Clinical orthopaedics and related research
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Scapulothoracic dissociation is an important and increasingly common clinical condition resulting from massive traction injury to the anterolateral shoulder girdle with disruption of scapulothoracic articulation. It frequently is accompanied by an acromioclavicular separation, displaced clavicular fracture, or sternoclavicular disruption. ⋯ Many patients have a poor outcome with a flail extremity in 52%, early amputation in 21%, and death in 10%. Early recognition of this injury combined with a logical treatment protocol can help to decrease the substantial morbidity and mortality associated with this condition.
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Clin. Orthop. Relat. Res. · Nov 2003
Predicting total knee replacement pain: a prospective, observational study.
To describe the natural history of pain after total knee arthroplasty and to identify factors predicting excessive postoperative pain, we used a prospective, observational study assessing clinical and radiographic variables preoperatively and at 1, 3, 6, and 12 months after knee replacement. Data sources included the visual analog pain scale and other measures of patient health, psychologic state, and component reliability. Regression analyses were conducted to identify specific factors predictive of postoperative pain, controlling for inequality of variables, and confirmed using regression diagnostics. ⋯ Pain after knee replacement resolves quickly, declining to approximately (1/2) by 3 months. However, one in eight patients report moderate to severe pain 1 year after surgery despite an absence of clinical or radiographic abnormalities. Development of office-based preoperative screening tools and interventions for these patients may reduce postoperative costs and improve patient-perceived outcomes.
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Clin. Orthop. Relat. Res. · Nov 2003
Comparative StudyStem fixation in revision total knee arthroplasty: a comparative analysis.
Methods of stem fixation are a controversial aspect of revision TKA. We sought to determine which technique was superior by reviewing 475 revision TKAs done between 1986 and 2000. Of these 475 revisions, 286 major component revisions were done using 484 extended stems for fixation. ⋯ Of the 95 implants placed with cementless stems, only 67 (71%) were categorized as stable. Eighteen (19%) were possibly loose requiring close followup and 10 (10%) were loose (two tibial and eight femoral implants). We currently would urge caution in using cementless metaphyseal engaging stems for fixation in revision TKA.
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Clin. Orthop. Relat. Res. · Oct 2003
Judet's quadricepsplasty, surgical technique, and results in limb reconstruction.
Quadricepsplasty has been described by Thompson and Judet to improve flexion in severely ankylosed knees. Judet's technique has potential advantages because it is less damaging to the quadriceps mechanism and addresses the problem of external fixator pin site tethering on the lateral side of the thigh. The outcome of Judet's quadricepsplasty was assessed in 10 consecutive patients who were treated with external fixation either as a primary treatment (three patients) or as a secondary treatment for nonunion or malunion (seven patients) in a limb reconstruction unit. ⋯ A minimal extension lag (10 degrees ) developed in one patient. Judet quadricepsplasty successfully increases flexion range with minimum impairment of quadriceps function. Familiarity with this technique might lower the surgeon's threshold for considering quadricepsplasty in patients with severe knee ankylosis after severe femoral fractures and in particular after a prolonged period of external fixation.
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Clin. Orthop. Relat. Res. · Oct 2003
Validity of index of suspicion for pulmonary embolism after hip arthroplasty.
Pulmonary embolism after total hip arthroplasty is problematic, and intravenous heparin treatment in the absence of pulmonary embolism carries risk. Algorithms for treating pulmonary embolism often cite clinical index of suspicion as a basis for initiating intravenous heparin, but most information regarding variables to predict pulmonary embolism originate from studies of patients rather than only from patients who had arthroplasty. We studied the hypothesis that a more homogenous subpopulation, patients who had total hip arthroplasty, may have findings more accurately predictive of pulmonary embolism. ⋯ No significant differences were found between patients with or without pulmonary embolism regarding subjective complaints, physical examination, blood gas results, electrocardiogram findings, radiographs of the chest, and imaging of the veins of the legs. All attempts to model these variables into an index of suspicion that accurately predicted pulmonary embolism were unsuccessful. We advise adherence to established treatment algorithms rather than clinical suspicion when deciding whether to initiate heparin therapy.