Iatrogenic transection of the peroneal and partial transection of the tibial nerve during arthroscopic lateral meniscal debridement and removal of osteochondral fragment.

Knee arthroscopy is a common orthopedic procedure that is generally considered relatively safe, with overall complication rates reported between 1% and 8%. Approximately 0.01% to 0.06% of these complications involve neurovascular structures. While peroneal nerve and tibial artery complications are well reported, to our knowledge, injury to the tibial nerve has not been reported. We report a case of injury to the tibial and peroneal nerves during routine meniscal debridement and osteochondral fragment removal in a 17-year-old high school athlete. The likely mechanism of injury was violation of the posterolateral corner by powered arthroscopic instrumentation during the attempt at removal of the loose body. The peroneal nerve was repaired with an interpositional sural nerve graft. Management of these injuries should consist of following patients closely with electromyograms and nerve exploration and repair in those cases that do not show interval improvement. Clinicians should exercise extreme care while using powered instruments in the posterolateral corner.

Incidence of radiographic cam-type impingement in young patients (<50) after femoral neck fracture treated with reduction and internal fixation.

BACKGROUND: Cam-type femoral impingement is caused by structural abnormalities of the hip and is recognized as a cause of degenerative hip arthritis. Identifiable etiologies of this structural abnormality include congenital malformation, pediatric hip disease, and malunion of femoral neck fractures after internal fixation. PURPOSE: The purpose of this study was to determine the prevalence of radiographic impingement in healed Orthopaedic Trauma Association (OTA) type 31B fractures treated with reduction and internal fixation. METHODS: Seventy OTA 31B hip fractures treated with internal fixation were identified from our institutional trauma database and radiographs were retrospectively reviewed for signs of impingement. Mean follow-up was 53 months after fracture. Alpha angle, Mose templates, and femoral head retroversion were the measurements used to determine impingement. RESULTS: The overall prevalence of any sign of radiographic impingement was 75%. Alpha angle was elevated in 32 hips (46%), asphericity was present in 46 femoral heads (65%), and femoral head retroversion was present in 26 hips (37%). The rates were highest in displaced subcapital fractures (OTA 31B-3) with a 63% (13/19) prevalence of elevated alpha angle, 68% (14/19) prevalence of asphericity, and 47% (10/19) prevalence of retroversion. CONCLUSIONS: Prevalence of radiographic signs of impingement in this population is higher than expected based on population-based controls. Surgeons must be vigilant about reduction and fixation of femoral neck fractures. Malunion should be recognized as early intervention may be beneficial in improving long-term outcomes.

Effectiveness of false profile radiographs in detection of pelvic discontinuity.

Pelvic dissociation is a rare but serious potential complication of total hip arthroplasty. The purpose of this study is to evaluate the effectiveness of the false profile view compared with traditional radiographs in detecting pelvic dissociation. Ten cadaver pelves were skeletonized, and noncemented acetabular hip arthroplasty components were implanted. Anteroposterior, lateral, iliac oblique, and false profile radiographs were obtained before and after creating pelvic dissociations and analyzed in a blinded fashion. The sensitivity of the false profile view for detecting pelvic dissociation was 79% (confidence interval, 70-86), which was greater than the sensitivity for anteroposterior and lateral views. This difference was statistically significant. False profile views are a potentially valuable addition to the traditional radiographic evaluation of pelvic discontinuity in hip arthroplasty.

Use of a free-functioning muscle transfer from a paralyzed lower extremity to restore upper extremity elbow flexion.

This report documents the use of a free-functioning gracilis muscle transfer from a lower extremity paralyzed from a spinal cord injury to restore elbow flexion in the patient's upper extremity which was paralyzed from a brachial plexus injury. The transfer was performed nine months after injury and resulted in functional elbow flexion. Clinical examination and EMG analysis document function of the transferred muscle with grade 4 muscle strength. The resultant effect on the skeletal muscle is different after upper motor neuron injury versus lower motor neuron injury. The successful function of a free-functioning muscle transfer after a spinal cord injury in this case has important implications for patients with spinal cord injury.

Shoulder arthroplasty in hemophilic arthropathy.

BACKGROUND: Currently there is little information available on shoulder arthroplasty in patients with painful hemophilic arthropathy. The purpose of this study was to report the results of shoulder arthroplasty in a series of patients, many with long-term follow-up. METHODS: The departmental database was queried for shoulder arthroplasties done in patients with painful hemophilic arthropathy from 1977 to 2007. Seven shoulder arthroplasties (6 patients) were followed clinically for an average 13.8 years (range, 33-323 months). RESULTS: Pain relief was achieved in 5 patients (6 shoulders). Average postoperative elevation was 131°. Average postoperative external rotation was 40°. Average postoperative internal rotation was to lumbar 4. Based on the modified Neer score there were 2 excellent, 4 satisfactory, and 1 unsatisfactory results. None of the shoulders required revision or reoperation. One patient developed a transient brachial plexus neuropraxia which resolved. CONCLUSION: The results of shoulder arthroplasty in hemophiliacs with painful shoulder arthropathy are moderate and require significant preoperative planning and the support of a hematologist.