Do not leave the operating room without it.
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Bone Diseases↗
Biomedical subjects
A H Alexander
Publications and source records attributed to A H Alexander.
Acute dislocations of the distal radioulnar joint.
An injury to the DRUJ can occur in association with almost any fracture of the forearm or as an isolated phenomenon. A dislocation of this joint may be simple or complex. Constant awareness must be maintained during treatment of injuries of the wrist, forearm, and elbow if common pitfalls are to be avoided. Failure to diagnose and treat a complex DRUJ dislocation will lead to chronic, persistent subluxations or dislocations, or both, and to symptomatic osteoarthrosis. Failure to recognize a simple dislocation of the DRUJ associated with a fracture of the forearm may result in inappropriate or inadequate immobilization of the dislocated joint after internal fixation of the fracture. As a consequence, the injured TFCC may not heal, leading to recurrent post-operative instability. After either a simple or a complex dislocation of the DRUJ has been recognized, the treatment is relatively straightforward and rewarding. Despite the severity of these injuries, with proper diagnosis and management most patients will have a satisfactory outcome.
Acute Disease↗
In search of the perfect ACL brace.
Following my own acute anterior cruciate ligament (ACL) tear and reconstruction, I embarked on a subjective evaluation of ACL functional braces voluntarily supplied by vendors. Both custom and off-the-shelf braces were evaluated during daily activities and running. Scored subjectively on an ascending scale of 1 to 3 were Comfort (including freedom from slippage, abrasions, and pressure phenomena), Convenience (ease of application), Control (perceived resistance to anterior tibial translation), and Cosmesis (appearance, profile). On this rating scale, 1 represents below average, 2 is average, and 3 is above average. The Comfort score was doubled, as this feature determined whether the brace would be worn. The individual scores were then totaled for an overall rating. To avoid bias, I did all trials prior to reviewing the literature. Scores for custom braces were: Townsend, 14; Omni Scientific Elite, 11; Innovation Sports C.Ti.2, 10; 3M Lenox Hill Spectralite, 9; Orthotech Performer, 9; DonJoy Defiance, 9; and Sutter Talon, 9. Scores for OTS braces were: DonJoy Goldpoint, 13; Orthotech Controller, 11; Bledsoe Force III Light, 11; 3M Lenox Hill OTS, 10; Innovation Sports MVP, 8; Bledsoe Force II, 8; Bledsoe Force II Light, 8; Omni Scientific Spectrum, 7; Townsend OTS, 7; and DonJoy Playmaker, 6. This study does not validate the requirement for a functional orthosis following ACL reconstruction, but if one is desired, I prefer the custom Townsend and the OTS DonJoy Goldpoint. Two other higher scoring OTS braces also proved satisfactory (OTS Orthotech Controller and OTS Bledsoe Force III Light). To accommodate the majority of patients, orthopedic surgeons may need to provide a variety of OTS braces.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Clinical significance of leg-length inequality after total hip arthroplasty.
Sixty-eight patients were interviewed and examined after total hip arthroplasty (THA) to determine the clinical consequences (patient satisfaction, shoe lift use, gait abnormalities, etc) of leg-length inequality. No patient met clinical or radiographic criteria for revision THA. Minimum follow-up was 2 years, and average follow-up was 6.6 years (range, 2 to 20.5 years). A questionnaire, with specific questions about leg-length inequality, was completed by each patient. Leg-length inequality was determined by orthoroentgenography and compared with clinical measurements of leg length. The average inequality in this series of patients was 9.7 mm. A significant number (32%) of patients were aware of this inequality; the average leg-length inequality in this group was 14.9 mm. More than half of these patients were disturbed by the inequality. The magnitude of leg-length inequality closely correlated with awareness of the inequality, abnormal gait, use of ambulatory assistive devices, the need for a shoe lift, prior leg-length inequality, and revision THA. Clinical measures of leg-length inequality correlated poorly with values determined orthoroentgenographically. The high rate of dissatisfaction among patients with a leg-length inequality and the untoward results associated with this inequality indicate that surgeons performing THA should familiarize themselves with a reliable method for equalizing leg lengths intraoperatively.
Adult↗
Radionuclide imaging of the knee with chronic anterior cruciate ligament tear.
We studied the results of bone scans in 50 consecutive patients with symptomatic, unilateral, chronic anterior cruciate ligament (ACL) tears. All patients had failed conservative therapy and underwent radionuclide imaging of the knee prior to arthroscopic ACL reconstruction. The scintigraphic activity in each of the three knee compartments was quantitatively scaled from 1 (normal scintigraphic activity) to 4 (marked activity). Quantitative activity in each of the three compartments was correlated with plain radiographic, arthroscopic, and clinical findings. All but four of the scans (92%) showed abnormal scintigraphic activity. The quantitative activity was highest overall in the medial compartment (2.9), followed by the lateral (2.4) and patellofemoral compartments (1.9). In the subgroup of patients with normal menisci (10 patients), most of the abnormal activity was in the lateral compartment (2.9), implying that when the medial meniscus remains competent in the presence of a torn ACL, there is increased stress on the lateral compartment. There was little correlation with scintigraphy and roentgenographic changes, except in the presence of moderate or severe radiographic degenerative arthritis. Similarly, there was little correlation between increased scintigraphic activity and chondromalacia. These results provide a baseline for future studies that use scintigraphic imaging in monitoring restoration of bone homeostasis following ACL reconstruction.
Adolescent↗
High tibial osteotomy: fixation with cannulated screws.
There have been many modifications of the proximal tibial osteotomy since it was initially described by Jackson in 1958. The trend toward rigid internal fixation and early motion after osteotomy prompted the authors to develop a technique using cannulated screws for stabilization. This method is simple and quick, involves no soft-tissue dissection, and allows early postoperative motion.
Bone Screws↗
Mason type II radial head fractures: operative versus nonoperative treatment.
The most appropriate treatment of Mason type II radial head fractures remains controversial. Recommended treatment has included closed reduction and immobilization, resection, or open reduction and internal fixation. The cases of 29 Mason type II radial head fractures treated at Naval Hospital Oakland from 1983 to 1989 were identified. Twenty-six or 90% were available for detailed follow-up. All cases underwent standardized elbow evaluations and results were compared using an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function in activities of daily living. In addition, injury and follow-up radiographs were analyzed. Mean follow-up was 18 months. There were 10 cases treated by open reduction and internal fixation and 16 cases treated by closed means. At final follow-up, the operatively treated group had a mean elbow score of 92 and 90% good/excellent results. The nonoperatively treated group had a mean elbow score of 77 and 44% good/excellent results. This difference was statistically significant (p less than 0.01). Radiographic analysis revealed a higher incidence of articular depression, displacement, and joint narrowing in the nonoperatively treated group. We conclude that displaced radial head fractures treated nonoperatively have a higher incidence of pain, functional limitations, loss of strength, and radiographic evidence of arthritis when compared to those treated by open reduction and internal fixation.
Adult↗
Nonoperative management of herniated nucleus pulposus: patient selection by the extension sign. Long-term follow-up.
We have previously reported that the ability of patients with herniated nucleus pulposus (HNP) and radiculopathy to achieve full passive lumbar extension (negative extension sign) is a useful predictor of favorable response to conservative management. Of 154 patients with back pain and radiculopathy seen between 1979 and 1985, 73 were selected for conservative management based on this criterion. We also reviewed results of electromyography (EMG), computed tomography (CT), myelography, straight leg raise, crossed straight leg raise, deep tendon reflex, and dermatomal-sensory and motor deficits. Ninety-four percent of the subjects achieved full extension within 5 days of hospital admission. Although some patients who had full extension on admission subsequently underwent chemonucleolysis or surgery, none of those who could not extend initially and who later gained full lumbar extension required surgery. Of the 33 patients who were available for long-term follow-up, 94% were satisfied with the results, 82% were able to resume working, 73% required no analgesics, and 9% later required chemonucleolysis or surgery. Positive findings on admission EMG (5 of 7 patients), myelography (5 of 8 patients), or CT (9 of 11) did not preclude good results with conservative management. Female patients without complaint at follow-up (53%) outnumbered their male counterparts (25%). Patients (19 of 33) whose extension sign was initially positive on admission and became negative within 5 days of hospitalization (average, 1.6 days) had better outcomes with 95% satisfied, 90% without job changes, 74% not requiring analgesia, and none requiring surgery. At long-term follow-up, the extension sign effectively predicted a favorable response to nonoperative therapy of HNP in 91% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Praised be the general orthopaedic surgeon.
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Education, Medical, Graduate↗
Results of conservative treatment for recalcitrant anterior knee pain in active young adults.
The purpose of this study was to determine the success rate of a standard rehabilitation protocol in the treatment of recalcitrant anterior knee pain in active young adults. All patients were active military duty personnel. Patients with a diagnosis of recalcitrant anterior knee pain were enrolled in a standard supervised program of physical therapy. Between 1986 and 1989, 139 patients met the criteria for inclusion in the study. The average age was 25.5 years, and the average time in military service was 67 months. There were 123 men and 16 women. The average duration of supervised treatment was 5.3 months. Only 34% (47 patients) were successfully returned to duty. The remainder received medical discharges. Statistically significant factors associated with successful return to full duty included older age (27.4 vs 24.5 years) and longer duration in service (98 vs 51 months). In addition, patients who returned to duty did so after an average of only 3 months of supervised rehabilitation, whereas treatment failures averaged 7.5 months of therapy.
Adult↗
Complex dislocations of the distal radioulnar joint. Recognition and management.
Contrary to most reported series, it has been the authors' experience that dislocations of the distal radioulnar joint (DRUJ) associated with fractures of the forearm are frequently irreducible. This report reviews the authors' experience with these injuries, focusing on the recognition and management of what the authors call "complex" DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or "mushy" reduction caused by soft tissue or bone interposition. From 1984 until 1989, at the authors' institution, 11 patients were treated for fractures of the radius associated with dislocations of the DRUJ. Eight of these patients had a classic Galeazzi fracture dislocation. Two patients had severe open radius and ulnar fractures. One had an unstable comminuted intraarticular fracture of the distal radius. Of these 11 patients, four had "complex" dislocations of the DRUJ. In two cases, the extensor carpi ulnaris was displaced volar to the distal ulna, necessitating open reduction. A third case involved delayed recognition of multiple wrist and forearm joint dislocations associated with a severe open fracture of both bones of the forearm and required late exploration, reduction, and temporary internal fixation. A fourth case involved recurrent dorsal subluxation of the distal ulna after open reduction and internal fixation of a comminuted intraarticular distal radius fracture. It is clear that complex dislocations of the DRUJ occur more frequently than previously noted. Careful attention to these injuries during initial reduction attempts will reveal "mushy" or unobtainable reductions, an important indication for exploration for entrapped tendon, bone, or soft tissue.
Adolescent↗
Patellar fracture and avulsion of the patellar ligament complicating arthroscopic anterior cruciate ligament reconstruction.
Arthroscopic reconstruction of the anterior cruciate ligament-deficient knee using the middle third of the patellar tendon is an effective treatment for acute or chronic anterior cruciate ligament insufficiency. The strength of this bone-ligament-bone graft is superior to virtually all other autogenous tissue utilized. We report the complication of avulsion of one half of the remaining patellar tendon from the tibia associated with patellar fracture in the early postoperative period.
Adult↗
Lunate silicone replacement arthroplasty in Kienböck's disease: a long-term follow-up.
We report a long-term follow-up (average, 5 years) of 10 patients who had lunate silicone replacement arthroplasty for treatment of Kienböck's disease. Clinical results were assessed on relief of pain, return to normal occupation, and range of motion. At 18- to 20-months follow-up, eight patients had satisfactory results, whereas at final follow-up only five of the patients had satisfactory results. Three of five patients with radiographs averaging 57 months after operation had evidence of particulate synovitis. Contrary to our previous publications on silicone replacement arthroplasty, it was concluded that the success rate for silicone replacement arthroplasty and the incidence of particulate synovitis do not warrant the continued use of silicone replacement arthroplasty as a primary treatment modality for Kienböck's disease.
Adolescent↗
Partial versus complete acute anterior cruciate ligament tears. The results of nonoperative treatment.
A study was undertaken to determine whether a significantly different clinical outcome could be expected following nonoperative treatment of acute partial anterior cruciate ligament (ACL) tears from that of complete tears. A detailed follow-up of 107 patients with arthroscopically confirmed tears was obtained; 72 were complete tears and 35 partial. The overall results in those with partial tears were 23% excellent, 29% good, 17% fair, and 31% poor; with complete tears the results were 11% excellent, 20% good, 15% fair, and 54% poor. The patients with partial tears had a lower incidence of associated meniscal tears, needed fewer reconstructions and more of them returned to sport than those with complete tears.
Adolescent↗
Posttraumatic Aeromonas hydrophila osteomyelitis.
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Adolescent↗
Arthroscopy update #6. Arthroscopy in the osteoarthritic knee. Long-term follow-up.
A retrospective review was performed of 109 patients who underwent arthroscopic debridement of the knee for degenerative osteoarthritis. The results were evaluated using a modification of the Hospital for Special Surgery (HSS) scoring system as well as a subjective scale that measured the patients' degree of satisfaction with the procedure. Follow-up was obtained in 111 knees for an overall follow-up of 92% of knees. The mean age of the patients was 58.1 years, and the mean follow-up was 50.6 months. The overall results were 50 good, 20 fair, and 41 poor. Arthroscopic debridement offered measurable relief for 63% of the patients for a significant period of time. Although the results are equivocal by orthopaedic standards, 74% of the patients felt the procedure had been beneficial.
Adult↗
The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults.
The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.
Adolescent↗
Improved results with the "inverted T" modification of the Bristow procedure.
The results of two modifications of the Bristow procedure in 21 patients were compared an average of 53 months after surgery. Twelve patients had an "inverted T" modification (group T) and nine patients had May's modification (group M). Recurrence rates and functional limitation were determined, as well as range of motion, pain, and apprehension with abduction and external rotation. Preoperative instability was classified according to the method of Protzman. Surgical outcome was graded using the rating scale devised by Rowe in 1978. There were no postoperative dislocations. Overall results were 16 excellent, three good, one fair, and one poor. All 12 patients in group T had an excellent result. In group M, there were four excellent, three good, one fair, and one poor result. Clinical score was 95 in group T and 75 in group M. Pre- and postoperative external rotation at 90 degrees abduction were 91 and 89 degrees in group T, and 99 and 77 degrees in group M.
Adolescent↗