RESUMEN
Obesity, one of the most common health problems in the United States, is becoming more prevalent. At the same time, because of technological advances, the rate of spine surgeries is on the rise. Given these trends in obesity and spine surgeries, it can be inferred that the number of obese patients who undergo spine surgeries will increase as well. When spine surgeries are planned for obese patients, several factors must be considered. Obesity is closely correlated with additional medical comorbidities including hypertension, coronary artery disease, and diabetes mellitus. Preoperative evaluation may be more difficult, as more extensive medical testing may be needed. Adequate radiographic images can be difficult to obtain because of patient size and equipment limitations. Administering anesthesia becomes more difficult, as does proper patient positioning. After surgery, obese patients are at higher risk for wound infection and deep vein thrombosis. Nevertheless, appropriate clinical outcomes can be achieved in obese patients who undergo spine surgery. Obesity is not a contraindication for spine surgery. Patient selection is key in achieving favorable clinical outcomes.
Asunto(s)
Obesidad/diagnóstico , Obesidad/epidemiología , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/métodos , Enfermedades de la Columna Vertebral/epidemiología , Índice de Masa Corporal , Comorbilidad , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Incidencia , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Medición de Riesgo , Enfermedades de la Columna Vertebral/diagnóstico , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/epidemiología , Resultado del Tratamiento , Estados Unidos , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/epidemiologíaRESUMEN
The ilium and the fibula are the most common sites for bone-graft harvesting. The different methods for harvesting iliac bone graft include curettage, trapdoor or splitting techniques for cancellous bone, and the subcrestal-window technique for bicortical graft. A tricortical graft from the anterior ilium should be taken at least 3 cm posterior to the anterior superior iliac spine (ASIS). Iliac donor-site complications include pain, neurovascular injury, avulsion fractures of the ASIS, hematoma, infection, herniation of abdominal contents, gait disturbance, cosmetic deformity, violation of the sacroiliac joint, and ureteral injury. The neurovascular structures at risk for injury during iliac bone-graft harvesting include the lateral femoral cutaneous, iliohypogastric, and ilioinguinal nerves anteriorly and the superior cluneal nerves and superior gluteal neurovascular bundle posteriorly. Violation of the sacroiliac joint can be avoided by limiting the harvested area to 4 cm from the posterior superior iliac spine (PSIS) and by not penetrating the inner cortex. The caudal limit for bone harvesting should be the inferior margin of the roughened area anterior to the PSIS on the outer table to keep from injuring the superior gluteal artery. Potential complications of fibular graft harvesting include neurovascular injury, compartment syndrome, extensor hallucis longus weakness, and ankle instability. The neurovascular structures at risk for injury during fibular bone-graft harvesting include the peroneal nerves and their muscular branches in the proximal third of the fibular shaft and the peroneal vessels in the middle third.
Asunto(s)
Trasplante Óseo , Peroné , Ilion , Recolección de Tejidos y Órganos , Peroné/anatomía & histología , Humanos , Ilion/anatomía & histología , Articulación SacroiliacaRESUMEN
The intramedullary fibular graft was used in four patients for tibiotalocalcaneal fusion. There were three men and one woman. The average age was 49.7 years (range, 35-73 years). The initial injuries were three pilon fractures and one ankle fracture. Tibiotalocalneal arthrodesis was performed as a salvage procedure for patients with significant posttraumatic arthritis of the ankle, concomitant subtalar arthritis, and severe osteopenia. The average followup was 28 months (range, 24-31 months). All the patients had successful arthrodesis and were satisfied with the outcome results. The average preoperative American Orthopaedic Foot And Ankle Society ankle-hindfoot score for the whole group was 49.5 (range, 44-54) and improved postoperatively to 78.5 (range, 71-81). Three patients had a good score and one patient had a fair score. There was no postoperative infection or fracture of the graft.
Asunto(s)
Traumatismos del Tobillo/cirugía , Artrodesis , Peroné/trasplante , Fijación Intramedular de Fracturas/métodos , Adulto , Anciano , Calcáneo/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Astrágalo/cirugía , Tibia/cirugíaRESUMEN
This retrospective study evaluated the diagnostic value of computed tomography in patients with sacroiliac pain. Computed tomography scans of the sacroiliac joints of 62 patients with sacroiliac joint pain were reviewed. The criteria to include the patient in the current study were pain relief after a local injection in the sacroiliac joint under computed tomography guidance, a physical examination consistent with a sacroiliac origin of the pain, and negative magnetic resonance imaging of the lumbar spine. A control group consisted of 50 patients of matched age who had computed tomography scans of the pelvis for a reason other than pelvic or back pain. Computed tomography scans showed one or more findings in 57.5% and 31% of the sacroiliac joints in the symptomatic and the control groups, respectively. The computed tomography scans were negative in 37 (42.5%) symptomatic sacroiliac joints with a positive sacroiliac joint injection test. The sensitivity of computed tomography was 57.5 % and its specificity was 69%. The finding of the current study suggests limited diagnostic value of computed tomography in sacroiliac joint disease because of its low sensitivity and specificity. With clinical suspicion of a sacroiliac origin of pain, intraarticular injection is currently the only means to confirm that diagnosis.
Asunto(s)
Artralgia/diagnóstico por imagen , Articulación Sacroiliaca/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anestésicos Locales/administración & dosificación , Anestésicos Locales/uso terapéutico , Anquilosis/diagnóstico por imagen , Antiinflamatorios/administración & dosificación , Antiinflamatorios/uso terapéutico , Artralgia/tratamiento farmacológico , Betametasona/administración & dosificación , Betametasona/uso terapéutico , Quistes Óseos/diagnóstico por imagen , Estudios de Casos y Controles , Femenino , Glucocorticoides/administración & dosificación , Glucocorticoides/uso terapéutico , Humanos , Inyecciones Intraarticulares , Lidocaína/administración & dosificación , Lidocaína/uso terapéutico , Vértebras Lumbares/patología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Osteosclerosis/diagnóstico por imagen , Examen Físico , Radiografía Intervencional , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
Thirty upper limbs from skeletally mature embalmed cadavers were studied to determine the anatomic reliability of the posterior interosseous nerve as a donor nerve graft. The posterior interosseous nerve branches 0.43 +/- 0.52 cm from the distal edge of the superficial head of the supinator and 8 +/- 1.6 cm from the lateral epicondyle form a common leash. There are 6 branches, which are arranged from the ulnar to the radial side at their origin from this leash. The first and second branches supply the extensor digitorum communis, the third branch supplies the extensor carpi ulnaris, the fourth branch supplies the extensor digiti minimi, and the fifth branch arises from the undersurface of the common leash and divides into 2 sub-branches (medial and lateral) 10.1 +/- 3.2 cm distal to the lateral epicondyle and 12.8 +/- 2.2 cm proximal to Lister's tubercle. These 2 sub-branches make an inverted V shape around the extensor pollicis longus. The medial branch supplies the extensor pollicis longus and extensor indicis proprius. The lateral branch supplies the extensor pollicis longus and extensor pollicis brevis and ends at the wrist capsule. At a mean distance of 8.1 +/- 1.2 cm proximal to Lister's tubercle the lateral sub-branch gives off its last muscular branch to the extensor pollicis longus and becomes a pure sensory terminus. As the terminal part of the lateral sub-branch approaches the wrist capsule it expands at a mean distance of 1.9 +/- 0.5 cm proximal to Lister's tubercle. The sixth branch arises from the radial side of the common leash and divides into 3 sub-branches. The first sub-branch supplies the abductor pollicis longus and extensor pollicis brevis, the second supplies the abductor pollicis longus, and the third supplies the superficial head of the supinator. This study showed that the mean length obtainable for harvesting the lateral sub-branch of the fifth branch of the posterior interosseous nerve is 6.2 +/- 0.7 cm, which represents the length of the nerve between the last muscular branch to the extensor pollicis longus to the point at which the nerve expands.
Asunto(s)
Antebrazo/inervación , Transferencia de Nervios , Nervios Periféricos/anatomía & histología , Muñeca/inervación , Adulto , Femenino , Humanos , Masculino , Nervios Periféricos/trasplante , Valores de ReferenciaRESUMEN
STUDY DESIGN: A retrospective study of 24 sacroiliac joint computed tomographic (CT) scans of patients with persistent donor site pain. OBJECTIVE: To illustrate the computed tomographic findings of sacroiliac joints in patients who underwent posterior iliac bone graft harvesting with subsequent persistent donor site pain. SUMMARY OF BACKGROUND DATA: In a previous study the posterior iliac bone harvesting site was divided into three zones. Zone 1 carried no risk of violation of the synovial part of the sacroiliac joint. In Zones 2 and 3 there was a potential risk of violation to the synovial part of the sacroiliac joint. There is no study in the literature on the effect of violating the different parts of the sacroiliac joint during posterior iliac bone graft harvesting. METHODS: Computed tomographic scans of the sacroiliac joints of 22 patients with persistent pain in 24 sacroiliac joints after posterior iliac bone graft harvesting were retrospectively reviewed. RESULTS: Of the 16 sacroiliac joints with evidence of disruption of the inner table at the ligamentous part, 10 showed mild degenerative changes, and 6 showed moderate changes. Three joints with evidence of disruption of the inner table at the synovial part showed severe degenerative changes. Five joints with no evidence of inner table disruption did not show degenerative changes. CONCLUSION: There is a high prevalence of inner table disruption in patients with persistent sacroiliac joint pain after posterior iliac bone graft harvesting. The computed tomographic scan showed that involvement of the synovial part caused more severe degenerative changes than involvement of the ligamentous part.
Asunto(s)
Artralgia/etiología , Artralgia/patología , Trasplante Óseo/efectos adversos , Ilion/patología , Ilion/cirugía , Complicaciones Posoperatorias , Articulación Sacroiliaca/lesiones , Articulación Sacroiliaca/patología , Adulto , Anciano , Anciano de 80 o más Años , Artralgia/fisiopatología , Enfermedad Crónica , Femenino , Humanos , Ilion/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Articulación Sacroiliaca/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
The charts and radiographs of 118 patients with 126 intraarticular fractures of the calcaneus were reviewed retrospectively. Eleven of 126 (8.7%) calcaneal fractures had injuries consisting of intraarticular calcaneal fracture, lateral subluxation or dislocation of the posterior facet, fracture extension into the calcaneocuboid joint, peroneal tendon subluxation, subluxation of the talus in the ankle mortise, and complete disruption of the anterior talofibular and calcaneal fibular ligaments or fracture of the lateral malleolus. There were six women and five men. The average age was 40 years (range, 17-65 years). The mechanism of injury was a motor vehicle accident in eight and a fall from a height in three. According to the classification of Sanders et al eight fractures were Type II, one was Type III, and two were Type IV. Followup at an average of 26 months (range, 14-38 months) showed that eight of 11 patients (72.7%) had either good or excellent results. When lateral subluxation of the posterior facet of the calcaneus is identified with a preoperative computed tomography scan, operative management is indicated, and the surgeon should search for associated injuries that should be addressed at the time of surgery.
Asunto(s)
Traumatismos del Tobillo/cirugía , Calcáneo/lesiones , Calcáneo/cirugía , Fracturas Óseas/cirugía , Luxaciones Articulares/cirugía , Adolescente , Adulto , Anciano , Traumatismos del Tobillo/diagnóstico por imagen , Calcáneo/diagnóstico por imagen , Femenino , Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico por imagen , Humanos , Luxaciones Articulares/complicaciones , Luxaciones Articulares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Radiografía , Estudios RetrospectivosRESUMEN
STUDY DESIGN: An anatomic study. OBJECTIVES: To evaluate the effect of displacement of the fractured posterior facet in tongue fracture of the calcaneus on the congruity of the subtalar joint. METHODS: Eleven feet were used in this study. Seven females and four males with age range from 59 to 78. The specimens were dissected from both the lateral and the medial aspects of the calcaneus to expose these surfaces. A primary fracture line was created first, then a secondary line was engineered to simulate tongue fracture. Displacement of the superio-lateral fragment was done with 5-mm increment. Radiography was performed and the graphs were scanned and studied on specific computer software to explore the effects of displacement on joint congruity. RESULTS: The anterior end of the fragment of the tongue fracture, when displaced, not only is depressed but also rotated in the sagittal plane in a downward or planterward direction. The articular surface of the posterior facet of the calcaneus and the inferior facet of the talus are maintained in congruence with each other despite the varying degree of displacement and rotation. CONCLUSION: Congruity of the subtalar joint in tongue fractures is maintained despite different degrees of displacement. This study explains why the non-surgical treatment outcome is comparable to that of the operative treatment in tongue fractures of calcaneus. It also explains why tongue fractures have a good outcome with closed reduction.
Asunto(s)
Calcáneo/lesiones , Fracturas Óseas/fisiopatología , Luxaciones Articulares/fisiopatología , Articulación Talocalcánea/fisiopatología , Anciano , Fenómenos Biomecánicos , Cadáver , Calcáneo/anatomía & histología , Femenino , Fracturas Óseas/diagnóstico por imagen , Humanos , Luxaciones Articulares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Radiografía , Rango del Movimiento Articular , Sensibilidad y Especificidad , Articulación Talocalcánea/patologíaRESUMEN
Thirty upper limbs from skeletally mature embalmed cadavers were studied to define the most common pattern of the terminal branches of the posterior interosseous nerve. At 0.43 +/- 0.52 cm from the distal edge of the superficial head of the supinator and 8 +/- 1.6 cm from the lateral epicondyle, the posterior interosseous nerve branches, forming a common leash. There were six branches, which were arranged from the ulnar to the radial side at their origin from the common leash. The first and second branches supplied the extensor digitorum communis, the third branch supplied the extensor carpi ulnaris, the fourth branch supplied the extensor digiti minimi, and the fifth branch arose from the undersurface of the common leash and divided into two branches (medial and lateral) at 10.1 +/- 3.2 cm distal to the lateral epicondyle and 12.8 +/- 2.2 cm proximal to Lister's tubercle. The medial branch supplied the extensor pollicis longus and extensor indicis proprius. The lateral branch supplied the extensor pollicis longus and extensor pollicis brevis and ended at the wrist capsule. The sixth branch arose from the radial side of the common leash and divided into three branches. The first branch supplied the abductor pollicis longus and extensor pollicis brevis. The second branch supplied the abductor pollicis longus. The third branch supplied the superficial head of the supinator. The authors of this study describe the most efficient way to identify the six branches and how to avoid the risk of damaging them during surgical exposure.
Asunto(s)
Antebrazo/inervación , Nervios Periféricos/anatomía & histología , Disección , Femenino , Humanos , MasculinoRESUMEN
An extensile posterior approach to the radius was studied on 20 forearm anatomic specimen upper limbs. The skin incision followed a line from the lateral epicondyle of the humerus to a point corresponding to the middle of the posterior aspect of the wrist. Dissection was done between the extensor digitorum communis and the extensor carpi radialis brevis. The posterior interosseous nerve was identified, and the muscle fibers of the superficial head of the supinator were divided from distal to proximal to the posterior interosseous nerve, which was dissected and carefully retracted laterally. The muscle fibers of the deep head of the supinator were divided to the bone. An incision was made along the superior and inferior margins of the abductor pollicis longus and extensor pollicis brevis. A nerve tape was placed around the two muscles, and they were retracted proximally and medially or distally and laterally, as necessary. To expose the distal third of the radius, the obliquely placed muscles, abductor pollicis longus, and extensor pollicis brevis were retracted proximally and medially. Dissection was done between the extensor carpi radialis brevis and extensor pollicis longus. Anatomic study of the posterior interosseous nerve branches was done to understand the vulnerability of such branches seen in this approach.
Asunto(s)
Antebrazo/cirugía , Radio (Anatomía)/cirugía , Antebrazo/anatomía & histología , Humanos , Músculo Esquelético/anatomía & histología , Músculo Esquelético/cirugía , Nervios Periféricos/anatomía & histología , Nervios Periféricos/cirugía , Radio (Anatomía)/anatomía & histología , Valores de ReferenciaRESUMEN
The charts and radiographs of 99 patients with 106 intraarticular fractures of the calcaneus were retrospectively reviewed. There were 75 men and 24 women. The average age was forty-two (range, 17 to 81). Fifty-seven of the fractures were left and 49 were right. The mechanism of injury was a fall from a height in 69 patients and motor vehicle accident in 30 patients. According to Sanders classification, seventy-one cases (67%) had type II fractures, 25 cases (23.6%) had type III, and ten cases (9.4%) had type IV. All the patients had operative management through a limited sinus tarsi approach with minimal fixation of the fracture with one or several pins. One of the pins was usually applied from the talus to the calcaneus through the fracture after reduction of the posterior facet. Nine cases (8.5%) developed postoperative infection, four cases (3.8%) had superficial wound infection, four cases (3.8%) had pin tract infection and one case (0.9%) had osteomylitis. Our follow-up at an average of 29 months (range, 12 to 84 months) showed that the American Orthopedic Foot and Ankle Society, Ankle-Hindfoot Score for the all group was 77.6 (range, 31-91). Forty-one fractures (38.8%) were graded excellent, 39 fractures (36.7%) good, 14 fractures (13.2%) fair, and 12 fractures (11.3%) were failures. Although radiological degenerative changes in the subtalar joint were seen in 41 cases (38.7%), only six cases (5.6%) required subsequent subtalar fusion. The authors conclude that the operative method used in the current study which followed the principle of minimal soft tissue damage and minimal internal fixation may be a good option for management of calcaneus fractures.
Asunto(s)
Calcáneo/lesiones , Fijación de Fractura/métodos , Fracturas Óseas/cirugía , Luxaciones Articulares/cirugía , Articulaciones Tarsianas/lesiones , Articulaciones Tarsianas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Clavos Ortopédicos/efectos adversos , Femenino , Estudios de Seguimiento , Fracturas Óseas/complicaciones , Humanos , Luxaciones Articulares/complicaciones , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
Fifty-eight patients with 60 talar fractures were retrospectively reviewed. There were 39 men and 19 women. The age average was 32 (range, 14-74). Eighty six percent of the patients had multiple injuries. The most common mechanism of injury was a motor vehicle accident. Twenty-seven (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body. Forty-eight fractures had operative treatment and 12 had non-operative management. The average follow-up period was 30 months (range, 24-65). Thirty-two fractures (53.3%) developed subtalar arthritis. Two patients had subsequent subtalar fusion. Fifteen fractures (25%) developed ankle arthritis. None of these patients required ankle fusion. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints. Ten fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse. Avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck. Three rating scores were used in this series to assess the outcome: the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Maryland Foot Score, and Hawkins Evaluation Criteria. The outcome was different with every rating system. However, the outcome with AOFAS Ankle-Hindfoot Score and Hawkins Evaluation Criteria were almost equivalent. Assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then the body fractures.
Asunto(s)
Fijación Interna de Fracturas/métodos , Fracturas Óseas/cirugía , Astrágalo/lesiones , Adolescente , Adulto , Anciano , Placas Óseas , Tornillos Óseos , Femenino , Fijación Interna de Fracturas/instrumentación , Curación de Fractura/fisiología , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Ohio , Pronóstico , Rango del Movimiento Articular , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Centros Traumatológicos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
A technique to aid the reconstruction of the ulna in case of comminuted Monteggia fracture-dislocation is presented. This involves reducing the proximal radioulnar joint and temporarily transfixing the radial head to the ulna by 1 or 2 Kirschner (K) wires to establish the ulnar length. Once ulnar length has been defined, reconstruction of the comminuted ulna fracture is simplified. The radioulnar K-wires are then removed and the radioulnohumeral joint is tested for stability. This technique has been used in 6 cases of type-1 Monteggia fracture-dislocation with no subsequent malunion of the ulnar fracture or redislocation' of the radial head. After an average of 13 months follow-up, all patients had nearly full range of motion of the elbow joint.
Asunto(s)
Fracturas Conminutas/cirugía , Fractura de Monteggia/cirugía , Procedimientos de Cirugía Plástica , Cúbito/cirugía , Adulto , Anciano , Hilos Ortopédicos , Fracturas Conminutas/diagnóstico por imagen , Humanos , Masculino , Fractura de Monteggia/diagnóstico por imagen , RadiografíaRESUMEN
This is a report of 10 consecutive patients who had subtalar arthroscopy for persistent pain in the subfibular area after open reduction and internal fixation for intra-articular calcaneal fractures. The average period between the injury and the subtalar arthroscopy was 14.3 months (range, 6-36 months). The average follow-up period after subtalar arthroscopy for the patients who did not require further treatment was 16.7 months (average, 11-35 months). All the patients except two had chondromalacia. Three had grade II, three had grade III, and two had grade IV. Five patients had intra-articular adhesion. Two patients had a loose body. The power shaver has been used for debridement of the damaged cartilage and excision of the adhesion. Eight patients (80%) had considerable pain relief and did not require further local injection or surgical management. The two patients who required subtalar fusion had grade IV chondromalacic lesions. Only four patients had improvement in the range of motion of the subtalar joint. The preoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score for the whole group was 69.9 points (range, 68-74 points), which was improved postoperatively to 77.2 points (range, 48-90 points). Subtalar arthroscopy for persistent pain after calcaneal fractures should be considered, especially if the radiological examination shows mild degenerative changes in the subtalar joint.
Asunto(s)
Artroscopía , Calcáneo/lesiones , Fracturas Óseas/complicaciones , Dolor/etiología , Articulación Talocalcánea , Adulto , Femenino , Humanos , Artropatías/diagnóstico , Artropatías/etiología , Artropatías/cirugía , Masculino , Persona de Mediana Edad , Dolor/cirugía , Estudios RetrospectivosRESUMEN
This is a report of the first 33 consecutive patients who had arthroscopic anterior cruciate ligament (ACL) reconstruction in the day unit of Sandwell District General Hospital. Bone-patellar tendon-bone autograft was used. This study assessed post-operative pain control, clinical results and patient satisfaction with day case surgery. The mean age was 29 years, (range 17-43). The mean period between injury and reconstruction was 29 months, (range 2-50). The mean follow-up period was 16 months (range 6-31). In 31 patients (94%), adequate post-operative pain control was achieved with oral non opioid analgesic. No patient required readmission for pain control, nausea, vomiting or urinary retention. At the last follow up, the mean Lysholm score was 93.9, (range 68-100). Thirty-one patients (94%) were satisfied with the day case surgery and believed that they did not require hospitalization after surgery.