Compartment Syndrome of the Leg Associated With Fracture: An Algorithm to Avoid Releasing the Posterior Compartments.

OBJECTIVE: The purpose of this study is to report on a prospective series of patients in whom an algorithm was used to attempt to avoid releasing the posterior compartments in patients with lower leg compartment syndrome (CS) and the safety of such a practice. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. PATIENTS: A consecutive series of 39 patients was managed by one surgeon for CS using the reported protocol. INTERVENTION: Patients diagnosed with a CS of the leg were managed with a single operative protocol. After a standard anterior and lateral compartment release through a full-length lateral incision was performed, the superficial and deep posterior compartments were measured with the heel resting on a bolster. Using the preoperative diastolic blood pressure, a ΔP < 30 was considered to be a positive finding warranting a separate medial incision for release of the posterior compartments. If the ΔP was ≥30, the posterior compartments were not released. MAIN OUTCOME MEASUREMENTS: Need for medial release or development of posterior CS or sequelae. RESULTS: A consecutive series of 39 patients were managed by 1 surgeon for CS using the described protocol. Two patients with an isolated posterior CS were excluded. The other 37 had clinical symptoms or compartment pressures consistent with anterior compartment involvement. Of 37 patients, 21 had (57%) symptoms suggesting posterior compartment involvement. The preoperative pressure measurements averaged 41 mm Hg with an average ΔP of 38. After full-length release of the anterior and lateral compartments, only 3/37 (8%) required a posterior release for a ΔP of <30 mm Hg. The lowest ΔP in the posterior compartments of the remaining 34 patients averaged 59 (32-86). The compartment pressures in the superficial and deep posterior compartments decreased by 22 mm Hg and 24 mm Hg, respectively, after the anterolateral release. None of the patients who had only an anterolateral release developed sequelae of a missed posterior CS. CONCLUSIONS: The use of the reported algorithm is effective in avoiding posterior compartment release. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Massive rotator cuff tears without arthropathy: when to consider reverse shoulder arthroplasty.

Massive rotator cuff tears often present a challenge for the treating orthopaedic surgeon. A multitude of surgical approaches have been described to manage this condition, ranging from biceps tenotomy to complex muscle transfers to reverse shoulder arthroplasty. Among these procedures, reverse shoulder arthroplasty is increasingly advocated to relieve pain and restore function; however, the exact role of this arthroplasty procedure continues to be defined, particularly in patients without any evidence of associated glenohumeral arthritis. In this patient population, the reverse shoulder prosthesis is used primarily to address the instability associated with massive rotator cuff tears, as opposed to the more common application of arthroplasty to manage cartilage disease. Currently accepted indications for reverse shoulder arthroplasty include patients with pseudoparalysis and irreparable rotator cuff tears, with or without anterosuperior escape. Surgeons must be aware of conditions that may clinically mimic pseudoparalysis caused by a rotator cuff tear, such as axillary nerve injury, deltoid dehiscence, or cervical radiculopathy. These conditions produce deltoid insufficiency and are unlikely to benefit from a reverse shoulder arthroplasty. Caution is also warranted when considering this procedure in patients with massive rotator cuff tears in whom active forward elevation greater than 90° is preserved. These patients may achieve little benefit in range of motion and pain relief with a reverse shoulder arthroplasty.

Reverse Shoulder Arthroplasty in the Management of Irreparable Rotator Cuff Tears without Arthritis.

INTRODUCTION: The ability to provide reliable outcomes in treatment of patients with degenerative rotator cuff tears has become increasingly complicated, as a result of more advanced disease and the increased array of treatment choices. STEP 1 PREOPERATIVE PLANNING: Develop and communicate with a consistent team of interdisciplinary physicians both preoperatively and postoperatively; utilize advanced imaging modalities to evaluate muscle atrophy as well as glenoid and humeral bone stock. STEP 2 PATIENT POSITIONING: Place the patient in a beach-chair position, check the abdominal strap, and position yourself facing the axilla. STEP 3 SURGICAL APPROACH: Develop the subdeltoid and subacromial spaces and take care to avoid vigorous over-retraction of the deltoid. STEP 4 HUMERAL EXPOSURE AND PREPARATION: Perform the head cut utilizing the 135° resection guide, broach the humerus, and ream the humeral socket. STEP 5 GLENOID EXPOSURE AND PREPARATION GLENOSPHERE INSERTION: Ream the inferior surface to bleeding subchondral bone; bleeding subchondral bone on the inferior 50% of the prepared glenoid surface indicates a sufficient depth. STEP 6 FINAL HUMERAL PREPARATION: At final reaming, the edge of the reamer should sit flush with the cut surface of the humerus. STEP 7 TRIALING: Proper soft-tissue balance is frequently achieved by positioning the humeral component so that the rim of the socket lies just above the humeral osteotomy site at the anatomic neck. STEP 8 COMPONENT IMPLANTATION AND CLOSURE: When cementing the humeral component, the socket should match the reamed proximal part of the humerus. RESULTS: Initially, reverse shoulder arthroplasty was primarily used to treat osteoarthritis of the glenohumeral joint resulting from chronic rotator cuff deficiency or for true rotator cuff tear arthropathy. WHAT TO WATCH FOR: Indications Contraindications Pitfalls & Challenges.

Platelet-rich plasma: from basic science to clinical applications.

Platelet-rich plasma (PRP) has been utilized in surgery for 2 decades; there has been a recent interest in the use of PRP for the treatment of sports-related injuries. PRP contains growth factors and bioactive proteins that influence the healing of tendon, ligament, muscle, and bone. This article examines the basic science of PRP, and it describes the current clinical applications in sports medicine. This study reviews and evaluates the human studies that have been published in the orthopaedic surgery and sports medicine literature. The use of PRP in amateur and professional sports is reviewed, and the regulation of PRP by antidoping agencies is discussed.

Expression of nitric oxide, peroxynitrite, and apoptosis in loose total hip replacements.

Nitric oxide (NO) is an effector molecule associated with inflammation, immune function, bone metabolism, and the induction of apoptosis. This study examined the role of NO, peroxynitrite (ONOO(-)), and apoptosis in cases of revision total hip replacements (THRs). We hypothesized that apoptosis and excess production of NO contribute to the inflammatory reaction to orthopedic biomaterial wear debris that is associated with loosening and osteolysis. Periprosthetic membranous specimens were collected from revised cemented acetabular components with simple loosening and ballooning osteolysis. Synovial samples from patients undergoing primary THR were used as controls. The presence of macrophages (CD68(+)) and levels of inducible nitric oxide synthase (INOS), endothelial nitric oxide synthase (EcNOS), ONOO(-) (Nitro, assayed by the amount of nitrated tyrosine residues), and apoptosis (TUNEL staining) were examined using immunohistochemistry. Increased expression for INOS, EcNOS, and ONOO(-) in both the loose/osteolytic and the loose/non-osteolytic groups was observed when compared to the synovium group. There were no significant differences between the loose/osteolytic group and loose/non-osteolytic group for these biologic markers. TUNEL staining showed a significant increase in apoptosis in the loose/osteolytic group compared to the loose/non-osteolytic group and synovial tissues. These findings suggest that NO and NO-derived molecules, such as ONOO(-), may be involved in sustaining the foreign-body reaction to wear debris. NO and ONOO(-) may prove to be useful markers of prosthetic loosening whereas apoptosis may be a marker distinguishing ballooning from simple osteolysis.