Idiopathic heterotopic ossification in the intensive care setting.

Heterotopic ossification is characterised by the periarticular deposition of ectopic bone. It typically occurs after trauma, neurogenic injury, or congenital causes. Idiopathic heterotopic ossification has been rarely reported. A patient who developed idiopathic heterotopic ossification in the intensive care unit without any known predisposing conditions is presented.

Hereditary neuropathy with liability to pressure palsies mimicking multifocal compression neuropathy.

Hereditary neuropathy with liability to pressure palsies (HNPP) is a recurrent disorder of the peripheral nervous system characterized by reversible episodes of sensorimotor deficits after neural compression injuries. Also known as tomaculous neuropathy, HNPP is further characterized ultrastructurally by multiple focal thickenings (tomacula) of peripheral myelin and has an autosomal dominant inheritance. The neuropathology of HNPP includes a partial deletion encoding the peripheral myelin protein 22 (PMP-22) gene on chromosome 17, resulting in underexpression of PMP-22. We describe multiple compression mononeuropathies in an individual with HNPP and report neuropathologic findings in 2 clinically asymptomatic family members. Diagnosis was confirmed using pulsed-field gel electrophoresis. We believe that this diagnosis is clinically underappreciated by hand surgeons and should be considered in the differential diagnosis of patients with atypical presentations of compression neuropathies.

Flexor tenosynovitis due to Mycobacterium asiaticum.

Mycobacteria other than tuberculosis infections of the hand are seen with increasing frequency. A case of Mycobacterium asiaticum flexor tenosynovitis is described. Successful management included radical flexor tenosynovectomy and therapy with oral minocycline and clarithromycin.

Publication pattern of papers presented at the American Society for Surgery of the Hand annual meeting.

Publication of research results in peer-reviewed journals represents the consummation of the scientific method. In order to determine the rate of publication of oral presentations at the annual meeting of the American Society for Surgery of the Hand, every presentation (n = 397) from the 1990, 1991, and 1992 annual meetings was subjected to a Medline Plus computer search in January 1995. Meeting abstracts were grouped by program designation to scientific session, research session, and residents and fellows conference categories, and a Kaplan-Meier survivorship curve was formulated for each category. We determined an ultimate publication rate of 52% at 53 months. Subanalysis by year of presentation showed rates of 32%, 48%, and 51% for the respective years 1992, 1991, and 1990, with publication for most research occurring within 3 years of presentation. No statistically significant difference existed between the three categories, although a distinct trend toward higher ultimate publication rate (74%) was found for research abstracts. The ultimate publication rate for hand surgery presentations is comparable to that reported for other disciplines.

Orthopedic casualties in an activated National Guard Mechanized Infantry Brigade during Operation Desert Shield.

From November 1990 to April 1991, the 48th Infantry Brigade (Mechanized), an Army National Guard unit, was activated under Operation Desert Shield and deployed to the National Training Center, Fort Irwin, California, for training in desert warfare. All casualties requiring care beyond the battalion aid stations were evacuated to the medical company organic to the 48th Brigade. Each of 727 orthopedic patient visits were grouped into one of eight etiologies: trauma, degenerative, overuse, infectious, neoplastic, congenital/pediatric, miscellaneous, and psychiatric. Each case was also classified according to anatomic region, severity, and disposition as well as need for a minor procedure, operation, or referral. Orthopedic casualties in a reserve mechanized infantry brigade undergoing intensive field training primarily arose from four common etiologic/regional presentations: wrist/hand trauma, knee/leg trauma, spine/pelvis degenerative, and ankle/foot overuse. Many of these injuries are predictable consequences of a particular soldier's military occupational specialty and unit mission.

Outcome following epineurotomy in carpal tunnel syndrome: a prospective, randomized clinical trial.

To assess the efficacy of an adjunctive epineurotomy in carpal tunnel syndrome, 36 wrists in 33 patients were prospectively randomized into epineurotomy and non-epineurotomy treatment groups. The operating surgeons and evaluating therapist were double-blinded. Patients were evaluated preoperatively and at either 6 or 12 months postoperatively, with 15 patients examined at both postoperative time points. Evaluation consisted of five sensory and four motor tests: static and moving two-point discrimination, Semmes-Weinstein monofilament testing, vibratory (30 and 256 cps) sensibility, and dynamometer testing of grip strength and lateral, three-jaw, and tip pinch strengths. Sensory testing showed overall improvement within both groups postoperatively, but there was no difference between the two groups at either 6 or 12 months postoperatively. Motor testing revealed no improvement in the grip strength or lateral, three-jaw, or tip pinch of either group at 12 months when compared to preoperative levels. Twenty-four of 26 epineurotomy patients and all 10 control patients were satisfied with their clinical outcome 30 months after surgery. The addition of an adjunctive epineurotomy, although safe, offered no clinical benefit in the surgical treatment of carpal tunnel syndrome in this series.

Congenital constriction band syndrome: a seventy-year experience.

Seventy-one cases of congenital constriction band syndrome (CCBS) were reviewed. The year of birth, sex, ethnic background, gestational history, family history, and concurrent diagnoses were obtained. The anatomic patterns of involvement, degree of impairment, and number and type of surgical interventions were recorded. The incidence of CCBS appears to be rising. The average patient had three involved limbs, with a predilection for distal, central digits of the upper extremity. Abnormal gestational histories were found in 60% of the cases; 50% had concurrent diagnoses, and nearly one-third had club-feet. The average patient had a 20% whole body impairment and required three reconstructive procedures. Distraction osteogenesis and free osteocutaneous transfer were useful. We feel that the term "early amnion rupture sequence" more accurately reflects the true pathogenesis of CCBS.

Allograft salvage of failed total elbow arthroplasty. A report of two cases.

Infection after total elbow arthroplasty (TEA) is a devastating complication. Current management options include (1) salvage of the implant with debridement and parenteral antibiotics, (2) resection arthroplasty, and (3) arthrodesis. Most infected TEA patients ultimately require resection arthroplasty. Inadequate bone may preclude both revision TEA and successful resection arthroplasty. It is in these cases that the patient may benefit from allograft reconstruction. Two patients with painful flail elbows secondary to previous resection arthroplasties were treated successfully with cadaver allograft augmented with in situ autograft. Use of the allograft resulted in improvement from failure to excellent in this patient with posttraumatic arthrosis at five years after operation and from failure to good in a rheumatoid patient at two years after operation. Autograft-augmented allografts in the resected failed-TEA patient are a valuable and bone-preserving option. This may be especially useful in patients with significant bone loss or young patients with posttraumatic arthrosis, for whom arthrodesis may be the only other surgical option. The method should not preclude further revision TEA.

Utilization of the extended rectus abdominis myofasciocutaneous free flap in upper extremity reconstruction.

Degloving injuries of the upper extremity may require extensive soft tissue coverage. Free tissue transfer is often useful in the management of these injuries. We describe the use of an extended rectus abdominis myofasciocutaneous vascularized free flap in the management of a massive longitudinal upper extremity traumatic soft tissue defect.

Intraoperative dexamethasone irrigation in lumbar microdiskectomy.

In 45 lumbar hemilaminectomy/microdiskectomy patients, a control group of 23 patients had the standard operative procedure. The remaining 22 patients were treated with intraoperative irrigation of long-acting dexamethasone before incision closure. Age, weight, gender ratio, mean postoperative hospital stay, mean in-hospital narcotics usage, and incidence of perioperative complications among the two groups were compared. Age and gender ratios were comparable, although the control group was significantly heavier in body weight than the steroid-irrigated group. The steroid-irrigated group had a significant reduction in hospitalization and a marked reduction in narcotics usage compared with the control group. Postoperative fever occurred in one patient in the steroid group. The control group had three postoperative complications. These preliminary observations suggest that dexamethasone irrigation during lumbar diskectomy is a safe and effective adjunct to surgical management.

Fusobacterium osteomyelitis associated with intraosseous gas.

The diagnosis of acute anaerobic osteomyelitis was made in a 57-year-old hypertensive diabetic woman complaining of groin pain and fever. Roentgenograms and computed tomography demonstrated intraosseous gas in the right femoral head and surrounding soft tissue. Cultures obtained from open biopsy were positive for the anaerobic gram-negative bacillus Fusobacterium necrophorum, a normal inhabitant of the mouth, bowel, and urogenital tract. The patient responded to an antibiotic regimen of metronidazole combined with initial debridement and drainage, followed by resection of the femoral head (Girdle-stone arthroplasty). The hospital course was complicated by fungal and pseudomonal superinfection. The patient was afebrile and ambulatory at discharge two months after admission. A case of Fusobacterium necrophorum osteomyelitis causing intraosseous gas seems not to have been previously reported in the literature.