Elbow synovium as the initial site of colon adenocarcinoma metastasis: diagnosis by arthroscopic biopsy.

An acutely painful and swollen isolated joint has a broad differential. We present the case of an elderly male with four-month progressive, painful swelling of the right elbow. After an initial workup for inflammatory arthropathies was nondiagnostic and a trial of conservative management failed to relieve his pain, a diagnostic arthroscopy was performed. Biopsy revealed metastatic colon adenocarcinoma isolated to the synovial tissue of the elbow. This case provides an example of the presentation and progression of synovial metastasis from a visceral cancer and can potentially guide physicians in the diagnosis and management of similar cases.

Psoas impingement causing labrum tear: a series from three tertiary hip arthroscopy centers.

BACKGROUND: The term hip impingement is usually associated with psoas impingement after arthroplasty or femoroacetabular impingement (FAI). A recently, less commonly described mechanism of impingement and labrum pathology is the psoas tendon applying pressure to the acetabular labrum more medial to the typical FAI labrum lesion. Much is still unkown about the anatomy, pathology, and treatment of this entity. PURPOSE: This paper describes the successful arthroscopic treatment of a series of patients with a recently recognized cause of hip pain in the young athletic population without significant bony pathology or coxa saltans. Awareness of this entity is important to allow appropriate treatment of the labrum and psoas tendon. METHODS: Seven hundred hip arthroscopies by three surgeons at different centers were retrospectively reviewed. Athletes with labrum tears from the two to three o'clock position were evaluated for inclusion in the study. Patients with osteoarthritis, crossover sign, coxa profunda, CAM lesion, acute trauma, or coxa saltans were excluded. All authors were the primary surgeons and are fellowship-trained hip arthroscopists working in tertiary hip arthroscopy centers. Pre- and postoperative Harris Hip scores were obtained. Patients underwent diagnostic and therapeutic hip arthroscopy. The psoas tendon was released in all patients at the level of the capsule via a transcapsular approach. Labrum repairs were performed when deemed beneficial by the operative surgeon. RESULTS: Twenty-two patients (26 hips, 4 bilateral) were identified with a labrum tear apparently caused by psoas impingement and had no other significant hip abnormalities. All but one were female. Average age was 19 (12-25 years). Labral repair was performed in all but two patients. Average anchors used were 1.2 per hip. Pre- and postoperative Harris hip scores were obtained with a minimum follow-up of six months for 16 patients. Average Harris hip score improved from 70 preop to 94 postop. There were no significant complications identified. CONCLUSION: We describe a recently recognized entity encountered in the treatment of athletes with hip pain consisting of labrum pathology associated with the psoas tendon rather than bony abnormality. Arthroscopic treatment, including a psoas tendon release and a more medial labrum repair, can provide relief with no significant complications in the short term. CLINICAL RELEVANCE: Understanding the unique pathoanatomy of this entity may allow the surgeon to provide more thorough informed consent, prepare for a more medial labrum repair than usual, and provide appropriate referral when necessary.

Human cartilage repair with a photoreactive adhesive-hydrogel composite.

Surgical options for cartilage resurfacing may be significantly improved by advances and application of biomaterials that direct tissue repair. A poly(ethylene glycol) diacrylate (PEGDA) hydrogel was designed to support cartilage matrix production, with easy surgical application. A model in vitro system demonstrated deposition of cartilage-specific extracellular matrix in the hydrogel biomaterial and stimulation of adjacent cartilage tissue development by mesenchymal stem cells. For translation to the joint environment, a chondroitin sulfate adhesive was applied to covalently bond and adhere the hydrogel to cartilage and bone tissue in articular defects. After preclinical testing in a caprine model, a pilot clinical study was initiated where the biomaterials system was combined with standard microfracture surgery in 15 patients with focal cartilage defects on the medial femoral condyle. Control patients were treated with microfracture alone. Magnetic resonance imaging showed that treated patients achieved significantly higher levels of tissue fill compared to controls. Magnetic resonance spin-spin relaxation times (T(2)) showed decreasing water content and increased tissue organization over time. Treated patients had less pain compared with controls, whereas knee function [International Knee Documentation Committee (IKDC)] scores increased to similar levels between the groups over the 6 months evaluated. No major adverse events were observed over the study period. With further clinical testing, this practical biomaterials strategy has the potential to improve the treatment of articular cartilage defects.

Abdominal fluid extravasation during hip arthroscopy.

Hip arthroscopy has gained popularity in recent years as an alternative to open treatment for several conditions including bursitis, acetabular labral tears, synovitis, arthritis, extraction of loose bodies, and femoroacetabular impingement. Complications during hip arthroscopy are rare in the current literature, but reports include venous thromboembolism, peripheral nerve injury, septic arthritis, instrument failure, and various problems associated with joint traction. Extravasation of fluid into the abdomen during hip arthroscopy is another rare but known complication. We report an occurrence of extravasation of fluid into the abdomen during arthroscopic treatment of femoroacetabular impingement and our management of the condition postoperatively.

Type III acromioclavicular separation: rationale for anatomical reconstruction.

Treatment of acute type III acromioclavicular separation is controversial. In some patients, nonoperative treatment is associated with pain, weakness, and stiffness. Many acromioclavicular joint reconstructions are associated with complications and results not substantially better than those of nonoperative treatment. Use of autogenous free tendon graft to anatomically reconstruct the acromioclavicular and coracoclavicular ligaments offers several advantages over other surgical techniques. These advantages include improved biomechanical properties, no foreign body implantation, biological fixation, anatomical reconstruction, and early rehabilitation.

Treatment of osteoarthritis of the knee with microfracture and rehabilitation.

Microfracture is a single stage arthroscopic procedure that can be used in conjunction with other arthroscopic treatments for the treatment of osteoarthritis of the knee. It has a well-documented and successful track record and when used with the appropriate rehabilitation techniques can be very effective for pain relief and functional improvement. It has proven clinical benefit and is our technique of choice for the initial surgical treatment of osteoarthritis.

Assessment of tissue repair in full thickness chondral defects in the rabbit using magnetic resonance imaging transverse relaxation measurements.

The purpose of this study was to determine if the noninvasive and nondestructive technique of magnetic resonance imaging could be used to quantify the amount of repair tissue that fills surgically-induced chondral defects in the rabbit. Sixteen 4-mm diameter full-thickness chondral defects were created. A photopolymerizable hydrogel was used to seal the defects as a treatment modality. At 5 weeks, the animals were sacrificed and the distal femur was subjected to MRI analyses at high field (9.4 T). The transverse relaxation time (T(2)) in each defect was measured. Histology and histomorphometric analysis were used to quantify the amount of repair tissue that filled each defect. The relationship between T(2) and percent tissue fill was found to fit well to a negatively sloped, linear model. The linear (Pearson's product-moment) correlation coefficient was found to be r = -0.82 and the associated coefficient of determination was r(2) = 0.67. This correlation suggests that the MRI parameter T(2) can be used to track changes in the amount of repair tissue that fills cartilage defects. This would be especially useful in in vivo cartilage tissue engineering studies that attempt to determine optimal biomaterials for scaffold design.

Improvement in documentation of compartment syndrome with a chart insert.

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

Posterior only versus combined anterior and posterior approaches to lumbar scoliosis in adults: a radiographic analysis.

STUDY DESIGN: Retrospective study. OBJECTIVE: To compare the radiographic lumbar curve correction between a posterior only and combined anterior-posterior approach in patients with adult spinal deformity. SUMMARY OF BACKGROUND DATA: In adolescent idiopathic scoliosis correction, posterior only has been compared with the combined anterior-posterior approach; however, there have been no corollary studies in adult scoliosis. Traditionally, rigid lumbar curves have been treated with a combined anterior and posterior approach; however, the absolute indications for this approach are unclear. MATERIALS AND METHODS: A total of 180 patients with degenerative or adult idiopathic spinal deformity and curves measuring between 40 degrees and 70 degrees who underwent reconstructive spinal fusion. The minimum follow-up period was 28 months and average follow-up was 53 months. Of the 155 patients who underwent surgery, 80 underwent posterior only (35 with idiopathic and 45 with degenerative scoliosis) while 75 patients (30 with idiopathic and 35 with degenerative scoliosis) underwent combined anterior-posterior surgery. The groups were compared by age at operation, preoperative deformity, levels operated and postoperative correction and balance. RESULTS: There were no significant differences in sagittal and coronal plane curve and balance correction between the posterior only and the combined anterior-posterior groups. When the patients were subdivided into degenerative adult scoliosis and idiopathic adult scoliosis, there were again no significant differences in the sagittal and coronal curves or balance between the posterior only and combined anterior and posterior approaches. While the posterior only group and the same-day anterior and posterior surgery group had a similar major complication rate of 24% and 23%, respectively, patients who underwent staged anterior and posterior surgery had a major complication rate of 45%. CONCLUSION: When combined with extensive posterior releases, posterior only approach is just as effective as combined anterior and posterior surgery for adult lumbar scoliosis measuring between 40 degrees and 70 degrees .

Multifunctional chondroitin sulphate for cartilage tissue-biomaterial integration.

A biologically active, high-strength tissue adhesive is needed for numerous medical applications in tissue engineering and regenerative medicine. Integration of biomaterials or implants with surrounding native tissue is crucial for both immediate functionality and long-term performance of the tissue. Here, we use the biopolymer chondroitin sulphate (CS), one of the major components of cartilage extracellular matrix, to develop a novel bioadhesive that is readily applied and acts quickly. CS was chemically functionalized with methacrylate and aldehyde groups on the polysaccharide backbone to chemically bridge biomaterials and tissue proteins via a twofold covalent link. Three-dimensional hydrogels (with and without cells) bonded to articular cartilage defects. In in vitro and in vivo functional studies this approach led to mechanical stability of the hydrogel and tissue repair in cartilage defects.

Tip of the trade: a method of splinting for surgeons.

Mallet fingers are difficult to treat, especially in surgeons, who need to sterilize their hands continuously and who have constant strains placed on their fingers. We successfully treated a nondominant, fifth-digit, nonbony mallet finger in a surgical resident with a splint method composed of a bent, semitubular, small-fragment plate and Steri-strips (3-M, St. Paul, MN). This splinting method allowed the resident to continue performing surgeries while the injury healed.

Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis.

STUDY DESIGN: A retrospective study. OBJECTIVE.: To decipher the incidence, characteristics, functional outcomes, and complications of spinal fusion after revision surgery for recurrent pseudarthrosis in adult patients with scoliosis. SUMMARY OF BACKGROUND DATA: While the rate of spinal fusion has been examined in the past, there have been no studies that have examined the incidence, characteristics, functional outcomes, and complications of spinal fusion after pseudarthrosis repair in adult patients with scoliosis. MATERIALS AND METHODS: A total of 132 patients with failed spinal fusion surgery for adult scoliosis and painful pseudarthroses were studied. Each patient had an average of 3.7 spinal surgeries before undergoing revision at our institution. In addition to clinical assessment and imaging studies, pseudarthrosis was confirmed intraoperatively in all patients. All patients underwent reinstrumentation and fusion along with adjunctive procedures as needed. Spinal fusion was assessed clinically and radiographically after surgery for a minimum of 40 months. Subjective functional outcomes and complications associated with the procedures were also studied. RESULTS: The overall incidence of spinal fusion after revision surgery for pseudarthrosis in adult scoliosis was 90%. There was a propensity for pseudarthrosis to recur at the thoracolumbar and lumbosacral junctions. Increasing thoracolumbar kyphosis and loss of sagittal balance were significant risk factors for recurrent pseudarthrosis after revision surgery (mean thoracolumbar kyphosis of 23 degrees and mean sagittal balance of 7.9 cm anteriorly associated with persistent pseudarthrosis). Additionally, patients with multiple preoperative sites of pseudarthroses were at a higher risk for continued pseudarthrosis after surgery. Cigarette smoking, age, and surgical approach did not have any significant correlation with pseudarthrosis. Seventy-two percent of patients were satisfied with the outcome and 80% would have chosen to undergo surgery again if necessary. Thirty-three percent of patients who underwent surgery had some complication related to the surgery. CONCLUSION: Revision surgery for pseudarthrosis repair in adult scoliosis is most successful at attaining fusion when thoracolumbar and overall sagittal alignment are restored as much as possible.

Compartment syndrome: time from diagnosis to fasciotomy.

A definitive safe time to fasciotomy for compartment syndrome has not been established. Therefore, the records of 28 patients who had a fasciotomy for compartment syndrome at two trauma centers (18 level I, 10 level II) were reviewed to determine time from diagnosis to fasciotomy and clinical outcome. Average times at the two trauma centers (level I: 160 minutes, range, 50-315 minutes; level II: 105 minutes, range, 51-185 minutes) were significantly different. Ten patients (5 level I, 5 level II) with an average time from diagnosis to fasciotomy of 122 minutes (range, 70-185 minutes) sustained residual deficits. There was no correlation between time from diagnosis to fasciotomy and residual deficits. A time from diagnosis to fasciotomy as short as 70 minutes was associated with residual deficit, but a time as long as 315 minutes (patient with deficits) was associated with no functional deficits.

Documentation of acute compartment syndrome at an academic health-care center.

BACKGROUND: Documentation of the clinical course of a compartment syndrome is critical to effective treatment; however, such documentation often is found to be inadequate. METHODS: Notes and consent forms for thirty consecutive patients with adequate follow-up who had undergone fasciotomy for the treatment of compartment syndrome were reviewed for legibility, notation of the time and date, and documentation of the presence of core physical examination and history findings, including pain, paresthesias, tenseness, pain on passive stretch, sensory deficit, motor deficit, pulses, compartment pressures, and diastolic blood pressure. RESULTS: Documentation was inadequate for twenty-one patients (70%): the notes and consent forms were not timed or not dated (or both) for nine patients (30%), and the notes were at least partially illegible for sixteen patients (53%). The documentation was incomplete with regard to the presence of paresthesias in eleven patients, pain on passive stretch in ten, sensory deficit in nine, motor deficit in eight, pulses in seven, pain in five, and tenseness in three. The documentation was incomplete with regard to the blood and compartment pressures for sixteen and six patients, respectively. CONCLUSIONS: The documentation of the core history and physical examination findings was inadequate in this series of patients with compartment syndrome. On the basis of the results of this study, and through an organizational systems approach, we have instituted for our residents, nursing staff, and faculty an educational program on the documentation of compartment syndrome in patients who are at risk for this condition.

Resection and reconstruction of a massive femoral hemophilic pseudotumor.

Hemophilic pseudotumor is a rare, but well-known, complication of hemophilia. We describe a 50-year-old man with mild hemophilia A, but with no previous need for Factor VIII supplementation, who presented with a pathologic fracture of the right femoral neck and shaft caused by a large hemophilic pseudotumor. Initial nonoperative therapy with factor replacement and skeletal traction resulted in radiographic evidence of fracture healing, but the patient's pain persisted. Therefore, he had a radical resection of his hemophilic pseudotumor (soft tissue component and entire femur), and reconstruction with a custom total femoral replacement. Six months after resection, the patient returned to full-time employment. Although pseudotumor formation is a well-recognized complication of hemophilia, the pseudotumor in our study is one of the largest yet described. More importantly, to our knowledge this is the first report of a pseudotumor treated by radical resection and reconstruction with a custom femoral prosthesis. We think that radical resection and reconstruction with a custom total femoral prosthesis is a valuable alternative to amputation in massive pseudotumors of the femur and soft tissues of the thigh.