Raffy Mirzayan

The Posterior Fat Pad Sign in Association with Occult Fracture of the Elbow in Children

BACKGROUND An elevated posterior fat pad visible on a lateral radiograph of a childs elbow following trauma is generally considered to be suggestive of an intracapsular fracture about the elbow. However, in previous studies, the prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture has ranged from only 6 percent (two of thirty-one) to 29 percent (nine of thirty-one). We are not aware of any prospective studies, limited to children, on the value of an elevated posterior fat pad as an indicator of an occult fracture about the elbow. While it is common practice to manage children who have radiographic evidence of an elevated posterior fat pad as if they have a fracture, scientific evidence for this approach is lacking. METHODS Forty-five consecutive children who had an average age of four and a half years, a history of trauma to the elbow, and an elevated posterior fat pad without other radiographic evidence of a fracture were enrolled in the study. At an average of three weeks after the injury, anteroposterior, lateral, and two oblique radiographs were made and evaluated for evidence of fracture-healing. If there was evidence of new-bone formation on any of these four radiographs, it was considered to indicate a fracture of the elbow. RESULTS Thirty-four (76 percent) of the forty-five patients had evidence of a fracture. Eighteen (53 percent) of the thirty-four had a supracondylar fracture of the humerus; nine (26 percent), a fracture of the proximal part of the ulna; four (12 percent), a fracture of the lateral condyle; and three (9 percent), a fracture of the radial neck. CONCLUSIONS This prospective study demonstrated that the posterior fat pad sign was predictive of an occult fracture of the elbow following trauma in thirty-four (76 percent) of forty-five children who had no other evidence of fracture on anteroposterior, lateral, and oblique radiographs after the injury. This finding is in contrast to those of previous studies, in which the highest prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture was 29 percent (nine of thirty-one elbows). Our results support the practice of managing children who have a history of trauma to the elbow, an elevated posterior fat pad, and no other radiographic evidence of fracture as if they have a nondisplaced fracture about the elbow.

Management of Chronic Deep Infection Following Rotator Cuff Repair

Background: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. Methods: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. Results: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. Conclusions: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

The use of calcium sulfate in the treatment of benign bone lesions. A preliminary report.

Bone grafts are widely used by surgeons to correct bone defects resulting from a variety of causes, including tumors, trauma, and infection. Autogenous bone remains the ideal material for grafting because it is not antigenic and it has both osteoinductive and osteogenic properties1. The harvesting of autogenous bone, however, can be associated with substantial complications. The common problems that have been reported include pain at the donor site, palsy of the lateral femoral cutaneous nerve, injury of the superior gluteal artery, pelvic fracture, hematoma, infection, and gait disturbances2. Furthermore, the amount of autogenous bone graft available for harvesting is limited and may be insufficient to fill large osseous defects. The quality of the harvested autogenous bone is also variable1. Because of the complications associated with harvesting autogenous bone and its limited supply, many surgeons have sought bone-graft-substitute materials. A bone-graft substitute that has regained popularity recently is calcium sulfate, more commonly known as plaster of Paris. Plaster of Paris is derived from the common mineral gypsum, which contains calcium sulfate dihydrate (CaSO4 • 2 H2O). Calcium sulfate was first used by Dreesman2 to obliterate bone cavities caused by tuberculosis. In 1959, Peltier3 became the first American to report on the use of calcium sulfate as a bone-graft substitute. He and Jones found that calcium sulfate is …

3.0-Tesla MRI and Arthroscopy for Assessment of Knee Articular Cartilage Lesions

The purpose of this study was to evaluate the ability of 3.0-Tesla magnetic resonance imaging (MRI) to accurately assess knee articular cartilage lesions. Sixteen patients who had knee 3.0-T MRI and underwent knee arthroscopy for partial meniscectomy were included. Three fellowship-trained sports medicine orthopedic surgeons reviewed all images. Articular lesions on MRI were graded from I to IV and compared with arthroscopic grading using the Outerbridge and the International Cartilage Repair Society (ICRS) classifications. The articular surface was divided into 6 regions. Based on MRI findings, of the 288 articular surface evaluations, 113 (39%) surface evaluations were classified as disease-positive (grade 2 to 4). Kappa interrater reliability scores for MRI evaluation, Outerbridge classification, and ICRS classification were 0.13, 0.54, and 0.41, respectively. Using the Outerbridge classification as a reference standard, the sensitivity, specificity, and accuracy were 57%, 71%, and 63%, respectively. Using the ICRS classification, sensitivity, specificity, and accuracy were 59%, 71%, and 69%, respectively. When isolating the articular grading to the senior author on MRI evaluation vs Outerbridge classification, the sensitivity, specificity, and accuracy were 54%, 92%, and 75%, respectively. Based on the current findings, 3.0-T MRI is as an invaluable noninvasive tool with good diagnostic value for assessing articular cartilage lesions of the knee, although it may not be as sensitive and accurate as previously reported.

Culture Results and Amputation Rates in High-Pressure Paint Gun Injuries of the Hand

High-pressure paint gun injuries have been well described in the literature, and the use of antibiotics is recommended as part of their management. However, there is no scientific evidence to support the use of antibiotics. In addition, the type of paint injected (water- versus oil-based) has never been investigated to determine the extent of morbidity resulting from these injuries. This study examines the organisms cultured in wounds resulting from these injuries and whether the type of paint injected had an influence on amputation rates. Charts of 35 patients with high-pressure paint gun injuries to their hands were reviewed. The amputation rate was 50% with oil-based paints and 0% with water-based paints. Forty-seven percent of wound cultures were positive, with gram-negative bacteria found in 58% of isolates. Our findings support the use of antibiotics, which should cover both gram-positive and gram-negative organisms.

A Comparison of Mineral Bone Graft Substitutes for Bone Defects

Synthetic bone graft substitutes have evolved in response to the downsides of autograft and allograft. This article consolidates the literature regarding the use of mineral bone graft substitutes in the treatment of cavitary bone defects. No level I studies regarding their use in the treatment of bone tumors have been performed, but the clinical studies that have been published indicate that calcium sulfate resorbs too quickly and incites inflammatory reaction and hydroxyapatite resorbs too slowly and blocks new bone ingrowth; tricalcium phosphate and mineral bone graft composites have the biochemical profile that is most compatible with new bone formation. These studies also indicate that mineral bone grafts are safe and may be as effective as other graft options; however, radiographic interpretation may be inaccurate and no evidence exists to suggest that mineral bone graft substitutes are superior to no graft at all. The trauma literature has yielded numerous level I studies that indicate that calcium phosphate cements result in increased metaphyseal fracture stability, but have not yet detected any improvement in healing. Prospective randomized clinical trials in the treatment of bone tumors are necessary to properly delineate the real indications for bone grafting and to demonstrate the graft’s efficacy in this regard.

Cement technique correlates with tuberosity healing in hemiarthroplasty for proximal humeral fracture

BACKGROUND Tuberosity healing correlates with clinical outcomes after hemiarthroplasty for 4-part proximal humeral fractures (4PHFs). We seek to examine variables that affect tuberosity healing. METHODS This was a retrospective comparative study. At 1 year postoperatively, patients who underwent hemiarthroplasty for 4PHFs were divided into 2 groups: those with anatomically healed tuberosities and those with tuberosity nonunion. The primary variables included time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors included age, gender, osteoporosis status, diabetes status, and smoking status. RESULTS There were 84 individuals who met the inclusion criteria: 37 (44%) had anatomically healed tuberosities, and 47 (56%) did not. Individuals with anatomic healing had cement near or under the tuberosities 32% of the time, whereas individuals with nonunion or resorption had cement near the tuberosities 66% of the time (P = .002). There was no association between tuberosity healing and fenestration of the humeral stem (P = .84). Anatomic reduction between tuberosities was associated with healing (P <.001), whereas greater tuberosity-to-head height was not (P = .25). There were no significant differences in age, osteoporosis status, smoking status, diabetes status, or time to surgery between groups. Male patients had nearly double the rate of healing (P = .03). DISCUSSION AND CONCLUSION The classification and effect of cement technique on tuberosity healing have not previously been described. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for a 4PHF is a male patient with anatomic tuberosity reduction and limited use of cement.

Fresh osteochondral allograft transplantation for osteochondritis dissecans of the capitellum in baseball players

BACKGROUND Osteochondritis dissecans (OCD) of the capitellum is a rare yet debilitating injury seen in young athletes. This is the first report in the literature describing fresh osteochondral allograft transplantation (FOCAT) to treat OCD of the capitellum. METHODS Nine male baseball players (mean age, 15.3; range, 14-18 years), with OCD of the capitellum were treated with FOCAT. There were 6 pitchers and 3 position players. A ligament-sparing, mini-open approach was used. A fresh femoral hemicondyle was used as a donor source. Of the 9 patients, 7 required 1 plug and 2 required 2 plugs. The average plug diameter was 11 mm (range, 8-18 mm). Five plugs were press fit, and 4 required additional fixation. Clinical outcomes were evaluated at a mean follow-up of 48.4 months (range, 11-90 months). Preoperative and postoperative outcome scores were calculated using the paired t test. RESULTS The Mayo Elbow Performance score improved from an average 57.8 to 98.9 (P < .01). The Oxford Elbow Score improved from 22.4 to 44.8 (P < .01). The Disabilities of the Arm, Shoulder and Hand score improved from 35.2 to 5.4 (P < .01). The visual analog scale score improved from 7.8 to 0.5 (P < .01). The Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score improved from 32.6 to 82.5 (P < .01). All patients returned to throwing and were still active in their sport or played at least 2 years of baseball before leaving the sport unrelated to the elbow. CONCLUSIONS FOCAT for OCD of the capitellum in properly selected cases is a viable treatment with significant functional improvement and pain reduction in throwers.

Fresh Osteochondral Allograft Transplantation for the Treatment of Unstable Osteochondritis Dissecans of the Capitellum in the Elbow

Several surgical treatments have been reported in the literature for the treatment of osteochondritis dissecans of the humeral capitellum, including arthroscopic debridement, microfracture, and transhumeral drilling; none of which restore a hyaline articular cartilage surface and are asssociated with poor return to sport. Osteochondral autograft transfer from the patient’s own knee or rib has also been described, which restores hyaline articular surfaces and has better outcomes, but may lead to donor site morbidity. We describe our ligament-sparing technique and clinical experience with the transplantation of fresh osteochondral allograft to treat unstable osteochondritis dissecans of the capitellum, namely in overhead athletes.

Reconstruction of the Acromioclavicular Joint, its Superior Capsule, and Coracoclavicular Ligaments Using an Interpositional Acellular Dermal Matrix and Tibialis Tendon Allograft

Acromioclavicular (AC) separations are one of the most common shoulder injuries that may lead to pain, disability, and dysfunction of the shoulder girdle. Over 100 different surgical procedures have been described in the literature for the treatment of this injury. Initial surgical repairs were nonanatomic and nonbiological. In recent years, allograft reconstruction has become accepted for the treatment of chronic separations, but most reconstructions are aimed at restoring the coracoclavicular ligaments. Very little attention has been placed on the reconstruction of the AC joint itself. The technique described is an anatomic, biological reconstruction of the coracoclavicular ligaments to restore stability in the vertical plane, and of the AC joint to restore stability in the horizontal plane.