Description

The Journal of Surgical Orthopaedic Advances, a quarterly medical Journal, is now published by Data Trace Publishing. The Journal serves as the premier forum for the exchange of information and the presentation of new techniques and procedures, as well as updates about the ongoing educational activities of interest to all practicing orthopaedists. The original manuscripts, editorials, feature reports and book reviews are easy to read and provide orthopaedic specialists with insight on the innovations, trends, and issues effecting the orthopaedic field. Illustrations and expert photography combined with manuscripts, case studies, and special emphasis papers result in 60+ pages of pertinent orthopaedic information.

Publications in this journal

• Dismounted complex blast injury.

  Authors: Romney C Andersen, Mark Fleming, Jonathan A Forsberg, Wade T Gordon, George P Nanos, Michael T Charlton, James R Ficke

  Journal of surgical orthopaedic advances. 21(1):2-7.

  The severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremityThe severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremity (usually involving the non-dominant side), in addition to open pelvic injuries, genitourinary, and abdominal trauma. Initial resuscitation and multidisciplinary surgical management appear to be the keys to survival. Definitive treatment follows general principals of open wound management and includes decontamination through aggressive and frequent debridement, hemorrhage control, viable tissue preservation, and appropriate timing of wound closure. These devastating injuries are associated with paradoxically favorable survival rates, but associated injuries and higher amputation levels lead to more difficult reconstructive challenges.

• Resuscitation and blood utilization guidelines for the multiply injured, multiple amputee.

  Authors: Keith A Alfieri, Eric A Elster, James Dunne

  Journal of surgical orthopaedic advances. 21(1):15-21.

  Given the current tempo of overseas contingency operations, military orthopaedic surgeons are increasingly performing their duties in an austere environment. At Level 1 trauma centers and combatGiven the current tempo of overseas contingency operations, military orthopaedic surgeons are increasingly performing their duties in an austere environment. At Level 1 trauma centers and combat support hospitals, resources tend to be more abundant than in less ``metropolitan'' locations. Combat casualty care has reinforced the idea of a multidisciplinary team approach to severely injured trauma patients. During mass casualty situations, as seen recently in Haiti and in the wake of Hurricane Katrina, all members of the trauma team may need to perform duties on the periphery of their comfort zone. Early involvement of orthopaedic surgeons in damage control surgery, as well as resuscitation, are critical to the survival of patients with high amputations, multiple amputations, open pelvic injuries, and mangled extremities common in high-energy penetrating and blast-induced trauma. This article introduces the concept of Damage Control Resuscitation to the orthopaedic surgeon, and also presents a treatment guideline for use as appropriate.

• Dismounted complex blast injuries: patterns of injuries and resource utilization associated with the multiple extremity amputee.

  Authors: Mark Fleming, Scott Waterman, James Dunne, Jean-Claude D'Alleyrand, Romney C Andersen

  Journal of surgical orthopaedic advances. 21(1):32-7.

  The objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat betweenThe objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat between 2007 and 2010 was conducted. Data analyzed included age, injury mechanism, amputated limbs, number and type of associated injuries, blood products utilized, intensive care unit length of stay (ILOS), hospital length of stay (HLOS) and the Injury Severity Score (ISS). Patients were stratified based on the number of amputations. Sixty-three patients comprised the multiple extremity amputation (MEA) group. Ninety-eight percent sustained injuries from an improvised explosive device (IED) and 96% were dismounted. The ISS, number of surgical encounters, blood products utilized and ILOS were all clinically significantly different than controls. Care of multiple extremity amputees involves the utilization of significant resources. This knowledge may better help surgeons and administrators allocate assets at hospitals, both military and civilian, who care for this complex and challenging patient population.

• Ligamentous knee injuries in amputees.

  Authors: Kelly Kilcoyne, Jonathan Dickens, William Kroski, Scott Waterman, Jeffrey Davila

  Journal of surgical orthopaedic advances. 21(1):44-9.

  Combat-related musculoskeletal injuries occur commonly during military conflicts, as in Iraq and Afghanistan, and are caused by high-energy blasts. Ligamentous knee injuries resulting from theseCombat-related musculoskeletal injuries occur commonly during military conflicts, as in Iraq and Afghanistan, and are caused by high-energy blasts. Ligamentous knee injuries resulting from these blasts are often associated with lower extremity fractures or traumatic, transtibial amputations. Ligamentous knee injuries in amputees are often difficult to diagnose for a variety of reasons, including massive soft tissue trauma and delayed ambulation. While the algorithm for treatment is similar in non-combat, multi-ligamentous knee injuries, the timing of surgical intervention, graft choices, and methods of fixation are more limited. Additionally, the presence of traumatic brain injury and associated extremity trauma make rehabilitation of these injuries much more complicated. Despite these challenges, the recognition and treatment of ligamentous knee injuries in amputees is critical to returning these patients to an active lifestyle.

• Prosthetic advances.

  Authors: Zach T Harvey, Benjamin K Potter, James Vandersea, Erik Wolf

  Journal of surgical orthopaedic advances. 21(1):58-64.

  Much of the current prosthetic technology is based on developments that have taken place during or directly following times of war. These developments have evolved and improved over the years, andMuch of the current prosthetic technology is based on developments that have taken place during or directly following times of war. These developments have evolved and improved over the years, and now there are many more available options to provide a comfortable, cosmetic, and highly functional prosthesis. Even so, problems with fit and function persist. Recent developments have addressed some of the limitations faced by some military amputees. On-board microprocessor-controlled joints are making prosthetic arms and legs more responsive to environmental barriers and easier to control by the user. Advances in surgical techniques will allow more intuitive control and secure attachment to the prosthesis. As surgical techniques progress and permeate into standard practice, more sophisticated powered prosthetic devices will become commonplace, helping to restore neuromuscular loss of function. Prognoses following amputation will certainly rise, factoring into the surgeon's decision to attempt to save a limb versus perform an amputation.

• Combat-Related Hemipelvectomy

  Authors: MAJ Jean-Claude G. D’Alleyrand, MD, CDR Mark Fleming, DO, LtCol Wade T. Gordon, COL Romney C. Andersen, MAJ Benjamin K. Potter

  Journal of surgical orthopaedic advances. 21(1-2):38.

  Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are theTraumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. Second-look debridements and delayed wound closure are mandatory. A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries.(Journal of Surgical Orthopaedic Advances 21(1):38–43, 2012)

• Dismounted Complex Blast Injury

  Authors: COL Romney C. Andersen, MD, CDR Mark Fleming, DO, COL Jonathan A. Forsberg, LtCol Wade T. Gordon, CDR George P. Nanos, III, LtCol Michael T. Charlton, COL James R. Ficke

  Journal of surgical orthopaedic advances. 21(1-21):2.

  The severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremityThe severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremity (usually involving the non-dominant side), in addition to open pelvic injuries, genitourinary, and abdominal trauma. Initial resuscitation and multidisciplinary surgical management appear to be the keys to survival. Definitive treatment follows general principals of open wound management and includes decontamination through aggressive and frequent debridement, hemorrhage control, viable tissue preservation, and appropriate timing of wound closure. These devastating injuries are associated with paradoxically favorable survival rates, but associated injuries and higher amputation levels lead to more difficult reconstructive challenges. (Journal of Surgical Orthopaedic Advances 21(1):2–7, 2012)

• Complex Dismounted IED Blast Injuries: The Initial Management of Bilateral Lower Extremity Amputations With and Without Pelvic and Perineal Involvement.

  Authors: Christiaan N Mamczak, Eric A Elster

  Journal of surgical orthopaedic advances. 21(1):8-14.

  The magnitude of recent combat blast injuries sustained by forces fighting in Afghanistan has escalated to new levels with more troops surviving higher-energy trauma. The most complex and challengingThe magnitude of recent combat blast injuries sustained by forces fighting in Afghanistan has escalated to new levels with more troops surviving higher-energy trauma. The most complex and challenging injury pattern is the emerging frequency of high-energy IED casualties presenting in extremis with traumatic bilateral lower extremity amputations with and without pelvic and perineal blast involvement. These patients require a coordinated effort of advanced trauma and surgical care from the point of injury through definitive management. Early survival is predicated upon a balance of life-saving damage control surgery and haemostatic resuscitation. Emergent operative intervention is critical with timely surgical hemostasis, adequate wound decontamination, revision amputations, and pelvic fracture stabilization. Efficient index surgical management is paramount to prevent further physiologic insult, and a team of orthopaedic and general surgeons operating concurrently may effectively achieve this. Despite the extent and complexity, these are survivable injuries but long-term followup is necessary.

• Damage control and austere environment external fixation: techniques for the civilian provider.

  Authors: Wade T Gordon, Steven Grijalva, Benjamin K Potter

  Journal of surgical orthopaedic advances. 21(1):22-31.

  Extremity injuries associated with natural disasters and combat are typically high-energy, often open injuries, and routinely represent only part of the scope of injury to a poly-traumatized patient.Extremity injuries associated with natural disasters and combat are typically high-energy, often open injuries, and routinely represent only part of the scope of injury to a poly-traumatized patient. The early management of these injuries is normally performed in austere environments, and relies heavily on the principles of damage control orthopaedics, with external fixation of associated long bone and peri-articular fractures. While the general principles of ATLS, wound management, and external fixation do not differ from that performed in the setting of civilian trauma, there are special considerations and alterations in standard practice that become necessary when providing this care in an austere environment. The purpose of this article is to review the principles and techniques of damage control orthopaedics and external fixation in the management of extremity trauma in the setting of combat- and natural disaster-related injuries.

• Combat-related hemipelvectomy.

  Authors: Jean-Claude G D'Alleyrand, Mark Fleming, Wade T Gordon, Romney C Andersen, Benjamin K Potter

  Journal of surgical orthopaedic advances. 21(1):38-43.

  Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are theTraumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. Second-look debridements and delayed wound closure are mandatory. A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries.

• Advanced rehabilitation techniques for the multi-limb amputee.

  Authors: Zach T Harvey, Gregory A Loomis, Sarah Mitsch, Ian C Murphy, Sarah C Griffin, Benjamin K Potter, Paul Pasquina

  Journal of surgical orthopaedic advances. 21(1):50-7.

  Advances in combat casualty care have contributed to unprecedented survival rates of battlefield injuries, challenging the field of rehabilitation to help injured service members achieve maximalAdvances in combat casualty care have contributed to unprecedented survival rates of battlefield injuries, challenging the field of rehabilitation to help injured service members achieve maximal functional recovery and independence. Nowhere is this better illustrated than in the care of the multiple-limb amputee. Specialized medical, surgical, and rehabilitative interventions are needed to optimize the care of this unique patient population. This article describes lessons learned at Walter Reed National Military Medical Center Bethesda in providing advanced therapy and prosthetics for combat casualties, but provides guidelines for all providers involved in the care of individuals with amputation.

• Lessons to be learned from our combat surgeons.

  Authors: L Andrew Koman

  Journal of surgical orthopaedic advances. 20(1):1.

• Can an ankle-foot orthosis change hearts and minds?

  Authors: Jeanne C Patzkowski, Ryan V Blanck, Johnny G Owens, Jason M Wilken, James A Blair, Joseph R Hsu

  Journal of surgical orthopaedic advances. 20(1):8-18.

  The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting theThe current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population.

• Burden of musculoskeletal disease and nonbattle nontraumatic injury in both war and disaster zones.

  Authors: Brian R Waterman, Andrew J Schoenfeld, Courtney A Holland, Gens P Goodman, Philip J Belmont

  Journal of surgical orthopaedic advances. 20(1):23-9.

  Disasters, both man-made and natural, are a known cause of morbidity and mortality among vulnerable populations. The initial phase of public health response typically addresses immediate traumaticDisasters, both man-made and natural, are a known cause of morbidity and mortality among vulnerable populations. The initial phase of public health response typically addresses immediate traumatic injury or death in the wake of a disaster. However, little is known about the magnitude and cost of subsequent nontraumatic injury and illness in disaster zones. Known as ``the hidden epidemic,'' the incidence and epidemiology of disease and nonbattle injuries among military service members in deployed settings has been more extensively investigated and may serve as a proxy for the evaluation of civilian populations following natural disaster. Further, prior reports from the military setting may serve to inform the broader population on the ultimate burden of nontraumatic injury and illness in recent disasters, particularly as they relate to musculoskeletal health.

• Does a longer delay in fixation of talus fractures cause osteonecrosis?

  Authors: Jaime L Bellamy, John J Keeling, Joseph Wenke, Joseph R Hsu

  Journal of surgical orthopaedic advances. 20(1):34-7.

  This retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and aThis retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis.

• In vivo intra-articular negative pressure wound therapy effect on cartilage in a goat model.

  Authors: Kenneth Bode, Charles Haggerty, J T Tokish, Warren Kadrmas

  Journal of surgical orthopaedic advances. 20(1):44-9.

  This prospective, randomized, blinded pilot study determined if a difference was present in the histology and apoptotic rate of articular cartilage after application of a negative pressure woundThis prospective, randomized, blinded pilot study determined if a difference was present in the histology and apoptotic rate of articular cartilage after application of a negative pressure wound therapy (NPWT) device to an uninjured joint surface compared to a control side using Capra hircus goats. The goats were euthanized at 3 or 7 days after surgery. The en bloc joint resection was divided into medial (direct sponge contact) and lateral compartments (no sponge contact; indirect NPWT). In the necropsied cartilage and menisci, there were no gross or histologic/morphometric differences identified by a blinded veterinary pathologist. The percentages of apoptotic and necrotic chondrocytes based on flow cytometry were not statistically different. This study demonstrated that there were no observable deleterious effects to uninjured cartilage from direct or indirect intra-articular NPWT placement. These data suggest that NPWT may be placed safely in an intra-articular position for up to 7 days. Further studies in humans are warranted.

• Data-driven disaster management requires data: implementation of a military orthopaedic trauma registry.

  Authors: Jessica D Cross, Joseph C Wenke, James R Ficke, Anthony E Johnson

  Journal of surgical orthopaedic advances. 20(1):56-61.

  The Military Orthopaedic Trauma Registry (MOTR) is a comprehensive joint service registry of military orthopaedic injuries. Conceived in 2006, MOTR is now operational for retrospective data entry andThe Military Orthopaedic Trauma Registry (MOTR) is a comprehensive joint service registry of military orthopaedic injuries. Conceived in 2006, MOTR is now operational for retrospective data entry and prospective data collection of extremity injuries sustained by U.S. service members serving in current Overseas Contingency Operations. Running in tandem with data from the United States Army Institute of Surgical Research's Joint Theater Trauma Registry (JTTR), MOTR augments the casualty data included in JTTR with additional orthopaedic specific data (i.e., the injury patterns, characteristics, treatment, and complications associated with extremity war injuries). Extremity war injuries are the major clinical burden of the current conflicts. However, the scope of the injuries in detail useful to the orthopaedic researcher has never been prospectively collected. MOTR is designed to fill that gap in extremity trauma research. As such, MOTR represents an evolutionary step in the refinement of data-driven disaster management.

• Do plans and execution agree in a humanitarian medical mission?

  Authors: David M Doman, James A Blair, Matthew A Napierala, Mickey S Cho

  Journal of surgical orthopaedic advances. 20(1):67-73.

  There is a significant need for orthopaedic care in developing countries. For the past 10 years, the United States Army has supported annual orthopaedic hand surgery humanitarian missions toThere is a significant need for orthopaedic care in developing countries. For the past 10 years, the United States Army has supported annual orthopaedic hand surgery humanitarian missions to Honduras. The goal of this article is to compare the premission planning to the realities of mission execution to provide a template for future missions. Premission planning began 1 year before the mission. Based on previous missions, supplies were brought for 50 surgical cases. The mission began with 1 preoperative clinic day followed by 8 operative days and 1 postoperative clinic day. Of the 99 prescreened patients, 65 were indicated for surgery. A total of 58 surgeries were performed using innovative methods to stretch available supplies. A multidisciplinary and multination concerted effort is required for a successful humanitarian medical mission. A premission plan is critical prior to arrival and a contingency plan must be in place for missing mission-critical items.

• Deep vein thrombosis and pulmonary embolism in patients undergoing total hip arthroplasty: the promise of new oral anticoagulants.

  Authors: James Muntz

  Journal of surgical orthopaedic advances. 20(4):215-9.

  Although effective agents exist for thromboprophylaxis to decrease risk of venous thromboembolism, particularly following major orthopaedic surgery, including total hip arthroplasty, these agents areAlthough effective agents exist for thromboprophylaxis to decrease risk of venous thromboembolism, particularly following major orthopaedic surgery, including total hip arthroplasty, these agents are underused, and thromboembolic events continue to occur in patients undergoing these surgical procedures. One reason for suboptimal treatment may be concern about bleeding; another may be dissatisfaction with currently available prophylactic agents. New oral anticoagulants appear to be equally efficacious and will provide easier administration and management. They hold promise for improving utilization of thromboprophylaxis and consequently for reducing the incidence of venous thromboembolism.

• Effects of supplemental oxygen and hyperbaric oxygen on tendon healing in a rat model.

  Authors: Ryan Sieg, E'Stephan J Garcia, Andrew J Schoenfeld, Todd Collins, Brett D Owens

  Journal of surgical orthopaedic advances. 20(4):225-9.

  Systemic supplemental oxygen therapy (SOT) and hyperbaric oxygen therapy (HBOT) have been shown to positively impact wound healing. The purpose of this study was to evaluate the effects of SOT andSystemic supplemental oxygen therapy (SOT) and hyperbaric oxygen therapy (HBOT) have been shown to positively impact wound healing. The purpose of this study was to evaluate the effects of SOT and HBOT on tendon healing in a rat tendon model. The right patellar tendon of 90 male Sprague-Dawley rats was completely sectioned. Animals were randomized to receive HBOT, SOT, or room air therapy. Animals were sacrificed at 3- and 6-weeks postoperatively. The ultimate tensile strength in axial extension was compared between groups. Statistical significance was calculated using the Student's t-test. The SOT group exhibited the highest tensile strength at both time-points, although HBOT was the only treatment that exhibited a statistically significant increase in tensile strength between time-periods (p = 0.006). There was no statistical difference in ultimate tensile strength when the three groups were compared at the 3- or 6-week time-points. Results presented here cannot support the premise that intermittent HBOT or SOT significantly increases the healing of tendon repairs.

• Surgical reconstruction of end-stage ankle arthritis and concomitant stage II posterior tibial tendon insufficient flat foot.

  Authors: Sarang Desai, Randolph Grierson, Arthur Manoli

  Journal of surgical orthopaedic advances. 20(4):236-40.

  End-stage degenerative joint disease of the ankle and concomitant ipsilateral Stage II posterior tibial tendon insufficient flat foot is a well known entity. Despite this, treatment options have notEnd-stage degenerative joint disease of the ankle and concomitant ipsilateral Stage II posterior tibial tendon insufficient flat foot is a well known entity. Despite this, treatment options have not been discussed in the orthopaedic literature. A case series consisting of five patients was conducted to determine the efficacy of our treatment proposal. Our surgical treatment included an ankle fusion and concomitant flat foot reconstruction with a medializing calcaneal osteotomy, lengthening calcaneal osteotomy, and flexor digitorum longus transfer. At the final followup visit all patients were content with the results of the procedure, and would have it performed again. Each patient had significant relief of ankle and foot pain, and believed they had improved quality of life and function. Complications included two ankle nonunions treated with revision bone grafting and internal fixation, painful hardware and iliac crest hematoma. We conclude that our method of treatment is a viable option for this complex problem. A long recovery period should be anticipated and patients should be counseled accordingly.

• Use of a free-functioning muscle transfer from a paralyzed lower extremity to restore upper extremity elbow flexion.

  Authors: Brian T Carlsen, Matthew C Wendt, Robert J Spinner, Allen T Bishop, Alexander Y Shin

  Journal of surgical orthopaedic advances. 20(4):247-51.

  This report documents the use of a free-functioning gracilis muscle transfer from a lower extremity paralyzed from a spinal cord injury to restore elbow flexion in the patient's upper extremity whichThis report documents the use of a free-functioning gracilis muscle transfer from a lower extremity paralyzed from a spinal cord injury to restore elbow flexion in the patient's upper extremity which was paralyzed from a brachial plexus injury. The transfer was performed nine months after injury and resulted in functional elbow flexion. Clinical examination and EMG analysis document function of the transferred muscle with grade 4 muscle strength. The resultant effect on the skeletal muscle is different after upper motor neuron injury versus lower motor neuron injury. The successful function of a free-functioning muscle transfer after a spinal cord injury in this case has important implications for patients with spinal cord injury.

• H-Wave® effects on blood flow and angiogenesis in longitudinal studies in rats.

  Authors: Thomas L Smith, Michael F Callahan, Kenneth Blum, Nicholas A Dinubile, Thomas J H Chen, Roger L Waite

  Journal of surgical orthopaedic advances. 20(4):255-9.

  Effects of repeated H-Wave® device stimulation (HWDS) on blood flow and angiogenesis in the rat hind limb were studied. The hypothesis tested was that HWDS acutely increases hind limb blood flow, andEffects of repeated H-Wave® device stimulation (HWDS) on blood flow and angiogenesis in the rat hind limb were studied. The hypothesis tested was that HWDS acutely increases hind limb blood flow, and that repeated HWDS would elicit angiogenesis. Animals were HWDS-conditioned (``Conditioned'') or sham-stimulated (``Sham'') (n = 5/group) daily for 3 weeks. The contralateral limb in both groups served as the control. Each animal was injected with bromodeoxyuridine (BrDU). After 3 weeks, rats were anesthetized and iliac artery blood flow was measured bilaterally before, during, and after acute HWDS. HWDS of the Conditioned limbs elicited a 247% increase in blood flow above resting conditions compared to a 200% increase in control legs. Sham animals did not demonstrate between-leg differences in flow. Hindlimb musculature staining for BrDU revealed angiogenesis in Conditioned versus Sham groups. Flow changes accompanying HWDS corroborated earlier microvascular findings demonstrating a significant striated muscle arteriolar dilation with HWDS.

• Tarsal coalition resection with pes planovalgus hindfoot reconstruction.

  Authors: Jordan M Lisella, Joseph M Bellapianta, Arthur Manoli

  Journal of surgical orthopaedic advances. 20(2):102-5.

  Tarsal coalitions often present in young adults as a painful pes planovalgus hindfoot deformity. Resection of moderate and even large coalitions has become accepted as an alternative to arthrodesis.Tarsal coalitions often present in young adults as a painful pes planovalgus hindfoot deformity. Resection of moderate and even large coalitions has become accepted as an alternative to arthrodesis. A review of the literature, however, suggests that coalitions with severe preoperative planovalgus malposition treated with resection are associated with continued disability and deformity. The authors believe that malposition contributes to persistent pain and disability after simple coalition resection. The hypothesis is that resection of the coalition with simultaneous hindfoot reconstruction can improve clinical and radiographic outcomes. Seven consecutively treated patients (eight feet) were retrospectively reviewed from the senior author's practice. Clinical exam, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and radiographic measurements were evaluated after talocalcaneal coalition resection with simultaneous hindfoot reconstruction. All patients were satisfied and would have the same procedure again. All patients were either active students or gainfully employed at last follow-up. Clinical and radiographic hindfoot alignment was corrected reliably. The average increase in medial longitudinal arch height was 8.7 mm. After 2 years the average AOFAS hindfoot score was 88. Most patients had only mildly progressive arthrosis. There were two postoperative complications that resolved (superficial wound breakdown and calf deep vein thrombosis). This hindfoot reconstruction with coalition resection increased motion, reliably corrected malalignment, and improved pain. The authors believe that coalition resection and concomitant hindfoot reconstruction is a better option than resection alone or hindfoot fusion in patients with talocalcaneal coalition and painful pes planovalgus hindfoot deformity. Triple arthrodesis should be reserved as a salvage procedure.

• Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty.

  Authors: Tyler Steven Watters, Richard C Mather, James A Browne, Keith R Berend, Adolph V Lombardi, Michael P Bolognesi

  Journal of surgical orthopaedic advances. 20(2):112-6.

  Recently, patient-specific approaches to total knee arthroplasty (TKA) have been introduced that utilize preoperative magnetic resonance imaging data to manufacture custom cutting jigs specific to aRecently, patient-specific approaches to total knee arthroplasty (TKA) have been introduced that utilize preoperative magnetic resonance imaging data to manufacture custom cutting jigs specific to a patient's bony anatomy. These approaches intend to provide the benefits of accurate implant alignment while overcoming some of the proposed disadvantages of current computer navigation systems. In this study, a cost and benefit assessment of implementing the patient-specific approach compared to conventional and computer-navigated TKA was conducted at a large academic medical center. Fixed and time-dependent operating room (OR) costs were determined and compared, as well as the cost for processing operative equipment and additional procedure-related expenditures. Overall, patient-specific TKA was not cost saving in this model on a per-case basis compared to conventional methods, although it was less costly overall to the institution compared to implementing intraoperative navigation. However, the patient-specific approach provides the institution with an additional 28 minutes of available OR time per intervention based on reduction in preparation and operative times compared to conventional methods and an additional 67 minutes compared to computer navigation based on this model. This time savings is likely to provide a greater economic impact to the health care system than implant-related cost savings.

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