Opposition splint for partial thumb amputation: a case study measuring disability before and after splint use.

STUDY DESIGN: Case report. INTRODUCTION: A combined burn and a partial amputation can be extremely debilitating as the thumb constitutes 40% of the entire hand when evaluating functional impairment. PURPOSE OF THE STUDY: Measure disability with and without opposition splint use after partial thumb amputation due to a burn. METHODS: Impairment and disability measures were completed at discharge from the hospital and subsequently during outpatient follow-up visits while wearing and not wearing a thumb opposition splint at 3, 6, 8, and 15 months. Comparisons between disability and impairment scores were assessed over time. RESULTS: The difference between DASH scores with and without using the splint were 25 at 3 months, 16 at 6 months, 10 at 8 months, and 12 at 15 months. CONCLUSIONS: Splint use in this case demonstrated clinically significant changes over time with minimal changes in impairment indicating enhanced function and improved patient perception of disability. LEVEL OF EVIDENCE: 4.

Dieulafoy lesion as a cause of massive gastrointestinal bleeding.

The Dieulafoy lesion, also referred to as exulceratio simplex, caliber-persistent artery anomaly, or cirsoid aneurysm, is a relatively rare, yet possibly fatal cause of gastrointestinal bleeding. Recent journal articles suggest that this pathological entity is not as uncommon as once thought. Advances in endoscopic technique and esophagogastroduodenoscopy (EGD) have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both medical and surgical endoscopists be knowledgeable of the anatomy, diagnosis, and management of this pathology. Several therapeutic approaches to Dieulafoy's lesion are available and are described.

The effect of managed care on the treatment outcome of substance use disorders.

This study examined the effect of managed care and other reimbursement mechanisms on the outcome of substance abuse treatment at a single treatment facility. A retrospective review of 1594 patient records yielded treatment utilization, diagnostic, and demographic data. Recidivism rates for intensive managed care, traditional managed care, private pay, and state-funded groups of patients were compared. Results showed that, contrary to expectations, recidivism rates were not different for managed vs nonmanaged care patients. In addition, recidivist patients had significantly more ICD-9 diagnoses than nonrecidivist patients. A discussion of future research suggests that other outcome measures need to be examined in addition to recidivism rate, such as psychosocial functioning following treatment and indicator(s) of severity of illness, to better determine the effect of managed care and other reimbursement mechanisms on treatment outcome.

An analysis of failed Harrington rods.

Eight mechanically failed Harrington rods have been retrieved and examined clinically, metallurgically, and biomechanically to characterize the mode of instrument failure and to determine how future failure rates might be minimized. The results of the study indicated fatigue to be the mode of mechanical failure in all cases, however, in only one case was any significant metallurgical defect observed. Failure occurred at the ratchet-shaft junction in seven of eight cases with the remaining failure occurring at the midshaft region. This occurred in the rod with the metallurgical defect. The possibility of fatigue failure can be lowered by implementing both clinical and design considerations. Clinically, stress on the rod can be lowered by placing the ratchet-shaft junction as close to the hook as possible and by using the shortest rod possible. Both of these will minimize the moment arm at the vulnerable ratchet-shaft junction. Design modifications, including increased rod diameter, polishing the ratchet-shaft interface and material changes, can also be used to lower the stress on the rods and thus reduce the risk of mechanical failure.

Clinical and metallurgical analysis of retrieved internal fixation devices.

The clinical performance, corrosion characteristics, and metallurgical properties of 82 retrieved stainless-steel bone plates have been examined. The plates had been in situ for periods ranging from one to 169 months. Only 29% of these devices (24 of 82 plates) were removed on a routine asymptomatic basis, while 62% (51 of 82 plates) were removed for cause-related reasons such as implant-related pain, infection, nonunion or malunion, and so forth; seven plates were removed for unknown reasons. Although most patients who had plates removed for pain reported some improvement in symptoms, others felt no improvement after removal. On examination, over 89% of the recovered implants displayed some degree of either surface (pitting) or screw-plate interface (crevice and fretting) corrosion or both. Statistical analyses revealed that the metallurgical properties of grain size and nonmetallic inclusion content correlated significantly with the degree of both types of corrosion.

The effect of surface treatments on the interface mechanics of LTI pyrolytic carbon implants.

A mechanical and histological evaluation of LTI pyrolytic carbon implants was undertaken to determine the effect of various surface treatments on the retention characteristics of the implants. Five types of surfaces were evaluated, including as-deposited, fine grit-blasted, coarse grit-blasted, ground, and plasma oxygenated. The four surface treatments were chosen in an attempt to emulate the morphology of the as-deposited implants. The implants were evaluated in vivo by placement transcortically in the femora of adult mongrel dogs for periods of 12 to 24 weeks. Although the as-deposited implants exhibited the greatest interface strength at 12 weeks the results of mechanical testing after 24 weeks implantation indicated no statistically significant difference among the interface strength values or among the interface stiffness values of the implants. The histologic response of the implants was similar; while all implants exhibited areas of direct implant-bone apposition, the as-deposited implants exhibited this behavior to the greatest extent. Thus the ability to duplicate the biological response to the as-deposited LTI carbon surface appears possible by one or more of the treatments evaluated.

Post-sintering heat treatments for porous coated Ti-6A1-4V alloy.

Previous studies have shown that the application of a porous Ti-6A1-4V alloy coating results in a substantial decrease in the substrate material fatigue properties. This phenomenon is due to both a microstructural change from the equiaxed alpha-beta microstructure to a lamellar structure and a notch effect created by the porous coating. The lamellar microstructure has been shown to exhibit the worst fatigue properties of the most common structures obtained in Ti-6A1-4V alloy. This study examined various post-sintering heat treatments which would alter the material microstructure and possibly result in improved fatigue performance. The heat treatments examined produced alternate microstructures to the lamellar structure and some approached the totally transformed acicular alpha structure. The acicular alpha structure has been shown to exhibit the best fatigue properties for Ti-6A1-4V alloy in the notched condition.

Retrieval and analysis of intramedullary rods. A follow-up study.

From 1980 to 1983, 16 AO intramedullary femoral rods were retrieved and analyzed clinically, radiographically, and metallurgically. Cracking and/or fracture was observed in four of the 16 specimens. All cracks occurred at the point of maximum stress at the end of the slot. In two cases a structurally weaker weld zone coincided with this location. The weld zone and slot were also found to coincide in five of the uncracked rods. Two of the four cracked rods were removed because of pain, while only three of the 12 uncracked rods caused pain. Structural and material characteristics (i.e., the location of the weld at a point of maximum stress and significant variability in microstructure), rather than surgical technique or time in situ, were found to be responsible for the implant mechanical failures. Improvements should be made in fabrication techniques and material properties. For the present, careful assessment of a painful intramedullary rod and routine removal after healing are advisable.

Early, design-related failure in total knee arthroplasty a case report.

The analysis of retrieved implant devices can provide information unavailable through any other method. With the variety of implant designs rapidly increasing, retrieval and analysis of failed cases is an important means of evaluating existing designs, as well as suggesting modifications that might improve implant performance. This paper describes a case in which design considerations, rather than mechanical or material failure, appeared to be a major contributing factor.Sixteen months after insertion of a Howmedica Kinematic Rotating Hinge knee, the patient complained of barometric pain in the knee. Roentgenograms at that time showed the metallic axle component to be protruding laterally. Upon retrieval the polyethylene bumper-lock component exhibited deep scalloping on its surface, which unlocked the axle and allowed it to slide out.