Injuries to the midtarsal joint and lesser tarsal bones.

Injuries to the midtarsal joint and lesser tarsal bones occur relatively infrequently and often present with a benign appearance on imaging studies. These facts may lead to failure of diagnosis and/or inadequate and improper treatment, with subsequent disability for the patient. The clinician with a general knowledge of the various injury patterns to the midfoot is able to approach these injuries rationally and with an appreciation of their potential severity. This article reviews the mechanism, clinical and radiologic presentation, and treatment of midtarsal joint injuries and midfoot fractures.

Complications of iliac crest bone graft harvesting.

Autologous bone grafts harvested from the iliac crest are commonly used in reconstructive orthopaedic surgery. Autologous bone is used to help promote bone healing in fractures and to provide structural support for reconstructive surgery. The results of autologous bone grafting are more predictable than the use of xenografts, cadaveric allografts, or synthetic bone substitutes because autologous bone grafts provide osteoinductive and osteoconductive properties, are not immunogenic, and are usually well incorporated into the graft site. In a retrospective review of 414 consecutive cases of iliac crest bone graft procedures performed at Brooke Army Medical Center from 1983 to 1993, 41 (10%) minor and 24 (5.8%) major complications were identified. Minor complications included superficial infections, superficial seromas, and minor hematomas. Major complications included herniation of abdominal contents through massive bone graft donor sites, vascular injuries, deep infections at the donor site, neurologic injuries, deep hematoma formation requiring surgical intervention, and iliac wing fractures. Harvesting of iliac crest bone graft can be associated with significant morbidity. However, with adequate preoperative planning and proper surgical technique, the incidence of these complications can be reduced.

Suction injuries in children leading to acute compartment syndrome of the interosseous muscles of the hand: case reports.

Compartment syndromes of the interosseous musculature in the hands of children is a relatively rare phenomenon and is usually associated with crush injury, severe burn, or ischemic events. Two cases of intrinsic compartment syndrome in children, secondary to suction injuries of the hand, are presented. Two children experienced suction injuries to the upper extremity when their hands were caught in a swimming-pool intake pipe filtration system. The filtration system intake suction developed enough negative pressure to induce an acute compartment syndrome of the interosseous muscles, requiring acute surgical decompression. Early diagnosis, prompt surgical decompression, and early postoperative rehabilitation of this unusual etiology of compartment syndrome of the hand provided a favorable and functional outcome.

Prophylaxis of deep venous thrombosis after total hip arthroplasty by using intermittent compression of the plantar venous plexus.

A randomized, prospective, blinded study comparing the efficacy of prophylaxis of deep venous thrombosis by using (A) heparin-aspirin therapy, (B) intermittent pulsatile pneumatic-pump compression of the plantar venous plexus, or (C) both methods, was conducted in patients undergoing elective total hip replacement arthroplasty. Duplex ultrasonography was obtained in all 75 patients before surgery, at 1 week, and 2 weeks after surgery, to detect the presence or absence of deep venous thrombosis, with venograms confirming all positive results. Five of 25 patients in group A (heparin-aspirin) developed deep vein thrombosis. No deep venous thrombi were detected in groups B or C. One pulmonary embolus was detected in group A. The reduction in detectable deep venous thrombosis by the use of intermittent compression of the plantar venous plexus was significant. Wound drainage was decreased by 2 to 3 days (P < 0.05) in group B. It is concluded that, in this group of 75 consecutive patients, intermittent pulsatile compression of the plantar venous plexus was superior to heparin/aspirin pharmacologic prophylaxis for the prevention of deep venous thrombosis proximal to the calf.

The effect of postoperative wound drainage reinfusion in reducing the need for blood transfusions in elective total joint arthroplasty: a prospective, randomized study.

A prospective, randomized study was conducted in 24 patients using the Solcotrans Orthopaedic Drainage Reinfusion System (Smith & Nephew Richards Inc, Memphis, Tenn) for postoperative blood salvage in total joint arthroplasty. The amount of postoperative autologous blood salvage averaged 946 mL. Only 25% of the study group required postoperative transfusions, compared to 83% of the control group (P = .016). In total knee arthroplasties, only 11% of the study group required transfusions, compared to 78% of the control group (P = .018). There were no transfusion reactions, infectious complications, or coagulopathies. Postoperative blood salvage is a safe, reliable, and effective source of autologous blood.

Rupture of the triceps tendon associated with steroid injections.

Rupture of the triceps mechanism is an uncommon injury that has been recognized with increasing frequency in recent years. It has been proposed that such injuries commonly accompany fractures of the radial head and must be actively evaluated in the presence of such a fracture. We present a unique case of isolated rupture of the triceps tendon in an athlete who was lifting weights. This case was complicated by a history of olecranon bursitis that had been treated with numerous local steroid injections, as well as a history of anabolic steroid abuse. Both systemic steroids and local injections may predispose tendons to rupture. Triceps tendon ruptures may result in uniformly good to excellent results if recognized and treated surgically. This case also serves as a reminder of the risks of treating inflamed tissues with local steroid injections, especially in strength athletes who place high demands on their musculoskeletal structures. Finally, this case documents a second case of triceps mechanism rupture in an athlete who has abused anabolic steroids. A study by Hunter et al. suggests that oral steroid abuse may be associated with detrimental effects on the mechanical properties of connective tissue, demonstrating another negative effect of anabolic steroid use in athletes.

Pulsed, non-thermal, high-frequency electromagnetic energy (DIAPULSE) in the treatment of grade I and grade II ankle sprains.

Acutely sprained ankles represent a frequent and common injury among active duty troops in training, and are a significant source of morbidity with respect to days lost to training. Swelling in the form of periarticular edema limits motion, causes pain, prevents wearing of normal foot gear, and slows the healing process. Reduction of edema was attempted in acutely sprained ankles by the use of pulsed electromagnetic energy (Diapulse). In a randomized, prospective, double blind study of 50 grade I and II (no gross instability) sprained ankles, a statistically significant (p < 0.01) decrease in edema was noted following one treatment with Diapulse. The application of this modality in acutely sprained ankles could result in significant decreases in time lost to military training.

The prevalence of seropositivity for human immunodeficiency virus in patients who have severe trauma.

Patients who have severe trauma have been reported to have a substantially increased rate of seropositivity for human immunodeficiency virus when compared with the general population. We reviewed the records of 1226 consecutive Code-3 trauma patients who were treated at our institution in San Antonio, Texas, between 1987 and 1989. All of the patients had serum drawn to be tested for the human immunodeficiency virus. In contrast with previously published studies, only 0.8 per cent of these trauma patients were seropositive. There was no appreciable difference between the prevalence of seropositivity in patients who sustained blunt trauma and those who sustained penetrating trauma. Exposure to human immunodeficiency virus for medical personnel who care for trauma patients remains a concern, but the risk may be lower than previously reported.

The incidence of permanent upper and lower extremity profiles in active duty Army officers.

The records of 89,955 active duty Army officers were reviewed to determine their incidence of permanent upper and lower extremity profiles. Only 1,706 officers (1.897%) have permanent upper or lower extremity profiles. However, the incidence of such profiles varies with respect to rank, branch, and sex. Some officer groups have an incidence as high as 37%. Although the overall incidence of such profiles is quite low, the dramatically increased incidence in some officer groups demands scrutiny.

The use of metal-backed patellar prostheses in total knee arthroplasty.

Metal backing of polyethylene prosthesis components decreases deformity of the overlying polyethylene and enhances fixation to the underlying bone. Previous metal-backed patellar designs have often failed, primarily because of implant design and implantation technique. In 451 total knee arthroplasties using metal-backed patellar prostheses, there were no implant failures. The implants were dome shaped and did not have a metal endoskeleton. The component was inset into the patellar bone so that the base plate was below the superficial surface of the bone. These factors maximized polyethylene thickness and prevented wearing through to the metal base plate. The advantage of metal backing is that it strengthens the component and allows for possible biologic ingrowth. In this series, the combination of implant design and implantation technique may have eliminated serious problems seen with other metal-backed patellar implants.

Colonic pseudoobstruction associated with patient-controlled analgesia after total joint arthroplasty.

Patient-controlled analgesia (PCA) is a concept that permits patients to administer a prescribed dose of narcotic to themselves when they experience pain. Six patients developed colonic pseudoobstruction after the use of morphine sulfate administered via a PCA infuser. Early recognition and prompt treatment make this a transient, reversible illness. Treatment includes discontinuing the use of the PCA morphine, eliminating oral intake, ensuring adequate hydration and electrolyte balance, placing a nasogastric tube, rolling the patient, and closely observing for signs and symptoms of worsening colonic distention and possible rupture.

Resection arthroplasty for comminuted olecranon fractures.

Five cases of comminuted olecranon fractures treated by resection of the proximal fragments are reviewed. The patients' average age was 56 years and all were radiographically osteopenic. The triceps was advanced and attached to the distal olecranon with the elbow flexed at 90 degrees. A standard postoperative regimen was used with immobilization for three weeks in plaster at 45 to 60 degrees of flexion followed by progression to cautious active range of motion exercises. Follow-up of from 18 to 54 months shows an average active range of motion of 10 degrees flexion to 120 degrees flexion. There were no complaints or clinical evidence of instability and minimal degenerative changes were seen on radiography. We conclude that resection arthroplasty of comminuted olecranon fractures yields excellent clinical and functional results in elderly patients.

Cervical epidural anesthesia for surgery of the shoulder.

Regional anesthesia has some advantages over general anesthesia for shoulder surgery. Cervical epidural anesthesia, a regional technique not previously described for shoulder operations, was successfully used for surgical procedures on or near the shoulder joint. The technique provided good surgical anesthesia and postoperative analgesia, with few complications and a high degree of patient acceptance. Cervical epidural anesthesia offers some advantages over previously described techniques of regional anesthesia for shoulder operations, including a single needle insertion with no need to elicit paresthesias, lesser volumes of local anesthetic agents, and the ability to easily reinject the catheter intraoperatively if necessary and postoperatively for pain relief.

The release of 5-hydroxytryptamine from the rat stomach in vitro.

1. 5-HT was released into the lumen of the intact isolated rat stomach and into the bath fluid surrounding a preparation of the body and antrum stretched mechanically.2. Release of 5-HT increased when the pressure inside the intact stomach was raised or when the body/antrum preparation was stretched.3. This increased release was not prevented by hexamethonium, atropine, hyoscine or procaine, and was probably due to distortion of cells containing 5-HT.4. During periods of peristalsis induced by transmural stimulation the pharmacological activity of the fluid in the stomach was usually increased owing to a greater release of 5-HT and also to the release of an unidentified substance.5. In reserpine-treated rats, 5-HT was released into the stomach but transmural stimulation did not produce true peristalsis and only rhythmic contractions occurred.6. Peristalsis was seldom reduced by methysergide, and it is concluded that 5-HT is not essential for gastric peristalsis in the rat.