Recombinant human bone morphogenetic protein-2 for grade III open segmental tibial fractures from combat injuries in Iraq.

This is a retrospective consecutive case series of 138 Gustillo-Anderson type IIIB and IIIC segmental tibial fractures treated at Walter Reed Army Medical Center in soldiers injured in Iraq between March 2003 and March 2005. Five patients with a head injury and four who were lost to follow-up were excluded. The patients were treated definitively with either a ringed external fixator or a reamed intramedullary nail, evaluated in terms of supplementary bone grafting with either autogenous bone (group 1, 67 patients) or recombinant human bone morphogenetic protein-2 at 1.50 mg/ml applied to an absorbable collagen sponge (group 2, 62 patients). The mechanism of injury, defect size and classification, associated injuries, presence of infection, preliminary treatment/fixation, number of procedures before definitive management, time to and details of definitive management, subsequent infection, re-operation, smoking history and other complications were noted. Radiographs were assessed for union, delayed union or nonunion by an independent investigator. All the patients were male. Their mean age was 26.6 years (20 to 42) and the mean follow-up was for 15.6 months (12 to 32). Group 2 had a slightly higher profile of concomitant injuries and a slightly worse fracture classification, but these were not significant. The rate of union was 76% (51 of 67) for group 1 and 92% for group 2 (57 of 62; p = 0.015). There was also a higher rate of subsequent infection in group 1 (14.9%) compared with group 2 (3.2%; p = 0.001) and a higher rate of re-operation (28%) in group 1 (p = 0.003). There were no observed hypersensitivity reactions to the recombinant human bone morphogenetic protein-2 implant.

Spontaneous proximal thoracic curve correction after isolated fusion of the main thoracic curve in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. OBJECTIVES: To evaluate the spontaneous correction of the noninstrumented proximal thoracic (PT) curve after isolated correction of the main thoracic (MT) curve by either an anterior (ASF) or posterior (PSF) instrumentation and fusion. SUMMARY OF BACKGROUND DATA: There are no studies comparing the structural PT curve response after anterior versus posterior instrumented fusion of the MT curve in adolescent idiopathic scoliosis. METHODS: Eighty-five patients (single surgeon) with adolescent idiopathic scoliosis underwent operative instrumentation and fusion of their MT curve. All patients had a PT curve > or =20 degrees (average 29 degrees, range 20-49 degrees; average residual side-bending 18 degrees, range 3-42 degrees ) and were evaluated for preoperative PT curve flexibility and postoperative curve correction after PSF with the PT curve not instrumented (n = 44) and ASF with the PT curve not instrumented (n = 41). Minimum follow-up was 2 years (average, 3.6 years). Preoperative, 1 week postoperative, and latest follow-up (minimum 2-year) full-length radiographs were evaluated for the PT, MT, and thoracolumbar-lumbar coronal, side-bending, and sagittal Cobb measurements, as well as T1 tilt, clavicle angle, radiographic shoulder height, and the PT, MT, and thoracolumbar-lumbar apical vertical translation. A patient outcome questionnaire was also completed to correlate patient satisfaction with respect to their shoulder balance and overall appearance. RESULTS: The two groups were found to be statistically equivalent (P = 0.66) in terms of preoperative PT curve, MT curve, and MT side-bending curves, with the PT side benders slightly more flexible for the ASF (43%) versus the PSF group (31%) (P = 0.02). RADIOGRAPHIC: The spontaneous improvement in the PT curve was significant (P < 0.0001) in both groups. Additionally, this correction was maintained over time. However, the spontaneous PT curve correction was significantly greater after an ASF versus PSF correction of the MT curve on both the immediate postoperative (P =0.017) and minimum 2-year (P = 0.0024) evaluations, whereas the MT curve correction was the same in both groups (P = 0.45). There was no difference in the postoperative sagittal change in the PT curve (P = 0.12) between the two groups, and there was no difference in radiographic shoulder height (P = 0.5883). PATIENT OUTCOME: Both groups reported improvement in shoulder balance and clinical appearance, but there was no statistical difference between the two groups (P = 0.24). Additionally, no patients reported deterioration in either parameter. CONCLUSIONS: Spontaneous proximal thoracic curve correction consistently occurs after instrumented correction of the main thoracic curve. Furthermore, this spontaneous correction is as good as or slightly better after an ASF versus PSF of the MT curve. The preoperative side bender radiographs (PT curve flexibility) positively correlate with the postoperative spontaneous PT curve correction.

Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws.

STUDY DESIGN: An analysis of lumbosacral fusions for high-grade spondylolisthesis fusions with reduction and long fusions to the sacrum in ambulatory adults. OBJECTIVE: To assess the clinical and radiographic results of lumbosacral fusions using bilateral S1 and iliac screws. SUMMARY OF BACKGROUND DATA: S1 screws often fail with lumbosacral fusions, whereas L5-S1 pseudarthrosis is common in patients with deformity. MATERIALS AND METHODS: A total of 81 patients (38 revision, 43 primary) with minimum 2-year follow-up (average, 4.2 years; range, 2.0-7.1 years) underwent L5-S1 fusion using S1 and iliac screws (158 screws). Forty-nine of 81 constructs (61%) included an anterior load-sharing/fixation device. Group 1 included isthmic spondylolisthesis (n = 42), whereas Group 2 included long fusions (> or =3 levels) to the sacrum (n = 39). In Group 2, 15 patients (Group 2A) were fused from L1, L2, or L3 to the sacrum (3-5 levels, average 3.3 levels) and 24 patients (Group 2B) were fused from the thoracic spine to the sacrum (6-17 levels, average 11.5 levels). Twelve patients had pseudarthrosis at L5-S1. A patient questionnaire was completed. RESULTS: A total of 36 of the 38 revision patients had previous iliac crest harvesting, yet iliac screws were placed in 34 of 36 patients. Overall, 78 of 80 patients had iliac crest harvesting (one not attempted). None had loss of screw fixation or iliac crest fracture after harvesting. Four of the 81 patients (4.9%) had pseudarthrosis at L5-S1 after reconstruction. This included solid fusion in 10 of 12 patients presenting with L5-S1 pseudarthrosis. Fourteen percent of patients experienced some discomfort over the iliac screws; however, only one patient required screw removal. CONCLUSIONS: Bilateral iliac screws coupled with bilateral S1 screws provide excellent distal fixation for lumbosacral fusions with a high fusion rate (95.1%) in high-grade spondylolisthesis and long fusions to the sacrum. Previous iliac crest harvesting does not prevent ipsilateral screw placement (34 of 36 patients) or additional iliac harvesting (78 of 80 patients).

String test measurement to assess the effect of spinal deformity correction on spinal canal length.

STUDY DESIGN: Long cassette coronal and lateral radiographs before and after surgical correction were analyzed and string test measurements made by three observers in 55 surgical cases (13 surgical types). OBJECTIVES: The purpose of the study was to assess the effect of various corrective maneuvers for spinal deformity on the spinal canal length. SUMMARY OF BACKGROUND DATA: When perioperative neurologic deficit occurs, the surgeon removes implants because they are displaced into the spinal canal or the canal has been lengthened. It is important to know the effect certain constructs have on canal length because the ability of the spinal cord to adapt to canal lengthening is variable. METHODS: On the coronal radiographs the concave, convex, midvertebral, and adjusted midvertebral line, and on the sagittal radiographs, the anterior and posterior vertebral body lines were measured. The adjusted coronal line was the assumed path of the spinal cord starting at the midportion of the vertebral body at the top and the bottom of the deformity and then in between, hugging the pedicles as closely as possible while staying inside the pedicles. Adjustments for magnification were made. RESULTS: Anterior compression instrumentation without cages (n = 5) consistently shortened the spinal canal (mean delta -6.67 +/- 2.30 mm, P = 0.003), whereas instrumentation with cages (n = 13) lengthened the canal (mean delta 10.54 +/- 7.58 mm, P = 0.0003). Thoracic curves treated by posterior corrective forces (n = 14) demonstrated lengthening of the canal (mean delta 10.14 +/- 5.23 mm, P = 0.0001), large (n = 5) curves (81-140 degrees, mean delta 13.47 +/- 7.05 mm), and medium (n = 7) curves (50-80 degrees, mean delta 8.43 +/- 3.24 mm). CONCLUSIONS: Many deformity correction maneuvers, although they do not directly include application of posterior or anterior distraction forces, do indirectly lengthen the spinal canal.

Arthroscopic release for lateral epicondylitis.

PURPOSE: This study was performed to review the results of our early experience with recalcitrant lateral epicondylitis treated arthroscopically. TYPE OF STUDY: This study is a case series consisting of consecutive patients with lateral epicondylitis treated arthroscopically by 1 surgeon. METHODS: Patients failing a minimum of 6 months of conservative treatment underwent arthroscopic release of the extensor carpi radialis brevis (ECRB) origin using the proximal medial and proximal lateral portals. Associated intra-articular pathology was noted and addressed. The ECRB lesions were classified according to their gross morphology and resected with a shaver. The lateral epicondyle was then decorticated with a burr. RESULTS: Sixteen patients with recalcitrant lateral epicondylitis were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 16 elbows undergoing surgery, 5 (31.3%) were noted to have a type I lesion, characterized as fraying of the undersurface of the ECRB. Five (31.3%) had a type II lesion noted by linear tears within the ECRB, and 6 (37.5%) had a type III lesion, consisting of a partial or complete avulsion of the ECRB origin. Concurrent intra-articular pathology (synovitis, osteophytes) was noted in 3 of 16 elbows (18.8%) and was addressed arthroscopically. All patients were followed-up for a minimum of 1 year; however, 4 patients were lost to follow-up for this retrospective review due to military reassignment. Follow-up was obtained on 12 of 16 (75%) of patients at an average length of 24.1 months (range, 15 to 33 months). All patients reported improvement with the procedure. The average return to unrestricted work was 6.0 days (range, 0 to 28 days). CONCLUSIONS: Arthroscopic release effectively treats lateral epicondylitis while also affording visualization of the joint space to address associated intra-articular pathology. Additionally, arthroscopic release is minimally invasive and allows early rehabilitation and return to normal activities.

Measurement of thoracic and lumbar fracture kyphosis: evaluation of intraobserver, interobserver, and technique variability.

STUDY DESIGN: Statistical analysis of various measurement techniques for thoracolumbar burst fracture kyphosis on lateral radiograph. OBJECTIVE: To determine the most reliable measurement technique. SUMMARY OF BACKGROUND DATA: The treatment of thoracic and lumbar burst fractures involves many factors, including the degree of resultant kyphosis. Although various methods have been described, no study has directly compared these methods for reliability and reproducibility. METHODS: Fifty lateral radiographs of thoracic and lumbar burst fractures were randomly selected and measured on two separate occasions by three spine surgeons using five different measurement techniques. Radiograph quality, fracture type, and the center beam location were determined. Statistical analysis included analysis of variance for repeated measures and analysis of variance using a generalized linear model. RESULTS: Intraclass correlation coefficients were most consistent for Method 1 (rho = 0.83-0.94) followed by Method 4 (rho = 0.65-0.89) and Method 5 (rho = 0.73-0. 85). Intraobserver agreement (% of repeated measures within 5 degrees of the original measurement) ranged between 72% and 98% for all techniques for all three observers, with Method 1 showing the best agreement (84%-98%). Paired comparisons between observers varied considerably with interobserver reliability correlation coefficients ranging from 0.52 to 0.93. Method 1 showed the highest interobserver reliability coefficient (0.81, range 0.71-0.93) followed by Method 5 (0.71, range 0.68-0.75). Method 1 also had the highest percentage of agreement within categories (90% within 5 degrees ). CONCLUSIONS: Method 1 (measuring from the superior endplate of the vertebral body one level above the injured vertebral body to the inferior endplate of the vertebral body one level below) showed the best intraobserver and interobserver reliability overall.

Langerhans' cell histiocytosis in patients older than 21 years.

In this retrospective review of 541 patients with Langerhans' cell histiocytosis, 211 (39%) patients were older than 21 years of age, whereas 330 (61%) were younger than 21 years of age. The adult patients had a mean age of 32 years (range, 21-69 years) with 159 (75%) men and 52 (25%) women, whereas the pediatric patients consisted of 176 (55%) boys and 144 (45%) girls. This male predominance in adults was statistically significant. Three adults had the Hand-Schuller-Christian variant, whereas the remaining adults (208) had eosinophilic granuloma. The rib accounted for 25% of the adult lesions and only 8% of the pediatric lesions. Spine involvement was less common in the adult group (3% versus 10%) and was predominantly thoracic. The adult patients had 40 (77%) diaphyseal lesions, 12 (23%) metaphyseal lesions, and no epiphyseal lesions. The pediatric patients had 75 (54%) diaphyseal, 59 (42%) metaphyseal, and five (4%) epiphyseal lesions. Radiographic evaluation revealed similar margin and matrix patterns in both groups, with a geographic lesion without sclerotic borders being the most common pattern. Langerhans' cell histiocytosis is considered a pediatric disease. However, this study showed a significant number (39%) of patients older than 21 years of age with this condition.

Segmental limb reconstruction after tumor resection.

Limb salvage of large segmental and osteoarticular defects after tumor resection has become the standard of care for most patients with musculoskeletal tumors because overall survival is the same when compared with that seen in amputation patients. This study examines limb salvage for the surgical management of large segmental defects in terms of local recurrence, complications, and functional outcome in both primary and metastatic lesions. We retrospectively identified 32 patients with benign or malignant tumors of bone who underwent resection and limb salvage reconstruction by means of a custom or modular metal implant between 1985 and 1995. The most common tumor sites were the proximal femur (41%), distal femur (37.5%), and proximal humerus (12.5%). Primary bone lesions accounted for 18 patients (56%); metastatic disease accounted for 14 patients (44%). Osteosarcoma (n = 11) and chondrosarcoma (n = 3) were the most frequent primary tumors. The overall limb salvage rate (91%) was high, yet complications (28%) were common. Except for 3 patients who underwent amputation after prosthetic failure, all surviving patients were independent with or without assistive devices at latest follow-up. In patients with advanced metastatic disease, average survival was 7.6 months. No cases of aseptic loosening or implant breakage were observed in patients followed up for 2 years or more. Treatment after tumor resection with a limb salvage prosthetic reconstruction has shown good functional outcomes with an acceptable complication rate. This modality, therefore, offers patients a more favorable functional outcome with a more energy-efficient gait when compared with limb amputation.

A review of orthopedic injuries in three recent U.S. military conflicts.

We conducted a retrospective review of all patients with orthopedic injuries evacuated to a single medical center to evaluate the treatment and outcome of these injuries in three recent U.S. military conflicts: Operation Urgent Fury (Grenada), Operation Desert Shield/Storm (southwest Asia), and Operation Restore Hope (Somalia). Sixteen orthopedic casualties were originally treated at the medical detachment in Grenada before evacuation to the medical center. Most of these injuries were gunshot wounds to the extremities (11), with three known open fractures. Two patients (three extremities) sustained traumatic amputation (19% amputation rate). One hundred eighty-one patients with orthopedic injuries were medically evacuated from southeast Asia to the medical center for definitive treatment. Of these injuries, there were 143 fractures in 69 patients. One hundred of these fractures were open fractures, and 60% of these injuries were blast injuries. Furthermore, there were 26 amputations (14%). Twenty-two patients with orthopedic injuries were treated in Somalia and evacuated to the medical center. Thirteen of the 22 patients (59%) sustained gunshot wounds, and 2 (9%) sustained blast injuries. There were eight open fractures (36%) and three amputations in two patients (14%). Three of the 22 patients underwent successful limb salvage when ablation was the only other surgical alternative. It appears that a large percentage of medical center evacuations from military conflicts are for orthopedic injuries. Many of these injuries are the result of high-velocity weapons or blast injuries. Regardless of the size and/or purpose of the intervention, similar injury patterns and severity can be expected, because 51% of orthopedic patients had open fractures. Similarly, the rate of amputation associated with extremity trauma has not varied significantly since the Vietnam War.

Periosteal chondroma of the cuboid presenting in a 7-year-old-boy.

This case report discusses the finding of a periosteal (juxtacortical) chondroma of the cuboid in a 7-year-old male. While this lesion is well recognized in the tubular bones of adults, this case is unusual due to the child's age, the site of the lesion (cuboid), and the difficulty in establishing the diagnosis due to the cellular atypia. The child was treated with marginal resection and curettage with no evidence of local recurrence on follow-up. A review of the literature is also included in the discussion.

Thoracoscopic spine surgery: current indications and techniques.

The first report of thoracoscopic surgery was in 1910, after Jacobaeus used thoracoscopy to lyse tuberculous lung adhesions. However, it was not until the end of the century that Lewis (1991) recognized the value of thoracoscopic surgery, and Mack (1993) reported the application of video-assisted thoracic surgery (VATS) for spine surgery. VATS is still in its infancy and the application of this technology for spine surgery continues to rapidly expand. The current indications for thoracoscopic spine surgery include tissue biopsies, thoracic paravertebral abscess drainage and debridement, thoracic disc herniation excisions, anterior spinal release and/or fusion for spinal deformity, stabilization and fusion of thoracic and thoracolumbar fractures, corpectomy for vertebral tumors, and the placement of anterior spinal instrumentation with fusion. This article reviews these current indications for VATS--the technique and subsequent nursing implications.

Arthroscopic release for lateral epicondylitis: a cadaveric model.

At least 10 different surgical approaches to refractory lateral epicondylitis have been described, including an arthroscopic release of the extensor carpi radialis brevis tendon. The advantages of an arthroscopic approach include an opportunity to examine the joint for associated pathology, no disruption of the extensor mechanism, and a rapid return to premorbid activities with possibly fewer complications. A cadaveric study was performed to determine the safety of this procedure. Ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis tendon. The specimens were randomized with regard to the use of either a 2.7-mm or a 4.0-mm 30 degree arthroscope through modified medial and lateral portals. Following this, the arthroscope remained in the joint, and the portal, cannula track, and surgical release site were dissected to determine the distance between the cannula and the radial, median, ulnar, lateral antebrachial, and posterior antebrachial nerves, and the brachial artery and the ulnar collateral ligament. No direct lacerations of neurovascular structures were identified; however, the varying course of the lateral and posterior antebrachial nerves place these superficial sensory nerves at risk during portal placement. As in previous reports, the radial nerve was consistently in close proximity to the proximal lateral portal (3 to 10 mm: mean, 5.4 mm). The ulnar collateral ligament was not destabilized. Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings.

Acute and long-term response of the meniscus to partial meniscectomy using the holmium: YAG laser.

The purpose of this study was to evaluate the histological effects of holmium:YAG laser partial meniscectomy in an in vivo rabbit model and compare it with scalpel partial meniscectomy at selected time intervals. Twenty-four adult male New Zealand rabbits underwent bilateral partial medial meniscectomies through the avascular zone. In the right knee, partial medial meniscectomy was performed using a standard surgical blade; in the left knee, an anatomically similar partial medial meniscectomy was performed using a Ho:YAG laser (Coherent, Santa Clara, CA). All animals were randomized and three animals were killed at postoperative days I and 3, and postoperative weeks 1, 2, 3, 4, 6, and 10. Samples of all medial and lateral menisci, with attached synovium and vascular rim, from both knees were harvested and submitted for histological and/or ultrastructural examination. The results indicate that (1) at all time periods, laser cut menisci had more cell loss and matrix degradation; (2) synovial necrosis was more common in laser-treated knees; (3) the Ho:YAG laser creates three zones of damage in the meniscal fibrocartilage: a zone of fibrin and debris at the incision site, a zone of necrosis characterized by degeneration of the collagen and loss of viable cells, and a zone of thermal change characterized by collagen degeneration. The zone of thermal change, with its histological injury was thought at the time of surgery to be the viable border. The zone of thermal change may act as a barrier to delay healing, and the scalpel produced a consistently straighter cut.

Hip arthroscopy in Legg-Calve-Perthes disease.

The case of a 7-year-old boy with Legg-Calve-Perthes disease is presented. He had a prominent island of superficial epiphyseal ossification in his right femoral head, an unusual finding in Legg-Calve-Perthes disease. Hip arthroscopy was used successfully to identify and treat the lesion. After the procedure, the patient had a reduction in pain and an increase in range of hip motion. We believe that this case demonstrates the effective use of hip arthroscopy in the treatment of this unusual sequela of Legg-Calve-Perthes disease.

Rectus femoris muscle tear appearing as a pseudotumor.

Quadriceps muscle strains are common sporting injuries, but occasionally a tear of the rectus femoris muscle can appear as a soft tissue mass of the anterior thigh with or without a significant history of trauma. Between 1992 and 1996, seven patients were referred to the Orthopaedic Oncology Unit at Walter Reed Army Medical Center with an unexplained soft tissue mass of the thigh. Three were active duty soldiers, three were military dependents, and one was a retired serviceman. All patients were men, and the mean age was 32 years (range, 15 to 73). A palpable, mildly tender mass was confirmed on clinical examination. Laboratory studies and plain radiographs were normal. Magnetic resonance imaging showed an obvious, but often ill-defined, lesion at the musculotendinous junction of the rectus femoris muscle. Four patients subsequently underwent a tissue biopsy to rule out a soft tissue sarcoma. Histologic studies showed fibrosis, degeneration of muscle fibers, and chronic inflammatory cells with no evidence of malignancy. A chronic rectus femoris muscle tear can mimic a soft tissue tumor or sarcoma and needs to be excluded in the differential diagnosis. These tears may occur acutely or may represent an overuse injury caused by repeated microtrauma. Careful history taking, physical examination, and selective radiographic studies, specifically magnetic resonance imaging, can confirm the diagnosis of muscle tear and full functional recovery can be anticipated.

Spine fractures in active duty soldiers and their return to duty rate.

To evaluate the outcome of thoracolumbar spine fractures in active duty soldiers, we conducted a retrospective review of 23 soldiers followed at a single institution. Twenty-two charts were available for review. The average age was 31.9 years (range, 19-49 years), and the average follow-up was 3.6 years (range, 2-11 years). There were 20 males and 2 females. All injuries except one occurred between 1990 and 1994, and all were treated by a single surgeon. We attempted to correlate five independent variables with regard to whether the patient returned to his or her previous duty or was required to undergo a medical evaluation board to determine fitness for duty. The variables included military rank, physical job demands, fracture type, initial neurological status, and initial treatment (operative versus nonoperative). Fourteen of the 22 soldiers (64%) underwent medical evaluation boards, whereas 8 (36%) returned to their previous duties. We found a strong correlation between increasing military rank and return to preinjury duties. As expected, physical job demands correlated strongly with eventual disposition, in that soldiers in jobs with low physical demands were more likely to be retained on active duty in their present position. Neurologic status (except motor deficit), type of fracture (except fracture-dislocation), and initial treatment did not correlate well with eventual disposition.

A review of total joint replacement in active duty soldiers.

Thirty-two active duty soldiers (36 total joint replacements) were followed from 9 months and 18 years (average 4.1 years) to evaluate the outcome of total joint replacement in active duty soldiers. Follow-up consisted of clinical assessment and radiographic evaluation at 6 weeks, 3 months, 6 months, 1 year, and yearly thereafter. A Harris hip rating (HHR) was also completed at each clinic visit. There were 30 total hip arthroplasties in 27 patients with an average age at surgery of 40.8 years (range 31-58) and an average follow-up of 4.1 years. The HHR averaged 93 on latest evaluation. There were three revisions (average 7.2 years). Of the 27 patients, 18 were retained on active duty and 9 were separated from service. Of the senior enlisted (E7 or above) and officers (O4 or above), 16 of 17 (94%) were retained on active duty, whereas only 2 of 10 (20%) of the junior enlisted (E6 or below) were retained on active duty. There were 6 total knee arthroplasties in 5 patients with an average age at surgery of 49.8 years (range 33-58) and an average follow-up of 3.0 years (9 months to 4 years). There were no revisions, and all 5 soldiers were retained on active duty. Preliminary results from this study reveal that a high percentage of soldiers undergoing total joint replacement are retained on active duty (72%) and are able to continue active lives. Rank or seniority also appears to be a significant factor for retention on active duty. The revision rate (10%) and the rate of osteolysis (19%) are comparable with reported rates.