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PubMed1997

Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures.

In a prospective study conducted between 1992 and 1995, displaced Müller type C2-C3 intraarticular fractures of the distal femur were treated using an indirect plate fixation technique and a lateral parapatellar arthrotomy for the direct reduction of the condylar block. There were 6 closed, and 2 open fractures (1 grade II and 1 grade IIIB). Following reconstruction of the articular block, the block was indirectly reduced and fixed to the shaft by a plate inserted by the retrograde method beneath the vastus lateralis. Transcutaneous/transmuscular screws were used to fix the plate to the shaft. Time to bone healing was 12 weeks (median range 8-17 weeks) after surgery without needing primary or secondary bone grafts. There were no infections or refractures. Except for one case which required a corrective osteotomy for 10 degrees of varus malalignment, there were no revisions. According to the Neer score, there were 6 excellent or satisfactory results, 2 unsatisfactory results, and no failures. At follow-up, there were 2 varus-valgus deformities greater than 5 degrees, 2 leg length discrepancies greater than 10 mm, and 2 rotational deformities of 15 degrees. The treatment results for complex supracondylar/intracondylar fractures of the distal femur obtained with this technique compare favourably with other reported series using different techniques without the added morbidity associated with autogenous bone grafting. However, the surgical technique is demanding and special care must be taken to ensure correct axial alignment.

Adult↗
PubMed2001

The use of trans-articular and extra-articular external fixation for management of distal tibial intra-articular fractures.

Twenty-nine consecutive cases of distal tibial intra-articular fractures treated by trans-articular or extra-articular external fixation techniques have been reviewed. Eleven cases were treated initially with a trans-articular dynamic axial fixator. Of these seven were converted to an extra-articular SHF, for a combination of poor ankle motion and delayed healing of the metaphyseo-diaphyseal dissociation (MDD). Three of these cases (two patients) required bone grafting for delayed healing of the diaphyseal component of the fracture. Apart from one refracture through the MDD, no major complications were seen. No deep infections and no angular malalignments were noted. There were 11 pin track infections. Subjective assessment using short form-36 (SF-36) questionnaires, however, revealed significant differences compared to a normal population particularly in physical function and pain at a mean follow-up of 21 months. Using Bone's criteria for assessment of range of motion there were 62% excellent and good results, which dropped to 53% when fractures with a metaphyseo-diaphyseal extension were included. The use of minimally invasive techniques of internal fixation and stabilisation with a Sheffield hybrid frame in the management of distal tibial intra-articular fractures has minimal complications. Trans-articular external fixation is a good primary treatment for badly comminuted articular fractures with poor soft tissue condition. Conversion to extra-articular external fixation is recommended for slower healing fractures allowing ankle movement and early weight-bearing. The presence of a MDD dissociation lengthens the treatment time significantly, adds to the morbidity and affects final outcome.

Adult↗
PubMed1984

[Indication and technic of interlocking nailing of the femur].

Between 1973 and 1982 we treated 569 fractures of the femoral shaft by means of osteosynthesis. The internal nailing was performed in 41.6%. We used an interlocking nailing in 170 cases, 116 times statically and 54 times dynamically. An open reposition was performed in 48.2%. With only a very small incision we exposed the area of the fracture to insert the reamer guide under control of the fingers into the distal part of the femoral shaft. By using this technique there is no danger of disposing the fragments in order to achieve stabilisation in the correct position. 52.4% of the patients were younger than 30 years and 25.9% older than 30 years and 25.9% older than 60 years. In all cases we observed an osseous healing, twice a secondary cancellous bone craft was necessary. As complications we had an infection rate of 2.9%, loosening of the bolt in 0.6%, axial malalignment greater than 10 degrees in 0.6%, a rotary malalignment greater than 10 degrees in 1.2%. We did not observe any refracture. Less complications can be observed in interlocking nailing in comparison with plate osteosynthesis. Technique, indication, mistakes, and dangers as well as careful timing of operation are discussed. In open fractures delayed osteosynthesis by means of interlocking nailing is to be preferred to primary plate osteosynthesis. Fractures fixed by interlocking nailing had comparatively less complications in fracture healing and especially no more shortenings and rotation deformities, but the advantage of early full weightbearing. The interlocking nail has a very important value in the management of femoral shaft fractures.

Adolescent↗
PubMedDate not supplied

The clinical significance of the complete type of suprapatellar membrane.

The plicae are synovial septa remaining in adult life that existed in early fetal life. The suprapatellar plica separates the suprapatellar pouch from the knee joint. The plica syndrome has clinical significance, which has been occasionally overlooked, but the pathophysiology of symptomatic plicae may be hard to explain. To evaluate the clinical significance of the suprapatellar plicae, the authors reviewed 34 cases in 23 patients with vague pain around the knee and a total septum of the suprapatellar plica at arthroscopic examination from September 1991 to December 1993. The follow-up period was from 6 months to 2 years and 9 months. The most common presenting symptom was chronic mild knee pain, aggravated by prolonged squatting or standing, with other patients reporting recurrent swelling, instability, giving-way, or a feeling of snapping. The objective findings include palpable band on the superomedial side, audible snapping, and local tenderness, but there were no significant abnormal findings in the laboratory. The radiographic findings were few, with sclerosis of the articular surface of the patella in 2(6%), malalignment in 1(3%), and mild degenerative change in 4 cases(12%). Five of 11 patients evaluated by bone scan had increased uptake around the patellofemoral joint, and 7 of 13 knees had a relatively small suprapatellar bursa on conventional arthrogram or pneumoarthrogram. At arthroscopy, a suprapatellar plicae with complete septum was identified in 30 of 34 cases (88%) and associated lesions presented as meniscal tears, loose body, and discoid meniscus without tear. The complete plicae were surgically excised under arthroscopic control in 30 patients and the results were excellent in 22 patients (73%), good in 5 (17%), and poor in 3 (10%)at 17 months follow-up; there were no failures. In our opinion, the complete suprapatellar plica is clinically significant in patients who have equivocal diagnosis of knee problems and further studies of the pathophysiology of complete suprapatellar plica are needed.

Adolescent↗
PubMed2005

Chronic asymptomatic contralateral wrist scapholunate dissociation.

BACKGROUND: The authors report a series of six patients who presented with scapholunate dissociation, with no significant contralateral antecedent trauma and no rheumatoid arthritis or congenital ligamentous laxity. Such patients may present with pain or a snapping/popping sensation in one wrist, undergo radiographs of both wrists, and are discovered to have scapholunate gapping bilaterally. The literature contains few reports of this condition, and this series of six is a relatively large one for this infrequently reported condition. METHODS: The six charts were reviewed retrospectively; each patient was asked to return for follow-up and radiographic examination and each participated in a telephone questionnaire about pain, activity changes, new treatments, and exacerbation of wrist problems. The average follow-up was 39 months, with a range of 6 months to 13.5 years. RESULTS: One patient with severe unilateral instability and persistent pain underwent soft-tissue surgical repair (Blatt reconstruction); another demonstrated unilateral dorsal intercalated segment instability with moderate pain symptoms but declined surgical reconstruction. The other 10 wrists, despite radiographically demonstrated widened scapholunate angles and rotatory subluxation of the scaphoid, had mild or no pain and no dorsal intercalated segment instability deformity. CONCLUSIONS: The evolution of the bilateral form of scapholunate dissociation seems to be benign unless dorsal intercalated segment instability deformity is present, which may then rapidly progress to degenerative arthritis and scapholunate advanced collapse wrist. Severe or minor repetitive trauma, inflammation, infection, tumors, and congenital ligamentous laxity have been etiologically implicated in scapholunate dissociation. The natural history of scapholunate dissociation involves volar rotation of the scaphoid and dorsal rotation of the lunate, progressing to malalignment and eventual arthrosis between the scaphoid and radius, the capitate and lunate, and the lunate and hamate bones.

Adult↗
PubMed1993

[Carpal instability].

Traumatic carpal instability implies that the normal relationships of the radiocarpal and mid carpal joint are distorted either statically or during dynamic stress. Normal kinematics of the carpus are dysfunctional. The causes of carpal instability are dissociation of the intercarpal ligaments on either side of the lunate, a so-called scapholunate dissociation or a luno-triquetral dissociation. Carpal instability nondissociative is generally due to a laxity or attenuation of the intrinsic ligaments of the carpus and are associated with deformity of the distal radius. Ulnar translation of the carpus on the distal radioulnar articular surfaces occurs with shear stretching of the origins of the radiocarpal ligaments. The radial styloid attenuation of the ligaments may result in abnormal motions of the carpal bones going from ulnar to radial deviation at which time a catch-up click may occur. Carpal instabilities are usually associated with malalignment of the lunate with respect to the longitudinal axes of the radius and capitate and tends to assume an extended position with scaphoid fractures or injuries to the scapholunate ligament, a palmar flexed position with injuries to the luno-triquetral area or the ulnar capsule.

Biomechanical Phenomena↗
PubMed2006

Intramedullary fixation of tibial shaft fractures using an expandable nail: early results of 54 acute tibial shaft fractures.

OBJECTIVE: To evaluate and present our experience using the expandable nail system for the treatment of acute tibial shaft fractures. DESIGN: Retrospective study. SETTING: Two level-1 trauma centers-University teaching hospitals. METHODS: Fifty-four consecutive patients were treated by this nail system for acute tibial shaft fracture. Two nail diameters were used, 8.5 mm and 10 mm. Operation, hospitalization and healing times, reaming versus nonreaming, isolated versus multiple injuries, and reoperations were recorded and analyzed statistically. RESULTS: Follow-up was obtained either until fracture healing or for a minimum of 1 year with an average of 14 months (12 to 24). All fractures healed in an average time of 72 days (21 to 204). The average healing times for patients treated with 8.5-mm and 10-mm nails were 77.2 days (27 to 204) and 63.4 days (21 to 121), respectively. Average operative time was 103 minutes (40 to 185) if reamed and 56 minutes (30 to 80) if unreamed. Average healing times were 65.4 days (21 to 190) if reamed and 79.5 days (42 to 204) if unreamed. There were 11 complications (20.4%) related to the nailing: 3 deep infections, 2 superficial infections, 2 bone shortenings of 1 cm secondary to nail protrusion in the knee, 1 compartment syndrome, 1 fracture propagation, 1 distal malalignment, and 1 delayed union. Hardware was removed in 6 patients (3 infections, 2 patients' request and 1 protrusion into the knee), and 1 additional patient underwent exchange nailing due to a delayed union. CONCLUSIONS: The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. This study demonstrates satisfactory healing and alignment for the treatment of tibial shaft fractures using this device. However, caution must be exercised when using this nail in cases of significant comminution and in cases where the fracture pattern involves the more proximal or distal aspect of the tibial shaft.

Adult↗
PubMedDate not supplied

The treatment of nonunions without electrical stimulation.

In most cases of nonunions, healing occurs with rigid fixation of the fragments alone and without any electric stimulation. Most non-unions are programmed by nature to unite. In the majority of cases, the bone ends are well vascularized, much more so than in fresh fractures. Therefore, grafting after rigid fixation is generally unnecessary. Autologous cancellous bone transplant, however, is essential in avascular and infected nonunions. Rigid fixation not only has a very high rate of union, but also the advantage that malalignment and shortening can be corrected and that functional after treatment is possible. Nonsurgical treatments, including electrical stimulation, may also produce union but cannot correct concomitant deformity or other disabling lesions of the limb.

Adult↗
PubMed1996

Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment.

We performed a prospective, randomised trial on 120 patients with redisplaced fractures of the distal radius comparing four methods of treatment. The four treatment groups, each containing 30 patients, were remanipulation and plaster, open reduction and bone grafting, and closed external fixation with and without mobilisation of the wrist at three weeks. The radiological results showed improvement in angulation of the distal radius for the open reduction and bone grafting group. Functional results at six weeks, three and six months and at one year, however, showed no difference between any of the four groups. The main influence on final outcome was carpal malalignment which had a statistically significant negative effect on function.

Adolescent↗
PubMedDate not supplied

Adult acquired flatfoot deformity at the talonavicular joint: reconstruction of the spring ligament in an in vitro model.

The mobile unilateral flatfoot deformity of chronic posterior tibial tendon insufficiency has been difficult to correct by soft tissue procedures. The procedures can decrease pain, but they do not always correct the longitudinal arch or relieve all the symptoms. Using 10 fresh frozen cadaveric specimens and a rig for stimulation of weightbearing, the deformity associated with chronic posterior tibial tendon insufficiency was produced by multiple ligamentous release and documented by AP and lateral radiographs. Reconstruction of the spring ligament using a ligament bone autograft from the superficial deltoid ligament was then performed and tested under load. The mean correction was within 2.5 degrees of normal (over or undercorrection) on both the AP and lateral radiographs with the specimens under load. Clinical Relevance. In posterior tibial tendon insufficiency, it may be possible to address the ligament as well as tendon insufficiency to gain a corrected arch. The success of such a procedure will depend upon adequate tendon and ligament reconstruction in a fully mobile deformity. Questions remain as to the adequacy of this ligament graft, and a stronger free ligament graft, as well as correction of any bony malalignment, may be required.

Ankle Joint↗
PubMed1997

Treatment of tibial and femoral bone loss by distraction osteogenesis. Experience in 28 infected and 14 clean cases.

42 patients with diaphyseal bone defects (25 tibial and 17 femoral) who were treated by radical debridement and bone transport are reviewed. Their mean age was 35 (10-64) years and there were 29 men. 19 patients had active infections with drainage and 9 were previously infected. After resection of the infected and necrotic bone, the intercalate defect averaged 6 (3-12) cm. The mean duration of treatment was 10 (20-52) months. Regeneration of the distraction gap was achieved in all 42 patients. Union at the target zone was achieved in 38, and in the remaining 4 cases consolidation was achieved by application of autogenous bone grafts. The infection was eradicated in all 28 patients treated for bone defects associated with infection, without the need for a second operation. Complications were not severe and did not affect the final results. Residual malalignment remained in 2 patients, 1 femur and 1 tibia, with 10 degrees and 8 degrees of varus deformity, respectively. The final leg-length discrepancy never exceeded 1.5 cm. Residual fixed flexion of the knee was left in 5 cases, but never exceeded 10 degrees. Loss of 5 degrees to 10 degrees of dorsiflexion of the ankle joint remained in 7 patients. There were no intraoperative or postoperative neurovascular damage or compartment syndrome. Psychological intolerance was seen in 1 young patient. All patients, but 3 returned to their previous occupation. Bone transport is a simple and safe method for successful treatment of diaphyseal bone defects.

Adolescent↗
PubMed2004

Telescoping vascularized fibular graft: a new method for treatment of congenital tibial pseudarthrosis with severe shortening.

Vascularized fibular grafts have proved reliable in the treatment of congenital pseudarthrosis of the tibia with a high success rate. However, severe shortening cannot be primarily corrected by this technique and requires a second-stage lengthening procedure. Ilizarov's method allows correction of shortening and axial malalignment together with the non-union. However, in the dysplastic type with severe shortening, corticotomy of the affected bone may result in delayed consolidation or recurrence of disease. In addition, the large distraction distance (equal to the amount of shortening plus the resulting defect after excision of the pseudorthrosis site) requires prolonged frame application, which may not be tolerated by the patient. We present a new technique combining vascularized fibular graft and Ilizarov distraction that allows simultaneous correction of shortening while treating the non-union in a single-stage operation. This method avoids corticotomy in the congenitally affected bone and markedly shortens the time of frame application.

Bone Diseases, Developmental↗
PubMed1989

[Indications for computerized tomography of the wrist joint and carpal bones].

Twenty-nine patients with thirty-one fractures of the distal radius and persistent pain or disability had computed tomography of the radio-carpal and distal radioulnar joint. We found incongruity of the distal radio-ulnar joint in six patients. Ten patients had a rotational malalignment in supination. Seven patients suffered from rotational malalignment in pronation. The ability to quantify rotational malalignment and to have images of the degenerative arthritis following these disorders without superimposition aids in selecting surgical treatment.

Adolescent↗
PubMed1998

Articular cartilage: degeneration and osteoarthritis, repair, regeneration, and transplantation.

The degeneration of articular cartilage as part of the clinical syndrome of osteoarthritis is one of the most common causes of pain and disability in middle-aged and older people. The strong correlation between increasing age and the prevalence of osteoarthritis, and recent evidence of important age-related changes in the function of chondrocytes, suggest that age-related changes in articular cartilage can contribute to the development and progression of osteoarthritis. Although the mechanisms responsible for osteoarthritis remain poorly understood lifelong moderate use of normal joints does not increase the risk. Thus, the degeneration of normal articular cartilage is not simply the result of aging and mechanical wear. However, high-impact and torsional loads may increase the risk of degeneration of normal joints, and individuals who have an abnormal joint anatomy, joint instability, disturbances of joint or muscle innervation, or inadequate muscle strength or endurance probably have a greater risk of degenerative joint disease. Recent work has shown the potential for the restoration of an articular surface. Currently, surgeons frequently debride joints and penetrate subchondral bone as well as perform osteotomies, with the intent of decreasing symptoms and restoring or maintaining a functional articular surface. The results of these procedures vary considerably among patients. Clinical and experimental work has shown the important influence of loading and motion on the healing of articular cartilage and joints. Experimental studies have revealed that transplantation of chondrocytes and mesenchymal stem cells; use of periosteal and perichondrial grafts, synthetic matrices, and growth factors: and other methods have the potential to stimulate the formation of a new articular surface. The long-term follow-up of small series of patients has shown that the transplantation of osteochondral autologous grafts and allografts can be effective for the treatment of focal defects of articular cartilage in selected patients. Thus far, none of these methods has been shown to predictably restore a durable articular surface to an osteoarthritic joint, and it is unlikely that any one of them will be uniformly successful. Rather, the available clinical and experimental evidence indicates that future optimum methods for the restoration of articular surfaces will begin with a detailed analysis of the structural and functional abnormalities of the involved joint and the patient's expectations for future use of the joint. On the basis of this analysis, the surgeon will develop a treatment plan that potentially combines correction of mechanical abnormalities (including malalignment, instability, and intra-articular causes of mechanical dysfunction), debridement that may or may not include hunted penetration of subchondral bone, and applications of growth factors of implants that may consist of a synthetic matrix that incorporates cells or growth factors or use of transplants followed by a postoperative course of controlled loading and motion.

Adult↗
PubMed2003

[Fixation of periprosthetic femur fractures with the less invasive stabilization system (LISS)--a new minimally invasive treatment with locked fixed-angle screws].

The Less Invasive Stabilization System (LISS) is a minimally invasive technique indicated for fixation of periprosthetic fractures. This new system allows percutaneous placement of cortical-shaft screws and fixation of the fracture with fixed-angle locked screws with minimal surgical exposure of the mostly osteoporotic bone and without disturbance of the existing total joint replacement. Immediate range-of-motion exercises are begun postoperatively. A retrospective clinical review of 5 patients (2 total hip arthroplasties, 3 total knee arthroplasties) was performed to describe indications, surgical technique, intra- and postoperative complications and patient follow-up. Indications are periprosthetic distal femur fractures, per- and supracondylar fractures. Contraindications are none, except existing medical comorbidities. Extraarticular fractures were treated via stab incisions over the lateral femoral condyle. Fractures with intraarticular displacement were fixed via an anterolateral parapatellar approach to the knee joint. After anatomic reduction of femoral condyles, articular fragments are fixed with Kirschner wires, followed by closed reduction aligning the articular fragments controlling length, axis and rotation. The LISS is introduced proximally under the M. vastus lateralis along the femur. It is fixed with self-drilling cortical shaft screws, locked fixed-angle screws both proximally and distally. Range-of-motion exercises are begun on the second day postoperatively. Time to full weight bearing averaged 6-8 weeks depending on clinical and radiological findings. Benefits of the LISS technique include the minimally invasive approach with increased primary stability using monocortical fixings thus eliminating the need for spongiosaplasty and blood transfusion. Disadvantages of the percutaneous placement of the LISS include malplacement on the femur, proximal screw pull-out and postoperative rotational and axial malalignment.

Aged↗
PubMed1994

The embryology of lower-extremity torsion.

The presence of torsional deformities in the lower extremities of otherwise normal children is based on a variety of developmental processes. With intrauterine maturation, both rotation and external compression of the extremities take place. These forces result in the normal molding and final position of the limbs. Torsion of the extremities is, thus, a normal embryological process. It is imperative for the treating physician to understand these factors in human development to decide which cases are significant deviations from normal torsion. Knowledge of the embryology and natural history of these conditions is a key to appropriate treatment of patients with torsional or angular malalignments.

Bone Diseases, Developmental↗