Notes

Proof habitual conduct from non-alimentary tooth use on deciduous teeth from the Midsection and also Second Paleolithic Cantabrian area, Northern Spain.
Optimizing pain control following total knee arthroplasty is of utmost importance to the immediate post-operative course. Various anesthesia modalities are available, but studies comparing multiple anesthesia modalities, patient age, and sex are limited.

The purpose of our study was to examine the impact of patient age, gender, and perioperative anesthesia modality on postoperative pain following primary total knee arthroplasty.

443 patients who underwent primary total knee arthroplasty by 14 surgeons with some combination of general anesthesia, spinal anesthesia, femoral nerve block, and intrathecal morphine were identified. Anesthesia route and type, length of surgery, post-operative patient-reported pain measures using the Visual Analog Scale, opioid consumption, and length of hospital stay were recorded for each patient and used to compare differences among study groups.

No significant differences were noted between anesthesia groups with regards to postoperative pain or length of hospital stay. Pe Comparative study).
Asymmetric bilateral hip dislocations are a rare injury pattern in which one hip dislocates posteriorly, and the contralateral hip dislocates anteriorly. We report a case of bilateral asymmetric hip dislocations and provide a comprehensive review of all available reports, identifying 104 total cases, which is 70 more than previously reported.

To review and evaluate the total body of literature regarding bilateral asymmetric hip dislocations.

Comprehensive literature review and analysis of all reports of bilateral asymmetric hip dislocations with concurrent case report.

Bilateral, asymmetric represent approximately 0.01%-0.02% of all joint dislocations. There has been a substantial increase in the number of case reports in the literature in the last 10 years. Males are more likely than females to incur this injury pattern and the most common mode of injury is motor vehicle accident Urgent closed reduction should be attempted in an efficient and safe manner to avoid potential complications, and open redmerged. Common complications include nerve palsies, AVN and heterotopic ossification.
Lower extremity injuries secondary to low-energy gunshot wounds are frequently seen in the civilian populations of urban areas. Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative.

The purpose of this study is to present our outcomes in the treatment of low-energy gunshot wounds in a civilian population at an urban, level one trauma center in patients treated by a standard protocol.

One hundred and thirty three patients who sustained 148 gunshot wound injuries were treated at our level one trauma center between January 1(st), 2009 and October 1(st), 2011. Following IRB approval, we extracted information from medical records regarding hospital course, length of stay and type of operative or non-operative treatment. If available, injury and post-operative radiographs were also reviewed. Patients were contacted by telephone to obtain Short Muscued that patients continued to have difficulties with ADL's at long-term follow-up.
There are an estimated 150,000 hip fractures per year in the United States, with estimated costs of care between $10.3 billion and $15.2 billion. With such high costs and an increasing burden of care, there has been interest in newer methods to increase efficiency of care. One such method is expedited fracture care, with earlier operative intervention. The purpose of this study was to determine if intervention within six hours of admission decreased costs with no change in the rate of major complications.

A retrospective review of all patients age >65 undergoing operative intervention for a proximal femur fracture over a two year period were identified. Patients were divided into two groups those undergoing operative intervention < six hours after admission (early) and those undergoing operative intervention > six hours after admission. Patient age, average length of stay, and complication rates were determined for the two groups.

Our study identified 657 patients, 111 of which underwent early intervention with the remaining 546 undergoing late intervention. The average length of stay for the early intervention group was 4.11 days, compared to 5.68 days for die late intervention group (p=0.0005). There was a significant difference in average cost between the two groups. The average cost of the early intervention was $49,900, with the average cost of late intervention being $65,300 (p = 0.0086). There was no significant difference in incidence of major complications between the two groups.

Programs emphasizing early intervention for hip fractures have the potential for large healthcare savings, with an average savings of $15,400.

Level IV, therapeutic case series.
Level IV, therapeutic case series.
Many types of projectiles, including modern hollow point bullets, fragment into smaller pieces upon impact, particularly when striking bone. This study was performed to examine the effect on time to union with retained bullet material near a fracture site in cases of gunshot injury.

All gunshot injuries operatively treated with internal fixation at a Level 1 Trauma Center between March 2008 and August 2011 were retrospectively reviewed. Retained bullet load near the fracture site was calculated based on percentage of material retained compared to the cortical diameter of the involved bone. Analyses were performed to assess the effect of the lead-cortical ratio and amount of comminution on time to fracture union.

Thirty-two patients (34 fractures) met the inclusion criteria, with an equal number of comminuted (17) and non-comminuted fractures (17). Seventeen of 34 fractures (50%) united within 4 months, 16/34 (47%) developed a delayed union, and 1/34 (3%) developed a nonunion requiring revision surgery. Sixteen of 17 fractures (94%) that united by 4 months had a cumulative amount of bullet fragmentation retained near the fracture site of less than 20% of the cortical diameter. Nine out of 10 fractures (90%) with retained fragments near the fracture site was equal to or exceeding 20% of the cortical diameter had delayed or nonunion. Fracture comminution had no effect on time to union.

The quantity of retained bullet material near the fracture site was more predictive of the rate of fracture union than was comminution. IWP-4 beta-catenin inhibitor Fractures with bullet fragmentation equal to or exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union/nonunion compared to those fractures with less retained bullet material, which may indicate a local cytotoxic effect from lead on bone healing. These findings may influence decisions on timing of secondary surgeries.

Level III.
Level III.
High tibial osteotomy (HTO) is a well-established and commonly utilized technique in medial knee osteoarthritis secondary to varus malalignment. Accurate measurement of the preoperative limb alignment, and the amount of correction required are essential when planning limb realignment surgery. The hip-knee-ankle angle (HKA) measured on a full length weightbearing (FLWB) X-ray in the standing position is considered the gold standard, since it allows for reliable and accurate measurement of the mechanical axis of the whole lower extremity. In general practice, alignment is often evaluated on standard anteroposterior weightbearing (APWB) X-rays, as the angle between the femur and tibial anatomic axis (TFa). It is, therefore, of value to establish if measuring the anatomical axis from limited APWB is an effective measure of knee alignment especially in patients undergoing osteotomy about the knee.

Three independent observers measured preoperative and postoperative FTa with standard method (FTa1) and with circla2 compared to FTal. The femoro-tibial angle as measured on APWB with the traditional method (FTal) has a weak correlation with the HKA, and based on these findings, should not be used in everyday practice. The FTa2 showed better correlation with the HKA, although not excellent.

Level III, Retrospective study.
Level III, Retrospective study.
Dysplasia epiphysealis hemimelica (DEH), or Trevor's disease, is a developmental disorder of the pediatric skeleton characterized by asymmetric osteochondral overgrowth.

We present the case of a five year old boy with a two year history of right knee pain and evidence of DEH on imaging who underwent initial arthroscopic resection of his lesion with subsequent recurrence. The patient then underwent osteochondral allograft revision surgery and was asymptomatic at two year follow-up with a congruent joint surface.

To our knowledge, this is the first reported case of a DEH lesion treated with osteochondral allograft and also the youngest reported case of osteochondral allograft placement in the literature.

Osteochondral allograft may be a viable option in DEH and other deformities of the pediatric knee.

Level V.
Level V.
Patients with femoral trochlear dysplasia are at risk for chronic recurrent patellofemoral dislocations, with extreme cases often requiring a surgical procedure. Anteromedialization of the tibial tubercle with intraoperative femoral nerve stimulation and concurrent medial patella-femoral ligament (MPFL) reconstruction is a previously reported method of maximizing patello-femoral congruency. We hypothesize the Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction in patients with severe trochlear dysplasia provides equivalent postoperative clinical outcomes to the same procedure in patients with low level trochlear dysplasia.

48 knees underwent Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction for recurrent lateral patellar dislocations. MRI, surgeon intraoperative assessment, and X-ray were used to assess degrees of trochlear dysplasia; inter-observer and intra-observer error were measured. The knees positiveferences in estimates of patellofemoral congruency between the SD (2/11) and LD (8/37) (P>0.999) groups.

The Fulkerson osteotomy with femoral nerve stimulation aimed at maximizing patellofemoral congruency may be an equally effective procedure for patients with either severe or mild trochlear dysplasia.

Level III, Retrospective comparative study.
Level III, Retrospective comparative study.Medial patella subluxation is a disabling condition typically associated with previous patellofemoral instability surgery. Patients often describe achy pain with painful popping episodes. They often report that the patella shifts laterally, which occurs as the medial subluxed patella dramatically shifts into the trochlear groove during early knee flexion. Physical examination is diagnostic with a positive medial subluxation test. Nonoperative treatment, such as focused physical therapy and patellofemoral stabilizing brace, is often unsuccessful. Primary surgical options include lateral retinacular repair/imbrication or lateral reconstruction. Prevention is key to avoid medial patella subluxation. When considering patellofemoral surgery, important factors include appropriate lateral release indications, consideration of lateral retinacular lengthening vs release, correct MPFL graft placement and tension, and avoiding excessive medialization during tubercle transfer. This review article will analyze patient symptoms, diagnostic exam findings and appropriate treatment options, as well as pearls to avoid this painful clinical entity.
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