Chronic osteomyelitis of the calcaneus: treatment with a vascularized muscle flap.
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Adult↗
Biomedical subjects
J A Goulet
Publications and source records attributed to J A Goulet.
Compartment syndrome complicating tibial tubercle avulsion.
Avulsion of the tibial tubercle is an uncommon physeal injury. Complications from this fracture are infrequent. Adolescent boys developed compartment syndrome after tibial tubercle avulsion. Injury to the soft tissue surrounding the tibial tubercle avulsion may be more extensive than is usually appreciated. The anatomy of the proximal tibia and the tibial tubercle with nearby branches of the anterior tibial recurrent artery suggest a predisposing factor for the development of compartment syndrome. Compartment syndrome should be added to the list of possible complications of tibial tubercle avulsion fractures.
Adolescent↗
Interlocking intramedullary nails. An improved method of screw placement combining image intensification and laser light.
Insertion of distal interlocking screws in femoral nails can be technically demanding and may entail substantial exposure. A method of insertion of femoral interlocking screws that uses a laser guiding system in addition to the standard image intensifier was used in an attempt to improve the accuracy of distal screw placement and to limit radiation exposure. Using this technique, 97% of the distal femoral drill holes attempted were successfully made with the first pass of a drill. Little or no resistance to the drill was met from contacting the femoral nail. Average fluoroscopy time was 0.4 minute. Laser-assisted screw placement requires relatively inexpensive modifications of existing equipment and is easy to master. Compared with the more commonly used freehand method, laser-assisted screw placement appears to offer a reduction in the amount of time and radiation exposure required to insert distal interlocking femoral screws.
Bone Nails↗
Deep-vein thrombosis after fracture of the pelvis: assessment with serial duplex-ultrasound screening.
Sixty patients who had had a major fracture of the pelvis and were in stable condition on the orthopaedic ward three to five days after the injury were tested serially with duplex ultrasound, beginning approximately seven days after the injury, in order to determine the incidence of deep-vein thrombosis. Contrast venography was performed to confirm all positive non-invasive studies. Deep-vein thrombosis developed in eight patients (approximately 15 per cent). The thrombosis was in the popliteal or a more proximal vein in six of the eight patients, whereas in two it was distal to the popliteal vein. In four patients, evidence of thrombosis developed after one or more normal duplex-ultrasound studies. In one patient, symptoms that were suggestive of deep-vein thrombosis developed fifty-two days after the injury (four days after the fourth normal duplex-ultrasound examination), and ascending venography was entirely normal. Another patient had a pulmonary embolus fifteen days after the injury, and on the same day a duplex-ultrasound study was positive for thrombosis. During six weeks of follow-up after discharge from the hospital, symptoms of deep-vein thrombosis or pulmonary embolism did not develop in any patient in whom serial duplex-ultrasound studies had been negative.
Acetabulum↗
Results of treatment of displaced patellar fractures by partial patellectomy.
The results of partial patellectomy as a treatment for displaced patellar fractures were assessed retrospectively with use of clinical, radiographic, and isokinetic strength-testing criteria. Forty patients who had been followed for an average of 8.4 years were studied. In the extremity that had been operated on, the mean active range of motion was 94 per cent, the circumference of the thigh was 100 per cent, and the strength of the quadriceps was 85 per cent of these measurements in the contralateral extremity. The over-all result was rated as excellent in twenty patients, good in eleven, fair in six, and poor in three. There was a significant statistical correlation between the type of fracture and the outcome. The results of this study indicate that partial patellectomy can be an effective treatment for selected patellar fractures.
Adult↗
Complex acetabular fractures.
Displaced acetabular fractures belonging to the associated fracture group described by Judet and Letournel present a formidable diagnostic and therapeutic challenge. Of 116 acetabular fractures, 31 had associated fracture types with follow-up evaluation of one year or longer. The patients' mean age was 30.7 years, their mean injury severity score was 15, and the average follow-up period was 21 months. Four patients had failed previous acetabular surgery. Operating time averaged 4.5 hours. Mean blood loss was 1150 cc. Clinical results were satisfactory in 77% of cases, with 11 excellent, 13 good, four fair, and three poor results. Complex acetabular fractures can be reduced by a combined anterior and posterior approach designed by the authors. This approach offers significant advantages for visualization and stabilization of these fractures. The combined approach is recommended for the surgeon who has mastered the single-approach techniques for standard, simple fracture patterns.
Acetabulum↗
Intraoperative autologous transfusion in orthopaedic patients.
The cases of 175 consecutive patients who had intraoperative autologous transfusion during revision total hip arthroplasty, an elective operation on the spine, repair of trauma to the spine, or open reduction of a fracture of the acetabulum were reviewed to evaluate the applicability of this technique in orthopaedic operations. A separate group of forty-one consecutive patients who had open reduction of a fracture of the acetabulum or the spine before the introduction of the autotransfuser was reviewed and compared with the group that had autotransfusion. An autologous blood predeposit program was used for twenty-five of fifty-two patients who had a procedure on the hip and for fifty-one of fifty-five patients who had an elective procedure on the spine. The mean rate of red blood-cell salvage using the autotransfuser was 60 per cent over-all. The mean transfusion requirements were significantly less (p less than 0.001) in all groups of patients in whom the autotransfuser was used. Use of the autotransfuser reduced the mean requirement for banked blood in patients who had a fracture of the acetabulum from 3.8 to 2.3 units per patient, and significantly reduced the mean need for banked blood in individuals who had trauma to the spine from 2.7 to 1.8 units per patient (p less than 0.01). The use of prebanked autologous blood further reduced the mean requirement for homologous blood from 2.4 to 0.8 unit per patient in those who had revision total hip arthroplasty (p less than 0.005), and from 3.6 to 0.4 unit per patient in those who had an elective procedure on the spine (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Transfusion↗
Prolonged suppression of infection in total hip arthroplasty.
Nineteen periprosthetic infections after total hip arthroplasty were treated with prolonged suppressive antibiotics without removing the components. In 11, antibiotic therapy was monitored with serum bactericidal titers. Eleven had incision and drainage. Indications included patients' refusal of removal or medical contraindications to surgery. Requirements included well-fixed components, highly sensitive organisms, and no systemic sepsis. The follow-up period averaged 4.1 years after treatment. Nine hips showed no deterioration. Seven prostheses failed, five with progressive hip sepsis. Three patients had increasing symptoms without prosthesis removal. Although two-stage reimplantation is preferred, suppressive antibiotics and prosthesis retention can succeed in some patients and may be considered in old, frail patients with an early infection caused by bacteria responsive to oral antibiotic therapy. Suppressive therapy may also be considered for an otherwise compliant patient who refuses removal of an infected prosthesis. The organism must be sensitive to oral antibiotics, and the patient must be tolerant of the antibiotics.
Aged↗
Giant enlarging osteochondral mass in the popliteal fossa. A case report.
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Adult↗
A critical analysis of mechanical factors correlated with bone remodeling following total elbow arthroplasty.
Thirty elbows were critically reviewed for quantitative evidence of bone remodeling, with demonstrable bone remodeling noted in more than one half of the ulnae and humerii. Bone remodeling was analyzed statistically with independent variables of age, sex, handedness, diagnosis, implant design considerations, and implant alignment. Only implant design and alignment had a statistically significant impact on bone remodeling. Periarticular (zone 1) bone loss was statistically significantly correlated with a high percentage of diaphyseal medullary canal occupied by prosthesis, the presence of assymetric stem cortical contact, and lack of metaphyseal (zone 1) load transfer. Diaphyseal bone hypertrophy (zone 4) was statistically significantly correlated with a high percentage of diaphyseal medullary canal occupied by prosthesis (zone 4) and assymetric stem tip-to-cortical wall contact. Periarticular bone hypertrophy and diaphyseal bone atrophy did not occur. Fractures through the humeral condyles occurred in three elbows undergoing bone atrophy, but no implant loosening or failure could be correlated with bone remodeling. Bone remodeling does occur in a high percentage of stemmed elbow implants but to date has not been a factor in clinical failure.
Atrophy↗
Successive bilateral total knee replacement.
We studied the results of 304 posterior stabilized condylar knee arthroplasties, performed over a two and a half-year period, to compare unilateral, bilateral one-stage, and bilateral staged arthroplasty. The minimum length of clinical follow-up was two years. Using The Hospital for Special Surgery rating system, we found the clinical results to be identical for all three groups. The medical complications were similar in each group except that there was a higher incidence of thromboembolism and pulmonary embolism, as seen venographically, in the patients with staged procedures. We concluded that one-stage bilateral knee arthroplasty is preferable in a patient who requires replacement for severely arthritic knees.
Adult↗
Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union.
OBJECTIVES: To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing. DESIGN: Retrospective consecutive clinical series. SETTING: Level I trauma center and tertiary university hospital. PATIENTS: Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing. INTERVENTION: All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures. RESULTS: Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union. CONCLUSIONS: Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for additional bone grafting, and allows full weight-bearing and active rehabilitation. Tobacco use appears to have an adverse effect on nonunion healing after exchange reamed femoral nailing.
Adolescent↗
Clinical estimation of ilizarov fixator axial stiffness based on wire and half pin contributions.
A key parameter in the mechanical environment created in distraction osteogenesis is the axial stiffness of the external fixator. Mechanical testing of the frames with wire and half pins has been used to estimate the stiffness contributions of wires based on the span length and of half pins based on the offset length. A summation of the wire and half pin contributions appears to represent a suitable estimate for the axial stiffness of frames composed of a mixture of wires and half pins. Using this estimate, clinicians can make informed decisions regarding frame construction, and it may be possible to investigate the rate of bone formation relative to axial frame stiffness in the clinical setting.
Biomechanical Phenomena↗