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PubMed2000

Supracondylar femur fractures treated percutaneously.

One hundred twenty-five supracondylar fractures in 118 patients treated with the Green-Seligson-Henry supracondylar intramedullary nail were evaluated. One hundred four patients (111 fractures) were followed up to fracture union. The percutaneous technique was compared with open reduction and internal fixation using the same device. The mean operative time was greater for the open reduction technique when compared with the percutaneous technique (176 minutes versus 76.6 minutes, respectively), as was the mean estimated blood loss (229 cc versus 96.2 cc). The incidence of delayed union was approximately the same for patients who were treated with both techniques. However, the nonunion rate was significantly higher in the patients treated with open reduction and internal fixation than the patients treated with the percutaneous technique (5.6% versus 2.6%). Twenty-nine (39%) patients who were treated with open reduction and internal fixation required bone grafting versus only three (7%) patients who were treated with the percutaneous technique. Additionally, the percutaneous technique did not produce a higher incidence of malalignment and resulted in a greater postoperative range of motion than the open technique. The current study shows that percutaneous treatment of supracondylar femur fractures is possible and can decrease operative times, blood loss, the need for bone grafting, increase rates of union, and improve functional outcomes.

Adolescent↗
PubMed2001

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late.

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used. In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable. In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.

Adolescent↗
PubMed1993

Nonunion of tibial shaft fractures treated with locked intramedullary nailing without bone grafting.

Twenty-five nonunions of tibial fractures were treated with Grosse-Kempf slotted, locked nails in 20 men and 5 women 6 to 54 months after fracture. No bone grafts were performed in connection with nailing. For better alignment, opening of the nonunion site, fibular osteotomy/resection, or both were used. In one patient reoperation with nailing and bone grafting was necessary after the first nail broke. There were three postoperative infections (12%), two with persistent drainage. All nonunions healed. In one patient an external rotatory malalignment was corrected by a later osteotomy. In no case was the function of the ankle or foot impaired by the index operation. Static locking was not unfavorable for healing. We conclude that bone grafting is rarely needed and function is restored early after locked nailing of tibial nonunions.

Adolescent↗
PubMed2006

Bone remodelling after total hip arthroplasty using an uncemented anatomic femoral stem: a three-year prospective study using bone densitometry.

PURPOSE: To evaluate the clinical, radiological, and densitometric changes in the bone-remodelling patterns of femoral stems aligned in neutral, valgus, or varus positions. METHODS: Between February and October 2000, 70 patients underwent unilateral total hip arthroplasty for primary osteoarthritis using an uncemented Anatomique Benoist Girard (ABG) II stem. 69 patients (30 males and 39 females) with a mean age of 59 years (range, 38-76 years) and a mean body weight of 79.3 kg (range, 29-110 kg) completed 3 years' follow-up on bone remodelling. The clinical, radiological, and densitometric changes of the neutral, valgus, and varus groups were evaluated, and the difference in bone-remodelling patterns between the 3 groups was analysed. RESULTS: 54 patients had neutrally placed stems, while varus and valgus malalignment occurred in 6 and 9 patients, respectively. Clinical and radiological evaluations were very similar among the 3 groups. Only densitometry could detect traceable changes resulting from the differing biomechanics of the neutral, varus, and valgus stem alignments. CONCLUSION: The ABG II stem design made moderate errors in alignment biomechanically tolerable. Alignment defects had no clinical consequences and resulted in minimal differences in bone remodelling.

Absorptiometry, Photon↗
PubMed1986

[Acute ligamentous injuries of the Chopart and Lisfranc joint line].

The foot is a complex structure with numerous articular surfaces. As there are many potential complications (severe edema, compartment syndrome of the intrinsic foot musculature, bone and soft tissue necrosis, joint abnormalities, limitation of movement, deformities, etc.), traumatic surgeons must have a detailed knowledge of the relevant functional anatomy and treatment procedures. If there are multiple injuries, in the context of management, early definitive treatment for the injury is to be stressed. One requirement is an exact clinical and radiological diagnosis. As a rule, closed reduction is therapeutically successful. In a stable injury, immobilization can be achieved with a cast; in open wounds and malalignment of joint surfaces, an operative procedure is indicated. Particular attention must be paid to injuries of the tarsal bones in children to avoid delayed failure of growth, as the results of radiological investigations are often difficult to interpret. The diagnosis, techniques of management, and principles of follow-up are presented.

Casts, Surgical↗
PubMed1998

Arthrodesis for the treatment of arthrosis of the ankle and osteonecrosis of the talus.

We evaluated the results of arthrodesis that had been performed for arthrosis of the ankle and osteonecrosis of the talus in nineteen patients. Twelve patients were men, and seven were women. The mean age of the patients was thirty-four years (range, nineteen to fifty-eight years). The median interval between the injury and the index operation was twenty-one months (range, six to 408 months). The arthrodesis was performed at the level of the ankle only in three patients and in both the ankle and the subtalar joint in sixteen. External fixation was used in thirteen patients, internal fixation was used in four, and no fixation was used in two. Supplemental bone graft from the iliac crest was used in fourteen patients, and local bone graft was used in five. The mean duration of follow-up was six years (range, two to fifteen years). The clinical result was excellent in seven patients, good in six, fair in three, and poor in three. Union was achieved in sixteen ankles, but it was delayed in one of them. Complications occurred in four patients: one had a tibial stress fracture, one had an infection at the site of a non-union, and two had malalignment in plantar flexion. Overall, the arthrodesis was successful in these patients. The use of rigid fixation and bone-grafting had a rate of success approximating that reported for primary arthrodesis in patients who do not have avascular necrosis.

Adult↗
PubMed2002

Rib bone graft for posterior spinal fusion in children.

Treatment of columnar instability in children with conventional fusion procedures may preclude normal growth and cause dysfunction and pain due to malalignment or reduced mobility. To achieve normal growth, we have treated spinal instability in 7 children with posterior fusion, using bilateral rib transplants secured by horizontal laminar cerclages. Solid fusion was obtained and no serious complications occurred.

Age Factors↗
PubMed2001

Unreamed locked tight-fitting nailing for acute tibial fractures.

OBJECTIVES: Treatment of tibial fractures by unreamed locked nailing with loose-fitting nails has previously been shown to be associated with a low union rate and high implant failure rate. This report describes the authors' experience in using tight-fitting nails that were relatively larger than loose-fitting nails. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Forty-eight consecutive patients with fifty-two tibial fractures (excluding open IIIC fractures and those with bone loss) were studied: thirty-four men and fourteen women, with a mean age of 38 years. There were twenty-five closed fractures, nine Type I, eight Type II, four Type IIIA, and six Type IIIB open fractures. INTERVENTION: Unreamed nailing with tight-fitting nails using the Russell-Taylor system. OUTCOME MEASURES: Union rate, time to union, complication rate, and functional recovery, as well as nailing time, hospital time, and crutch-walking time were recorded. RESULTS: Union occurred in forty-eight of fifty-two fractures (92%) with a mean time to union of 18.2 weeks. Compartment syndrome occurred in three patients. Deep infection occurred in one Type II and one Type IIIB open fracture. Four fractures required additional exchange nailing or bone grafting to achieve union: one Type II, one Type IIIA, and two Type IIIB open fractures. Three malalignments resulted from operative technical error. The rate of both intraoperative bony split and screw breakage was 3.8% (2 of 52), but neither complication interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. CONCLUSIONS: Unreamed locked nailing with tight-fitting nails can produce satisfactory clinical results for acute tibial fractures. It has the advantages of technical simplicity and an acceptable risk of implant failure.

Acute Disease↗
PubMed2000

[Intramedullary nailing of humeral shaft fractures--initial experiences with an unreamed humerus nail]].

Interlocking intramedullary nailing has become the preferred method of internal fixation for diaphyseal fractures of the lower extremity. In shaft fractures of the humerus however open reduction and internal fixation with plates and screws is still considered the gold standard for operative treatment. The unreamed humerus nail (UHN) is a new implant for interlocking intramedullary nailing, which allows for stable fixation of humerus shaft fractures and immediate functional after treatment. The UHN could thus become an equal alternative to plate osteosynthesis. From this point of view we analyzed retrospectively 19 shaft fractures of the humerus, which have been treated at our institution with an UHN. Infections and iatrogenic nerve lesions did not occur. One patient with a rotational malalignment of 45 degrees underwent a secondary procedure. In two out of ten fresh fractures the bone healing failed and resulted in a non-union. In all cases of pathological fractures a good palliation could be achieved. With exception of two patients the range of motion of the shoulder and elbow was symmetric. We conclude that the UHN is a real alternative to plate osteosynthesis. Compared with most series of plate osteosynthesis published in the literature the risk for iatrogenic lesions of the radial nerve appears to be lower. Even in this small series we found however a rather high rate of non-unions.

Adult↗
PubMed2005

Single lateral locked screw plating of bicondylar tibial plateau fractures.

We prospectively followed a case series of 68 patients with 69 AO/ASIF 41-C-type fractures treated with the Less Invasive Stabilization System for the proximal lateral tibia. We assessed malreduction, secondary loss of reduction, and infection rates in patients with a locked screw plate for unilateral fixation of bicondylar fractures. Sixty-two (91%) patients returned for final followup (range, 11-13 months). Malreduction and malalignment were defined as an intraarticular step-off of 2 mm or greater, or as a malalignment in the frontal or sagittal plane greater than 5 degrees . Fourteen fractures were open. Primary bone grafting was done in 13 patients. Significant malreduction was seen in 16 patients. There were four superficial infections and one deep infection. One fracture did not heal, and nine patients had substantial loss of reduction. Unilateral locked screw plating is a good alternative for treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

Adolescent↗
PubMed1999

Surgical management of Paget's disease.

Orthopedic complications of Paget's disease occur commonly and arise as a result of chronically accelerated bone remodeling in focal regions of the skeleton. Complications include pathologic fractures with delayed union, progressive skeletal deformity, chronic bone pain and pagetic arthritis. The new bisphosphonates have transformed the treatment of Paget's disease in the past decade but have not yet been studied in depth for their ability to prevent orthopaedic complications. Although few patients with Paget's disease ever require surgical intervention, successful operative management of orthopaedic complications has dramatically improved the quality of life for many sufferers. Selected modalities with promising results include total hip replacement for end-stage pagetic arthritis of the hip, total knee replacement for end-stage pagetic arthritis of the knee, proximal tibial osteotomy for painful malalignment of the knees, internal fixation for pathological fractures, and decompressive laminectomy for spinal stenosis. Complications of surgery on pagetic bone include hemorrhage, infection, pathologic fracture, delayed union, nonunion, and aseptic loosening of hardware. Medical, surgical, and rehabilitative modalities provide a wide array of options in managing orthopaedic complications of Paget's disease and are useful in improving quality of life for sufferers of the condition. Prospective studies are needed to assess the ability of antipagetic medications to prevent severe long-term complications such as deformity, arthritis, and malignancy. Localization of susceptibility genes for Paget's disease may accelerate identification of targets for gene therapy and disease prevention.

Arthroplasty↗
PubMed1993

Correction of implant malalignment by segmental osteotomy: a case report.

This case report demonstrates that the position of malaligned osseointegrated implants can be corrected by a segmental osteotomy procedure with no loss of implants or bone support. The patient was a healthy teenage girl who sustained facial trauma with loss of teeth and alveolar bone. The defect was initially bone grafted. Brånemark implants were simultaneously placed in the graft. Their initial unfavorable positions and inclinations were later corrected by a segmental osteotomy.

Adolescent↗
PubMed2003

Less invasive stabilization system (LISS) in the treatment of distal femoral fractures.

The treatment of distal femoral fractures has been associated with a high rate of complications for a long time. Although implants and surgical techniques have improved, plate osteosynthesis and intramedullary nailing have been accompanied by a high occurrence of infection, non-union and malalignment. The treatment of soft tissue envelopes using "biological" osteosynthesis and minimally invasive approaches has resulted in a decrease in complication rates and ultimately led to the concept of the less invasive stabilization system (LISS). This is an extramedullary-applied, internal fixator shaped according to the implantation site anatomy, with minimal invasiveness. The purpose of this study was to present this new surgical technique and draw attention to its advantages and importance. Although this is not a scientific paper, we hope to provide enough evidence of the LISS usefulness. The main LISS components include multiple-fixed angle screws and an insertion handle for submuscular sliding of a fixator and placement of percutaneous, self-drilling, unicortical screws for fixation of the diaphyseal fracture fragments. The LISS has been designed to preserve periosteal perfusion and to facilitate a minimally invasive application. Since the first implantation of the LISS, only a few studies have been published on its use in treatment of distal femoral fractures. The rate of infection has been low, ranging from 0 to 4%. The rate of delayed union has been between 2.4 and 6.1%, but delayed unions do not necessarily lead to secondary bone grafting or repeat osteosynthesis as the LISS has a high and lasting stability. When the LISS is used, bone grafting is rarely necessary (0 to 1.6% in primary and 0 to 5% in secondary grafting). Also implant failure differs from the failure of plate osteosynthesis because, with the use of LISS, no screw loosening or secondary malalignment occurs. Implant failures (up to 7.4%) were recorded particularly at the time of LISS introduction in surgical practice and were attributed to the technique of implantation rather than to the implant itself. Good treatment outcomes have been reported. The average knee flexion has been 103 degrees and 107 degrees. In 72.5% of the patients, flexion has been more than 90 degrees and an extension lag of > or = 10 degrees has been found in only 7.5% of all cases. The average Neer score has ranged from 73.9 to 77.2 points. In conclusion, the LISS is a useful implant for treatment of distal femoral fractures, especially when bone quality is poor. Infection, delayed union and non-union rates are low, as shown by yet unpublished data from our clinic. Primary bone grafting, which is rarely necessary with this system, is carried out only when there is a great bone loss. Implant failure, such as screw loosening or secondary malalignment, is not seen.

Adult↗
PubMed2003

Residual challenges after healing of congenital pseudarthrosis in the tibia.

The purpose of the current study was to evaluate the clinical results of the Ilizarov bone transport method in the treatment of congenital pseudarthrosis in the tibia. In seven patients operated on between 2.6 and 7.8 years of age, primary healing of the pseudarthrosis was achieved in all patients (after additional bone grafting in two patients). Within a followup of 6 to 8 years, major complications occurred in all patients. Five refractures occurred, and in one patient the refracture did not heal. At the last followup, axial deformities and an abnormal malalignment test with lateral mechanical axis deviation of 10 mm or greater was found in all patients. Three patients had leg length inequality of 20 mm or more. The Ilizarov bone transport method is useful in achieving primary healing in congenital pseudarthrosis of the tibia, but residual challenges with secondary reconstructive surgery caused by refracture and postoperative deformities must be expected.

Bone Transplantation↗
PubMed2002

Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results.

BACKGROUND: We assessed the role of acute total hip arthroplasty in a selected group of patients with a displaced acetabular fracture and complicating features that greatly diminished the likelihood of a favorable outcome after open reduction and internal fixation. METHODS: Between 1985 and 1997, fifty-seven patients underwent an acute total hip arthroplasty for a displaced acetabular fracture. Patients were followed for a mean of 8.1 years (range, two to twelve years). The mean time from the injury to the arthroplasty was six days (range, one to twenty days). The mean age of the patients at the time of the arthroplasty was sixty-nine years (range, twenty-six to eighty-nine years). Indications for the acute arthroplasty included intra-articular comminution as well as full-thickness abrasive loss of the articular cartilage, impaction of the femoral head, and impaction of the acetabulum that involved >40% of the joint surface and included the weight-bearing region. RESULTS: At the time of the latest follow-up, the mean Harris hip score was 89 points (range, 69 to 100 points); forty-five patients (79%) had an excellent or good outcome. There were six cases of heterotopic bone formation, including one of symptomatic grade-IV ossification. During the initial six postoperative weeks, the acetabular cups subsided an average of 3 mm medially and 2 mm vertically. All of the cups then stabilized, and none were loose at the latest follow-up evaluation. Six patients had excessive medialization of the cup, but none had late loosening or osteolysis. Nine cups (16%) had notable polyethylene wear, but none were revised. No cup or stem had late clinical or radiographic evidence of loosening. There were three late procedures: one for revision of a malaligned cup because of recurrent dislocations, one for removal of hardware from the greater trochanter, and one for excision of heterotopic bone. CONCLUSIONS: In selected patients with a displaced acetabular fracture that has a low likelihood of a favorable outcome after fracture treatment, an acute total hip arthroplasty may provide an alternative means with which to achieve a painless, mobile hip. These complex procedures are best undertaken by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty.

Acetabulum↗
PubMed1998

Subtalar distractional realignment arthrodesis with wedge bone grafting and lateral decompression for calcaneal malunion.

BACKGROUND: The purpose of this study was to evaluate prospectively the efficacy of subtalar distractional realignment arthrodesis in the treatment of calcaneal malunion associated with subtalar arthritis, collapse of height, talonavicular subluxation, malalignment of the heel axis, and widening heel with calcaneofibular abutment. METHODS: Thirty-four patients with severe calcaneal malunion were treated with a lateral approach, lateral decompression, medial subtalar capsulotomy, and distraction and realignment of the subtalar joint with an anteriorly and laterally tapered wedge bone graft. The patients were evaluated with a functional rating scale and radiographs, both before and after surgery. RESULTS: Thirty-two of the 34 patients were evaluated at a mean of 71 months (range, 60-92 months) after the arthrodesis. Solid subtalar fusion was achieved in 31 of the 32 patients. The average gain of subtalar distraction was 12 mm. Neutral or mild valgus alignment was achieved in 26 of the 32 patients. The mean postoperative score (83) showed significant improvement over the mean preoperative score (47). Overall, the functional rating scale revealed excellent or good results in 26 patients and fair results in 6 patients. CONCLUSION: Coupled with wedge bone grafting, the subtalar distractional realignment arthrodesis achieved restoration of hindfoot height and axial alignment with a good union rate and significant improvement in the majority of patients with calcaneal malunion.

Adult↗