Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Jun 2006
Editorial Comparative StudyTotal hip arthroplasty dislocation: prevention and management: editorial comment.
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Clin. Orthop. Relat. Res. · May 2006
Comparative StudyIntraoperative electron radiotherapy for extremity sarcomas does not increase acute or late morbidity.
Intraoperative electron radiotherapy is used to treat surgical sites that potentially harbor occult tumor immediately after limb-sparing surgical resection of extremity soft tissue sarcomas. It is unknown whether single-fraction, high-dose intraoperative electron radiotherapy at the time of surgery increases wound morbidity when combined with preoperative or postoperative external beam radiotherapy. In a retrospective study, we evaluated whether intraoperative electron radiotherapy increased 90-day and late (> 90 days) wound complication rates by comparing patients who had adult extremity soft tissue sarcomas treated by limb-sparing surgery and preoperative (n = 14) or postoperative (n = 13) external beam radiotherapy. The median followup was 36 months. Seven (26%) patients had wound complications occurring within 90 days postoperatively and completion of radiotherapy. Late wound complication rates were similar. Two patients in each of the external beam radiotherapy groups required late subtotal limb amputations for prolonged wound complications. Our findings suggest intraoperative electron radiotherapy during limb-sparing surgery allows radiation dose escalation without increased 90-day or late-wound complication rates when combined with preoperative or postoperative external beam radiotherapy for patients with extremity soft tissue sarcomas. ⋯ Prognostic Study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · May 2006
Comparative StudyRevision total knee arthroplasty does not increase PACU utilization.
The hospital records of 232 consecutive cases of patients undergoing primary and revision total knee arthroplasty were analyzed to determine differences in operating room time, postanesthesia care unit time, operating room narcotic usage, and postanesthesia care unit narcotic usage between the two groups. The average operating room time for a surgeon performing revision total knee arthroplasty on a patient was greater than that for a primary total knee arthroplasty. However, there was no difference in average postanesthesia care unit time nor operating room and postanesthesia care unit narcotic usage. When stratified to anesthetic type and perioperative pain intervention, there was no difference in any of the measured parameters between the primary and revision groups. Thus, even with longer operating times, a patient undergoing revision total knee arthroplasty did not utilize more postanesthesia care unit time, nor more perioperative narcotics, than a patient undergoing primary total knee arthroplasty. ⋯ Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Apr 2006
ReviewExtraarticular hand fractures in adults: a review of new developments.
This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work. ⋯ Level V (expert opinion).
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Clin. Orthop. Relat. Res. · Apr 2006
ReviewCurrent concepts in volar fixed-angle fixation of unstable distal radius fractures.
We present new developments in the volar treatment of unstable distal radius fractures in adults. New perspectives on the anatomy of the wrist, the watershed line on the volar radius and the usefulness of the pronator fossa are presented and these help to avoid flexor and extensor tendon disturbance when using a volar approach. Other new insights on the bony anatomy of the distal end of the radius are discussed, which are important in improving the quality of fracture fixation, including the benefits of constructing a precise fixed-angle scaffold underneath the articular surface in order to stabilize it. A volar fixed-angle plate must support the dorsal, central and volar aspects of the subchondral bone in order to stabilize the most complex fractures. Awareness of the anatomy of blood supply to the distal radius: the dorsal retinaculum that feeds the distal fragments and the blood supply to the diaphysis through branches of the anterior interosseous artery is necessary to maximize healing potential and avoid complications. Volar fixed-angle plates need to withstand very high forces during rehabilitation, the magnitude of these forces are up to five times the loads applied on the hand. ⋯ Level V (expert opinion).