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PubMed2006

Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal.

OBJECTIVE: The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled. INTERVENTION: Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used. MAIN OUTCOME MEASURES: Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function. RESULTS: There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion. CONCLUSIONS: Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome.

Adolescent↗

PubMed1988

Ender nails for segmental tibial fracture. Early weight bearing in 22 cases.

Twenty-two consecutive segmental tibial fractures were treated by Ender nails and early weight bearing. Sixteen fractures were closed and six open. All the fractures healed after an average time of 4 months. No infection was encountered. Slight malalignment of the distal metaphyseal segment occurred in 5 cases, but all of them had full knee and ankle function.

Adult↗

PubMedDate not supplied

Femoral shaft fractures during childhood.

The treatment of femoral shaft fractures in the child is influenced by the anatomophysiological peculiarities of the bone in childhood. The authors report a personal series of 51 fractures treated surgically (Kuntschner, Rush, Kirshner, external fixator), and they analyze the most significant aspects of fractures of the diaphyseal segments during childhood: post-fracture lengthening and the ability for post-fracture malalignment to self-correct. Also considered are the different methods of treatment, emphasizing advantages and disadvantages (from an economical point of view, as well), to emphasize the authors' therapeutic orientation. Under 6-7 years: trans-skeletal traction for 5-6 days, reduction in narcosis without expecting to achieve anatomical reduction, pelvipodalic plaster. Over 10 years: surgical indications are more frequent, until they are the same as those for adults aged over 13-14 years. Between 7 and 10 years of age is a no man's land, where indications for surgery must be made based on the individual surgeon's experience.

Adolescent↗

PubMed1994

Paget's disease of bone: orthopedic complications.

Orthopedic complications of Paget's disease are among the most common indications for treatment of Paget's disease. These complications include severe bone pain, joint pain, skeletal deformity, pathological fracture, and rarely malignant degeneration. The use of effective pharmacological modalities has transformed the treatment of Paget's disease in the past four decades. Although few patients with Paget's disease ever require surgical therapy, successful surgical management of severe orthopedic complications has improved the quality of life for many sufferers. Selected modalities with promising results include total hip replacement for intractable pagetic arthritis of the hip, proximal tibial osteotomy for painful malalignment of the knees, total knee replacement for intractable arthritis of the knee, and internal fixation for pathological fracture. Common surgical complications of joint replacement include infection, hemorrhage, heterotopic ossification, and aseptic loosening. The medical, surgical, and rehabilitation modalities available in managing primary and secondary orthopedic complications of Paget's disease provide a wide array of options that must be carefully considered in each patient.

Arthroplasty↗

PubMedDate not supplied

Open fractures. Long-term results in 200 consecutive cases.

Two hundred consecutive patients admitted with 214 open fractures were reevaluated 6--10 years following injury. All patients were seen in follow-up by the authors. The average hospital stay was 36 days. Many of the patients sustained multiple injuries in automobile accidents. Concomitant head, chest or abdominal trauma occurred in 41% of the patients; 38% sustained multiple fractures. The average patient achieved full weight-bearing at 28 weeks. Late complications were infrequent. All postoperative bone infections (7%) were eradicated with appropriate treatment an average of 27 months postinjury; all of the infected fractures united, and no major limitations of motion resulted. Roentgenograms taken an average of 8 years postinjury revealed only 9 patients with major joint incongruities or arthritic changes. All of the fractures were united except for one with an asymptomatic fibrous union of the patella. Anatomic restitution was possible in most patients. Only one patient had an axial malalignment which necessitated correction by osteotomy and 6 patients had shortening of 1 cm or less. The functional results were excellent with only minor limitations of motion having been found in 25 patients. Disability payments were made to 39 patients and all patients (except for the one who retired due to age) had returned to their prior jobs.

Femoral Fractures↗

PubMed1987

Locked flexible intramedullary nails in treatment of unstable femoral fractures.

Twenty patients with unstable femoral fractures were treated with distally locked flexible intramedullary nails. We present our surgical technique and our results. The method has the following advantages: it prevents rotational malalignment and shortening, it is a closed procedure, no reaming is necessary, there is no increase in c-arm time, and there is minimal increase in operative time. Locked flexible intramedullary nails should be used in patients with unstable femoral fractures who have dense metaphyseal bone. Osteopoenia is a contraindication to this method as it increases the risk of nail penetration into the hip.

Adolescent↗

PubMed1993

Direct leg lengthening.

Twenty patients with an average posttraumatic leg length shortening of 4.6 cm (range 2.5-9) underwent direct leg lengthening. The operation time averaged 210 min and the peroperative blood loss was 1,800 ml. Angular and rotational malalignment, when present, were corrected. Lengthening averaged 3 cm. At follow-up, two patients had serious sequelae after vascular injuries. Seven patients had postoperative neurological complications, which in four cases resolved completely. The time required for solid union of the lengthened segment averaged 10 months. Bone grafting two or more times was performed in six patients. Seventeen patients were assessed an average of 7 years (range 3-10) after surgery. Thirteen of these were satisfied with the results of the lengthening. Complications of the procedure and/or a remaining major leg length inequality could explain the dissatisfaction of the others. A majority of the patients complained of low-back pain both preoperatively and at follow-up. Few complaints about the joints in the long leg were expressed. Preoperative pain about the hip and knee in the short leg existed in more than half of the patients, and these complaints were reduced on a weak statistical level at follow-up. Walking ability improved in 12 patients, working ability in 10, and recreational activity level in eight. Direct leg lengthening is generally regarded as major, demanding surgery, entailing potential risks of serious complications, and should be used with great care and only in selected cases.

Adolescent↗

PubMed1989

Posterior extensive simultaneous multisegment decompression with posterolateral fusion for cervical myelopathy with cervical instability and kyphotic and/or S-shaped deformities.

From June 1978 to May 1988, posterior decompression with posterolateral fusion was performed at Tenri Hospital on 63 cases of cervical myelopathy with instability and/or malalignment including kyphotic and/or S-shaped deformities. Among 46 cases followed up for more than 1 year, 41 cases (89.1%) improved; 21 cases (45.7%) were rated excellent, six (13%), good; 14 (30.4%), fair; one (2.2%), unchanged; and four (8.7%), poor. On x-ray examination, bone consolidation at the bone implanted area was satisfactory in 30 cases (65.2%). Cervical instability disappeared at 55 cervical interspaces of 40 cases (78.6%). Displacement at unstable interspace disappeared or improved at 49 of 61 cervical interspaces (80.3%). Although cervical kyphosis or S-shaped deformity could not be improved, accelerated progression of these deformities appeared to be prevented.

Adult↗

PubMed1991

[Principles and pathogenesis of post-traumatic axial malalignment in the growth years].

Deviations of the axis or leg-length discrepancies after fractures in children and adolescents can be due to growth disturbances or can be the result of incomplete reduction of the fracture. We distinguish between four types of growth disturbances. In type I, the overall growth activity of the cartilage is increased; growth is then enhanced, which results in the affected bone being too long without deviation; this usually occurs after fractures of the metaphysis or diaphysis. In type II, activity, the epiphyseal cartilage is severely impaired or completely arrested. The direction of growth is unchanged. This results in shortening of the bone, usually due to severe damage to the germination zone of the growth cartilage after destruction of the vessels or infection. In type III, growth of the epiphyseal plate is partially stimulated. The consequence of this disturbance is deviation of the axis with overgrowth (this is in fractures of the proximal tibia). Type IV is characterized by an asymmetric arrest of growth. This results in deviation of the axis and shortening. The cause of such growth arrest can be epiphyseolysis or epiphyseal fracture. The defect in growth cartilage heals with a bone bridge. This is a very serious kind of growth disturbance, and it occurs in only 1% of all fractures before skeletal maturity. Correction after incomplete reduction of fractures during growth can be direct or indirect and specific or nonspecific. Direct corrections occur in combination with fracture healing; indirect corrections occur with physiological changes of the growing skeleton without association with the healing process.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1984

Surgical management of torticollis.

Torticollis is a clinical sign of either CNS or musculoskeletal dysfunction. Thorough clinical and neuroradiographic evaluation is indicated for determination of the source, course, and exact nature of the deformity before a considered approach to surgical management is undertaken. Torticollis of neurogenic origin is managed by surgical decompression of the brainstem or cervical spinal cord when indicated, as in the presence of hydrocephalus, the Arnold-Chiari malformation, syringobulbia , syringomyelia, colloid cyst of the third ventricle, or neoplasms in the third ventricle, posterior fossa, or cervicomedullary junction. In progressive and medically refractory cases of spasmodic torticollis, neuroablative procedures, neuroaugmentive procedures, selective muscle excisions, and radical cervical muscle excisions have been used to control the dystonia. Torticollis of musculoskeletal origin is often secondary to or associated with trauma, although congenital craniocervical anomalies may be a predisposing factor. The primary goals of surgery for craniovertebral or upper cervical spine deformity are reduction of the malalignment; decompression of the brainstem, cervical spinal cord, and/or nerve roots if necessary; and stabilization of the upper cervical spine.

Arnold-Chiari Malformation↗

PubMed2006

Patellofemoral joint kinematics in individuals with and without patellofemoral pain syndrome.

BACKGROUND: Patellofemoral pain syndrome is a prevalent condition in young people. While it is widely believed that abnormal patellar tracking plays a role in the development of patellofemoral pain syndrome, this link has not been established. The purpose of this cross-sectional case-control study was to test the hypothesis that patterns of patellar spin, tilt, and lateral translation make it possible to distinguish individuals with patellofemoral pain syndrome and clinical evidence of patellar malalignment from those with patellofemoral pain syndrome and no clinical evidence of malalignment and from individuals with no knee problems. METHODS: Three-dimensional patellofemoral joint kinematics in one knee of each of sixty volunteers (twenty in each group described above) were assessed with use of a new, validated magnetic resonance imaging-based method. Static low-resolution scans of the loaded knee were acquired at five different angles of knee flexion (ranging between -4 degrees and 60 degrees). High-resolution geometric models of the patella, femur, and tibia and associated coordinate axes were registered to the bone positions on the low-resolution scans to determine the patellar motion as a function of knee flexion angle. Hierarchical modeling was used to identify group differences in patterns of patellar spin, tilt, and lateral translation. RESULTS: No differences in the overall pattern of patellar motion were observed among groups (p>0.08 for all global maximum likelihood ratio tests). Features of patellar spin and tilt patterns varied greatly between subjects across all three groups, and no significant group differences were detected. At 19 degrees of knee flexion, the patellae in the group with patellofemoral pain and clinical evidence of malalignment were positioned an average of 2.25 mm more laterally than the patellae in the control group, and this difference was marginally significant (p=0.049). Other features of the pattern of lateral translation did not differ, and large overlaps in values were observed across all groups. CONCLUSIONS: It cannot be determined from our cross-sectional study whether the more lateral position of the patella in the group with clinical evidence of malalignment preceded or followed the onset of symptoms. It is clear from the data that an individual with patellofemoral pain syndrome cannot be distinguished from a control subject by examining patterns of spin, tilt, or lateral translation of the patella, even when clinical evidence of mechanical abnormality was observed.

Adult↗

PubMed2001

On longitudinal bone growth, short stature, and related matters: insights about cartilage physiology from the Utah paradigm.

Precursor cell division in growing cartilage determines human height, the lengths of the spine and limb bones, the alignment of joints, spines and limbs, and the ratio of spinal length to limb length. That division also helps to determine the sizes and shapes of joints, apophyses and epiphyses. Ideas about what controls those facts are changing. To former views, in which mainly genetic and humoral factors controlled them, the Utah paradigm of skeletal physiology adds long-overlooked biomechanical including muscular factors. These three kinds of factors would collaborate in controlling the precursor cell division that determines the above skeletal features. Problems with that control clearly cause or help to cause many clinical disorders. Examples include short stature, gigantism, premature and delayed skeletal maturation, some changes in fracture patterns associated with puberty, joint malalignments, congenital hip dysplasia, scoliosis, limb torsions, the ball-and-socket ankle, and some skeletal abnormalities in Marfan's syndrome and the osteochondrodystrophies. The physiology such things depend on has matured sufficiently to justify a review for pediatricians, endocrinologists and other clinical specialists, and many basic scientists.

Animals↗

PubMed1995

Late open nailing for neglected femoral shaft fractures.

The results of open nailing in 14 cases of neglected closed femoral shaft fractures were reviewed. The mean patient's age was 28 years (range, 17-50). The mean delay to definitive treatment was 4.6 months (range 2-10). All fractures were malaligned with an average shortening of 4.9 cm (range 2.5-6.5). All cases underwent one-stage open nailing using the Küntscher nail fixation. The femur was shortened at the fractured end of one or both fragments to accomplish reduction in nine cases. The mean length of the bone resected was 9 mm (range 5-15). Only local callus was used for bone grafting in all cases. There were no neurovascular complications. All fractures healed an average of 3 months (range 2-4) after operation. Six cases had regained full knee flexion at the time of the latest follow up. Eight cases had decreased knee flexion with an average arc of knee flexion of 119 degrees (range, 100-125). The mean length of hospital stay was 7 days (range, 5-12). The method was found to be safe and effective with acceptable shortening and knee motion.

Adolescent↗

PubMed1976

Effects of collagenase upon the intervertebral disc in monkeys.

The authors studied 5 rhesus monkeys for the effects of annulotomy, with or without the addition of a bacterially-derived collagenase into the nuclear-evacuated centrum of lumbar intervertebral discs. The animals were sacrificed from 3 weeks to 21 months after the single or staged double procedures. The earliest radiographic changes were loss of height of the interspace at 7 days, erosion of the vertebral body margins at 3 weeks, malalignment at 6 weeks, osteophytic formation at 3 1/2 months, sclerosis of vertebral body surfaces at 9 1/2 months, and fusion of adjacent vertebral bodies at 13 1/2 months. Pathological changes included early loss of disc convexity, focal new home formation, osteophytic new growth, through-and-through bone formation, irregular cystification, and disc replacement by hyaline fibrous tissue. Changes were reminiscent of those seen in humans with naturally acquired disc disease or aging of the disc. Injuries were produced in a tissue that probably has a limited scope of variation in reaction to insult.

Animals↗

PubMed2002

[Clinical trial with the distal femoral nail].

METHODS: The clinical results after DFN-osteosynthesis of n = 56 AO-classification 33A-fractures (32%), 33C-fractures (43%), 32X-fractures (21%) and treatment of non-union (4%) are presented. RESULTS: Follow-up was available for 54 fractures (96%) after a mean of 1.2 years (range 0.2-2.8 years). 95% of patients showed full-weight-bearing with a knee flexion of 120 (60-140) degrees. Extension-deficit > 10 degrees was observed in 5.4%. All fractures were consolidated. One soft-tissue infection, one partial loss of reduction and one implant failure were observed. A significant axial malalignment was found radiologically in 17%, a loosened spiralblade or locking screw in 7.4%. In 91% of cases the result was judged as good to excellent by patients. CONCLUSION: The mechanical stability of the implant allows a save osteosynthesis of unstable supracondylar and complete articular femoral fractures without additional bone grafting. Mechanical stability and minimal invasive operative technique permit a safe bone healing without major complications.

Adolescent↗

PubMedDate not supplied

Insufficiency fractures in patients with chronic inflammatory joint diseases.

OBJECTIVE: To describe the typical sites of stress fractures in the lower extremities and pelvis in rheumatoid patients (rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, ankylosing spondylitis). METHODS: Thirty-three patients with 52 stress fractures [mean age 44 years (range 11-73)] were studied at the authors' institution when they were being treated for their rheumatic diseases. Fourteen patients had RA, 9 JCA, 5 PsoA, and 5 SPA. Stress fractures were detected from patient documents and from series radiographs in suspected cases. In some cases magnetic resonance imaging was also performed. RESULTS: One patient presented with 5 fractures, 2 patients with 4 and 3 fractures, and 7 patients with 2 fractures each. Other patients (n = 19) had only one fracture each. The metatarsal (MT) bones were the most common site of involvement. Twenty-five of the 52 fractures were located on MT I-V. The second and third most common sites were thefibula (n = 13) and tibia (n = 6). All fractures of the lower tibia or fibula were associated with valgus malalignment of the ankle. CONCLUSION: If a patient with rheumatic disease experiences sudden and unexplained pain localised in the forefoot, above the ankle, below the knee, or in the pelvis, a stress fracture should be suspected. Patients with severe osteoporosis, high-load corticosteroid or methotrexate therapy, or marked joint deformity are at high risk of developing stress fracture.

Adolescent↗

PubMed1998

[Treatment of knee osteoarthritis].

Osteoarthritis of the knee is not a well defined illness, but is a result of different causes that may lead to joint failure due to chondral damage, synovial inflammation, subchondral bone formation, and the formation of osteophytes along the joint lines. The pathogenesis is unclear. We still lack treatment to cure the early process of chondral degeneration. The treatment of choice in early and moderate osteoarthritis of the knee is limited to counselling, physiotherapy, analgesics, and surgical correction of malalignment. Documentation is still lacking on chondral debridement and transplantation of the degenerated cartilage by cultured chondrocytes, periosteum or perichondrium. An effective and well documented treatment of end-stage osteoarthritis of the knee in the older population is replacement of the joint by a knee prosthesis.

Analgesics↗

PubMed2004

The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results.

OBJECTIVES: To report on the use of a new plating system in the treatment of high-energy tibial plateau fractures using minimally invasive stabilization techniques. DESIGN: Prospective, consecutive patient series. SETTING: University Level I trauma center. PATIENTS: Thirty-seven patients with 39 fractures of the tibial plateau were treated using specialty plates. All fractures were OTA class 41C. Ten of the fractures were open, including eight Gustilo and Anderson Type IIIA and two Type IIIB. Thirty-three patients with 34 fractures had follow-up of at least 12 months. INTERVENTION: Internal fixation with the Less Invasive Stabilization System (LISS, Synthes USA, Paoli, PA) using minimally invasive techniques. MAIN OUTCOME MANAGEMENT: To determine clinical outcome, time to union, fracture alignment, articular step-off, incidence of complications, Short Form-36 outcome scores, and Lysholm knee scores in patients with associated ligament injuries. RESULTS: All 34 of the fractures healed without additional surgical intervention or bone grafting. The mean follow-up in our series was 21 months, with a range of 12 to 38 months. Twenty-nine patients with 30 fractures had follow-up of greater than 1 year. The average time to radiographic callus was 6.1 weeks, and the average time to complete union was 15.6 weeks. The articular step-off average was 0.8 mm, with a range of 0 to 5 mm. The postoperative alignment demonstrated 1 patient with a malalignment of 5 degrees procurvatum and 1 patient with 4 degrees of valgus. There were two superficial wound infections and no cases of deep infection or osteomyelitis. CONCLUSIONS: The use of LISS plates appears to stabilize complex fractures of the tibial plateau with a low incidence of complications. The LISS system functioned well in maintaining alignment and obtaining union in these high-energy fractures.

Adult↗