Timothy A. Burd

The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures.

Objectives To identify factors affecting the outcomes of surgery for acetabular fracture in patients over the age of 60 years. Design Retrospective review of records and radiographs; current examination, radiographs and outcome surveys when possible. Setting Academic, Level 1 trauma center. Patients/Participants Forty-eight patients over age 60 with displaced acetabulum fractures. Intervention Surgical reduction and fixation. Main Outcome Measurements Clinical ratings and radiographic evaluations, Short Musculoskeletal Functional Assessment survey (SMFA), SF-36, and hip-specific questions. Radiographs were evaluated using the criteria of Matta. Results Ten patients died since surgery. Four were lost to follow-up. Seven had >12 months of follow-up information in the chart. Twenty-seven had current evaluations for the study. Average follow-up was 37 months, range 1–114 months. The average age at surgery was 71.6 years (range 61–88). No perioperative deaths occurred. Initial reductions achieved: 61% anatomic, 34% imperfect, and 5% poor. A specific radiographic finding (superomedial dome impaction) predictive of failure was identified. This was designated the “Gull Sign.” These patients had inadequate reduction, early fixation failure, or medial/superior joint narrowing and subluxation. Functional outcomes in patients with current examination were similar to age-matched controls. Radiographic outcomes: 30% excellent, 30% good, 9% fair, 23% poor, and 7% arthroplasty. Anatomic reduction was closely related to good or excellent radiographic result. Conclusions While some patients over sixty years of age can have satisfactory functional outcomes after acetabular fracture fixation, a significant number will have failure of the procedure. Osteopenic patients with superomedial dome impaction (the Gull Sign) did not benefit from attempted open reduction and internal fixation in this series.

Surgical correction of internal coxa saltans: A 20-year consecutive study

Purpose To report the complications associated with surgical correction of internal snapping hip. Study Design Retrospective review. Methods A review of 92 cases of internal coxa saltans (12 bilateral) from 1982 to 2002 was performed to identify complications following primary surgical correction. An inguinal approach was used for iliopsoas tendon fractional lengthening. The average follow-up time per patient was 5.4 years. Results A total of 40 complications occurred in 32 patients. Complications included persistent hip pain (n = 6), sensory deficit (n = 8), and hip flexor weakness persisting longer than 1 month (n = 3). Additionally, painful bursa formation (n = 1), hematoma requiring reexploration (n = 1), and superficial infection (n = 1) were noted. Some patients developed recurrent snapping after a 3-month snapping-free interval (n = 9), and some patients never had complete resolution of snapping and were considered failures (n = 11). Of these failures/recurrences, 8 patients had a second tenotomy with 4 failures. Two had a third tenotomy, with 1 failure. Conclusions In this series, primary iliopsoas tendon lengthening in patients with internal coxa saltans was without any complication in only 60% of patients; however, overall patient satisfaction was 89%.

A New Operative Approach in the Correction of External Coxa Saltans The Snapping Hip

Background External snapping hip is an entity that describes a snap that is felt on the lateral aspect of the hip. Several surgical interventions are described. Hypothesis The external snapping hip can be corrected with a simple procedure that is minimally invasive and less demanding than other techniques. Study Design This is a retrospective review from June 1994 until January 2002 looking at released external snapping hips. Methods There were 16 patients with 17 hips; follow-up was in 15 patients with 16 snapping hips. Twelve patients with 13 hips were contacted by telephone interview, and 3 were followed up by their most recent chart note. All underwent the same procedure performed by the senior author. The questionnaire was conducted at an average of 32.5 months after surgery (range, 9-74 months). For 3 patients, chart-only follow-up was at 6 weeks, 3 months, and 6 months, respectively. Results Fourteen of 16 hips remained asymptomatic after final surgical release (2 hips needed a second release). All patients contacted by telephone would undergo the same procedure again if faced with the same symptoms. Conclusions This technique is simpler than most of those previously described with the benefit of no formal postoperative regimen and comparable results.

Short segment bone-on-bone instrumentation for single curve idiopathic scoliosis.

Study Design. Retrospective case series review. Objectives. To evaluate the outcomes of a new short segment anterior scoliosis technique with complete removal of the discs, bone-on-bone apposition of the vertebral bodies, and dual rod instrumentation. To evaluate a new preop planning technique for scoliosis instrumentation. Summary of Background Data. Scoliosis surgery traditionally was performed via a posterior approach, but anterior scoliosis instrumentation has proven to be superior regarding the amount of curve correction and the number of segments saved from instrumentation. Methods. Thirty-one patients with single curve idiopathic scoliosis less than 75° were operated using the bone-on-bone surgical technique with dual rod instrumentation (Kaneda Anterior Scoliosis System, Depuy AcroMed, Raynham, MA from 1996 until 2001). Average follow-up was 40 months (range 15–77 months). Results. Surgical correction of the major curve averaged 73.9% over the instrumented levels and 51.4% over the entire curve. The average number of discs fused was 4.6 for thoracic curves and 3.3 for thoracolumbar and lumbar curves. There were no implant-related complications or nonunions. The compensatory curves spontaneously improved by an average of 38.6%. Uneventful healing of all fusions occurred—most within 8 to 12 weeks. One compensatory thoracic curve progressed and posterior instrumentation was done 28 months after correction of the major thoracolumbar curve. Conclusions. Surgical correction was achieved in over half the levels that would have been operated by standard posterior segmental fixation. Bony healing due to the bone-on-bone apposition was achieved uneventfully after apical correction of the spinal curvature in all patients. Use of dual rod instrumentation (Kaneda Anterior Scoliosis System) is fundamental in maintaining the correction of the curvature achieved in the operating room. The preoperative planning technique worked well.

Enhanced Fracture and Soft-Tissue Healing by Means of Anabolic Dietary Supplementation

BACKGROUND Malnutrition is common in hospitalized injured patients. It contributes to delayed fracture-healing and increased morbidity. However, relatively little attention has been directed toward nutritional strategies for augmenting musculoskeletal recovery after a fracture. This animal study was designed to examine the effects of dietary protein intake and the role of conditionally essential amino acids in muscle and bone-healing after a fracture. METHODS One hundred adult male rats were used. Ten rats served as controls and received a 15% protein diet throughout the study. The remaining ninety rats received a 6% protein diet for five weeks to induce protein malnutrition. The rats underwent intramedullary nailing and closed midshaft fracture of one femur. After the fracture, they were separated into three isocaloric dietary groups. Group P6 received a diet with 6% protein; Group P15, a diet with 15% protein; and group P30, a diet with 30% protein with conditionally essential amino acids. At two, four, and six weeks after surgery, ten animals from each group were killed and the femora were evaluated with dual x-ray absorptiometry, histomorphometric assessment of callus, and torsional testing. The quadriceps muscles were analyzed for total mass, total protein content, and for mRNA expression of insulin-like growth factor-1 (IGF-1), IGF-2, IGF receptors, actin, myosin, and vascular endothelial growth factor (VEGF). RESULTS The P30 group demonstrated elevations in albumin, body mass, muscle mass, total protein content of muscle, and bone mineral density in the fracture callus compared with the P6 diet group at six weeks (p < 0.05). Molecular analysis of muscle revealed that IGF-1, IGF-2, IGF receptors, myosin, actin, and VEGF gene expression were significantly (p < 0.001) higher in the P6 group compared with the P30 group. Biomechanical testing of the femora, however, showed no significant differences. CONCLUSIONS Dietary supplementation with conditionally essential amino acids in malnourished animals had anabolic effects on bone mineralization, body mass, and muscle mass.

In vitro elution of tobramycin from bioabsorbable polycaprolactone beads.

Objectives To compare the in vitro elution characteristics of tobramycin impregnated beads made of polycaprolactone (PCL) and polymethylmethacrylate (PMMA). Design Six-millimeter PCL and PMMA beads with 6% tobramycin were formed and placed in phosphate-buffered saline or newborn calf serum and incubated at room temperature or 37°C. Aliquots were taken at intervals for eight weeks. Tobramycin levels were determined by fluorescent assay and antibacterial efficacy was assessed by measuring the zones of inhibition against Staphylococcus aureus and Pseudomonas aeruginosa on agar diffusion plates. Results Tobramycin elution rates at room temperature were similar up to three weeks. At three weeks, elution rates from PCL beads were twice those from PMMA beads, and at eight weeks, elution from PCL was quadruple that from PMMA. At 37°C, tobramycin elution rates from PCL were eight times greater than those from PMMA by eight weeks. Total tobramycin eluted from PCL beads was 38.9% and 20% in PMMA beads. All samples showed bacteriostatic activity against S. aureus and P. aeruginosa at eight weeks. Conclusions These in vitro results show that PCL has superior antibiotic elution characteristics compared with PMMA, and this may translate into a more effective antibiotic delivery vehicle. In addition, PCL is a bioabsorbable polymer, which may decrease the need for a second surgical procedure to remove retained beads.

Post-traumatic catamenial sciatica.

This article presents a unique case of posttraumatic extrapelvic endometriosis presenting as a gluteal mass causing cyclic sciatica. A 38-year-old woman presented with an enlarging right buttock mass over the previous 6 years. She also had symptoms of radicular pain referred to the right leg and foot with sitting and daily activity. Four years prior to noticing the mass, she sustained a gunshot wound through the lower abdomen while 5 months pregnant. Excisional biopsy of the gluteal mass revealed endometrioma. Sciatica is a common and painful disorder that is believed to have an incidence of 40% in the adult population. Sciatica is most often due to intraspinal pathology affecting the lumbar nerve roots. There are many recognized extraspinal etiologies for sciatica in the literature including aneurysms, sciatic hernia, abcess, neoplasm, trochanteric wire, piriformis syndrome, ischial fracture, a posteriorly flexed uterus, and even an intrauterine device following uterine perforation. Similarly, endometriosis is a gynecologic condition that represents a significant health problem for women of reproductive age as it occurs in up to 50% of premenopausal women and 71% to 87% in women with chronic pelvic pain. Although rare, endometriosis has a well known ability to migrate outside of the abdominal cavity and proliferate ectopically under the control of systemic estrogen.

Short-segment bone-on-bone fusion of adolescent idiopathic scoliosis using Kaneda Anterior Spinal System

Abstract Purpose of study: The objective of this study was to evaluate a new technique for treatment of idiopathic scoliosis with a single major curve using the short-segment, bone-on-bone approach and the Kaneda Anterior Spinal System (KASS). This report describes the technique and presents the results for our first 10 patients. Methods used: The short-segment bone-on-bone KASS technique was performed in 10 consecutive patients with adolescent idiopathic thoracic or thoracolumbar scoliosis. The mean age was 14.4 years (12 to 20 years), and the average follow-up was 44 months (range, 34 to 61 months). None were lost to follow-up. of findings: Preoperatively, the major curve averaged 48 degrees (38 to 55 degrees); this corrected to 11 degrees (0 to 20 degrees) postoperatively (77% correction rate). Preoperative compensatory curves measured 34 degrees (29 to 39 degrees); these spontaneously corrected to 13 degrees postoperatively (62% correction rate) as a consequence of correction of primary curve. The preoperative tilt angle was 20 degrees (14 to 28 degrees). Postoperatively the tilt angle was reduced to 6 degrees (2 to 10 degrees). The tilt angle correction was 70%. The fusion was healed and postoperative immobilization discontinued 6 to 10 weeks after the procedure. There was no loss of correction. The average number of vertebra fused using our technique was five (four discs). The average number of posterior fusion levels are proposed by King was 10. There were no implant problems, nonunions or serious peri- or postoperative complications. Relationship between findings and existing knowledge: The bone-on-bone short-segment technique permits correction of single-curve idiopathic scoliosis below 75 degrees over half the levels that have been traditionally operated on by posterior instrumentation, yet provides 77% average correction with no nonunion, no loss of correction and healing in 6 to 8 weeks. Overall significance of findings: The new short-segment, bone-on-bone approach for single major curves using the KASS instrumentation provides excellent correction over half the levels operated on by previous posterior systems with rapid fusion and with no loss of correction. Disclosures: Device or drug: Kaneda Anterior Spinal System. Status: approved. Conflict of interest: Robert Gaines, consultant speakers bureau; and, other support from De Puy Acromed.