Closed reduction of dislocated total hip with S-ROM constrained acetabular component.

One of the major disadvantages reported for the use of the S-ROM constrained total hip arthroplasty is the need for mandatory urgent revision surgery in cases of dislocation. In patients who are medically compromised and poor surgical candidates, this disadvantage presents a difficult management dilemma. To address this problem, we have developed a technique for closed reduction of dislocated S-ROM constrained hips. This technique has been used successfully on 3 patients, all of whom were medically compromised and poor surgical candidates. All patients tolerated the procedure well, and all went on to revision total hip arthroplasty on an elective basis after medical optimization.

Salvage and reconstruction of complex post-extirpative knee wounds: a successful surgical protocol.

Six patients with massive post-extirpative wounds of the knee, all of whom had received adjuvant therapy, underwent wound closure and limb salvage via free-tissue transfer in all but one case. No instance of delayed wound healing requiring surgery occurred among the patients reconstructed by microsurgical tissue transfer. Five of the six patients are presently ambulating on the salvaged extremity. A protocol for management of these complex wounds is presented.

Local or free muscle flaps and unreamed interlocked nails for open tibial fractures.

The treatment of open tibial fractures associated with severe soft tissue injuries remains a difficult dilemma, even to the experienced fracture surgeon. To ascertain the efficacy of nailing tibial fractures with severe soft tissue injuries, a review of all open tibial fractures treated at the authors' institution was done. Those fractures initially stabilized with nonreamed nails which required muscle flaps for coverage were selected for study. Thirty-three patients (26 men, seven women) were treated with intramedullary nailing and muscle flap coverage for the soft tissue defects. The average length of followup was 12.1 months (range, 7-42 months). The average time to union was 27 weeks (range, 14-45 weeks). There were five (15%) infections: two (6%) superficial wound infections, one (3%) flap infection, and two (6%) cases of osteomyelitis. In no patient did the infection result in limb ablation. Thirteen of 33 (42%) patients required secondary procedures to enhance union. In this study, it was found that although delayed procedures frequently were required to promote fracture union, the time to union, and infection rates were not significantly different from those reported for external fixation of fractures that require local or free muscle transfers.

Silastic metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis.

Two hundred sixty-four patients with rheumatoid arthritis were treated with 901 Swanson silastic arthroplasties of the metacarpophalangeal joints. Average followup was 8 years with a minimum of 2 years. Preoperative ulnar deviation averaged 45 degrees and improved to an average of 15 degrees postoperatively. Active flexion arc averaged 40 degrees preoperatively and 50 degrees postoperatively, an increase of 10 degrees. The extensor lag postoperatively improved to 10 degrees from 50 degrees preoperatively, placing the arc of metacarpophalangeal joint motion between 10 degrees and 60 degrees flexion. Complications included dehiscence and delayed wound healing (2%), superficial infection (0.5%), deep infection (3%), and prosthetic fracture (14%). Subjectively, most patients thought that their postoperative function was improved. This was thought to be attributable in part to the correction of the ulnar deviation deformity of the fingers, and the shifting of the arc of motion of the metacarpophalangeal joints to one allowing increased metacarpophalangeal extension, thereby improving the opening capacity of the digits and the overall function of the hand.

Microvascular transplantation in the salvage of lower extremity trauma in the elderly.

Successful salvage of Gustilo IIIB tibial fractures with microvascular transplantation has been documented in the young. Similar results from the application of these techniques to the elderly has not been demonstrated. An 8-year review located 12 patients 60 years or older who underwent soft tissue reconstruction of IIIB tibial fractures with microvascular transplants. Ten patients were available for long-term follow-up (average 43 months). To date, 80% remain ambulating with no secondary amputations or late infections reported.

Subtotal calcanectomy for osteomyelitis of the os calcis: a reasonable alternative to free tissue transfer.

Composite wounds of the heel with secondary secondary osteomyelitis of the calcaneus remain a reconstructive challenge. A paucity of regional flaps has often necessitated microvascular transplantation in order to obtain wound healing. Subtotal calcanectomy, traditionally a technique of the orthopedic surgeon, can, in selected cases, eradicate infection and achieve wound closure and limb preservation. A review was undertaken of one hospital's experience with this procedure over a 4-year period. Five patients with osteomyelitis of the os calcis were identified who were successfully managed with subtotal calcanectomy.

Use of the Autobac IDX system for rapid identification of Enterobacteriaceae and nonfermentative gram-negative bacilli.

The Autobac IDX system was evaluated for its ability to accurately identify 290 gram-negative bacilli from 18 different genera. Excluding isolates with a low identification probability, the overall sensitivity of the system was found to be 95.8%. Late lactose-fermenting Escherichia coli, Citrobacter freundii, and Proteus mirabilis accounted for over 90% of the misidentifications. The Autobac IDX system offers a rapid and reliable method for the identification of gram-negative bacilli.