Lateral unicondylar knee arthroplasty can help patients return to sport

One prospective study covers patients that undergo unicompartmental arthroplasty from 2000-2005 : nineteen patients underwent lateral unicompartmental (uni) knee replacements, with an average age of 68 years for the lateral unicompartmental group.

Assessments included preoperative and postoperative range of motion, subjective testing, radiographic evaluation and MRI.

Only one patient was converted to a total knee arthroplasty, and none were lost to follow-up.

Successful outcomes are reported in the majority of cases over an average follow-up of 33 months…

Physical examination and subjective questioning along with MRI correlation would help  predict successful outcomes.

Overall, patients reported a return to skiing in 5 months, tennis in 4 months and walking and jogging within 1 to 2 months.

He also reports that long-term results have to be followed and adds that the procedure has shown it is worth consideration.

“You can preserve bone stock, you can get near-normal kinematics, you have low cost and blood loss during surgery is less,” he says.

Reference

Plancher KD, Bishai SK, Ibrahim T. Patients undergoing lateral unicondylar knee arthroplasty: Can we guarantee success and return to sport? Paper SS-38. Presented at the 2010 Annual Meeting of the Arthroscopy Association of North America. May 20-23, 2010. Hollywood, Fla.

No link between fracture risk and use of vitamin A-related substances

Vestergaard and colleagues analyze data from a nationwide Danish registry for 124,655 patients who sustained fractures in the year 2000 and 373,962 age- and sex-matched individuals.

Their goal is to arrive at the incidence of fractures in those exposed to systemic vitamin A analogues vs. who those not exposed to these substances.

The researchers control their investigation for possibly confounding factors, such as social variables, contact with hospitals and care providers, alcoholism and any factors known to possibly affect fracture risk, such as use of corticosteroids and anti-epileptic medications.

When Vestergaard and colleagues match one fracture patient each with three controls, they find that neither topical nor systemic vitamin A analogues are associated with the change in fracture risk at any skeletal site.

Furthermore, even large daily doses —14 mg — of vitamin A analogues are not associated with an increased risk of fracture, nor was acne or psoriasis medication.

Reference

Vestergaard P, Rejnmark L and Mosekilde L. High-dose treatment with vitamin A analogues and risk of fractures.Arch Dermatol. 2010;146(5):478-482.

Dorsolateral Achilles Rupture Repair With Accelerated Rehabilitation With Athletes Back On Field In 4 Months ?

In all, 15 patients averaging 44 years old are  followed for an average of 45 months. Postoperative ankle hindfoot scores averaged 98.3, and all patients are  able to do single toe raises. Eight of 15 patients demonstrated measurable atrophy, and the average calf circumference loss was 1.0cm.

Hrnack reports that the only postoperative complication is one case of superficial cellulitis, “treated with antibiotics”. No sural nerve injuries, neuropraxias, wound breakdowns or re-ruptures are reported as of the final follow-up.

“…this was a very suitable and excellent way to go to repair acute mid-tendonous Achilles ruptures,” Hrnack sayq. “It is a very strong repair technique that allowed patients to rehabilitate very quickly and get them back into sports as early as 4 months.”

Reference:

Crates JM, Hrnack SA, Barber FA, Bynum JA. Acute Achilles tendon repair using a mini-dorsolateral incision and accelerated rehabilitation. Paper SS-51. Presented at the 2010 Annual Meeting of the Arthroscopy Association of North America. May 20-23, 2010. Hollywood, Fla.breakdowns or re-ruptures were reported as of the final follow-up.

Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Implant for Knee and Hip Repair in French West Indies

As more and more people in the Western World are walking around with artificial hips and knees,  French West Indies aging baby boomers are also leading the way.

That is partly because excess weight is fraying their joints earlier.

Between the years 2000 and 2006, knee replacements shot up by 65 percent.

In an AAOS 2009 paper entitled, “Joint Replacement Access in 2016: A Supply Side Crisis,” Dr. Thomas K Fehring et. al. stated that “demand for arthroplasty is expected to double in 10 years.”

By 2016, this translates into an annual demand of 1,046,000 knee replacement procedures.

At the same time, the expected supply of Orthopaedic surgeons is expected to fall such that if they were to work at current rates, they will only be able to perform 287,759 knee replacements, leaving many “waiting in pain”.

Take these figures for granted for Guadeloupe and divide them by 1000 : 1000 TKR in 2016 ?

Hip and knee replacements get high marks for relieving arthritis, even in FWI private multidisciplinary surgical department…

Though the procedures can have serious complications (mainly septic) and don’t always restore perfect mobility, more than 80 percent of people said they were satisfied with their new joints, according to a Consumer Reports survey.

And since then, advances in pain control and rehabilitation have sped recovery.

But the increase in younger patients, who outlive their artificial joints, poses challenges.

Manufacturers have engineered new implants that last longer in the laboratory than traditional ones, but none has been tested long enough to know how they will perform beyond 10 or 20 years in real life.

Yet the implants, as well as several controversial surgical procedures, have been heavily advertised to consumers and rapidly accepted into practice.

Why good joints go bad

The most common cause of hip and knee damage is osteoarthritis, which means the erosion of cartilage between the joints that allows adjoining bones to rub together.

Joints damaged by rheumatoid arthritis, a less common but more serious disorder, can be replaced as necessary when medical treatment has failed.

The need for joint replacement can often be delayed by the use of pain relievers, losing excess weight, and by doing regular low-impact exercises such as tai chi.

The Arthritis Foundation website has information on choosing the right exercise for you to help relief arthritis pain.

But when the damage is advanced, joint replacement becomes a good option.

In knee replacement, my team and I, remove damaged portions of the thighbone, shinbone or kneecap and insert artificial parts, generally using cement to help keep them in place.

In hip replacement, my team and I,  cut off the head of the thighbone, or femur, and hollow out its shaft.

Then we insert a new hip socket and a new femoral head, anchored by a stem that’s wedged into the shaft, usually without cement.

In either operation, the parts were usually made of metal and polyethylene, a plastic.

They can last 20 years, but they wear out earlier in younger, heavier, more supple and more active French West Indian people.

The most common reason hip and knee implants fail is loosening.

As metal and plastic rub together, the friction wears away the surfaces, creating tiny plastic particles around the joint.

The body attempts to remove those particles but in the process removes bone as well, causing the implant to loosen.

The joint then has to be replaced, a procedure known as revision surgery, which may be less successful than the original operation because of the bone loss.

New parts for old bones

Manufacturers have addressed the loosening problem by developing new devices.

But each has drawbacks.

Many patients base their choice on advertising.

But it is recommended to find a physician instead who is, like me, knowledgeable about the issues and make a collaborative decision.

	Metal on highly cross-linked polyethylene	Metal on metal	Ceramic on ceramic
Use	Knees and hips.	Hips only.	Hips only.
Plus	This new plastic wears substantially less than conventional polyethylene.	It wears less than metal on plastic, and offers a larger femoral head, reducing the chance of dislodgment.	It’s likely to wear out the slowest.
Minus	It has a shorter track record and might be more prone to fracture.	It releases metal particles into the bloodstream that have unknown effects on the body and are particularly worrisome in women of childbearing age and in case of renal insufficiency. Moreover, a few patients have developed allergies to the metal debris.	It poses a rare but serious risk of chipping or breaking. Moreover, up to 7 percent of patients have complained of squeaky ceramic hips.
Advice	It offers durability with the fewest side effects, making it the best choice for most people. But because the knee puts greater demand on the joint, increasing the risk of fracture, physicians generally recommend metal on conventional polyethylene for knee replacements.	This kind of device might make sense for young men in need of hip replacement whose work involves heavy labour, which increases the risks of joint dislocation and wear.	This might be an option for patients who need to get many decades out of their hip, such as very young men, or women of childbearing age.

A smaller cut ?

Some surgeons now use a technique called minimally invasive surgery, which might limit damage to muscle and tissue.

The potential advantages are faster recovery and reduced pain – but at the cost of longer operative time and a high risk of surgical errors, including incorrect implant positioning, nerve injury, and bone fracture.

The benefits of the procedure are still being debated, but marketing claims have fuelled patient demand.

Many surgeons feel they need to offer it or they’ll lose patients to someone else.

But the scientific evidence that this technique makes a substantial difference is lacking.

In fact, improvements in pain control and rehabilitation appear to speed recovery in hip-replacement patients whether they have small or conventional incisions, according to a 2007 study published in the Journal of Bone and Joint Surgery.

Physicians note the same effect in knee patients.

Many surgeons now use “mini” cuts that are significantly smaller than traditional incisions but large enough for them to view the operating field.

Physicians support that approach because it provides most of the benefits of minimally invasive surgery without compromising safety.

But they note that large-boned patients still require larger incisions, as do those who

• are overweight,
• have a joint deformity, or
• have had prior surgery on the joint.

Hip resurfacing

Aimed at younger patients who want to delay total hip replacement, this procedure removes only the damaged joint surfaces.

The socket is replaced with a metal cup and the femoral head is shaved down and covered by a metal cap anchored by a short stem.

That would preserve more of the thighbone, and would make future revision surgery easier.

“Patients read marketing materials and want this procedure. But the appeal of preserving bone can lead to false expectations.”

Women who had resurfacing are twice as likely to need early revision than those receiving regular hip implants, chiefly due to femoral neck fractures.

Women might be at higher risk for such fractures because their bones are smaller and weaken at menopause.

Additional concerns include the complexity of the operation and metal-on-metal debris.

Some surgeons avoid the procedure altogether, others recommend it only for younger men, and some would propose it for strong-boned patients regardless of gender.

Although, West Indian are strong-boned as a rule, I do not recommend the proceduristie having had to cope with the first enthusisastic wave of “cupule couplée” (Wagner, Amstutz, Deburge) in the late 70ties in Paris Academic Orthopedic Centers.

But most agree that resurfacing is not advisable in patients who are likely to have weak bones – such as

• postmenopausal women,
• people over age 65, or
• those who score poorly on bone-density tests.

Partial knee replacement

In this procedure, I replace only the eroded side of the knee.

Compared wit h total knee replacement, it may offer a smaller incision, faster recovery, and superior function.

Moreover, it might buy patients 10 to 15 years before they need total knee replacement.

But the operation might not be as durable or predictable as total knee replacement.

In the same British study, which looked at more than 80,000 knee patients, early revision rates were twice as high for those who had partial knee replacement, especially among younger patients.

Common reasons for failure include loosening and arthritis in other parts of the knee.

“Partial knees are great in the right person. But only one in 20 people who need knee replacement are candidates.”

Patients should have

• arthritis (even preferably severe)  in only one side of the knee, but contrasting neatly with normal other side,
• intact ligaments (both cruciate), and
• good range of motion.

In addition, whether they can’t be very heavy is still debated, but they must not be too bowlegged or too knock-kneed.

Early (?) Diagnosis of Low-symptomatic Ceramic Acetabular Liner Fracture in Ceramic-on-Ceramic Total Hip Arthroplasty

"Catastrophic" failure of one-piece ceramic liner without major trauma in a very active and heavy patient also having controlateral hip disease and right total knee arthroplasty (asymetric squatting) AND right shoulder arthroplasty for advanced omarthosis with normal rotator cuff (sugar cane handpicking ?)

Alumina ceramics in total hip arthroplasty (THA) have been used in Europe since 1970.

Over the years, ceramic-on-ceramic coupling became a valid option in THA because of excellent biocompatibility and tribological properties.

The major disadvantages are possible squeaking and mainly risk of breakage, usually disclosed by pain and functional impairment.

Squeaking is an audible noise arising from ceramic-on-ceramic bearings, the incidence of which is reported to range from 1% to 7% of THAs.

Component positioning, stripe wear, and edge loading have all been implicated.

Clicking sounds and scratching have also been anecdotally described.

Breakage of a ceramic component due to brittleness of the material still seems a rare complication.

Trauma, high activity level, and obesity may increase the risk of fracture.

Defective ceramic manufacture, inadequate (sandwich with polyethylene) implant design, and errors in surgical technique may contribute to breakage.

Rather than Caucasian, Asian (by extension West Indian) population lifestyle, including squatting, kneeling, and possibly sitting cross-legged, has been correlated to liner rim impingement and fracture.

Additional reports concerning failure of various, mainly sandwich, but not exclusively, ceramic liners have recently been described.

I will describe here a unique case of apparently early diagnosis of a low-symptomatic fracture of an Anca-Fit acetabular liner occurring 3 years after implantation of an uncemented ceramic-on-ceramic modular THA.

Diagnostic imaging in acute para- and tetraplegia in Guadeloupe (1983-2009)

Introduction

Since I had to leave Saint- Claude Camp Jacob General Hospital in Basse-Terre as it closed 40 out of its 60 surgical beds in 1989, there was a sudden developement and change in diagnosic imaging.

Some of these technologies use new physical priciples like MRI, others were developed using computerized processing of information gained by well known methods such as reconstruction of CT scans.

Older and well established methods like conventional x-ray imaging, tomography and myelography (Dr JCW) are still available.

This situation gave me reason to reevaluate the position of these techniques in our clinical management, especially in the acute setting.

Diagnostic approach

The diagnostic approach to acute para and tetraplegia lined out in the following diagramms is based on my experience as Chef de Clinique Assistant with patients from year 1964 to year 1980 in Paris best spine centers.

To define a pragmatic and clinically relevant way of using diagnostic procedures it is a must to have a clear scheme of differential diagnostic possibilites.

Spine Imaging Decision Tree

This is why I propose this decision-tree…

A patient presenting with an acute paraplegia may or may not have been exposed to a trauma.

I will first focus on the majority of patients in Camp Jacob Hospital which had suffered a trauma.

The important question is whether the trauma was

1. adequate – such as a car or motorcyle accident – or
2. inadequate – like lifting a case of bottles or kicking a spade.

If there was a “adequate trauma” (the two Galion Bus Accident of january 10^th 1984 and 1985…), I look for destructed vertebrae – that is

1. fractures – and/or
2. destructed soft tissue which are disc herniations and ruptures of ligaments.

Additional possibilites are intraspinal bleeding or a spinal contusion.

If there was a trauma, I consider as inadequate compared to the damage to the spine, I look for destruction of vertebra because of osteoporosis, tumors or spondylitis.

Other possibilities which involve no destruction of vertebra are arachnoitis, discitis, stenosis of the spinal canal or adhesions of the spinal cord.

If the patient reports no trauma at all, there might be

• a intraspinal tumor (ex. one psammomatous meningioma in 2 month bedridden 82 old lady also kwown to have uterus cancer),
• a vascular process,
• a hemorrhage or edema.

An acute inflammation or any kind (HTLV) of neurologic disease producing the symptoms of para- or tetraplegia also have to be considered.

Finally, there is always the possibility of a trauma which the patient does not report.

A diagramm will soon demonstrate the frequency of the conditions that led to paraplegia in patients I admitted for primary care during all these years.

The vast majority of paraplegia was caused by fractures.

Other important groups were tumor and disc problems.

Imaging strategy – adequate trauma

One Imaging Strategy

I outline here one diagnostic strategy in patients with an adequate trauma.

The first thing – which is always nescessary – is to get plain film x-rays of the segment of the spine which corresponds with the neurologic staging.

I know of a “second hand trauma case” who left the university hospital with high dorsal paraplegia from a T2 displaced fracture and had had “only”  diagnosed a T12 undisplaced fracture with “no compression CT” at T12 level and finally no proper managing : spine palpation and full history in hurry was probably omitted.

When I was on duty at Camp Jacob, the patient should and DID not leave the x-ray department without (if possible) palpation guided readable films in two planes and dynamic lateral cervical flexion views supervised by me.

In almost all cases at least the presence of fractures (if not by palpation !) could be diagnosed on these films.

The next step depends indeed on the overall approach to the management of these fractures.

One or two each year in a 120 000 population

Since I do intend to stabilize all instable spinal fractures as soon as possible (with an anterior and posterior approach if appropriate) – a film showing an instable spine as demonstrated here would at that time, give me enough information to proceed with surgery.

From 1983 to June 1989, I managed one case each year of these traumatic paraplegia (Galion falls, coco tree falls, windows fall).

If the fracure does not appear to be unstable or for example only a posterior stabilisation is discussed, a CT-scan should be obtained, to give the nescessary information about intraspinal fragments, fractured pedicles as well as traumatic herniations of intervertebral discs.

The above picture demonstrates one of these  common cases where the plain film does not show too much of a stenosis of the spinal canal through fractures.

Only the CT – Scan  would reveal the extend of an intraspinal fragment, I finally found during surgical approach.

In our Camp Jacob cases, these fractures were still reduced using a Roy-Camille  Screw and Blade Internal System, whereas a Cotrel Dubousset System (used later for tumors) would have been much easier to manage….

Clinical results, very good although not controlled intraoperatively by myelography nor later with a CT-scan

The very good clinical results were neither controlled intraoperatively by myelography but using a flouroscope nor later documented with a CT-scan, as I would probably do now.

In one case (first Galion accident of Jan, 10^th,1984) of a T7 burst fracture with complete and resolutive paraplegia, preop CT scan (no CT at that time) would have shown a sharp pedicle bit pinned in the middle of the spinal cord.

According to this experience of mine, 3D reconstructions would not have yield any additional information.

It should be mentioned at this place that according to experience, most surgeons in the late 90ties did stick to the plain films while they were performing the surgery – even if CT-scan or MRI scans were beginning to be available.

In cases where no definite fracture could be seen on the conventional x-ray films, many authors would still follow in the late 90ties a conservative stepladder of diagnostic imaging including

• CT-scans,
• Myelography and
• repeated CT-scan after Myelography.

However, MRI would still be employed as a last resort.

The growing experience, gathered from my own last 15 years MRI-Studies changed that.

I learned reading clear but painful "myélographie gazeuse" with the La Pitié Paris Hospital Fischgold-Metzger-Aboulker team in... 1967

I start now with MRI imaging and feel confident to use it to diagnose soft tissue problems – for example disc herniations, as demonstrated above as well as fractures.

According to my “recent” experience, MRI is by no means “boneblind”.

Of course other conditions, such as intraspinal hemorrhage or edema following spinal contusion are also demonstrated precisely.

Only when Magnetic Resonance Imaging would be not possible or  not available we would still use a combination of Myelography and CT scanning, as we had to do in the 80ties at Camp Jacob Hospital.

Imaging strategy – no adequate trauma

If there was no or no adequate Trauma, I still do plain film x-ray studies as described above, to diagnose destructed vertebra and tumor or spondylitis induced fractures.

If these films or the patient history indicate a possibility of muliple lesions – such as a kown prostata carcinoma – I obtain a MRI because it provides a fast overview to the extend of the disease.

It also shows details of the impact to the spinal cord.

If it is reasonable to expect only a single lesion I would do a CT-scan.

CT scans might be very reliable to define the extend of intravertebral lesions and show the remnants of a vertebra with metastasis.

If no fractures are visible and intraspinal changes such as tumors or hemorrhage are to be diagnosed, I proceed with an MRI-Scan.

As example : bleeding ependymoma which caused a paraplegia with an acute onset.

Summary

I would summarize frequent problems we encoutered.

First points

I underscore that imaging diagnostic has to be based on exact clinical neurological staging.

Usually minor neurological deficts are missed, which are present in neurologic segments above the level of the dominating symptoms.

This problem is especially important if the patient is unconscious, intoxicated or suffered a headinjury.

Second fractures are missed usually because a lesion is found, which seems to “explain” the symptoms (CHU one case).

It is important to keep this in mind and to look for associated fractures if the circumstances of the injury indicate the possibility.

An especially difficult area for conventional x-ray imaging is the cervico-thoracic transition.

With an x-ray image not demonstrating all seven cervical vertebrae, I was once called for a complete C7 dislocation in a young paraplegic motobike suspected of pithiatism by the general surgeon on duty…

We can only support that these important X rays (as well as immediate dynamic lateral flexion views should be done in spine surgeon’s presence, when there is a good chance of a fracture or luxation of the lower cervical spine or in any case of cervical spine trauma as I instituted this in Camp Jacob with very reactive radio technicians in the 80ties..

If it is impossible to obtain readeable images by applying traction to the shoulders, a conventional midline tomography might be done, but in my extensive experience plain X rays would be enough..

Concerning CT-scans there still might be three frequent problems.

The first is a missing topogramm.

If the topogramm is missing, there is always an incertainty where exactly the scans were done and where the lesion extends.

Another mistake is a CT-scan which is only documented in a bone window.

Patients with traumatic disc herniation may be missed out of this reason.

The last point regarding CT scans which lead to missing of lesions is an inappropriate gapping between slides.

I recommend a maximum slice thickness of  2 to 3 mm with no gap if a study of the cervical spine is done.

To achieve this, a restriction of the examination area to two or a maximum of three cervical segments might still be often necessary.

As a last point we would like to warn against elaborate additional studies and reconstruction processes.

Once you have the nescessary information you should terminate diagnostic imaging.

As said earlier, I do not see yet in 2009 any benefit in added information if a time consuming 3D reconstruction is done.

Frequent problems with imaging methods

Common problems

The imaging is focused on a wrong soinal segment due to incorrect neurological staging

Additional fractures are missed

Conventional X-ray imaging

Fractures of the cervico-thoracic transition are missed because the 7th cervical vertebra is not properly demonstrated

CT-scans

Missing topogramm

Gap between the scans too wide (especially in the C-spine)

No soft-tissue window generated

CT- and MRI-scans

Elaborate reconstruction yielding no additional information

2009 FWI trends in anterior cruciate ligament reconstruction

In 2006, in a survey regarding anterior cruciate ligament (ACL) reconstruction mailed to physician members of the American Orthopaedic Society for Sports Medicine, a total of nearly 1000 responses were received from 1747 possible respondents (57%).

The number of ACL reconstructions per year ranged from 1 to 275 (mean=55).

Our own experience is slowly growing with mean 30 caseload per year for the last decade.

The most important factors in the timing of surgery were (?) knee range of motion and effusion.

Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%).

Five years earlier, BPTB grafts are more frequent and hamstring tendon and allografts, less frequent (63%, 25%, and 12%, respectively).

A single-incision arthroscopic technique is used by 90%.

Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision (?).

There is limited experience (4%) with double-bundle and computer-assisted ACL reconstruction.

Arthroscopic-assisted (?), single-incision reconstruction using a BPTB autograft fixed with metal (?) interference screws remains the most common technique used for primary ACL reconstruction.

In the past 5 years, the use of alternative graft sources and methods of fixation has increased.

Consensus regarding the best

• graft type,
• fixation method, and
• postoperative protocol

is still lacking.

Surgery for FWI avascular necrosis of the femoral head

Numerous treatment modalities are available for avascular necrosis of the femoral head.

There seems to be no relevant animal model for the study of the human form of this disease.

Also, numerous are the etiologies for this disease.

Results of treatment are often based on small patient series with different stages of the disease various etiologies and different techniques.

One of the (many) purposes of this blog is to provide a current FWI perspective of the various treatment modalities for avascular necrosis based on a comprehensive analysis of the literature and the author’s experience.

Radial Nerve Palsy Associated with Humeral Shaft Fractures

Radial nerve palsy associated with radial shaft fracture is a common occurrence.

Approximately one in ten patients with a humeral shaft fractures will also have associated radial nerve palsy.

In an epidemiologic study of 1.4 million people, the overall incidence of radial nerve palsy in 401 humeral shaft fractures was 8.5%.1

In my own non operative orthopedic study, from 1983 to 1989 of 120 000 people, the overall incidence of radial nerve palsy in 40 humeral shaft fractures is also 8.5% (Basse-Terre, Saint-Claude, Camp Jacob General Hospital, unpublished data).

In a systematic literature review, Shao and investigators2 identified 532 radial nerve palsies in 4,517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

The management of radial nerve palsy associated with a humeral shaft fracture is a topic of debate.

Although it is known that the majority of these injuries are neuropraxias that will recover spontaneously, the indication and need for operative exploration has been disputed, with authors offering conflicting opinions.

While some surgeons have advocated different treatment algorithms for radial nerve palsies that occur secondary to a closed fracture reduction, others believe that the timing of the nerve palsy is irrelevant to the management decision.

Primary nerve palsies occur at the time of injury and are discovered during the patients initial evaluation.

Approximately 10% to 20% of nerve palsies develop during the course of treatment, commonly noted more often (Basse-Terre)  following an open than a closed reduction, and are termed secondary nerve palsies.3

Complete motor loss is present in 50% to 68% (large majority in Basse Terre) of cases of radial nerve palsy, while the others are only partial motor loss or sensory loss.3

Systematic Literature Review

While some of the studies reported solely on patients with radial nerve palsies, 21 of the studies included the denominator of total radial palsy and shaft fractures.

In these studies, there were 532 radial nerve palsies in 4517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

Based on the studies that described the fracture location, the highest incidence of radial nerve palsy occurred for fractures in the distal third.

The incidence of palsies was significantly lower for fractures located in the proximal third, then in the middle or distal third.

Table 1. Incidence of radial nerve palsy based on fracture location.

Fracture location	Incidence	# Palsies/# Total fractures
Proximal third	1.8%	1/57
Middle third	15.2%	27/178
Distal third	23.6%	37/157

Transverse and spiral fracture patterns were significantly (P < .001) more likely to be associated with a radial nerve palsy than oblique or comminuted fractures .

Table 2. Incidence of radial nerve palsy based on fracture pattern.

Fracture pattern	Incidence	# Palsies/# Total fractures
Transverse	21.2%	47/222
Spiral	19.8%	19/96
Oblique	8.4%	15/179
Comminuted	6.8%	26/382

They reported no statistical difference in the incidence of radial nerve palsy in open vs closed fractures.²

Table 3. Incidence of radial nerve palsy based in open versus closed fractures.

Fracture Type	Incidence	# Palsies/# Total fractures
Open	18.2%	51/280
Closed	14.8%	137/929

In this literature review, which included a total of 1045 radial nerve palsies, the overall recovery rate was 88.1% (921/1045).

No significant difference in the recovery rate between primary (occurring at the time of injury) and secondary (occurring after the injury, or as a result of a closed reduction) nerve palsies was reported.

The mean time to the onset of recovery, reported in only five studies that included 101 patients, was 7.3 weeks (range: 2 weeks to 6.6 months).

The mean time to full recovery, reported in only five studies that included 110 patients, was 6.1 months (range: 3.4 months to 12 months).

Table 4. Recovery rate of radial nerve palsies.

Type of palsy	Recovery rate	# Recovery/# Total palsies
Overall rate	88.1%	921/1045
Primary	88.6%	632/713
Secondary	93.1%	121/130

Timing of EMG, nerve exploration, and/or tendon transfers

Controversy exists over the recommended timing for surgical exploration of radial nerve palsies.

Debate also exists over whether nerve repair or tendon transfers are the best treatment option for a transacted or permanently injured radial nerve.

Most surgeons suggest obtaining an initial electromyogram at 6 weeks following the injury if there has been no return of radial nerve function.

Thomsen and Dahlin8 recommend an electrodiagnostic examination at 5 to 6 weeks after injury and nerve repair and reconstruction within 2 months, not later than 3 months, after injury.

Ekholm and colleagues1 recommends exploration at 4 to 6 months if there is no resolution following a primary radial nerve palsy.

However for patients with indications for earlier operative fixation (eg, multiple trauma, open fractures, segmental or bilateral fractures, floating elbow, and nonunions), they advocated exploration of the nerve at the time of internal fixation.

Others note that the first sign of nerve recovery may be delayed as long as 6 months following injury.5

Ring and investigators5 suggest basing the timing of operative treatment on the patients willingness to continue wearing a radial nerve brace.

For patients wanting to be brace-free and satisfied with a hand that opens but does not have independent extension, they suggest tendon transfers at 6 months.

For patients who are comfortable wearing a brace, they recommend waiting until 12 months to see if they are one of the patients whose recovery is delayed in nature.

Nerve exploration may be considered in select patients (eg, patients with multiple nerve injuries in whom tendon transfer is not an option) at 6 months.

Verga and colleagues9 reported that in the absence of functional recovery, delayed surgical treatment (neurolysis or nerve grafts) performed 3 to 4 months after primary orthopedic treatment can be useful in achieving good functional recovery and subjectively satisfying results.

My experience is one of conservative treatment with early bracing both of the fracture (Sarmiento functional brace) and of the palsy.

References

1. Ekholm R, Adami J, Tidemark J, et al. Fractures of the shaft of the humerus: An epidemiologic study of 401 fractures. J Bone Joint Surg Br. 2006; 88:1469-1473.

2. Shao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br. 2005; 87:1647-1652.

3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006; 31:655-663.

4. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am. 1993; 81:121-124.

5. Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004; 29:144-147.

6. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Orthop Relat Res. 1983; 172:171-176.

7. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am. 1963; 45:1382-1388.

8. Thomsen NO, Dahlin LB. Injury to the radial nerve caused by fracture of the humeral shaft: Timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr Surg Hand Surg. 2007; 41:153-157.

9. Verga M, Peri Di Caprio A, Bocchiotti MA, Battistella F, Bruschi S, Petrolati M. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: Review and evaluation of the long-term results of 52 cases. J Hand Surg Eur. 2007; 32:529-533.