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The materials of clinical observations of 103 patients with pseudarthrosis and unhealing crural fractures, in whom 104 operations of compression-distraction osteosynthesis were accomplished, are analysed. The results of the treatment in various groups of patients are described.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Neglected femoral neck fractures are frequently complicated with nonunion and avascular necrosis of the femoral head. The treatment is especially difficult in young adults because arthroplasty is not indicated. Five cases of neglected femoral neck fractures in young patients were treated by open reduction and internal fixation with pins. The defect of the femoral neck was filled with a block of vascularized iliac bone graft. After at least two years, the fractures were healed without avascular necrosis of the femoral head. The leg-length discrepancy was corrected in all but one case. The pedicled iliac graft provided a viable bone graft, which maintained the viability of the head and hastened fracture healing.
Most serious lower-limb injuries with severe bone and soft tissue damage heal when treated wisely by techniques available today. Unfortunately, a small percentage of patients face prolonged physical and economic disability as a result of extensive damage to bone and soft tissue, nonunion of fractures with infection, nerve and blood-vessel injury, and complications of surgical treatment. Every effort should be made to effect union by established methods but a small percentage of fractures do not heal satisfactorily. Failure of infected lower-limb fractures to unite after prolonged treatment or the prospect of prolonged treatment or the prospect of prolonged morbidity and disability occasionally justify amputation in one lower limb. When a lower-limb prosthesis can provide stability support, and mobility painlessly, and overcome the morbidity and disability of an infected ununited fracture, amputation may be the treatment of choice. In the present review of our experiences in the past 17 years with patients having severly injured and diseased lower limbs where little chance existed for rehabilitation to acceptable levels of function by various methods of treatment, open amputation through infected bone followed by secondary closure was chosen to salvage the unfortunate patient with littlw chance of achieving acceptable function after infected ununited fractures of the lower limbs.
A patient with osteomyelitis of the scaphoid in childhood resulting in a pathologic fracture with nonunion is presented. This ununited fracture of the scaphoid was successfully grafted eight years later with a satisfactory outcome.
One hundred and twenty-five patients with one hundred and twenty-seven ununited fractures of the tibial diaphysis were treated exclusively with pulsing electromagnetic fields. The over-all success rate in healing of the fracture with this surgically non-invasive out-patient method was 87 per cent. The success rate was not materially affected by the age or sex of the patient, the length of prior disability, the number of previous failed operations, or the presence of infection or metal fixation.
This study reviews the cases of 52 patients with 52 ununited fractures and osteotomies who were treated with two methods of electrical stimulation, one surgical, the other nonsurgical. Seventeen patients, 14 of whom had concomitant bone grafting, had implantation of a bone growth stimulator. There were three synovial pseudarthroses but no active infection in this group. The overall success rate in healing of the fractures was 82%. Thirty-five patients, of whom four had initial concomitant bone grafting, were treated with pulsing electromagnetic fields (PEMF). There were six draining infections but no pseudarthrosis in this group. Two nonunions healed after bone grafting was combined with PEMF treatment, when the latter alone had failed. Eighty-one percent of the fractures united, and drainage ceased in five of the six infections.
The current indications and technique of wrist osteotomies for ununited fractures of the distal radius are presented. A three-dimensional correction at the metaphyseal level is technically feasible. This not only restores the normal orientation of the articular surface thus reestablishing normal load distribution but also the radial length up to 10 mm which is a prerequisite to prevent ulno-carpal impingement. Painful limitation of forearm rotation due to degenerative changes in the distal radioulnar joint may be treated with Bowers hemiresection arthroplasty. If the radioulnar index should be greater than 10-12 mm an additional shortening osteotomy of the ulna may become necessary. Every additional operation on the ulna should be based on the radiological comparison of the distal radioulnar joint of the opposite hand.
The elderly population is larger, healthier, and more active than ever. Osteoporosis-related fractures and their sequelae are becoming more commonplace. Successful management of these problems requires adequate internal fixation of osteoporotic bone. Fixation of osteoporotic bone has evolved from the use of cement or allograft-augmented screws to fixed-angle plates, and now to fixed-angle screws that thread into and engage solidly the hole in the plate, creating a fixed blade. Familiarity with these techniques may facilitate the care of elderly patients requiring operative fracture care.
BACKGROUND: Delayed union or nonunion of a fracture of the humerus is an infrequent but debilitating complication. Open reduction and internal fixation combined with autologous bone-grafting can result in reliable healing of the fracture; however, there is morbidity associated with the bone-graft donor site. This study was designed to evaluate healing of ununited fractures of the humeral shaft treated by one surgeon at one institution with a strict and consistent surgical protocol but with the use of two different types of bone graft: autologous iliac crest bone graft and demineralized bone matrix. METHODS: A consecutive retrospective cohort series was analyzed. From 1992 to 1999, forty-five patients with an aseptic, atrophic delayed union or nonunion of a humeral shaft fracture were treated with open reduction and internal fixation with a plate and autologous iliac crest bone graft. The mean time from the fracture to the surgery was 14.0 months, and the mean duration of follow-up was 32.8 months. From 2000 to 2003, thirty-three patients with the same condition were treated with the same protocol with the exception that demineralized bone matrix was used instead of autologous iliac crest bone graft. The mean time from the fracture to the surgery in that group was 22.6 months, and the mean duration of follow-up was 20.4 months. All patients in both groups were assessed clinically and radiographically. RESULTS: Osseous union was noted clinically and radiographically following the index surgery in 100% of the forty-five patients treated with autologous bone graft and 97% (thirty-two) of the thirty-three patients treated with demineralized bone matrix. The mean time to union was 4.5 months in the group treated with autologous bone graft and 4.2 months in the group treated with demineralized bone matrix. The overall functional outcome did not differ between the groups; however, twenty (44%) of the autologous bone-graft recipients had donor site morbidity, including a prolonged pain in the majority and a superficial infection requiring irrigation and débridement in one patient. CONCLUSIONS: Healing of an ununited humeral shaft fracture can be achieved consistently with rigid plate fixation and lag-screw compression augmented with either autologous cancellous bone graft or commercially available demineralized bone matrix. The harvest of the autologous bone graft is frequently associated with complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
The anterior approach as described by Matte and Russe for treatment of ununited fractures of the scaphoid was employed in 48 patients using autologous cortical cancellous pegs and chips. Operative intervention occurred in an average period of 14 months after fracture. The average time to radiological union was 3.5 months; the average follow-up was 2 years. Union occurred in 43 patients. The anterior approach is recommended because of its simplicity. Neither avascular necrosis nor a small proximal pole fragment are contraindications to the procedure.
We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.
Kuntscher Y nail is biomechanically a stable assembly and is useful in the management of unstable intertrochanteric, subtrochanteric and pathological fractures involving the upper end of the femur. In addition, it was ideal in special situations with fracture of the upper end of the femur; in a mentally ill patient with an unstable trochanteric fracture, for non-union of a trochanteric fracture and for a fracture of the upper end of the femur associated with a fracture further distally of the femoral shaft. Although it proved to be a very stable fixation, the control of external rotation of the distal femoral shaft was a significant problem in two cases. In all six cases stable fixation was achieved which progressed to sound union, including the case with ununited fracture. No technical difficulty was encountered at the time of operation although this could pose a significant problem. The main danger is the splintering of the lateral subtrochanteric femoral cortex during insertion of the neck piece and inability to negotiate the Kuntscher nail through the fenestration in the neck piece.
Better anatomical and functional results in the treatment of malunion, ununited fractures and pseudoarthrosis are gained through the combination of compression osteosynthesis with bone plasty and open reduction of the dislocated capitellum with the formation of the ligamental system. Resection of the dislocated capitellum leads mostly to the dysfunction and disability.