Matthew E. Oetgen

Trigger finger: etiology, evaluation, and treatment.

Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.

Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial.

BACKGROUNDnAlthough osteoporosis is strongly associated with hip fractures, the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5% and 30%. Currently, most patients receiving treatment have been referred back to their primary care physician for osteoporosis management. The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months.nnnMETHODSnA prospective randomized trial was conducted to assess the difference in the rate of osteoporosis treatment when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and usual care.nnnRESULTSnSixty-two patients were enrolled in the study. Thirty-one patients each were in the control and intervention groups. The percentage of patients who were on pharmacologic treatment for osteoporosis at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic (58%) than when treatment was managed by a primary care physician (29%) (p = 0.04).nnnCONCLUSIONSnAn active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture.

Development of a femoral non-union model in the mouse

OBJECTIVESnAdvancements in our knowledge of fracture healing have occurred in large part by the understanding of this process on a microscopic level. The ability to develop experimental non-union models in animals will assist in the investigation of this problem and are likely to lead to novel treatments. We report on a technique for developing experimental non-unions in mice.nnnMETHODSnFemoral fractures were created in 48 CD1 mice, 24 mice underwent standard closed femoral fractures, and 24 mice underwent creation of a femoral non-union through an open osteotomy and fracture devascularisation method. All fractures were subsequently rodded. Histological examinations of the fractures were then conducted at eight time points post-operatively.nnnRESULTSnThe control group showed normal fracture healing with histological evidence of bony fracture bridging by 28 days and mature bony remodelling at 63 days. The non-union group showed delayed fracture healing at all time points and no evidence of bony healing at 63 days.nnnCONCLUSIONnThis is the first report of a reliable method to develop fracture non-union in mice. We believe this technique will be critical to further the investigation of fracture non-union in normal mice and provides the great advantage of using the plethora of transgenic and knockout mouse models to analyse non-union at the cell and molecular level.

Non-operative treatment of common finger injuries

Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.

Core Needle Biopsies of Musculoskeletal Tumors: Potential Pitfalls

Core needle biopsy is a powerful tool used to diagnose and develop a treatment strategy for musculoskeletal tumors. With accuracy rates reported between 69% and 99%, it is evident that errors in diagnosis occur, and they can lead to devastating consequences. We reviewed pathology reports of preoperative core needle biopsies in an attempt to determine factors associated with false negative diagnoses for the purpose of improving surgical planning. We retrospectively reviewed all office-based core needle biopsies accomplished in our practice over a 6-year period. One hundred nineteen biopsies were identified, of which 82 fulfilled criteria to be included in the study population. The pathologists report of each biopsy was reviewed and categorized based on the findings into 1 of 2 diagnostic groups: neoplastic or nonneoplastic. The results of the biopsies were then compared to the pathology results of the final surgical resection, and the rates and nature of false negative biopsy results (unrecognized malignant pathology) were compared for each group. Seventy-one biopsies were categorized as neoplastic based on the pathology report. No false negative results were found in this group when compared to the final surgical resection pathology. Eleven biopsies were categorized as nonneoplastic, of which 6 were found to be false negatives when compared to the final surgical pathologic diagnosis. The rate of false negative results significantly increased in biopsies whose reports were categorized as nonneoplastic compared to biopsies categorized as neoplastic (P<.0001). We found core needle biopsies of musculoskeletal lesions to be safe and effective in diagnosing pathologic processes. In cases in which analysis of the biopsy specimen did not identify a specific neoplastic process, we found a high incidence of undiagnosed malignancy upon definitive surgical resection. Pathology reports of core needle biopsies that specify only normal, inflammatory, or other nonspecific tissue descriptions should alert the clinician to the increased possibility of a false negative result, and require further tissue analysis.

Does the morphology of foramen transversarium fractures predict vertebral artery injuries

Study Design. Retrospective review of foramen transversarium fracture morphology variables and their relationship to vertebral artery injury. Objective. We examined the morphology of foramen transversarium fractures to determine if different patterns of these fractures predicted vertebral artery injury to more specifically identify at risk patterns in which vertebral artery evaluation may be warranted. Summary of Background Data. Risk fractures for vertebral artery injury have been previously reported to include cervical subluxation or dislocations, C1–C3 fractures, and foramen transversarium fractures. There have been no reports determining if specific foramen transversarium fracture patterns are predictive of vertebral artery injuries. Methods. We reviewed the initial cervical CT scans of 171 patients seen in our level one trauma center between January 2002 and March 2008 and identified all patients with foramen transversarium fractures. Additionally, CT angiograms were reviewed in these patients to identify patients with vertebral artery injuries. The morphology of the foramen transversarium fractures was compared in those patients with and without vertebral artery injury to identify fracture patterns predictive of arterial injury. Results. Twenty-one (12%) patients were found to have foramen transversarium fractures with 5 (24%) of these patients having associated vertebral artery injury. Multilevel foramen transversarium fractures (P = 0.025) were significantly more frequent in vertebral artery injuries. Logistic regression identified multilevel fractures (odds ratio 17.33) and fracture comminution (odds ratio 10.50) as significant variables influencing vertebral artery injury after foramen transversarium fracture. Conclusion. We found patients presenting with multilevel foramen transversarium fractures and foramen transversarium fracture comminution to be at significantly increased odds of vertebral artery injury. Patients with these fracture patterns should undergo further evaluation with vertebral artery imaging.

A novel technique for arthroscopically assisted femoral bone tunnel grafting in two-stage ACL revision.

This technique of bone grafting of improperly positioned bone tunnels in failed ACL reconstructions is technically straightforward and effective in challenging cases.

Does Vertebral Endplate Morphology Influence Outcomes in Lumbar Total Disc Arthroplasty? Part II: Clinical and Radiographic Results as Evaluated Utilizing the Vertebral Endplate Yue-Bertagnoli (VEYBR) Classification

Study Design This study was a prospective study with a minimum patient follow-up of 2 years. Objective The purpose of this study was to evaluate the clinical usefulness of a vertebral endplate classification system (VEYBR) in predicting outcomes following lumbar arthroplasty. Background In the present study, our previously described endplate classification system was evaluated to determine its clinical usefulness in patients undergoing lumbar arthroplasty. Methods The patient cohort in this study consisted of 80 patients who had been enrolled in the US FDA ProDisc clinical trial. Radiographs were classified using the VEYBR classification. The preoperative categories (Types I to V) were then correlated with the patients’ visual analogue scores (VAS) and Oswestry Disability Index (ODI) scores and radiographic outcomes at an average follow-up point of 28 months. Results The rank order of total change in VAS based on preoperative VEYBR classification was Type IV, III, I II, and V, with Type IV having the greatest improvement in VAS and Type V having the least improvement. The rank order of total change in ODI was Type IV, II, III, I, and V. We found no differences in clinical outcomes among the 5 vertebral endplate types. Type II endplates had least optimal sagittal positioning. Conclusions Although not statistically significant, there was a strong trend for Type V endplates to have the least improvements in VAS and Oswestry clinical outcome scores. Knowledge and use of the endplate classification system did lead to consistent implant placement across endplate classes which may indicate the usefulness of this classification system in preoperative planning, especially for physicians in the “learning curve” phase of this procedure. Level of Evidence Case series (Level IV).

Does Vertebral Endplate Morphology Influence Outcomes in Lumbar Total Disc Arthroplasty

Study Design This study was a prospective study with a minimum patient follow-up of 2 years. Objective The purpose of this study was to evaluate the clinical usefulness of a vertebral endplate classification system (VEYBR) in predicting outcomes following lumbar arthroplasty. Background In the present study, our previously described endplate classification system was evaluated to determine its clinical usefulness in patients undergoing lumbar arthroplasty. Methods The patient cohort in this study consisted of 80 patients who had been enrolled in the US FDA ProDisc clinical trial. Radiographs were classified using the VEYBR classification. The preoperative categories (Types I to V) were then correlated with the patients’ visual analogue scores (VAS) and Oswestry Disability Index (ODI) scores and radiographic outcomes at an average follow-up point of 28 months. Results The rank order of total change in VAS based on preoperative VEYBR classification was Type IV, III, I II, and V, with Type IV having the greatest improvement in VAS and Type V having the least improvement. The rank order of total change in ODI was Type IV, II, III, I, and V. We found no differences in clinical outcomes among the 5 vertebral endplate types. Type II endplates had least optimal sagittal positioning. Conclusions Although not statistically significant, there was a strong trend for Type V endplates to have the least improvements in VAS and Oswestry clinical outcome scores. Knowledge and use of the endplate classification system did lead to consistent implant placement across endplate classes which may indicate the usefulness of this classification system in preoperative planning, especially for physicians in the “learning curve” phase of this procedure. Level of Evidence Case series (Level IV).

Revision total hip arthroplasty using the Zweymuller femoral stem

BackgroundA variety of femoral stem designs have been reported to be successful in revision total hip arthroplasty without consensus as to optimal design. We evaluated the clinical and radiographic outcomes in a consecutive series of femoral revisions using a wedge-shape, tapered-stem design at medium and long-term follow-up.Materials and methodsWe performed a retrospective review of clinical and radiographic outcomes of twenty-eight consecutive femoral revisions arthroplasties, which were done using the Zweymuller femoral stem.ResultsThe mean follow-up was 7.4xa0years (range 2–15xa0years). No stem re-revision was necessary. All stems were judged to be stable by radiographic criteria at the most recent follow-up. The final mean Harris hip score was 90. There was no difference in Harris hip scores, implant stability, or radiological appearance (distal cortical hypertrophy or proximal stress shielding) of the implants between medium-term (mean 5.7xa0years) and long-term (mean 12.4xa0years) follow-up.ConclusionsWe found the Zweymuller femoral stem design to be durable for revision hip arthroplasty when there is an intact metaphyseal-diaphyseal junction for adequate press-fit stability at surgery.