Long-term evaluation of hip arthroplasty in patients with an ipsilateral knee arthrodesis.

Hip arthroplasty with an ipsilateral knee arthrodesis occurs infrequently but does raise concern regarding surgical technical difficulties, dislocation, sepsis, and long-term loosening. Sixteen patients were evaluated 7.5 years (average period) after surgery. Technical difficulties were not prohibitive. No dislocation or revision was necessary in any of the cases. Two patients died as a result of unrelated sepsis from an infected knee. Loosening and protrusio of the acetabulum occurred in two patients. Hip arthroplasty in patients with a fused knee does not incur undue risk of loosening or instability and can provide long-term good function and pain relief. Patients with multiple joint arthroplasties, in whom concurrent sepsis occurs, can have devastating results.

Metachronous infections in patients who have had more than one total joint arthroplasty.

Sixty-eight patients who had had 159 replacement arthroplasties of more than one major joint between 1975 and 1984 and who had had an infection after at least one of these procedures were identified in a retrospective review. Subsequent infection in another total joint replacement was documented in ten of these patients. The risk of development of an infection about another total joint replacement after an infection had occurred about one total joint replacement in a patient who had had more than one arthroplasty was 18 per cent, according to the survivorship-analysis method of Kaplan and Meier. Many variables that were previously thought to increase the risk of infection, such as rheumatoid arthritis, older age of the patient, previous operations, and the use of corticosteroids or immunosuppressive agents, or both, were not found to increase the risk of a subsequent infection in patients who had had more than one arthroplasty with infection of one of the arthroplasties. The recent occurrence of a major systemic infection did increase the risk of infection about the other total joint replacements. Eight of the ten subsequent joint infections were due to the same causative organism as the index infection about a total joint replacement and occurred within the first year after the index infection. The initial treatment of the index infection included specific parenteral antimicrobial therapy combined with débridement and excisional arthroplasty in forty patients, removal of the components and arthrodesis in three patients, and débridement with retention of the prosthesis in twenty-five patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Partial rupture of the distal biceps tendon.

Rupture of the distal biceps tendon is a relatively uncommon injury. Roentgenograms often demonstrate osseous changes at the radial tuberosity consistent with the degenerative tendon changes seen at the time of surgical repair. Partial rupture of the distal biceps tendon exhibits features similar to that of complete disruption, including acute antecubital pain, weakness of elbow flexion, and forearm supination, and differs only in that the biceps tendon is still palpable in teh partial rupture. The clinical presentation, surgical confirmation, and treatment of this condition seems not to have been reported previously in the literature.

Concomitant scapholunate dissociation and Kienböck's disease.

Six men had concurrent scapholunate dissociation and Kienböck's disease, a finding suggestive of a common cause. Five patients attributed the onset of wrist pain to a single traumatic event. Three had x-ray evidence of scapholunate dissociation before the onset of lunate osteonecrosis. Biomechanical factors that may be of significance are ulnar minus variance, lesser compliance of the triangular fibrocartilage, ulnar translation of the carpus at impact with shear fracture through the lunate, and disruption of the scapholunate interosseous membrane occurring under similar stress. Lunate osteonecrosis may depend on a susceptible vascular pattern or intraosseous injury or both. The development of lunatomalacia complicates an already unstable wrist. Treatment options vary according to the clinical stages of each condition, although contrasting treatments have not established optimal care.

Bipartite patella in the adolescent: results of surgical excision.

We evaluated the results of excision of the fragment in 16 patients with symptomatic bipartite patellae. In nine, the pain began following trauma; in seven, the onset was insidious. The pain was aggravated by activity in all patients. The average age at surgery was 14 years, 6 months, and the average postoperative follow-up was 7 years. Fifteen of the patients were markedly improved; one was not.

Adamantinoma of the radius. A case report.

Adamantinoma is a rare, primary, malignant bone tumor; only one such case involving the radius has been reported. A second case is documented. This patient was treated by en bloc excision and reconstruction with microvascular fibula transfer. Although adamantinoma is not considered to be a high-grade lesion, aggressive treatment is warranted for lesions of the radius.

Posterior cruciate condylar total knee arthroplasty. Five-year results.

A series of 189 consecutive posterior cruciate condylar total knee arthroplasties (TKAs) in 151 patients was reviewed. Of these, 18 patients died (22 knees), and two patients (three knees) were lost to follow-up study, leaving 164 knees in 131 patients for evaluation at 5.3 +/- 0.8 years (mean +/- SD). Before surgery 91% of the patients experienced moderate to severe pain with weight bearing, whereas 6% had such pain at five years. The average motion was -5 degrees -107 degrees before surgery and -1 degrees -101 degrees at last examination. The percentage of patients who could walk more than six blocks (600 m) increased from 9% preoperatively to 61% at last examination. The percentage of patients who could independently climb stairs increased from 37% preoperatively to 69% at last examination. Hospital for Special Surgery (HSS) scores improved an average of 29 points, from 57 preoperatively (poor) to 86 (excellent) at last examination. Complications included an overall reoperation rate of 3.7% (seven knees), with a revision rate of 1.6% (three knees). Lucent lines greater than or equal to 1 mm at five years were present in 6% of knees and progressed in 3%. Overall, the results after posterior cruciate-sparing TKAs were excellent, with few complications.

Postoperative pain relief using local anesthetic instillation.

Effective pain control following surgery is a concern. Oral narcotic agents may be effective yet have many side effects. Parenteral agents are impractical in outpatient procedures. Local blocks may distort tissue planes and require additional time and technical skill to administer. We have found that instillation of local anesthetic (0.5% bupivacaine [Marcaine, Sensorcaine]) into the wound prior to closure is a safe and effective means of providing significant reduction in postoperative foot pain.

Anterior knee pain.

Anterior knee pain is a common symptom, especially in adolescence, and often no specific cause is sought or identified. Physicians who treat patients with knee pain should understand the normal anatomic features and the biomechanics of the patellofemoral joint. We review this information and discuss important aspects of the physical examination and roentgenographic evaluation in patients with anterior knee pain. Once the clinical cause of anterior knee pain has been established, directed nonoperative treatment including physical therapy should be initiated. Surgical intervention is generally reserved for patients in whom nonoperative management is unsuccessful and identifiable abnormalities exist.

Locating the lateral antebrachial cutaneous nerve.

Dissections of 20 antebrachial specimens were done to define the location of the proximal lateral antebrachial cutaneous nerve, which is the distal sensory extension of the musculocutaneous nerve. Our findings varied from those noted in most anatomic and surgical texts in that the nerve emerges from the lateral aspect of the biceps tendon at the level of the interepicondylar line. At the point defined, the distribution of the nerve in ten volunteers was successfully anesthetized with 1.5 ml of 1% lidocaine. The accurate anatomic localization of this nerve should be of interest to surgeons and anesthesiologists in supplementing failed axillary blockade, in diagnosing and treating the musculocutaneous impingement syndrome, in harvesting the proximal nerve for diagnostic tests or donor graft purposes, and in differentiating the sensory distribution of this nerve from that of the radial nerve.

Congenital annular constricting bands: review of the literature and a case report.

Conditions associated with congenital annular constricting bands include autoamputation, acrosyndactyly of the hands and toes, clubfeet, lymphedema, pseud-arthrosis, and nail deformities. The association of congenital annular constricting bands and angular deformities of long bones is exceedingly rare. Reported is one such case treated with fibrous release and crescentic osteotomy.

Analysis of microvascular changes in frostbite injury.

Reported here is the characterization of the hairless mouse ear as a model system for defining the microvascular effects of minimal frostbite injury by means of gross, in vivo microscopic, histologic, and electron microscopic analysis. Initial efforts, using controlled temperatures and time of freezing, defined the minimum conditions necessary to produce consistent tissue necrosis to be -4 degrees C for 3 min. In vivo observation, after rapid thaw, showed a return of blood flow to apparent normal prefreeze rates, followed by a gradual sludging of blood 15 to 20 min post-thaw and eventually in cessation of blood flow. No vascular spasm was observed. Histologic and electron microscopic examination, unexpectedly, did not reveal evidence of early platelet or fibrin thrombi. However, marked vasodilatation and circulatory congestion began 2-3 hr after thawing. Subsequently, prominent discontinuities between damaged endothelial cells and breaks in the microvascular basement membranes were found at the light and ultrastructural level. Interstitial edema and extravasated erythrocytes occurred shortly thereafter, preceding gross tissue necrosis evident at post-freeze Day 3. We conclude that in this animal system thrombus formation is not an initial event, but rather that vascular injury in the form of endothelial cell damage predominates in early frostbite injury.

Knee stability in orthotic knee braces.

The ability of six commercially available orthotic knee braces to stabilize ligamentous injuries of the knee was evaluated using fresh cadaver specimens. Anterior, valgus, and rotational forces were applied to the intact knee, after the anterior cruciate and medial collateral ligaments were cut, and after application of the knee braces. Bony displacement was measured using half pins and an external fixator applied to the tibia and femur. There was a significant difference in brace performance, most likely due to differences in brace design. Of the six braces tested, the 3D 3-Way Brace provided the greatest knee stability.