Posterior Soft Tissue Research Articles

Letter to the Editor: Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

To the Editor I read with great interest the article, ‘‘Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis’’ by Kim et al. [4]. I have several comments on the risk factors for developing proximal junctional kyphosis (PJK). Previous studies [1, 3, 6, 8] have implied that PJK may arise iatrogenically and suggested the importance of preserving the posterior soft tissues. Rhee et al. [6] reported PJK is more commonly associated with posterior instrumentation than with anterior instrumentation in patients with adolescent idiopathic scoliosis. Yagi et al. [8] also reported that an anterior surgical approach was associated with a lower incidence of PJK (6%) than a posterior approach (27%) in patients who underwent surgery for adult idiopathic scoliosis. Verma et al. [7] showed no significant change in the proximal junctional angle (PJA) at the 2-year followup in patients with thoracolumbar adolescent idiopathic scoliosis who underwent anterior spinal fusion. In addition, previous studies demonstrated that PJK was evident immediately after surgery. Rhee et al. [6] reported that the increase in PJA from postoperatively to preoperatively was 1° in patients with anterior thoracic surgery and 6° in patients with posterior thoracic surgery. Kim et al. [5] reported an immediate postoperative change in PJA from 6° to 13° in the PJK group, whereas a smaller change from 6° to 8° was noted in the nonPJK group. Similarly, Yagi et al. [8] reported an immediate postoperative change in PJA from 2.3° to 11.4° in the PJK group, while an increase from 4.6° to 6.2° was noted in the nonPJK group. The thoracic spine is inherently more rigid than the lumbar spine owing to the support of the rib cage. Therefore, these immediate increases in PJA do not resemble typical adjacent segment disease that might arise from prolonged mechanical stress. In fact, preservation of the facet joint capsule of the supraadjacent level in the thoracic spine during surgery is not easy. The facet joint capsule of the thoracic spine is not as thick or well defined as that of lumbar spine and is easily disrupted during surgical exposure. In addition, pedicle screw placement in the upper thoracic spine often violates or affects the supraadjacent facet capsule [1]. The entry point of the pedicle screw is very close to the supraadjacent facet joint, particularly when an anatomic trajectory is performed to prevent the screw from going into the upper disc space. When the facet joint capsule, and/or either the supraspinous or interspinous ligaments providing posterior stabilization are disrupted, this can lead to an immediate increase in kyphosis because the alignment of the upper thoracic spine is kyphotic. Preservation of muscle attachment is also important in retaining posterior stabilization and preventing kyphosis. The splenius capitis originates from the ligamentum nuchae and spinous processes of the C7 vertebra and T1–3 vertebrae, and it inserts on the lateral portion of the occipital bone, the superior nuchal line, and the mastoid process of the temporal bone [2]. The splenius cervicis muscle originates from the spinous processes of T3–6 and rises to insert on the transverse processes of C1–3 [2]. These muscles serve to extend the spine but often are dissected to expose the upper end segment, while efforts are made to preserve the supraspinous and interspinous ligaments. On the basis of the abovementioned observations, posterior soft tissue disruption attributable to surgery may be the strongest risk factor for the development of PJK. Unfortunately, the current literature does not include this as a risk factor in the analysis because it is difficult to assess disruption of the posterior soft tissues by current imaging modalities, especially with instrumentation. Although previous studies implied the importance of preserving the posterior soft tissues, this needs more emphasis. Meticulous preservation of the posterior soft tissues (ie, facet joint capsule, ligaments, and muscles) during surgery would dramatically reduce the incidence of postoperative PJK.

Reply to Letter to the Editor: Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

The posterior tension band complex, as articulated so clearly by Dr. Yoshihara, in my opinion makes an important contribution to the etiology of proximal junctional kyphosis (PJK). However, my hesitation in attributing the posterior tension band as the most important risk factor is largely owing to the lack of supportive data in the current literature. This lack of data lies partially in the difficulty of measuring the preservation of the posterior structures and lack of consistency with which the data often are presented. For example, if the dissection of the posterior muscular attachments to transverse processes of the upper thoracic vertebrae plays a pivotal role in the development of PJK, studies should consistently show upper instrumented vertebrae of T1–T6 having a higher incidence of PJK [1]. More recent literature comparing PJK rates in those with upper thoracic (T1–T3) versus lower thoracic (T10–T12) instrumented vertebrae [4, 8] have determined that upper instrumented vertebrae in the lower thoracic spine had a higher PJK rate. In addition, some studies [4–8] have failed to show a difference in PJK rates between different upper instrumented vertebrae. The etiology of PJK is clearly multifactorial and therefore, studies should focus on conducting multivariate analyses when identifying risk factors associated with the development of PJK. We did not investigate the posterior soft tissue integrity. As mentioned by Dr. Yoshihara, the difficulty in including this as a risk factor lies in the inability to reliably quantify the extent of soft tissue dissection and facet capsule disruption at the time of the index operation. One point mentioned by Dr. Yoshihara is that pedicle screw instrumentation damages the supraadjacent facet capsule owing to the footprint of the screw head. Although I agree this is theoretically possible, this has not been supported consistently in the literature [2, 4, 7, 10]. If this were true, one would expect constructs using hooks at the upper instrumented vertebrae to have lower rates of PJK. In fact, reports are inconsistent when it comes to instrumentation type at the upper instrumented vertebrae and PJK, with one report [2] showing a difference and others [4, 7, 10] showing no difference whether a pedicle screw or a hook is used at the upper instrumented vertebrae. As our understanding of the etiology of PJK improves, the spectrum of pathologic features encompassing PJK is becoming more transparent. Earlier studies have described PJK to be a pure radiographic finding [1, 6] while more recent studies [4, 5] suggest differences in Scoliosis Research Society outcomes scores between those with and without PJK. In studies such as those referenced by Dr. Yoshihara [2, 3, 9], no differences in health-related quality of life questionnaires were noted between patients with and without PJK and therefore, the amount of increase in PJK angle noted may be of questionable clinical importance (if it is attributed solely to the posterior approach). This shows the necessity in distinguishing purely radiographic PJK versus progressive PJK causing pain versus catastrophic PJK which often can present with myelopathy and spinal cord impingement. Studies that focus on differences between these subsets of patients with PJK will be useful in determining clinically important risk factors since it is entirely plausible that the inclusion of less severe cases of PJK with more severe cases in a study cohort can have an umbrella effect and dilute otherwise important findings. At the recent Hibbs Society Meeting held during the 2012 Annual Scoliosis Research Society Meeting in Chicago, Illinois, USA, a group of surgeons met with interest on the topic of PJK. It is clear that our understanding of PJK has improved since it was first described [1] but much work remains in understanding the cause and optimal method for treating severe cases. I believe these questions will be answered in future studies and will help us tailor methods for the prevention of PJK.

Surgical Management of Congenital TEV in Children at PMC Hospital Nawabshah

Introduction: Talipes equino varus TEV is one of the most common congenital anomaly. It is managed by some common ways i-e., conservative & surgical methods. Among surgical methods are Turco’s posterior medial release, posterior soft tissue release operation (Attenborough), four quadrant release (Mc Kay). Objective of this study was to determine the reliability of surgical option like postero medial release in children having congenital TEV. Material & Methods: This study was carried out during the period from October 2002 to March 2005 in the Deptt. of Orthopaedics of PMCH Nawab Shah. The inclusion criteria were children 2 months to 30 months of age having moderate to severe club foot. Clubfoot secondary to some other disorder such as cerebral palsy, arthrogryposis multiplex congenital, myeldysplasia or DDH were not included in this study. The deformity was treated surgically in all cases by postero medial release. Follow-up period was one & half year. Results: A total 57 patients were included in this study with the age range of 2 months-2.5 yrs with moderate to severe deformity. Forty two were male (73.7%) and 15 patients (26.3%) were female, seventeen patients (29.8%) had bilateral club foot while the rest the rest of 40 patients (67.1%) had unilateral deformity. Positive family history of club foot was in 10 patients (17.5%). Results were concluded on 57 patients who completed one & half year follow-up. Excellent results were observed in 41 patients (71.9%), good in 11 patients (19.2%), fair in 2 children (3.5%). No patients lost to follow up.Conclusion: Children up to 30 months (2 months - 2.5 years) age with congenital TEV can be treated with surgery successfully.

Posterior Femoral Condylar Offset After Total Knee Replacement in The Risk of Knee Flexion Contracture

The aim of this study was to clarify the risk of knee flexion contracture associated with a posterior femoral condylar offset after total knee replacement (TKR). Radiographs from 100 healthy Japanese volunteers were included in the study. We evaluated femoral component posterior offset in various implants and compared them with the normal Japanese knee. Posterior offset of the femoral condyle is up to a maximum of 4.7 times greater than that of the healthy Japanese knee in all knee implants. Excess posterior offset of the femoral condyle in TKR prostheses may cause knee joint flexion contracture due to the relative shortening of the posterior soft tissue.

Influence of a Secondary Downsizing of the Femoral Component on the Extension Gap: A Cadaveric Study

The purpose of this study was to evaluate the effect of a secondary reduction of the femoral component size on flexion and extension gaps intraoperatively in posterior-stabilized total knee arthroplasty (PS-TKA) monitored by computer-assisted surgery. The authors hypothesized that cutting additional bone on the posterior femoral condyle may increase the extension gap due to the posterior capsule and soft tissue loosening. Reduction of the femoral component size was performed by additional 4-in-1 cuts after the PS-TKA on 15 cadaveric knees using a ligamentous tension device with the aid of computer-assisted surgery. Measurements of the medial and lateral flexion gaps, as well as the medial and lateral extension gaps, were recorded before and after reducing the femoral component size. Trial components were used from a mobile-bearing total knee system.After reducing the femoral component size, the medial and lateral flexion and extension gaps measured larger than their initial size. The mean increases of the medial extension and flexion gaps and the lateral extension and flexion gaps were 1.3 ± 0.9, 1.0 ± 1.2, 1.1 ± 1.2, and 1.3 ± 1.3 mm, respectively; all 4 differences were significant (P ≤ .05). Surgeons should be aware of the effect of downsizing components intraoperatively because it might lead to an extension laxity. Thus, a downsizing of the femoral component may compromise the postoperative stability of TKA.

Paraspinal ganglioneuroma in the proband of a large family with mild cutaneous manifestations of NF1, carrying a deep NF1 intronic mutation

Supporting Information The following Supporting information is available for this article: Fig. S1. (a) Chest radiograph – there is a large right paraspinal soft tissue opacity at the base of the right hemithorax, not in the middle mediastinum, as it is not silhouetting the right heart border. (b) Magnetic resonance imaging – axial T2 and coronal inversion recovery (IR) sequences reveals a posterior mediastinal soft tissue mass along the lateral margin of the spinal column. Coronal T1 post gadolinium sequence shows the mass to heterogeneously enhance. Involvement of multiple right-sided neural foramen is well seen on this sequence as well as on the Sagittal T2 sequence. (c) A cluster of maturing ganglion cells within the Schwannian stromal background. Note the increased nuclear to cytoplasmic ratio and multinucleation within these cells compared to a mature ganglion cell. (d) A mature ganglion cell stained with synaptophysin. Note the positive staining within the borders of the intracytoplasmic secretory vesicles at the periphery of the cell. Table S1. Summary of reported individuals with neurofibromatosis type I and ganglioneuroma Table S2. Summary of the 10 deep intronic neurofibromatosis type I mutations with mRNA effect reported so far Additional Supporting information may be found in the online version of this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Radiography and sonography of clubfoot: A comparative Study

Background:Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.Materials and Methods:Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.Results:MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.Conclusion:All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Posterior ankle and subtalar arthroscopy: indications, technique, and results.

Over the decades, arthroscopy has grown in popularity for the treatment of many foot and ankle pathologies. While anterior ankle arthroscopy is a widely accepted technique, posterior ankle/subtalar arthroscopy is still a relatively new procedure. The goal of this review is to outline the indications, surgical techniques, and results of posterior ankle/subtalar arthroscopy. The main indications include: 1) osteochondral lesions (of subtalar and posterior ankle joint); 2) posterior soft tissue or bony impingement; 3) os trigonum syndrome; 4) posterior loose bodies; 5) flexor hallucis longus (FHL) tenosynovitis; 6) posterior synovitis; 7) subtalar (or ankle) joint arthritis; 8) posterior tibial, talar, or calcaneal fractures (for arthroscopic reduction and internal fixation). Although posterior ankle/subtalar arthroscopy has shown to be safe and effective in the treatment of many of the above mentioned conditions, thorough knowledge of the anatomy, correct indications, and a precise surgical technique are essential to produce good outcomes.

Mid-Term Outcome of Total Hip Replacement Using the Posterior Approach for Displaced Femoral Neck Fractures

Treatment of displaced femoral neck fractures with total hip replacement (THR) in appropriately selected patients has become more widely accepted. The use of the posterior approach for THR remains controversial due to concerns regarding dislocation, the cause of which is multi-factorial. This study is a single surgeon series of 45 consecutive active, healthy patients (mean age 78 years) with displaced femoral neck fractures treated with THR through a posterior approach. Large diameter heads (32mm in 47%, ≥36mm in 48% of patients) and an anatomic posterior soft tissue repair were utilised to minimize the risk of dislocation. Outcomes were reported at a mean of 2 and 6 years. The mortality rate was 13% at 2 years and 40% at 6 years. All revision surgery (4.4%) was performed for dislocations which occurred in 6.7% of patients. Good VAS pain, OHS and SF-12 scores were reported both at 2 and 6 years. Patient satisfaction with the results of surgery was high.

Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: A comparative prospective multicenter study

Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias since the open-wedge technique was preferred in cases with substantial varus deformity. We emphasize the importance of surgical technique to avoid alteration of the tibial slope, particularly in opening-wedge high tibial osteotomy for which we recommend a release of posterior soft tissue and a complete osteotomy of the posterior cortex of the tibia. III. Prospective consecutive nonrandomized multicenter study.

Breast Reconstruction with the Profunda Artery Perforator Flap

The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape. All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar. Therapeutic, V.

Is the Dislocation Rate Higher after Bipolar Hemiarthroplasty in Patients with Neuromuscular Diseases?

Patients with neuromuscular disease reportedly have a higher incidence of postoperative dislocation after bipolar hemiarthroplasty. Although the literature has focused on a high prevalence of preoperative neurologic conditions in patients who had dislocations after bipolar hemiarthroplasties, the relative incidence of dislocation in patients with neuromuscular disease and without is unclear. We therefore (1) asked whether the incidence of postoperative dislocation after bipolar hemiarthroplasty was greater in patients with neuromuscular disease than for those without, and (2) whether function differed between the two groups, and (3) explored potential risk factors for dislocation in two groups. We retrospectively reviewed 190 patients who underwent bipolar hemiarthroplasties for fracture of the femoral neck between 1996 and 2008. Of the 190 patients, 42 had various neuromuscular diseases and 148 had no history of neuromuscular disease. Intraoperative stability was tested and posterior soft tissue repair was performed in all patients. We determined the incidence of dislocation, postoperative leg length discrepancy, and femoral offset in patients with or without neuromuscular disease. The incidence of dislocation was 2.6% in all patients. We observed similar rates of dislocation in the two groups: 4.8% (two of 42 hips) in patients with neuromuscular disease and 2.0% (three of 148 hips) in patients without neuromuscular disease. In femoral neck fractures in patients with neuromuscular disease, careful preoperative management and operative technique such as a posterior soft tissue repair might decrease the risk of postoperative dislocation; therefore, we consider the bipolar hemiarthroplasty a reasonable treatment option. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical Technique: A Simple Soft-tissue-only Repair of the Capsule and External Rotators in Posterior-approach THA

Posterior soft tissue repair after posterior THA reportedly decreases the risk of dislocation. Previously described techniques often require drill holes through the greater trochanter, do not include both the short external rotators and the capsule, or require a complex series of multiple sutures. We therefore describe a technique to address these issues. The posterior soft tissues were repaired with a single nonabsorbable suture passed through the external rotators and posterior capsule and then through the capsule and posterior border of minimus in a figure-of-eight pattern. This repair remains pliable and obliterates the dead space. We retrospectively reviewed 165 patients who underwent 178 primary THAs through a mini-posterior THA and also underwent soft tissue repair using our technique. We determined the rate of dislocation and complications associated with this technique. The minimum clinical followup was 1 year (mean, 23 months; range, 12-37 months). This repair was associated with a low risk of dislocation at 1 year (one of 178 hips, 0.56%) and no apparent complications related to the technique. This soft tissue to soft tissue repair technique after posterior-approach THA is technically straightforward and reliable with a low associated dislocation rate. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Spa-Drain Entrapment Complicated by Suspicions of Nonaccidental Trauma and Epilepsy Onset

We present here the case of an adolescent female near-drowning victim who was reportedly discovered submerged and unconscious by family members in a whirlpool spa. Physical examination revealed extensive posterior soft tissue bruising, which raised the suspicion of nonaccidental trauma. Detailed forensic evaluation of the injuries and the scene proved that the soft tissue findings represented an unusual manifestation of whirlpool-spa suction-vent injury. Medical evaluation indicated that epilepsy onset might have contributed to the near-drowning, although forensic evaluation of this possibility was less convincing. In this article we review these rare but important injuries, which have the potential to be confused with child abuse, and detail the atypical presentation and clinically presumed etiologic event in our case.

Surgical Technique: When to Arthroscopically Repair the Torn Posterior Cruciate Ligament

Posterior cruciate ligament injuries can occur as isolated ligament ruptures or in association with the multiligament-injured knee. Delayed reconstruction, at 2-3 weeks post-injury, is predominantly recommended for posterior cruciate ligament tears in the multiligament-injured knee. While acute bone and soft tissue avulsion patterns of injury can be amenable to repair, the described techniques have been associated with some difficulties attaching the avulsed ligament. As part of a reconstruction/repair of a multiligament-injured knee, we performed arthroscopic primary repair of the posterior cruciate ligament by passing Bunnell-type stitches into the substance of the ligament using a reloadable suture passer. We then passed the sutures through drill holes into the femoral footprint of the ligament and tied them over a bony bridge. We retrospectively reviewed three patients with posterior cruciate ligament tears associated with a multiligament-injured knee. All patients had posterior cruciate ligament soft tissue avulsions or "peel off" injuries diagnosed by MRI. The described repair technique was used to repair the posterior cruciate ligament avulsion. Minimum followup was 64 months (mean, 68 months; range, 64-75 months). ROM, stability testing, and functional outcome scores (Lysholm and modified Cincinnati) were recorded. Mean ROM was 0° to 127°. Posterior drawer testing was negative in all three patients. The mean Lysholm score was 92 and the mean modified Cincinnati score was 94. Followup MRI confirmed ligament healing in all patients. We believe arthroscopic posterior cruciate ligament repair for soft tissue peel off injuries is a technique that, when applied to carefully selected patients, may be helpful to the surgeon treating patients with a multiligament-injured knee. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Dislocation After Total Hip Arthroplasty: A Randomized Clinical Trial of a Posterior Approach and a Modified Lateral Approach

We compared the dislocation rate of total hip arthroplasty between posterior approach and lateral approach in a prospective randomized trial. One hundred ninety-six hips were randomly chosen for a posterior approach with a posterior soft tissue repair (99 hips) or a lateral approach (97 hips). The average duration of follow-up was 37.9 months. Three hips (3%) dislocated in the lateral group, whereas none from the posterior group dislocated. At the final follow-up, the Harris hip score and limping were similar in the 2 groups. The joint stability obtained by the posterior soft tissue repair in the posterior approach group seemed to produce more favorable result when compared to the stability obtained from the lateral approach group.

Posterior Approach Using Anterior Ankle Arthrodesis Locking Plate for Tibiotalocalcaneal Arthrodesis

Tibiotalocalcaneal arthrodesis is a successful treatment for patients with severe pain and functional disability in the ankle and subtalar joint. Patients with post-traumatic ankle and subtalar joint arthritis, and/or Charcot deformity, often present with compromised skin and soft tissue structures. In the present report, we describe a technique using an anterior ankle arthrodesis locking plate placed posteriorly to obtain hindfoot and ankle fusion. This technique, which uses the well vascularized, thick, posterior soft tissue envelope, provides very good exposure of the articular surfaces for resection and tibiotalocalcaneal fusion. The technique provides a valuable option for patients with compromised skin and soft tissue structures over aspects of the ankle that make other approaches risky and complicated.

Achilles Allograft Reconstruction for Recurrent Dislocation in Total Hip Arthroplasty

Recurrent dislocation secondary to posterior soft tissue deficiency is a challenging complication of total hip arthroplasty. We describe the use of an Achilles allograft sling to improve hip stability. Eight patients treated with the sling were followed an average of 5 years. Seven patients had no recurrent instability and good postoperative range of motion. One graft failed in a patient with a neuropathic hip. Cadaveric biomechanical testing was also performed to investigate the stiffness and torque to failure of the sling in 6 specimens. Allograft slings can be used to improve hip stability. The technique is relatively easy to perform and does not limit postoperative range of motion. The graft decreases joint stiffness and has a greater torque to failure than the intact capsule.

Tendency for Lower Dislocation Rate in THA Employing Posterior Soft Tissue Repair

Ms. Hoffmeister is a freelance medical writer in Camp Hill, Pennsylvania.FigureAll authors and staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with or financial interests in any commercial companies pertaining to this educational activity. To earn CME credit, you must read the CME articles and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This continuing medical enduring material activity expires March 31, 2012. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity. Lippincott's Bone and Joint Newsletter is an independent publication solely owned and published by Lippincott Williams & Wilkins and has no affiliation with the Journal of Bone & Joint Surgery.

The “anconeus slide”: rotation flap for management of posterior wound complications about the elbow

Wound dehiscence at the tip of the olecranon is not an uncommon complication associated with surgical approaches to the elbow that involve a posterior skin incision. Various flaps have been described in the treatment of such soft tissue defects, but have associated morbidity. The "anconeus slide" rotation flap has low morbidity and is technically simple. In this study, we review the surgical technique and describe our experience with the anconeus rotation flap in 20 consecutive patients. The records of 20 patients who underwent an anconeus rotation flap by a single surgeon, from September 2006 to March 2010 were reviewed. The procedure was performed in the setting of total elbow arthroplasty (TEA) in 12 patients, revision total elbow arthroplasty in 3 patients, wound complications in 4patients, and for an acute open distal humerus fracture in 1 patient. Patients were evaluated postoperatively for wound healing, pain, and postoperative Mayo Elbow Performance Scores (MEPS). All 20 patients healed their surgical wounds completely. Postoperative MEPS scores averaged 79.3 (range, 50-100). The anconeus rotational flap is a technically simple, reliable, and safe option for treatment of posterior wound complications about the elbow, and in the setting of primary and revision TEA when wound healing is a clinical concern. We recommend its use in patients who have either compromised posterior soft tissue coverage, triceps insufficiency, or factors associated with the potential for compromised wound healing.