Timing of surgery in acute anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft.

To determine if patients who delayed anterior cruciate ligament reconstruction until a convenient time regained quadriceps muscle strength allowing them to return to sports participation at a different rate than patients who had early surgery for anterior cruciate ligament reconstruction, we studied 143 patients who had the same surgical procedure and postoperative rehabilitation program. Group I delayed surgery at a mean of 40 days after injury; Group II had early surgery at a mean of 11 days after injury. Statistically, Group I patients had significantly better mean quadriceps muscle strength at 2 months (P = 0.017) and at 4 months (P = 0.0055) postoperatively. At least 65% quadriceps muscle strength was achieved by 40 of the 50 patients (80%) tested in Group I at 2 months, allowing the patients to progress to sport-specific rehabilitation. Only 35 of the 66 patients (53%) tested in Group II were able to progress toward sports activities at 2 months. By 6 months, 29 of the 40 patients (73%) tested in Group I compared with 27 of the 58 patients (47%) tested in Group II had 80% quadriceps muscle strength. This study demonstrates that the return of quadriceps muscle strength was faster for our patients who delayed anterior cruciate ligament reconstruction than for our patients who had early reconstruction. Thus, despite delaying their early reconstructions, Group I was able to progress sooner from the date of surgery to sport-specific rehabilitation.

The use of caudal epidural anesthesia in clubfoot surgery.

We reviewed records of 31 children who had surgical release of 41 clubfeet under general anesthesia with supplemental caudal epidural anesthesia. Compared to an equivalent group of 27 children (39 feet), the caudal epidural group exhibited a statistically significant decrease in intraoperative narcotic requirement. One child had a bloody tap, and caudal epidural anesthesia was abandoned, but there were no other complications. Excellent postoperative pain relief persisted for > or = 8 h. Twenty-five of 31 caudal epidural patients were discharged safely on the same day as surgery without any surgical complications. Use of caudal epidural supplementation and outpatient surgery (where indicated) met with a high degree of parent satisfaction. Cost savings of outpatient clubfoot surgery, when compared to overnight stay, were disappointingly low.

Diaphyseal humerus fractures: natural history and occurrence of nonunion.

We reviewed 38 fractures of the humeral shaft which had been treated non-operatively to identify factors prognostic of nonunion. Of these, 23 healed uneventfully and 15 progressed to nonunion. Factors prognostic of nonunion included long oblique fracture pattern, alcohol abuse, and obesity. In patients with these risk factors, lack of clinical and radiographic evidence of healing 8 to 10 weeks post-injury suggests an impending nonunion, and operative intervention should be considered.

Fracture of the trochlea.

Isolated fracture of the humeral trochlea is rare. Recent fracture classification schemes do not specifically address this injury in regards to treatment. This case report describes an isolated fracture of the humeral trochlea treated with open reduction internal fixation. Radiographic union was present at 13 weeks, and at 20 weeks post-op, the patient had regained full elbow range of motion minus 5 degrees of terminal flexion. Open reduction and internal fixation can be performed with success if the trochlear fragment is large enough.