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PubMed2000

Changes in bone mineral density at the proximal tibia after total knee arthroplasty: a 2-year follow-up of 28 knees using dual energy X-ray absorptiometry.

The change in bone mineral density at the proximal tibia during 2 years after total knee arthroplasty was studied in 28 knees (28 patients: 10 men and 18 women; median age: 71 years) with dual energy x-ray absorptiometry. Bone mineral density was measured at the proximal tibia at nine regions of interest below the tibial component within 1 week after the operation (baseline); measurements were repeated at 3, 6, 12, and 24 months. All but one knee was malaligned before the operation, and all but three were corrected to within the normal range of alignment after it. The mean bone mineral density of all nine regions of interest at the proximal tibia temporarily decreased by 13% (p = 0.001) during the initial 3 months, probably due to a general metabolic reaction of the skeleton to the operative trauma combined with the effect of the postoperative immobilization, and then the initial level was regained for as long as 2 years. The overall changes in mean bone mineral density to 2 years were insignificant (p > 0.05); however, a great variation (43.9% decrease to 98.0% increase) was observed on an individual basis. This change over time was significantly associated (R2 = 0.36, p = 0.002) with the level of the baseline bone mineral density, which in turn was partly related (R2 = 0.24, p = 0.009) to the amount of malalignment of the knee before the operation. Knees with high baseline levels (n = 14: 11 with varus and three with valgus alignment) displayed a decrease of 10.0 +/- 14.0% (mean +/- SD, p > 0.05) for as long as 2 years, whereas those with low baseline levels (n = 14: seven with varus and six with valgus alignment and one neutrally aligned) had an increase of 19.1 +/- 38.2% (p = 0.038). In both groups, the mean bone mineral density converged to a level of 0.75-0.95 g/cm2 at 2 years.

Absorptiometry, Photon↗
PubMed1987

Complications of external fixation of open fractures of the tibia.

Forty-two cases of open fractures of the tibia treated by external fixation are presented. Forty-three per cent of patients developed sepsis around one or more pins. Pin track sepsis occurred in 78 per cent of cases involving transfixion pins through muscle and bone but in only 17 per cent of cases using transcutaneous half-pins. Malalignment of more than 5 degrees in any plane was seen in 38 per cent of cases, almost half of which increased in plaster after removal of the fixator.

Adolescent↗
PubMed2002

Malalignment at the Lisfranc joint: MR features in asymptomatic patients and cadaveric specimens.

OBJECTIVE: To assess the frequency of malalignment in the 1st, 2nd and 3rd tarso-metatarsal joints (Lisfranc joint) in cadaveric specimen and asymptomatic individuals utilizing oblique axial MR images. DESIGN AND PATIENTS: Four fresh frozen cadaveric feet were dissected in the oblique axial plane at 5 mm slice thickness. Thirty MR studies in 29 patients who had no history of pain, trauma or surgery at the tarso-metatarsal area were included in our study. The 1st to 3rd tarso-metatarsal joints were evaluated on the MR studies and cadaveric slices by two musculoskeletal radiologists for (1) the presence of a medial and/or lateral step-off and (2) articular surface divergence. RESULTS: In the cadaveric dissections there were lateral step-offs in the 1st ( n=3) and in the 2nd ray ( n=3) respectively. No joint incongruity was evidenced. The MR studies in the patients population depicted 28 step-offs (9 medial, 19 lateral) in the 1st ray, 16 (2 medial, 14 lateral) in the 2nd ray and two in the 3rd ray. Joint incongruity was present in the 2nd ray ( n=6) and in the 3rd ray ( n=12). All the above findings were limited to a few images. CONCLUSIONS: Isolated joint malalignment with otherwise normal findings (no ligamentous injury, no fracture and no bone marrow edema) might reflect normal anatomic features at the tarso-metatarsal joints and must be interpreted carefully.

Adult↗
PubMed1994

Scaphoid shift in the uninjured wrist.

To determine the prevalence of a positive scaphoid shift in an uninjured population, 100 patients presenting with symptoms unrelated to trauma or wrist instability underwent physical and radiographic evaluation. On physical examination, the scaphoid shift maneuver was performed bilaterally, and generalized ligamentous laxity was assessed using standard criteria. Standard x-ray films were inspected for carpal abnormalities, and the radiolunate and scapholunate angles were measured. The prevalence of a positive scaphoid shift was 32%; the shift was painless in all patients. Fourteen patients had a unilateral scaphoid shift. Patients with a positive scaphoid shift had increased generalized ligamentous laxity manifested by a decreased average thumb-to-forearm distance and an increased mean flexion-extension arc. A positive shift was not correlated with radiographic carpal malalignment.

Carpal Bones↗
PubMed2006

Clinical application of intraoperative skeletal traction in the dog.

The purpose of this clinical study was to evaluate the technical feasibility of a method for pre-operative and intra-operative traction for reduction of fractures of the appendicular skeleton. Traction was used in 24 diaphyseal fractures in 21 dogs. For each dog, the data pertaining to signalment, limb circumference, fracture type, interval between fracture and surgery, and the traction modalities were recorded. In patients with a latency between trauma and surgery of less than three days, the duration of traction required to realign the bone segments was shorter than that required for older fractures (P = 0.02). Intraoperative malalignments were corrected by manoeuvres performed with the traction stand. Once realigned, fracture segments were kept stable for prolonged periods, without the need for a surgical assistant. Postoperative radiographs were evaluated for fracture reduction and axial alignment. Postoperative alignment was judged excellent in 21 fractures and good in three fractures. Fractures were stabilized using external skeletal fixation (n = 10), plates (n = 11) or locked nails (n = 3), depending on the fracture type. The use of the technique was straight-forward and easily applied in a surgical setting. However, its use requires careful application because of the potential for iatrogenic tissue damage.

Animals↗
PubMed1995

[Tibiotarsal arthrodesis: value of external fixator associated with in situ cancellous bone graft. Initial results apropos of 18 cases].

Tibio-talar arthrodesis poses some problems and the most frequent are non-union and varus malalignment of the ankle joint. The aim of this report was to present a new technique of ankle joint arthrodesis. The principles of this procedure are as follows: firstly, the external fixation (A.L.J.) is framed, secondly, perpendicular cuts are made in the tibial plafond and talus through an anterior longitudinal approach; and thirdly, the gap is filled with cancellous bone graft which is taken preferably on the iliac crest. If the back-foot is not correctly lined up preoperatively, the external device is framed in two steps: the first step consists in putting the pins. Then perpendicular cuts are made, and the back-foot is correctly lined up using calcaneal pins. The second step consists in connecting tibial pins and foot pins using union-rods. The last step of the procedure is to fill the gap with cancellous bone graft. The external fixation device is removed after 45 days and a shortleg walking cast is put for 45 days. Between 1981 and 1992, 18 arthrodesis were performed on various diagnosis: 9 post-traumatic tibio-talar osteoarthritis, 4 residual neurologic diseases, 2 rheumatoid arthritis and 3 recent post-traumatic lesions. There were 17 patients (one bilateral case), 4 females and 13 males; the middle age at the time of operation was 44.5 years (20 to 60) and there were 10 right ankles and 8 left. The tibio-talar arthrodesis was performed alone in 14 cases, but it was associated with a talo-calcaneus arthrodesis in 4 cases. The after care was without complications except 3 pins infection which cured with antibiotics. All the cases had a good bony union within 3 to 6 months and the orientation of the backfoot was always satisfactory without varus malalignment. All the patients could put one's shoes without having recourse to orthopaedic shoes. In conclusion, this operative procedure seems to minimize the problems and pittfalls of the ankle arthrodesis.

Adult↗
PubMed1999

Retrograde compression screw fixation of acute proximal pole scaphoid fractures.

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization.

Acute Disease↗
PubMed1995

Fifth metatarsal fractures. Biomechanics, classification, and treatment.

Fractures of the fifth metatarsal are treated conceptually based on anatomic location and character of the fracture site. Intra-articular disruptions require reconstruction, if possible. Malalignment of acute fractures requires either closed reduction or open reduction if the malalignment represents a load-bearing dysfunction to the forefoot. Segmental defects require bone grafting and stabilization with plate and screws. Jones fracture is most effectively managed with medullary lag screw delivery in the active or athletic patient. Casting can be considered for high-risk patients. Late bone grafting for sclerotic nonunion is necessary with inlaid grafts harvested from the calcaneus or tibia. Tuberosity fractures require open reduction only when articular involvement is a problem or when distraction is apparent. Otherwise, they can be expected to heal rapidly without long-term problems.

Fractures, Bone↗
PubMed1997

Limb lengthening in Turner syndrome.

We report the results and complications of eight consecutive patients who underwent bilateral tibial lengthenings for dwarfism associated with Turner syndrome. Lengthening was performed via distraction osteogenesis with monolateral external fixation. Tibias were lengthened an average distance of 9.2 centimeters or 33 percent of the original tibial length. The average total treatment time was 268 days. The overall complication rate was 169 percent for each tibia lengthened and each segment required an average of 1.7 additional procedures. Seven cases (44 percent) required Achilles tendon lengthening and nine cases (56 percent) developed angulation before or after fixator removal; six of these segments required corrective osteotomy for axial malalignment. Two cases (12.5 percent) developed distraction site nonunion and required plating and bone grafting. From this series we conclude that tibial lengthening via distraction osteogenesis can be used to treat disproportionate short stature in patients with Turner syndrome. However, the benefit of a cosmetic increase in height may not compensate for the high complication rate. Efforts to determine the psychosocial and functional benefits of limb lengthening in patients with short stature is necessary to determine the true cost-benefit ratio of this procedure.

Adolescent↗
PubMedDate not supplied

Rotational osteotomy of the distal tibia and fibula.

A surgical technique for distal transverse osteotomy of the tibia and fibula to correct torsional malalignment of the leg is described. Thirty-two derotation osteotomies have been performed on 19 patients, whose average age at the time of surgery was 12 years; average follow-up was 2 years. Average torsional change following surgery was 38 degrees. Ninety-four percent of the patients available for follow-up (16 or 17) had a successful outcome. The two small incisions required in this procedure are cosmetically acceptable, and the location of the osteotomy in metaphyseal bone provides stability. We conclude that this osteotomy is a simple, safe, and effective procedure for correction of torsional malalignment in carefully selected patients.

Adolescent↗
PubMed1982

Treatment of therapeutically resistant non-unions with bone grafts and pulsing electromagnetic fields.

This study reviews the cases of eighty-three adults with ununited fractures who were treated concomitantly with bone-grafting and pulsed electromagnetic fields. An average of 1.5 years had elapsed since fracture and the use of this combined approach. Nearly one-third of the patients had a history of infection, and an average of 2.4 prior operations had failed to produce bone union. Thirty-eight patients who were initially treated with grafts and pulsed electromagnetic fields for ununited fractures with wide gaps, synovial pseudarthrosis, and malalignment achieved a rate of successful healing of 87 per cent. Forty-five patients who had initially been treated unsuccessfully with pulsing electromagnetic fields alone had bone-grafting and were re-treated with pulsing electromagnetic fields. Ninety-three per cent of these fractures healed. The residual failure rate after two therapeutic attempts, one of which was operative, was 1.5 per cent. The median time to union for both groups of patients was four months.

Adult↗
PubMed2002

Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate.

BACKGROUND: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate. METHODS: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function. RESULTS: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10 degrees of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year. CONCLUSIONS: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.

Aged↗
PubMed2004

Arthrodesis of the ankle joint.

Arthrodesis of the ankle that uses lag screws for internal fixation is a safe and biomechanically stable method to obtain a solid ankle fusion; it generates good to excellent results in most patients. Prompt bone healing can be expected and allows a functional rehabilitation with full weight bearing. The surgical technique can be simplified further when using cannulated screws. Malalignment hazards while doing the ankle fusion are minimized by respecting the shape of the ankle mortise because no osteotomy of the lateral malleolus is performed. Generally, removal of the implanted material is not necessary. Major complications such as infection, stress fractures, or nonunion were not seen in our series. A meticulous resection of all cartilage and sclerotic bone and an atraumatic surgical technique are essential for preventing those major complications. The need for revision surgery is minimized by correction of talar malalignment, fusion with the ankle in a 90 degrees position, and preoperative evaluation of the subtalar joint. External fixation methods are used in cases of osteitis, osteonecrosis, osteoporosis, and poor soft tissue conditions. With severe loss of bone stock at the distal tibia, stability can be achieved by using an intramedullary nail for ankle fusion.

Ankle Joint↗
PubMedDate not supplied

Statistical analysis of axial deformity during distraction osteogenesis of the tibia.

In this study, we documented the prevalence of coronal axis malalignment in a series of 93 tibias (from 54 patients) lengthened with monolateral fixation. The average length obtained by distraction osteogenesis was 8.9 cm (range, 3.5-15.6) or 38% of the original bone length (range, 11-78%). Fifty (54%) of 93 tibias had documented valgus angulation of > or = 10 degrees or had fixator manipulation during the lengthening process for undesirable or progressive angulation; no cases of varus angulation were noted. Thirteen (14%) segments had later corrective osteotomy for unsatisfactory valgus malalignment. Statistical analysis revealed two factors to have a significant effect on the rate of malalignment. Those cases that had tibial osteotomy below the proximal one third of the original tibial length and those cases in which the fixator was placed > 5 degrees out of parallel had higher rates of angulation or manipulation (p < 0.001 and p = 0.002). Although the percentage of original bone lengthened was not statistically significant (p = 0.083), it did have an important effect on rates of axial malalignment. From this study we conclude that relatively high rates of malalignment in the tibia during distraction osteogenesis with monolateral external fixation are predominately the result of more distal osteotomies and nonparallel fixator placement. Attention to these details in general, and particularly where long lengthenings are planned, may significantly reduce this common complication.

Adolescent↗
PubMed1996

Congenital onychodysplasia of the index fingers--Iso-Kikuchi syndrome. A case involving the second toenail.

We report a case of congenital onychodysplasia of the index fingers (Iso-Kikuchi syndrome) in a 2-year-old boy who had nail deformities on both index fingers and the left second toe. He had a micronychia of the left index fingernail, malalignment and abnormal lunula of the right index fingernail and micronychia and malalignment of the left second toenail. Congenital onychodysplasia of the index fingers (COIF) is a rare condition characterized by various forms of nail dysplasia commonly involving the index fingers, but not infrequently also the neighbouring fingers such as the middle fingers and thumbs. The five criteria characterizing COIF include the following: (i) congenital occurrence; (ii) unilateral or bilateral index finger involvement; (iii) variability in nail appearance; (iv)possible hereditary involvement; and (v) frequently associated bone abnormalities. The nails of COIF include the full spectrum of nail dysplasia, from an irregular lunula, malalignment, micronychia (hypoplastic and rudimental), polyonychia (split rudimental), and anonychia, specifically affecting the index fingers. Our patient represents various forms of nail dysplasia of the both index fingers and left second toe such as micronychia, malalignment and abnormal lunula. To our knowledge, the association with second toenail dysplasia in COIF has not previously been reported.

Child, Preschool↗
PubMed1979

Total joint arthroplasty. The knee.

Total knee replacement has become an established form of treatment for gonarthrosis and usually results in excellent relief of pain and approximately 90 degrees of joint motion with satisfactory joint stability. The anatomic stability that cannot be restored at surgery must be provided for by additional prosthetic stability. Fixation of prosthetic devices, particularly in the tibia, is marginal and results in an increased incidence of loosening when the quality of bone is weak, as in osteoporosis, or when shear stress is increased because of malalignment or prosthetic constraint. Resurfacing techniques provide the greatest options if surgical revision is necessary. Surgical goals should be realistically assessed so as to maintain the best potential for future treatment options.

Arthroplasty↗
PubMed1991

Salvage of nonunion following ankle arthrodesis for failed total ankle arthroplasty.

Revision operations for nonunion following total ankle arthrodesis for total ankle arthroplasty (TAA) were reviewed in ten patients. Operations averaged 2.0 years after prior arthrodesis attempts and featured external fixation in seven, internal fixation in one, percutaneous pin fixation in one, and cast immobilization only in one. Bone graft was used in seven. Union was achieved in 78%. The one complication was an infection in a patient with prior sepsis. The results were considered excellent in three, good in one, fair in three, and poor in two of the nine patients with adequate follow-up evaluation (average, 7 years). Despite successful arthrodesis, residual symptoms were common because of factors such as hindfoot degenerative arthritis and malalignment.

Activities of Daily Living↗