November 9, 2011
By: Bellapianta J, Swartz F, Lisella J, Czajka J, Neff R, Uhl R.
Randomized prospective evaluation of injection techniques for the treatment of lateral epicondylitis
Lateral epicondylitis is a commonly made diagnosis for general practitioners and orthopedic surgeons. Corticosteroid injection is a mainstay of early treatment. However, conflicting evidence exists to support the use of steroid injection, and no evidence in the literature supports an injection technique. Nineteen patients diagnosed with acute lateral epicondylitis were evaluated to compare the peppered- and single-injection techniques using the Disabilities of the Arm, Shoulder and Hand (DASH) score, visual analog score (VAS), and grip strength. For elbows with a single injection, mean grip strength increased from 22.9 to 27.8 (P=.053), mean VAS pain score decreased from 4.8 to 3.6 (P=.604), and mean DASH score decreased from 2.6 to 1.8 points (P=.026). For elbows with peppered injections, mean grip strength increased from 28.7 to 32.8 (P=.336), mean VAS pain scores decreased from 3.7 to 2.3 (P=.386), and mean DASH score decreased from 2.6 to 1.3 (P=.008).No studies have directly compared the peppered-injection technique to the single-injection technique. Our results suggest that patient outcome is improved with the single injection. The biomechanical or chemical reason for the distinction is yet unknown, but we postulate that the peppered technique may actually further damage the already compromised tendon. The theory that the peppered injection stimulates blood flow may be overestimated or false. Histochemical studies of the pathologic tissue must be performed to further delineate the reason for improved outcomes with the single-injection technique.
July 11, 2011
By: Bellapianta JM, Andrews JR, Ostrander RV
Bilateral os subtibiale and talocalcaneal coalitions in a college soccer player: a case report
An os subtibiale is an accessory bone separated from the distal medial tibia proper. Subtalar tarsal coalition is a failure of joint formation between the talus and calcaneus during hindfoot maturation. The patient in this case report has large bilateral os subtibiale and subtalar coalitions, which were undiagnosed throughout his soccer career until recently when he began having anteriorlateral ankle pain. After failing conservative treatment the patient underwent ankle arthroscopy, which revealed a fully separated, large articular portion of the medial malleolus. The hypertrophic synovium and cartilage were debrided and the patient had a full recovery, returning to soccer 8 weeks after surgery. Os subtibiale is a rare but well-described entity in the radiology and orthopaedic liturature. To our knowledge, bilateral os subtibiale this large has not been described. In addition, an os subtibiale with concomitant subtalar coalition has never been reported. This report will hopefully alert clinicians about these 2 rare anatomic findings and encourage them to use caution when evaluating suspected fractures of the medial malleolus that could be functional os subtibiale ossicles. In addition, we hope to shed some light on the complicated coupling of motion between the ankle and subtalar joint. These may have developed together to allow more normal coupled motion between the ankle and subtalar joint in this high-level college soccer player, and may be relevant to future reports or research in this area.
August 20, 2011
By: Lisella JM, Bellapianta JM, Manoli A.
Tarsal coalition resection with pes planovalgus hindfoot reconstruction
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.
November 9, 2011
By: Bellapianta J, Dow K, Pallotta NA, Hospodar PP, Uhl RL, Ledet EH.
Threaded screw head inserts improve locking plate biomechanical properties
The purpose of this study was to determine if the stiffness and fatigue life of locking one third tubular plates are enhanced by placing a locking screw head to fill the empty hole of the plate. We hypothesize that both the stiffness and fatigue life of the plates will be improved at physiologically relevant loads by filling the empty center hole of each plate.
The mechanical stiffness and fatigue life of plates with an open versus filled center hole were assessed through finite element analysis and experimentally using a synthetic bone model under four-point bending. Two plate manufacturers were evaluated, Synthes (n) and Stryker (r). Five-hole one third tubular plates were mechanically cycled with and without filling the central screw hole while load, displacement, and number of cycles were collected. Stiffness was calculated and cycles to failure and mode of failure were monitored. Five plates were evaluated for the filled (F) and open (O) configurations for the n and r plates.
Finite element analysis indicated that filling the hole resulted in reduction in maximum stress at the periphery of the center hole by a factor of 2.43 and 2.29 for the n and r plates, respectively. Experimentally, a fourfold improvement was observed in fatigue life of the Synthes plates when a screw head was used to fill the central screw hole (P < 0.005; nF = 45,450 cycles versus nO = 10,305 cycles). The Stryker plates reached the maximum number of cycles (1 million) without fatigue failure in both O and F configurations. Improved bending stiffness was noted for both the n and r plates when the central hole was filled compared with open. For the Stryker plate, this increase was statistically significant (P < 0.011).
The methodology proposed in this study for extending fatigue life and increasing stiffness of locking plates can potentially be extended to any locking plate. Adding a screw head or screw heads to open holes in locking plates adds little additional time or expense and no morbidity to the procedure but can have substantial effects on the mechanical properties of the implant, particularly in lower-profile plates that are initially less rigid and robust.
March 17, 2009
By: Bellapianta JM, Ljungquist K, Tobin E, Uhl R.
Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft-tissue infection. The single most important variable influencing mortality is time to surgical débridement. Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.
May 21, 2007
By: Bellapianta J, Gerdeman A, Sharan A, Lozman J.
Use of the reamer irrigator aspirator for the treatment of a 20-year recurrent osteomyelitis of a healed femur fracture
NIn the following case, a 20-year-old male was involved in a motorcycle accident where he sustained an open midshaft femur fracture treated with open reduction and internal fixation. Several weeks later, the wound became infected and the plate was removed. Over the following 20 years numerous incision and debridements were performed, with multiple courses of antibiotics for persisting infection. One year following reaming with the reamer-irrigator-aspirator (RIA), the patient is symptom free. It is our belief that organisms were sequestered in the fibrous and bony tissue at the healed fracture site, and, by opening the canal and allowing it to revascularize, the infection was cleared.