Uninjured Extremity Research Articles

Chronic distal biceps avulsion treated with suture button

Distal biceps tendon avulsions account for 3%-10% of all biceps ruptures. Treated nonoperatively, these injuries lead to a loss of endurance, supination strength, and flexion strength compared with operative repair or reconstruction. Operative management of chronic injury has classically been with graft tissue to augment the contracted muscle. We present our results for chronic distal biceps avulsions secured with suture button through a single transverse incision in high flexion without the need for allograft augmentation. This was a retrospective review of 20 patients with 21 injuries who underwent primary surgical repair of chronic distal biceps tendon avulsions at an average of 10 weeks (range 4-42 weeks). All patients were treated with a single transverse incision with a suture button armed with nonabsorbable no. 2 core sutures. Postoperatively patients were found to have 50°-90° flexion contracture. All patients were placed in a simple sling postoperatively with gentle extension to gravity as tolerated immediately and no formal physical therapy. Patients were surveyed regarding pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and overall satisfaction. Range of motion (ROM), flexion, and supination strength compared to the contralateral uninjured extremity were evaluated at final follow-up. Mean clinical follow-up was 26 months. All patients regained full ROM and 5/5 flexion and supination strength at final follow-up. MEPSs were 100 for all responding patients compared with an average 47.5 preoperatively (P < .0001). The mean postoperative ASES score was 97.2 compared with 41.9 preoperatively (P < .0001). Mean OESs pre- and postoperatively were 24.2 and 48, respectively (P < .0001). The mean VAS score was 4.4 preoperatively and was reported as 0 by all patients at final follow-up (P < .0001). Two patients had transient sensory radial nerve neuropathy, and 1 patient has persistent palsy. No synostoses occurred. Four patients reported supination fatigue postoperatively compared with the uninjured extremity. Given these results, we feel that chronic distal biceps tendon ruptures can be repaired successfully with a single incision using suture button technique without the use of a graft. Though the flexion contracture is significant postoperatively, all patients regained full ROM and had excellent postoperative functional outcome scores.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction.

The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach. Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome. The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed. ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon. Level IV. See Instructions for Authors for a complete description of levels of evidence.

Isolated Distal Ulna Fracture With Distal Radioulnar Joint Dislocation: A Novel Fracture Pattern.

Background: Galeazzi fractures composed of a middle to distal third radius fracture with dislocation and/or instability at the distal radioulnar joint (DRUJ) have been well described for decades. However, the inverse scenario has seldom if ever been described in the literature. Methods: We explore the case of a 25-year-old active patient who experienced a traumatic distal ulna fracture with dislocation of the DRUJ without a distal radius fracture. Results: It was successfully treated with open reduction and Kirschner wire fixation. The patient regained equivalent strength and range of motion compared with the contralateral uninjured extremity. Conclusion: We feel this patient's successful postoperative course can guide future treatment plans for orthopedic surgeons who encounter similar fractures.

A Comparison of Nonoperative and Operative Treatment of Complete Proximal Hamstring Ruptures.

Background:The early repair of acute proximal hamstring ruptures provides better clinical results than delayed repair. However, it is unclear how nonoperative treatment compares with the operative treatment of these injuries.Purpose:To compare the clinical results of the nonoperative and operative treatment of acute proximal hamstring ruptures.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 25 patients with complete, retracted proximal hamstring ruptures presenting to 1 institution were retrospectively reviewed. All patients were given the option of proximal hamstring repair at the time of the initial evaluation. Patients with at least 12 months of follow-up from the time of surgery or injury were included in the evaluation. Both nonoperative and operative treatment groups were evaluated using the same outcome measures. The primary outcome measure was the Lower Extremity Functional Scale (LEFS). Secondary outcome measures included the Short Form–12 (SF-12) physical and mental component summaries, strength testing, a single-leg hop test, the patient’s perception of strength, and the ability to return to activity.Results:There were 11 patients treated nonoperatively, with a mean follow-up of 2.48 ± 3.66 years, and 14 patients treated operatively, with a mean follow-up of 3.56 ± 2.11 years. The mean LEFS scores for the nonoperative and operative groups were 68.50 ± 7.92 and 74.71 ± 5.38, respectively (P = .07). No statistical differences were found between the groups regarding SF-12 scores and mean single-leg hop distance compared with the uninjured leg. Isometric testing of the injured hamstring in the nonoperative group demonstrated significant clinical weakness compared with the uninjured side at both 45° and 90° of flexion (57.54% ± 7.8% and 67.73% ± 18.8%, respectively). Isokinetic testing of the injured leg in the operative group demonstrated 90.87% ± 16.3% strength of the uninjured leg. All patients in the operative group were able to return to preinjury activities, whereas 3 patients in the nonoperative group were unable to return (chi-square = 4.33, P = .07).Conclusion:Patients with acute proximal hamstring ruptures treated surgically regained approximately 90% strength of the uninjured extremity and tended to have a greater likelihood of returning to preinjury activities than patients treated nonoperatively.

The use of two K-wires in cross-leg free flap as a simple fixation technique together with -Y- artery anastomosis

Cross-leg free flap is a method that can be utilized in cases of serious injury where no available recipient vessels can be found in the neighboring sites to defects. Plasters or external fixators are generally used for postoperative immobilization, and generally, one of the major arteries of the uninjured extremity is sacrificed for flap revascularization. Here, we present the -Y- anastomosis method, which obviates the need to resort to major artery sacrifice, used together with K-wire as a simple but influential fixation technique in cross-leg free flap.

Secondary extremity compartment syndrome after traumatic cardiac arrest

The objective of this case report is to investigate the pathophysiology, diagnosis, and surgical management of secondary extremity compartment syndrome. This case-based review documents the development of secondary extremity compartment syndrome in the setting of high-volume fluid resuscitation for a hemorrhagic cardiac arrest complicated by a global ischemia-reperfusion injury. A 21-year-old male presented with traumatic, hemorrhagic cardiac arrest. Following a resuscitative thoracotomy, massive transfusion and return of spontaneous circulation, the patient underwent damage control surgery. Over the first 48 h following the injury, the patient developed progressive diffuse interstitial edema ultimately culminating in compartment syndrome of the remaining three uninjured extremities as well as both uninjured gluteal compartments. The patient underwent bilateral lower extremity, thigh, gluteal, and right upper extremity compartment fasciotomies, with the left lower extremity being the single, traumatically injured extremity. To our knowledge, this is the only case of secondary extremity compartment syndrome in which bilateral gluteal compartments and bilateral thigh compartments were involved in addition to the bilateral upper and right lower extremities. The goal of this case report is to examine the pathophysiology of the development of secondary extremity compartment syndrome, with an emphasis on early recognition and surgical intervention.

Incisura Morphology as a Risk Factor for Syndesmotic Malreduction.

The goal of this study was to objectively assess if rotational or translational syndesmotic malreduction is associated with certain syndesmotic morphologies. Prior studies based on subjective assessment of syndesmotic morphology and reduction have not shown any difference between groups. Thirty-five prospectively recruited patients with operatively treated syndesmotic injuries were recruited at an Urban Level I Trauma Center. Patients underwent postoperative bilateral computed tomographic (CT) scans of the ankle to assess incisura depth and syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of syndesmotic reduction were measured at several anatomic points and compared to the incisura depth. There was a significant correlation between more shallow syndesmoses and increased anterior translation of the fibula in the incisura (r = -0.63, P ≤ .001). Six of 8 patients with "shallow" (≤2.5 mm) incisura were anteriorly malreduced greater than or equal to 1.5 mm compared to the contralateral ankle. The anterior malreduction rate in those with a shallow incisura was significantly greater than in the "non-shallow" patients (P < .001). There were 9 patients with incisurae greater than or equal to 4.5 mm deep. Five of the "deep" patients had posterior malreductions greater than or equal to 1.5 mm. The posterior malreduction rate in the "deep" group was significantly greater than the "non-deep" patients (P = .02). There was a significant correlation between increasing syndesmotic depth and increased malrotation (r = .46, P = .01). Syndesmotic morphology was found to be associated with specific malreduction patterns. Shallow syndesmoses were correlated with anterior fibular malreduction, and were less likely to be malrotated. Conversely, deep syndesmoses predisposed to posterior sagittal plane and rotational malalignment. Preoperative CT scans that assess the syndesmosis morphology may allow surgeons to alter reduction strategies to avoid syndesmotic malreduction. Level III, retrospective cohort study.

Increased Reduction Clamp Force Associated With Syndesmotic Overcompression.

The distal tibiofibular syndesmosis is disrupted in up to 45% of operatively treated ankle fractures, and syndesmotic malreduction has historically been correlated with poor outcome. The purpose of this study was to quantify the clamp force used during syndesmotic reduction and to evaluate the effect of clamp force on fibular overmedialization (overcompression) at the level of the distal tibiofibular syndesmosis. A prospectively recruited cohort of 21 patients underwent operative syndesmotic reduction and fixation. A ball point periarticular reduction forceps that was modified to include a load cell in one tine was used for the reduction, and the clamp force required for reduction was measured. Patients underwent postoperative bilateral computed tomographic scans of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences in fibular medialization, translation, and rotation within the tibial incisura were measured. These findings were correlated with the reduction clamp force utilized to obtain the reduction. Syndesmotic overcompression (fibular medialization greater than 1.0 mm when compared with noninjured ankle) was seen in 11 of 21 patients (52%). Increased clamp force significantly correlated with syndesmotic overcompression. The mean reduction clamp forces were 88 N for the undercompressed group, 130 N for the adequately compressed group, and 163 N for the overcompressed group. This study demonstrated a significant correlation between increased clamp forces and syndesmotic overcompression, and determined objective forces that lead to overcompression. Our results indicate that surgeons should be cognizant of the clamp force used for syndesmotic reduction. Level III, case-control series, in accordance with STROBE guidelines.

Minimal invasive fixation of distal tibial fractures does not result in rotational malalignment: A report of 24 cases with CT imaging.

Tibial torsion is rotation of the proximal versus the distal articular axis in the transverse plane. This study used computed tomography (CT) to examine rotational malalignment in the crus following use of minimally invasive plate osteosynthesis (MIPO) technique in distal tibial fractures and evaluated effect of rotational difference on clinical outcomes and VAS scores. Analysis of 24 patients who were operated on for closed distal tibial fracture with MIPO technique between 2010 and 2012 was conducted. Malrotation was defined as rotational difference >10°. Operated knees were evaluated with 0.5-mm, fine-cut, 3-dimensional CT scan performed in cooperation with radiology department. Side-to-side difference in tibial torsion angle >10° was considered significant degree of malrotation. All patients were assessed clinically (visual analogue scale [VAS] and American Orthopaedic Foot and Ankle Society [AOFAS] scores) and radiologically at final visit. Mean follow-up period was 20.00±9.46 months (range: 18-51 months). Mean VAS score was 2.58±0.83 (range: 1-4) and mean AOFAS score was 87.50±4.05 (range: 78-93). Mean tibial rotation angle was 31.54±6.00° (range: 18-45°) on healthy side and 32.00±6.24° (range: 10-43°) on the operated side. No statistically significant difference was determined (p>0.05). Use of intraoperative fluoroscopy, cable technique, and uninjured extremity as reference, can reduce incidence of rotational malalignment of distal tibial fractures treated with MIPO.

Treatment of Nonunion of Forearm Bones Using Radial Forearm Bone Flap.

Background:Treatment of forearm fracture nonunion is challenging. Several surgical techniques for the treatment of forearm nonunion have been reported.Objectives:The aim of this prospective study was to evaluate the effects of the radial forearm bone graft technique in cases with forearm nonunion.Patients and Methods:We treated 7 patients with forearm nonunions via radial forearm bone flap and internal plate fixation. On the preoperative examination and last follow-up, the quick disabilities of the arm, shoulder, and hand (Q-DASH) score, elbow, forearm and wrist arches of motion and grip force were measured. At the final follow-up, radiographic union and patient satisfaction and return to work were assessed.Results:The mean follow-up duration was 34 ± 23 months. The Q-DASH scores improved from 70 ± 6 points preoperatively to 13 ± 15 points at final follow-up (P < 0.01). The preopetative range of motion (ROM) was 101 ± 26 degrees; whereas the final forearm ROM was 140 ± 17 (P = 0.01). All nonunions united uneventfully (range 3-6 months). At the last follow-up, the grip force was 83% of uninjured extremity and all patients were satisfied with the outcome of the operation.Conclusions:Radial forearm bone flap is a safe, useful and novel technique in cases with forearm nonunion.

Functional Outcomes of Replantation Following Radiocarpal Amputation

To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. Therapeutic IV.

Ligamentous Lisfranc Injuries in the Athlete

Ligamentous injuries to the midfoot during athletic endeavors are becoming more common and more troublesome as they can take significant time before the athlete is able to return to play. Late changes in alignment or posttraumatic arthritis are complications of inadequate treatment. The mechanism of injury is either direct impact to the dorsal midfoot or a twisting injury to the hindfoot with a plantar-flexed, fixed forefoot. Examination reveals ecchymosis and pain in the midfoot. Rarely is there enough instability to allow detection on physical examination. Provocative tests such as external rotation stress of the midfoot or physical activity (single leg hop or walking on tip toes) can recreate symptoms if the patient’s pain allows for it. Weight-bearing anteroposterior and lateral radiographic examination of both feet focusing on the midfoot is essential, allowing comparison between the injured and uninjured extremity. Diastasis between the proximal first and second metatarsal is a classic radiographic finding, but proximal extension between the cuneiforms can also be present. A more severe injury shows loss of the longitudinal arch or subluxation of the midfoot that is identified on a lateral radiograph. A tear or an avulsion of Lisfranc ligament along with other midfoot ligaments is the underlying pathology. Advanced imaging modalities including computed tomography and magnetic resonance imaging are useful in these more subtle injuries or when more specific anatomical detail is required. Nondisplaced injuries are typically treated conservatively with a period of non–weight bearing followed by a gradual return-to-play protocol. Injuries with diastasis or loss of arch height, in addition to cases subluxation or dislocation of joints or displaced fractures require surgical intervention to restore normal anatomical relationships--the most significant factor suggestive of a good result. Arthrodesis of the affected joints is advocated for severe intra-articular injury and has been proposed for purely ligamentous injuries, although this is controversial in an athlete as a primary repair technique.

Assessment of Kinematic Asymmetry for Reduction of Hamstring Injury Risk

Context:Kinematic asymmetry is believed to be associated with elevated risk for muscle injury, but little is known about the links between hamstring injuries and asymmetry of sprinting mechanics.Objective:To evaluate the value of kinematic analysis of sprinting for the detection of injury-related asymmetry in athletes with a history of hamstring strain.Participants:Six sub-elite male sprinters, including two who sustained a hamstring strain injury.Outcome Measures:Absolute differences between left and right symmetry indices and symmetry angles were both calculated for ground contact time and selected angular displacements. Measurements were acquired at foot strike, during the stance phase, and at toe-off.Results:At toe-off, injured athletes exhibited greater knee flexion and less hip extension for the injured extremity compared to the uninjured extremity. Symmetry indices for these variables markedly exceeded an established 15% threshold for clinically relevant asymmetry. Each of the uninjured athletes exhibited a high degree of symmetry for all parameters, with mean values for symmetry indices significantly lower than the 15% threshold (P &lt; 0.05).Conclusions:Kinematic analysis of sprinting asymmetry appears to be valuable for identification of elevated risk for hamstring injury.

Fluoroscopy-Assisted Stress Testing of the Thumb Metacarpophalangeal Joint to Assess the Ulnar Collateral Ligament

Diagnostic stress testing of ulnar collateral ligament (UCL) injuries of the thumb metacarpophalangeal (MCP) joint is pivotal to determining treatment. Comparison to the uninjured extremity and fluoroscopy-assisted examination are readily available modalities in the assessment of these patients, with 5-10° differences impacting treatment. Comparative examination, however, assumes that both extremities are normally equal, which has never been verified experimentally. Comparison of clinical and fluoroscopic examination has also never been scrutinized. One hundred asymptomatic participants underwent both fluoroscopic and traditional stress examinations to determine maximum passive radial deviation at neutral MCP flexion. Absolute clinical vs. fluoroscopic differences demonstrated a significant difference of 5.6° (SD 5.1°). Absolute variability between left-to-right measurements was 4.5° (SD 4.1°) and increased significantly as baseline stress deviation increased (R = 0.43; p < 0.001). Left-to-right difference exhibited no correlation to age, gender, or BMI. The current investigation demonstrates right-left differences and differences between clinical and fluoroscopic testing of which practitioners should be aware when making treatment decisions for UCL injury of the thumb MCP joint.

Plating of Acute Humeral Diaphyseal Fractures Through an Anterior Approach in Multiple Trauma Patients

We evaluated the clinical and long-term functional outcomes of humeral diaphyseal fractures treated with acute anterior plating in a trauma population. Single-center, retrospective cohort analysis with long-term prospective follow-up. Urban, Level I trauma center. Ninety-six patients with high-energy fractures of the humeral shaft were treated over a 10-year period. All patients were treated by a standard surgical protocol of open reduction through an anterior approach with small or large fragment fixation in the supine position. Mechanism of injury, time to union, complications, and range of motion during clinical follow-up were obtained. We also prospectively assessed long-term strength, range of motion, and perceptions of disability using the Disabilities of the Arm, Shoulder and Hand questionnaire. Mean time to surgery was 5 days (standard deviation, 11 days); 97.5% of patients achieved union in an average of 16.9 weeks (range, 6-56 weeks). Complications included two postoperative infections, two nonunions, and three implant failures. Long-term follow-up (n = 34) averaged 4.75 years (range, 1.4-10.8 years). On average, no significant differences between the injured and uninjured extremities were seen in range of motion at the shoulder and elbow with the exception of shoulder flexion. A modest loss of upper extremity strength in the injured arm was appreciated. The mean Disabilities of the Arm, Shoulder and Hand score was 25.9 (range, 0-79). A standard anterior surgical approach with small fragment fixation is a safe and effective treatment for humeral shaft fractures in multiple trauma patients. We show a high union rate and few complications, although a modest loss of function and some perceived disability exists in the long-term.

Outcomes of Modified 2-incision Technique With Use of Indomethicin in Treatment of Distal Biceps Tendon Rupture

Multiple surgical techniques for distal biceps tendon ruptures exist. Heterotopic ossification is an associated omplication of the 2-incision technique. The purpose of this study was to review the results of distal biceps tendon repairs via the modified 2-incision technique using indomethacin chemoprophylaxis. A retrospective review of 34 2-incision repairs of the distal biceps tendon was performed. All patients received 6 weeks of indomethacin treatment postoperatively to prophylax against heterotopic ossification. Outcome measures included disabilities of the arm, shoulder, and hand (DASH) scoring, incidence of heterotopic ossification, and forearm range of motion. Of the 34 elbows, 2 had minor complications that resolved within 6 weeks of presentation. The average DASH score at final follow-up was 3.8. No cases of heterotopic ossification, nerve palsies, reruptures, or radioulnar synostoses were observed. At final follow-up, no significant difference was noted in range of motion between the injured and uninjured extremity in all planes. The Morrey modification of the 2-incision technique can be safe and provide full functional recovery in patients with ruptured distal biceps tendons when performed in conjunction with indomethacin prophylaxis.

Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm (Fig. 1) is based on the expert opinion of WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part I algorithm emphasizes evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in interventional radiology, while a Part II algorithm (2011) will focus on operative techniques. Peripheral vascular injures defined as axillobrachial and branches in the upper extremity and femoropopliteal and branches in the lower extremity account for 40% to 75% of all vascular injuries treated in civilian trauma centers.1–4 With the exception of the axillary artery, the long tracks of named arteries and veins in the extremities make them particularly susceptible to either penetrating or blunt trauma. This fact coupled with the smaller diameter of many of these vessels (as compared with those in the thorax or abdomen) and the ability of the patient and others to control external hemorrhage with compression contribute to a low incidence of death in the field.

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients

BackgroundAlthough the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.ObjectiveTo compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients.MethodsA multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher’s exact tests, Mann–Whitney U-tests and adjusted analysis of variance (ANOVA).ResultsForty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17–86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up.ConclusionsOur findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

Clinical and functional outcomes and proprioception after a modified accelerated rehabilitation program following anterior cruciate ligament reconstruction with patellar tendon autograft

The aim of this study was to evaluate the clinical and functional outcomes and proprioceptive function in patients who received a modified accelerated rehabilitation program after anterior cruciate ligament (ACL) reconstruction with a patellar tendon (PT) graft. The study included 38 patients (33 men, 5 women; mean age 27.6 ± 6.4 years; range 18 to 45 years) who underwent ACL reconstruction with a PT graft and participated in a modified accelerated rehabilitation program. Only six patients were athletes. Isokinetic strengths of concentric knee extension and flexion were measured with the Cybex isokinetic dynamometer, and static balance was tested with the Sport-KAT device. For proprioceptive assessment, active repositioning was measured at knee flexions of 40°, 20°, and 5° with an isokinetic dynamometer. Activity levels and subjective functional results were evaluated with the Tegner activity scale and Lysholm knee score, respectively. For objective functional testing, single leg hop, triple leg hop, and one-legged crossover hop tests were used. Knee stability was assessed with the Lachman test and anterior drawer test and knee range of motion was measured. The mean follow-up period was 16.2 ± 9.8 months. There was no graft failure during the follow-up. Twenty patients (52.6%) had hypoesthesia at the donor site and 15 patients (39.5%) had anterior knee pain. Before surgery, all the patients had positive results in the Lachman and anterior drawer tests. After surgery, the Lachman test was negative in 32 patients (84.2%), while six patients (15.8%) had grade 1 laxity. The mean Lysholm knee score showed a significant increase postoperatively (p<0.001). The mean preoperative and postoperative Tegner activity scores were not significantly different (p>0.05). There were no significant differences in the range of motion between operated and uninjured extremities (p>0.05). The two extremities were similar in proprioception and balance (p>0.05). Isokinetic quadriceps muscle strength was significantly decreased in the operated extremity only in extension at 60°/sec angular velocity (p<0.05). Other muscle strength measurements were similar in both extremities. The ratios of flexion/extension muscle strength were significantly greater in the involved extremity at all angular velocities (p<0.05). The mean performance scores of three functional tests were more than 85% of the uninvolved extremity. All the patients returned to preinjury daily activities or sports activities in 6 to 12 months postoperatively. We had satisfactory clinical, proprioceptive, and functional results in achieving dynamic and static stability of the knee with the modified accelerated rehabilitation program after ACL reconstruction with a PT graft.

Microsurgical treatment of infected extremities after blood vessel prosthesis

Objective To report the clinical effects of microsurgery in treatment of infected extremities after blood vessel prosthesis were transplanted.Methods From Jan.1998 to Dec.2008,8 cases of major vascular injuries in extremities were blood-supplied by cross bridge vascular anastomosis from uninjured extremities,including 4 cases of femoral artery and vein,2 cases of popliteal artery and vein,and 2 cases of brachial artery and vein. Results After 3 years of follow-up,blood circulation of infected extremities were reestablished in each of 8 cases,as well as function and appearance recovered.Conclusion The procedure of cross bridge vascular anastomosis from uninjured extremities may efficiently restitute the blood supply of the infected extremities after blood vessel prosthesis were transplanted,and decrease the rate of amputation. Key words: Blood vessels; Injury; Blood vessel prosthesis; Microsurgical operation