Comparison of sensory recovery at the subfascial and suprafascial donor sites of the free radial flap.

The radial flap may be raised using a subfascial or suprafascial approach. The latter donor site is associated with fewer healing complications. We retrospectively evaluated the quality of sensory recovery within two comparable groups of 30 patients with subfascial and suprafascial donor sites. When considering the two groups, two-point discrimination was the modality most commonly reduced, with 97% of patients in both groups having reduced sensation in at least one anatomical zone. Sensation of sharp touch was most often lost; 90% in the subfascial and 83% in the suprafascial groups lost sensation in at least one anatomical zone. Roughly half the patients had reduced perception of light touch (43% and 50%), whilst perception of heat (27% and 17%) and cold (33% and 27%) were lost least often. At least one modality in at least one anatomical zone was lost or reduced in all patients, and roughly two-thirds (73% and 63%) had a reduction in 3 or more. The only significant difference between the donor and non-donor arms was reduced perception of sharp touch in the anterior forearm in both groups (p<0.001). Perception at the two sites (including the anatomical snuff box) was similar except for superior thenar palmar light touch (p=0.015) in the suprafascial group, which may indicate injury to the thenar cutaneous sensory branches during subfascial dissection.

Influence of acetabular and femoral version on fractures of the femoral neck.

BACKGROUND: Fractures through the proximal femur are broadly grouped into intertrochanteric fractures and intracapsular fractures. It is not clear why a patient may sustain an intertrochanteric fracture as compared with an intracapsular fracture. There is an established relationship between relative hip retroversion and the development of osteoarthritis. We postulate retroversion also may be a risk factor for having intracapsular fractures develop. QUESTIONS/PURPOSES: We looked specifically at the geometry of the hip to analyze the possibility of a relationship between acetabular version, femoral version, and Mckibbin's instability index and fracture type. PATIENTS AND METHODS: We recruited 40 patients with fractures of the femoral neck for the study. There were 15 men and 25 women with a mean age of 80 years (range, 57-92 years). There were 14 intertrochanteric fractures and 26 intracapsular fractures. After treating their fracture, the contralateral hip was scanned in a CT scanner and assessed by two independent observers to establish the acetabular and femoral version. RESULTS: We found no correlation between proximal femoral fracture type and the contralateral femoral version, femoral neck length, acetabular version, or Mckibbin's instability index or between fracture type and age or gender. CONCLUSIONS: There appears to be no correlation between proximal femoral fracture type and acetabular or femoral version. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Assessment of CAOS as a training model in spinal surgery: a randomised study.

The objectives of this study were (1) to quantify the benefit of computer assisted orthopaedic surgery (CAOS) pedicle screw insertion in a porcine cadaver model evaluated by dissection and computed tomography (CT); (2) to compare the effect on performance of four surgeons with no experience of CAOS, and varying experience of pedicle screw insertion; (3) to see if CT with extended windows was an acceptable method to evaluate the position of the pedicle screws in the porcine cadaver model, compared to dissection. This was a prospective, randomised, controlled and blinded porcine cadaver study. Twelve 6-month-old porcine (white skinned Landrace) lumbar spines were scanned pre-operatively by spiral CT, as required for the CAOS computer data set. Computer randomisation allocated the specimens to one of four surgeons, all new to CAOS but with different levels of experience in spinal surgery. The usual anatomical landmarks for the freehand technique were known to all four surgeons. Two pedicles at each vertebral level were randomly allocated between conventional free hand insertion and an electromagnetic image guided surgery (NAVITRAK) and 6.5 mm cancellous AO screws inserted. Post-operatively, spiral CT was blindly evaluated by an independent radiologist and the spine fellow to assess the accuracy of pedicle screw placement, by each method. The inter- and intra-observer reliability of CT was evaluated compared to dissection. The pedicle screw placement was assessed as perfect if within the pedicle along its central axis, or acceptable (within < 2 mm from perfect), and measured in millimetres from perfect thereafter. One hundred and sixty-six of 168 pedicles in 12 porcine spines were operated on. Complete data were present for 163 pedicles (81 CAOS, 82 freehand). In the CAOS group 84% of screws were deemed acceptable or perfect, compared to 75.6% with the freehand technique. Screw misplacement was significantly reduced using CAOS (P = 0.049). Seventy-nine percent of CAOS screws were ideally placed compared with 64% with a conventional freehand technique (P = 0.05). A logistic linear regression model showed that the miss placed pedicle screw rate was significantly reduced using CAOS (P = 0.047). CAOS benefited the least experienced surgeons most (the research registrars acceptable rate increased from 70 to 90% and the spine fellow from 76 to 86%). CAOS did not have a statistically significant effect on the experienced consultant spine surgeon increasing from 70 to 79% (P = 0.39). The experienced general orthopaedic surgeon did not benefit from CAOS (P = 0.5). CT compared to dissection showed an intra-observer reliability of 99.4% and inter-observer reliability of 92.6%. The conclusions of this study were as follows: (1) an increased number of pedicle screws were ideally placed using the CAOS electromagnetic guidance system compared to the conventional freehand technique; (2) junior surgeons benefited most from CAOS; (3) we believe CAOS (Navitrak) with porcine lumbar spines evaluated by post operative CT, represents a useful model for training junior surgeons in pedicle screw placement; (4) experienced spine surgeons, who have never used CAOS, may find CAOS less helpful than previously reported.

Pain related to the psoas muscle after total hip replacement.

Residual pain after total hip replacement may be due to a number of causes both local to and distant from the hip. We describe pain related to the psoas muscle after total hip replacement in nine patients. All presented with characteristic symptoms. We describe the key features and management. Gratifying results were achieved with treatment. This diagnosis should be considered when assessing patients with pain after total hip replacement.

Management of distal femoral fractures in elderly patients using retrograde titanium supracondylar nails.

We present our experience with a retrograde supracondylar nail used for the management of fractures of the distal femur in elderly patients. Eighteen fractures of the distal femur in 18 patients were treated with AIM titanium supracondylar nails. Sixteen patients with a median age of 83 years (62-100 years) were finally available for review. All 16 fractures were classified as extra-articular type A according to the AO classification. The average operative time was 58 min. Follow up ranged between 4 and 35 months (average 20.4 months). Fifteen fractures (93.7%) united in an average duration of 3.6 months. The average range of motion achieved at the knee was 100. 6 degrees. There were no implant failures, knee sepsis or wound healing problems. One non-union and two stress fractures of the femur above the nail were the main complications in this series. We concluded that the AIM titanium supracondylar nail is a useful alternative implant for the management of the osteoporotic fractures of the distal femur particularly the extra-articular AO type A fracture in the elderly population.