Since its introduction in the late 20th century, the 2-stage induced membrane technique has been lauded for its bone-reconstruction advantages over alternatives such as distraction osteogenesis and vascularized bone. The cases presented in this month’s “Case Connections” demonstrate that the technique can work with a variety of bone-defect shapes, sizes, and locations.
The springboard case, from the August 10, 2016 edition of JBJS Case Connector, describes 3 cases of chronic post-infection osteomyelitis in children in whom large diaphyseal defects were successfully treated with the induced membrane technique. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 50-year-old diabetic man with a necrotic foot ulcer in whom an extensive midfoot defect was successfully treated with this technique
- successful induced-membrane treatment of a 7-year-old girl with congenital pseudarthrosis of the clavicle
- 2 cases of trauma-caused segmental bone loss that were treated successfully with the induced membrane technique
It is imperative to resolve all active infection before or during stage 1 of this procedure, and careful spacer removal prior to stage 2 is of paramount importance to prevent damage to the induced membrane.
The ability of the small and complexly connected wrist bones to function properly supports everything from activities of daily living and work to the creation of art and music. This month’s “Case Connections” article explores wrist dislocations that required open reduction and some form of fixation. Considering the high degree of anatomical derangement and instability in these cases, the outcomes were remarkably good, thanks to carefully planned and executed orthopaedic interventions.
The springboard case, from the July 27, 2016 edition of JBJS Case Connector, describes the treatment of a 47-year-old male bicyclist who was hit by a car and sustained complete scaphoid and lunate dislocations. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 22-year-old man who sustained volar dislocation of the hamate and scapholunate dissociation as a result of a motor-vehicle accident
- a 30-year-old man who experienced volar dislocation of the lunate as well as of the proximal pole of a fractured scaphoid after falling from a height of 15 feet with his outstretched hand and wrist in extension
- a 25-year-old man who fell from a height of 20 feet and dislocated the hand and wrist dorsally about the scaphoid and lunate.
Anatomical reduction frequently required both dorsal and volar exposures. In one case, a successful outcome was achieved without addressing ligamentous injuries.
Despite the relative rarity of necrotizing fasciitis (NF), orthopaedists can expect to see at least 1 case of NF in their career. This month’s “Case Connections” springboards from a recent case report about necrotizing fasciitis in which the infectious source was highly unusual, followed by three additional case reports related to NF from the JBJS Case Connector archives
- In the June 8, 2016, edition ofJBJS Case Connector, Connor et al. reported on the case of a 70-year-old man who developed necrotizing fasciitis of the thigh and calf through a colon perforation caused by sigmoid diverticulitis.
- Zani and Babigian described a case of NF in the shoulder of a 53-year-old woman following acromioplasty and open rotator cuff repair.
- The bacteriumAeromonas hydrophila caused NF in a 58-year-old non-immunocompromised man, as described in a case report by Borger van der Burg et al.
- Cheng et al. described 3 fatal cases of necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus(MRSA).
Time and teamwork are of the essence in the management of necrotizing fasciitis. To hasten diagnosis, clinicians are advised to submit blood and tissue samples for pathological analysis as soon as possible. A multidisciplinary team that includes an infectious-disease specialist should be assembled in cases of suspected NF.
The indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. The May 2016 “Case Connections” article springboards from a May 25, 2016 JBJS Case Connector report about an isolated avulsion of the teres minor tendon that was repaired arthroscopically. That unique case is linked to three others from the JBJS Case Connector archive:
- Arthroscopic treatment of a knee flexion contracture
- Arthroscopic reduction/fixation of an acetabular rim fracture
- Arthroscopically assisted medial femoral condyle reduction
As impressive as these minimally invasive solutions are, orthopaedists should always keep in mind that arthroscopy, like any other surgical procedure, is not without its potential complications (see related “Case Connections” article).
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We posted our first “Case Connections” article about bisphosphonate-related atypical femoral fractures (AFFs) one year ago. Since then, JBJS Case Connector has published three additional case reports on the same topic, suggesting that it’s time for a revisit. These three recent cases demonstrate that AFFs can occur despite prophylactic intramedullary (IM) nailing of an at-risk femur, that AFFs can present as periprosthetic fractures, and that men taking bisphosphonates—not just women—can experience AFFs.
Marc Swiontkowski, MD, Editor-in-Chief of The Journal of Bone & Joint Surgery (JBJS) and Co-Editor of JBJS Case Connector, has announced that, effective January 1, 2016, Ronald W. Lindsey, MD, will join Tom Bauer, MD as Co-Editor of Case Connector. Dr. Swiontkowski will step down from his role as Case Connector Co-Editor but will remain as Editor-in Chief of JBJS. “I am confident that Ron and Tom will help move Case Connector into position as a foremost resource for clinicians seeking guidance and information on rare and unusual conditions from across the globe,” said Dr. Swiontkowski.
Dr. Lindsey is a Professor of Orthopaedic Surgery & Rehabilitation and Chair of the Department of Orthopaedic Surgery & Rehabilitation at the University of Texas Medical Branch, as well as a former Associate Editor for JBJS. After receiving his medical degree from Columbia University College of Physicians and Surgeons and completing an orthopaedic residency at Yale-New Haven Hospital, Dr. Lindsey pursued several fellowships at prestigious European orthopaedic institutions, including AO and spine fellowships at the University of Basel, and a spine fellowship at the University of Marseilles.
“I look forward to working with Dr. Bauer and the JBJS Case Connector editorial board to continue building a premier online database of peer-reviewed orthopaedic cases and the technology that enables orthopaedists to efficiently filter case information,” said Dr. Lindsey. “Our goal will always be to assist orthopaedic surgeons in the search for clinical precedents, connections, and trends in their efforts to improve patient care.”
Ceramic hip components are often chosen for younger patients to minimize long-term wear. Ceramic femoral head fractures arise mainly from trauma; non-compatible, damaged, or contaminated femoral head/stem taper connections; or material or manufacturing defects.
Because ceramic head fractures are more likely to occur from insults during or after implantation than from manufacturing defects, the Watch includes four “golden rules” surgeons can follow to reduce the risk of these events, including making sure that the tapers on both the head and stem are compatible in all dimensions. The Watch also emphasizes the importance of patient education, during which patients should be encouraged to promptly report any and all postsurgical irregularities.
The November 25, 2015 “Case Connections” looks at four JBJS Case Connector cases involving injuries to the cervical spine in which the outcomes were about as good as anyone could have wished, considering the potential for disaster. Two of the cases required surgical intervention to achieve the positive outcomes, but the outcomes in the other two cases were remarkably positive without surgery.
While these four cases of cervical spine injury had relatively “happy endings,” orthopaedic surgeons and other health-care professionals treating patients with any suspected spine injury are trained to proceed with the utmost care and caution out of concern for devastating neurological sequelae. Watchful waiting under close medical scrutiny is sometimes warranted, but many cases of cervical fracture, dislocation, or instability call for operative stabilization to reduce the risk of life-changing or life-threatening consequences. The potential seriousness of surgical complications when operating on the spine must also be recognized.