plate and screw technique and report the short-term postoperative results. Methods: Seventeen patients with volar shear PIP dorsal fracture-dislocations were treated with transverse plate and screw constructs at an average of 21 days (range, 2-52) after injury. Information on postoperative stability, range of motion at PIP and distal interphalangeal (DIP) joints, and radiographic outcomes and complications were retrospectively collected. Results: At a mean of 7.3 months post-operation (range, 1.5-24), there were no recurrent dislocations and an average PIP arc of 77.4° and DIP arc of 61.5°. Sixteen of 17 patients had radiographically concentric joints, with 1 patient showing slight radiographic dorsal subluxation not apparent clinically. Two of 17 patients (11.8%) had revision surgery for tenolysis and removal of hardware to improve range of motion at 4 and 9 months post-operation. Conclusions: In the setting of PIP dorsal fracture-dislocations with volar shear component >40% of the articular surface, the Seatbelt procedure allows for concentric joint and articular surface reduction with subchondral support for maintenance of stability. This volar transverse plating technique allows for highly functional range of motion without PIP dorsal subluxation clinically in the setting of comminution and delayed presentation.

Interobserver and intraobserver reliability of radiographic classification of acromioclavicular joint dislocations

HYPOTHESIS AND BACKGROUND The classification and treatment of acromioclavicular (AC) joint dislocations remain controversial. The purpose of this study was to determine the interobserver and intraobserver reliability of the Rockwood classification system. We hypothesized poor interobserver and intraobserver reliability, limiting the role of the Rockwood classification system in determining severity of AC joint dislocations and accurately guiding treatment decisions. METHODS We identified 200 patients with AC joint injuries using the International Classification of Diseases, Ninth Revision code 831.04. Fifty patients met inclusion criteria. Deidentified radiographs were compiled and presented to 6 fellowship-trained upper extremity orthopedic surgeons. The surgeons classified each patient into 1 of the 6 classification types described by Rockwood. A second review was performed several months later by 2 surgeons. A κ value was calculated to determine the interobserver and intraobserver reliability. RESULTS The interobserver and intraobserver κ values were fair (κ = 0.278) and moderate (κ = 0.468), respectively. Interobserver results showed that 4 of the 50 radiographic images had a unanimous classification. Intraobserver results for the 2 surgeons showed that 18 of the 50 images were rated the same on second review by the first surgeon and 38 of the 50 images were rated the same on second review by the second surgeon. CONCLUSION We found that the Rockwood classification system has limited interobserver and intraobserver reliability. We believe that unreliable classification may account for some of the inconsistent treatment outcomes among patients with similarly classified injuries. We suggest that a better classification system is needed to use radiographic imaging for diagnosis and treatment of AC joint dislocations.

Percutaneous Treatment of Unstable Scaphoid Waist Fractures

Background: Percutaneous techniques have been described for the treatment of nondisplaced scaphoid fractures, although less information has been reported about outcomes for unstable, displaced fractures. The aim of this study was to evaluate the union and complication rates following manual closed reduction and percutaneous screw placement for a consecutive series of unstable, displaced scaphoid fractures. Methods: A total of 28 patients (average age, 27 years; 22 male/6 female) were treated for isolated unstable displaced scaphoid waist fractures. Closed reduction and percutaneous headless, compression screw fixation was successfully performed in 14 patients (average age, 32 years; 10 male/4 female), and the remaining 14 patients required open reduction. Patients who underwent percutaneous treatment were followed for radiographic fracture union and clinical outcomes. Results: Thirteen of 14 fractures (93%) had clinical and radiographic evidence of bone union at an average of 2.8 months postoperatively. Average visual analog pain score at the time of union was 0.9. The average Quick Disability of the Arm, Shoulder, and Hand score at 2.5 years follow-up (range, 1.5-8.3 years) was 9.6 (range, 0.0-27.3). Complications included 1 case of nonunion and 1 case of intraoperative Kirschner wire breakage. Conclusions: Manual closed reduction followed by percutaneous headless, compression screw fixation was possible in 50% of patients who presented with acute unstable, displaced scaphoid fractures. This technique appears to be a safe and effective method when a manual reduction is possible, and it may offer a less invasive option when compared with a standard open technique.