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PubMed1995

Angular limb deformity in a calf treated by periosteotomy and wedge osteotomy.

A carpus valgus deformity was diagnosed in a five-week-old Brown Swiss calf. The 45 degrees deformity was caused by the malaligned healing of a fracture of the left metacarpus after birth trauma. The deviation improved to 25 degrees after being treated with a semicircular lateral periosteotomy above the distal physis of the radius. A complete correction was made by means of a wedge osteotomy five months after the first treatment. A 20 degrees wedge of bone was removed. The metacarpus was stabilised with a seven-hole dynamic compression plate which was removed 12 weeks later. Thirty months later the calf was sold as a pregnant heifer at an auction of breeding cattle.

Animals↗

PubMed2005

Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant.

BACKGROUND: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures. METHODS: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months. RESULTS: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status. CONCLUSIONS: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant. LEVEL OF EVIDENCE: Therapeutic Level IV.

Adult↗

PubMedDate not supplied

Treatment of congenital pseudarthrosis of the tibia by the Ilizarov method.

Three cases of congenital pseudarthrosis were treated by the Ilizarov method. Consolidation was obtained by 3.5 months in three patients who had undergone several previous surgical procedures. Although the length of follow-up was short (maximum 3.5 years), consolidation occurred more quickly than by traditional methods. This technique also permitted both simultaneous correction of axial malalignment and leg lengthening. We think that this method has a place as a salvage procedure except where the distal fragment is very thin or dystrophic.

Bone Lengthening↗

PubMed2005

Cartilage restoration, part 2: techniques, outcomes, and future directions.

In part 1 of this 2-part Current Concepts article, the authors reviewed the basic science of normal articular and meniscal cartilage and its response to injury. They reviewed the historical perspectives and basic science behind these various methods and presented a rationale for patient evaluation, treatment selection, and timing. In part 2, the authors review the specific indications for the treatment of chondral injuries and describe the techniques and outcomes of the various treatment options, including palliative, reparative, and restorative procedures. In addition, they will examine specific complex clinical scenarios emphasizing treatment options of comorbid conditions including ligament instability, meniscal deficiency, and malalignment. A limited review of the application of these techniques in joints other than the knee will also be presented. A conceptual algorithm is developed to assist in clinical decision making.

Bone Transplantation↗

PubMed2002

Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain's tenosynovitis: a case report.

STUDY DESIGN: Case study. OBJECTIVES: To describe the use of conventional physical therapy interventions together with Mobilization With Movement (MWM) techniques in the treatment of an individual with a complicated scenario of de Quervain's tenosynovitis. BACKGROUND: The patient was a 61-year-old woman who presented with signs and symptoms consistent with de Quervain's tenosynovitis of the right hand. Range limitations in all motions of the right wrist and first carpometacarpal joint complicated her presentation. METHODS AND MEASURES: Physical therapy included conventional intervention with superficial heat, ice, iontophoresis, and transverse friction massage directed to the first dorsal tunnel. Conventional joint mobilization techniques addressed the motion limitations of the first carpometacarpal, radiocarpal, and midcarpal joints. In addition, MWM techniques were utilized to promote pain-free wrist and thumb mobility. The specific MWM techniques used with this patient involved active movements of the thumb and wrist superimposed on a passive radial glide of the proximal row of carpal bones. RESULTS: The described treatment regime, which involved conventional physical therapy interventions, along with MWM, aided in the complete resolution of this patient's impairments and functional limitations. CONCLUSION: The combination of conventional physical agents, exercise, and manual therapy, and the less conventional MWM techniques, proved successful with this patient. MWM involving the correction of minutejoint malalignments, coupled with active motion of the wrist and first carpometacarpal joints, was an effective and efficient adjunct physical therapy intervention. Because subtle changes injoint alignment may contribute to painful syndromes in the tendon complexes that cross a malaligned joint, use of MWM as a treatment technique warrants continued research.

Exercise Therapy↗

PubMed2005

[Internal fixation of sacroiliac joint disruption].

OBJECTIVE: Stabilization of the completely disrupted sacroiliac (SI) joint with two three-hole DC plates. INDICATIONS: Definitive treatment of the posterior pelvic ring in type C injuries (AO classification) with complete SI joint disruption, transiliac or transsacral fracture-dislocation of the SI joint with an insignificant, small fragment. Emergency stabilization of the SI joint following a laparotomy. CONTRAINDICATIONS: Poor general health of patient. Local soft-tissue damage. Rotationally unstable type B pelvic injuries. SURGICAL TECHNIQUE: Supine. Anterolateral approach to the iliac crest. Subperiosteal detachment of the iliac muscle. Debridement of the SI joint and reduction under direct vision. Stabilization of the SI joint with two three-hole DC plates inserted at an angle of 70-90 degrees. POSTOPERATIVE MANAGEMENT: Partial weight bearing on the injured side at 15 kg for 8-12 weeks with two forearm crutches. Implant removal 6-12 months after injury provided ankylosis has not occurred. RESULTS: In 27 patients with disruption of the SI joint consistent with a type C injury, the average displacement of the affected SI joint was 16 mm (8-30 mm). Complications relating to the osteosynthesis occurred as a deep infection in one patient, originating from a concomitant acetabular osteosynthesis. Iatrogenic nerve damage (lateral femoral cutaneous nerve) was present in two patients. 16 patients were followed up using radiologic techniques (pelvic, possibly inlet and outlet views, computed tomography). 13 SI joints healed in anatomic position. The malalignments observed were relatively slight (2-4 mm). There was no secondary implant failure. Almost all patients (n = 14) showed posttraumatic changes of the SI joint (osteophytes, arthrosis, ankylosis).

Adolescent↗

PubMed2004

Cervical spine injuries associated with lateral mass and facet joint fractures: new classification and surgical treatment with pedicle screw fixation.

To clarify the injury pattern, initial spinal instability, degree of discoligamentous injuries in cervical lateral mass and facet joint fractures, we retrospectively analyzed radiological parameters and introduced a new classification for these injuries. Surgical treatment was performed with cervical pedicle screw fixation (CPS), and overall neurological and radiological outcome was evaluated with a minimum follow-up period of 2 years. Lateral mass fractures were divided into the following four subtypes: separation, comminution, split, and traumatic spondylolysis. The sagittal and frontal alignments were evaluated at both mainly injured and adjacent spinal segments on radiographs. The initial discoligamentous injuries were investigated on magnetic resonance imaging in terms of their frequencies, subtype of injuries, and involved spinal levels. Anterior translation of fractured vertebra was demonstrated in 77% of lateral mass fractures, while 24% of anterior translation was observed, even in cephalad-adjacent vertebrae. On magnetic resonance imaging, signal changes in anterior longitudinal ligament (ALL) and intervertebral disc were demonstrated in 76% of caudal segments and 24% of cephalad segments adjacent to fractured vertebra of lateral mass fractures. The subtype analyses of lateral mass fractures demonstrated high rates of anterior translation in separation, split, and traumatic spondylolisthesis, as well as significant coronal malalignment in comminution and split types (p<0.05). Thirty-one patients underwent surgical treatments using a cervical pedicle screw fixation. The CPS provided the superior capability of deformity correction without pseudoarthrosis, as well as excellent neurological recovery. The average numbers of stabilized segments were minimized without serious complications. In separation, facet joint fracture, and fractures with mild lateral mass comminution, the single level posterior fixation can be considered. The significant unstable injuries of split and comminution type with coronal malalignment can be treated with exclusive two-level posterior stabilization with CPS. The initial evaluation of fracture subtypes helps to successfully minimize the stabilized spinal segment.

Adolescent↗

PubMedDate not supplied

Biomechanical considerations of multiple-component hip prostheses. Analysis of three failures of the Lippman transfixation hip prosthesis.

Three cases are presented and analyzed in which a Lippman Transfixion Hip Prosthesis had to be replaced because of the discomfort of the patient. In each case, there was evidence of wear between the head of the prosthesis and the flange. The different wear patterns indicated problems which exist in the alignment of component parts of the prosthesis. In each case there was low grade sepsis to which the debris may have contributed. Because of phagocytosis, amount of debris accumulation was difficult to evaluate. The factors which appear to have contributed to the amount of debris accumulation were: the length of time the prosthesis had been used; the degree of alignment and amount of debris which may be formed and is phagocytized; the degree of manufacturing control. The design of this prosthesis incorporated mechanical problems which are generally undesirable because of: the eventual deformation of the end of the pivot rod or hole in the head of the prosthesis: progressive loosening of the movement due to this and inherent malalignment; the difficulty in fabrication, assembly and installation of the prosthesis because of the multiplicity of parts; the difficulty in maintaining adequate control of surface finishes.

Arthroplasty↗

PubMed2006

[Intramedullary locked nailing in the treatment of proximal femoral fractures].

INTRODUCTION: The aim of the study is evaluation of results of operative treatment the proximal femoral fractures with intramedullary locked nailing. MATERIAL AND METHOD: In years 1996-2004 44 patients were treated because of proximal femoral fractures with closed reduction and stabilization with intramedullary locked nailing. There were 15 women and 29 men in average age 60 years (18-95 years). There were 2 femoral neck fractures and 42 peritrochanteric fractures. The fracture of femoral shaft in 2 patients accompanied the fracture of proximal part of femur. The morphology of fractures was estimated according to AO classification. Clinical results were evaluated with Harris hip score (HHS). RESULTS: The average follow up is 8 months (from 6 to 24 months). There was good reduction of 27 fractures on postoperative radiograms. The average 15 degrees of varus lack of reduction was noted in 17 peritrochanteric fractures (from l0 to 35 degrees). There were mainly 31.A.3 unstable fractures according to AO classification. 3 patients died during three postoperative months from causes not connected with operative treatment. 39 fractures united in the period from 10 to 16 weeks. Delayed union--after 6 months occurred in 2 persons. Fatigue fracture of intramedullary rods occurred to both of this patients. The average Harris Hip Score was 86 points (from 70 to 100 points) after union of fractures. CONCLUSIONS: (1) The use of intramedullary locked nailing in the treatment of fractures of proximal part of femur leads to union without additional immobilization. (2) Closed intramedullary locked nailing in the treatment of unstable intertrochanteric fractures is connected with the risk of varus malalignment of fragments, which does not delay union, but decreases functional outcome. (3) Proper operative technique decreases the number of intra- and postoperative complications.

Adolescent↗

PubMed2002

Revision ankle arthrodesis.

Between 1996 and 1999, we performed successful revision ankle arthrodesis for aseptic nonunion in 10 patients using external fixation with bone graft and an implantable bone stimulator. The etiology of the ankle arthrosis in the patients was post-traumatic in eight and rheumatologic in two. The average age of the patients was 54. On average, each patient had received 2.5 previous surgeries (range, 1 to 5) prior to the original fusion attempt. Fusion occurred in all 10 of these patients at an average of 12.8 weeks following revision (range, nine to 20 weeks). Complications occurred in two patients: one had a pin tract infection which resolved with local pin care and oral antibiotics; the second patient had a varus malalignment which was accommodated with orthotics. This patient also had a deep peroneal nerve neuropraxia which resolved with observation. We evaluated all 10 patients with clinical and radiographic examination, and determined their functional results for a duration of follow-up of 15 months (range, six to 36 months). Using a modification of the AOFAS ankle/hindfoot scoring system, the results were: three excellent, four good, two fair, and one poor. All but one of these patients were satisfied with the outcome of this procedure. Radiographic analysis supported good clinical alignment and solid fusion.

Adult↗

PubMed1983

Early surgical management of cleidocranial dysplasia: a preliminary report.

Cleidocranial dysplasia is an interesting syndrome for the dental practitioner. The failure of eruption of the permanent teeth is secondary to both a mechanical obstruction and a lack of resorption of the overlying bone. Various modes of treatment have been suggested to manage this problem. We feel that early surgical management with serial uncovering of the permanent teeth is the best choice. This treatment will probably need to be combined with orthodontics or prosthetic care, depending on the success of the surgical procedures. In both of our cases the erupting teeth have been malaligned and malrotated, necessitating subsequent use of orthodontic appliances. To our knowledge these patients are among the youngest patients with cleidocranial dysplasia to undergo this treatment. Our preliminary results are encouraging.

Child↗

PubMedDate not supplied

A dynamic biomechanical analysis of the etiology of adolescent tibia vara.

Biomechanical overload of the proximal tibial physis due to static varus alignment and excessive body weight has been implicated in the etiology of infantile tibia vara. Whether a similar pathophysiologic process applies to adolescent tibia vara is controversial, with poor consensus concerning the nature and significance of static knee alignment early in the course of the disease. This study examines the hypothesis that dynamic gait deviations to compensate for increased thigh girth associated with obesity (fat-thigh gait) could result in increased loading of the medial compartment of the knee during the gait cycle. Three-dimensional motion analysis was used to identify the kinematic/kinetic profile associated with fat-thigh gait. Gait deviations identified were dynamic stance-limb knee varus, increased stance-limb knee rotation, and swing-limb circumduction. Pathologic compressive forces were generated in an anthropometric model by using recorded fat-thigh gait deviations and clinically appropriate excessive body weight. This analysis supports the clinical observation that underlying static varus malalignment of the knee is not a prerequisite for the development of adolescent tibia vara and illustrates the significance of dynamic gait deviations when considering knee-joint loading.

Adolescent↗

PubMed2000

Comparison of ender nails, dynamic hip screws, and Gamma nails in the treatment of peritrochanteric femoral fractures.

Three hundred seventy-six patients with peritrochanteric fractures treated over a 10-year period were reviewed. In 85 patients treated with Ender nailing, the most frequent complications were leg shortening (34), external rotation failure (21), and postoperative distal gliding of the nails (7). In 183 patients treated with dynamic hip screws or a 95 degree condylar or a 130 degree blade plate, 3 presented with infection, 5 with instability, and 4 with femoral head necrosis. In 105 patients treated with Gamma nailing, the most serious complications were infections (3), inward rotation failure (2), postoperative bleeding at the insertion site (2), and shaft fracture (1). Because of its inherent instability, Ender nailing is no longer used. The implantation technique for the dynamic hip screw is safer and simpler than the various models of the ASIF blade plate. However, the dynamic hip screw has been superseded by the Gamma nail because of its absolute stability. In the beginning, Gamma nailing was technically more demanding with a higher number of intraoperative complications. In this study, the number of malalignments did not differ significantly between the dynamic hip screw (14) and the Gamma nail (11), but was high with Ender nailing (56).

Activities of Daily Living↗

PubMed2004

Correction of Madelung's deformity by the Ilizarov technique.

We present our experience with correction of Madelung's deformity by the Ilizarov technique. Seven patients (eight deformities) were treated by osteotomy of the radius with subsequent lengthening and angular correction. They were reviewed at a mean of 30 months (1.5 to 5.5 years). At the time of operation their mean age was 19 years (9 to 44). At follow-up all were free from pain and supination had improved by a mean of 34 degrees and pronation by 9 degrees. Flexion had increased in most cases with a median increase of 15 degrees, but only one patient gained further extension. Radial and ulnar deviation were increased by a mean of 6 degrees and 9 degrees, respectively. Radiographic measurements showed that the mean volar angulation had been reduced from 25 degrees to 11 degrees, ulnar inclination from 45 degrees to 30 degrees and carpal malalignment (volar translation) from 7 to 2 mm. The mean lengthening of the radius was 12 mm (6 to 25). All the patients were satisfied with the functional and cosmetic results.

Adolescent↗

PubMed2005

Pediatric skeletal trauma: a review and historical perspective.

Pediatric fractures are commonly classified into five types: plastic deformation, buckle fracture, greenstick fracture, complete fracture, and physeal injuries. The most important anatomic characteristic in the pediatric skeleton is the presence of growth plates and the thick periosteum. It is important to emphasize that just as adult intra-articular fractures require anatomic reduction, so do pediatric articular injuries. The periosteum in children contributes immensely to rapid fracture healing and helps in the reduction and in the maintenance of reduction. In this study, I review some basic principles for the treatment of fractures in children, the main complications of pediatric fractures, and the outcomes assessment in children. The main complications of fractures in children are malalignment, physeal arrest, and refracture cause by fast fracture healing. Nearly all fractures in children can be treated in a cast without worry about stiff joints or need for physical therapy to mobilize injured joints.

Bone Development↗

PubMed1991

Metatarsus primus varus. A statistical study.

A survey of 6000 schoolchildren discovered 36 cases of unilateral and 60 cases of bilateral hallux valgus, defined as a metatarsophalangeal angle of more than 14.5 degrees, measured on standing radiographs. Metatarsus primus varus was found not only in the early stages of hallux valgus but in the unaffected feet of children with unilateral hallux valgus. Adduction of the first metatarsal is not due to differential growth of the cortices of the first metatarsal nor is it a consequence of malalignment of the metatarsocuneiform joint. The intermetatarsal angle did not correlate with the angle of metatarsus adductus nor with the intercuneiform angle.

Anthropometry↗

PubMed1992

Femoral shaft fractures in the elderly treated with Grosse-Kempf slotted locked intramedullary nail.

Thirty-one femoral shaft fractures in patients over 60 years of age were treated with the Grosse-Kempf slotted, locked intramedullary nail and followed for a median of 24 months. The patients tolerated the operation reasonably well and the mortality was not higher than the mortality connected with femoral neck fractures. Three reoperations were performed due to intra- and postoperative complications. The main reason for the less satisfactory result was shortening > 2 cm after unstable dynamical locking. This occurred in 8 of 15 dynamically nailed fractures with locking screw(s) in one end of the nail only. A 9 cm shortening among these was the reason for one of the two poor results in the series. The other poor result was a malalignment of the distal fragment in a statically locked fracture. We conclude that locked intramedullary nailing is a good way to treat femoral shaft fractures in the elderly, the high subtrochanteric, midshaft and infraisthmic fractures.

Aged↗

PubMed1985

Osteochondral allografts in the treatment of osteonecrosis of the knee.

In summary, patients with spontaneous osteonecrosis of the knee requiring surgery were elderly and generally had late stage IV disease. They seemed to do better with osteotomy and debridement than with osteochondral allograft replacement because they could not tolerate restricted weight bearing. Patients with steroid-induced osteonecrosis did well initially after allograft replacement (6 to 18 months), especially in experiencing pain relief. However, because of the continuous use of high doses of steroids, revascularization of the allografts was poor, resulting in graft subsidence. Patients have better long-term results following osteotomy and debridement. Patients with traumatic osteonecrosis and osteochondritis dissecans had the best results following osteochondral allograft replacements. In conclusion, based on our series and others, our current surgical approach in the management of osteonecrosis of the knee is as follows: 1. In patients with spontaneous osteonecrosis with asymptomatic small lesions, nonsurgical treatment is recommended. For an asymptomatic or symptomatic large lesion with associated angular deformity, the active patient should have a tibial osteotomy for stages I and II and tibial osteotomy and debridement for stages III and IV. Less active patients with symptomatic stage III or IV disease should have unicompartmental or total knee prosthetic arthroplasty. 2. For steroid-induced osteonecrosis, osteochondral allografts are not recommended. If the patient's systemic disease has a limited prognosis, or if the patient has multijoint involvement, total knee or unicompartmental arthroplasty is warranted. If the patient has a good prognosis and is active, debridement with or without realignment should be performed. 3. For traumatic osteonecrosis in the younger patient or for osteochondritis dissecans, fresh osteochondral allograft replacement is recommended. High tibial osteotomy in combination with allograft replacement should also be done if there is associated malalignment. The realignment should be done prior to or simultaneously with the allograft (providing the osteotomy is done on the side of the joint opposite the allograft).

Adolescent↗