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PubMed1983

The treatment of femoral fractures by cast-brace application and early ambulation. A prospective review of one hundred and six patients.

One hundred and six patients with 108 femoral shaft fractures were treated with a cast-brace. Ninety-eight cast-braces included an abdominal band and hip hinge. At follow-up three femora showed coronal malalignment that exceeded 9 degrees and sixty-nine showed varying degrees of sagittal malalignment (thirty-eight having anterior bowing and thirty-one, posterior bowing). Four patients regained only 100 degrees of knee flexion or less and four others had hyperextension of the knee of more than 10 degrees. Thirty-eight patients showed signs of knee instability but only four of them had symptoms of instability. Four fractures were treated operatively to correct excessive shortening or angulation and another fracture was bone-grafted to promote union. The mean shortening was 10.9 millimeters (standard deviation, 8.8 millimeters). Although the more comminuted of the eighty-five middle-third fractures shortened more than the others, the results of this method of treatment for these comminuted fractures were acceptable.

Adult↗

PubMed1999

Tibiotalar joint arthrodesis for the treatment of severe ankle joint degeneration secondary to rheumatoid arthritis.

The technical aspects of fusion of the rheumatoid ankle do not deviate from those in the post-traumatic or osteoarthritic ankle. Screw fixation can usually be achieved, and rarely is fixation failure a problem in rheumatoid ankle arthrodesis. If fixation is difficult because of deformity or bone quality, external fixation or locking intramedullary nails should be used. The placement of cannulated screws and adequacy of screw fixation has not been a problem (Fig. 13). Screw fixation provides compression and prevents rotation. The surgeon, however, needs to be assured that no screws invade the subtalar joint and that all threads are beyond the arthrodesis site. A washer may be necessary for further stability if this screw is not inserted at too great an angle. The authors have found that troughing out of the cortical surface of the tibia with a power bur aids in screw insertion. Not only does the trough act as a countersink, but it also provides a path for screw insertion and prevents palpable screw irritation. Malalignment is unforgiving. The foot must be placed neutral to dorsiflexion and plantarflexion. Equinus positioning places added stress on the tibia and a back-knee gait occurs. Approximately 5 degrees of valgus is recommended, and varus positioning is unforgiving. Internal and external rotation is determined by the position of the contralateral extremity. Nonunion does not seem to be a problem with rigid internal fixation to any greater degree in patients with RA. Despite this, patients may continue to have pain despite solid fusion, which can be caused by incomplete correction of deformity, painful internal fixation, or adjacent joint pathology. Additionally, patients may experience supramalleolar pain above the fusion site consistent with tibial stress fracture, which is more common if the subtalar or midtarsal joint is rigid or if the patient is obese. A rocker sole shoe with impact-absorbing soles used after brief periods of guarded mobilization in a removable walking cast alleviates this stress on the tibia. Neurovascular insult can be avoided with careful dissection direct to bone, incisions placed in nerve-free zones, and avoidance of plunging deep posteriorly-medially and anteriorly when dissecting and resecting surfaces. Arthrodesis of the tibiotalar joint in the patient with RA should be performed to relieve severe pain caused by advanced arthrosis. Achieving a solid arthrodesis does not seem to be a problem and provides the patient with pain relief; however, marked improvement in patient function and level of activity remains limited by the nature of RA and adjacent joint involvement.

Ankle Joint↗

PubMed1997

[Pediatric forearm fractures. Diagnosis, therapy and possible complications].

Nonoperative management of forearm fractures in children has a good outcome in over 90% of all cases. In our own series (n = 102) there were only six children (6.1%) with significant limitation (> 25 degrees) of forearm rotation. In these cases two out of four (50%) were located in the proximal third but only two out of 68 in the distal third. Indications for operative stabilization are the following: compound fractures, fractures associated with vessel and nerve injuries, joint fractures, dislocated fractures of the middle and proximal third, and Monteggia/Galeazzi injuries. As implants intramedullary devices are preferred. Twenty children were managed with elastic IM rods between 1994 and 1995 at our institution. At final follow-up all had a free ROM and a maximal axial malalignment of less than 5 degrees. In the region of the distal forearm K-wires are useful. Plates play a dominant role for corrections and nonunions; external skeletal stabilization is indicated for temporary fixation in compound fractures.

Bone Plates↗

PubMed2003

TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia--early results in 92 cases.

High Tibial Osteotomy (HTO) is an established treatment for unicompartmental osteoarthritis of the knee with malalignment. The classic procedure for correcting varus deformity is the lateral closed wedge osteotomy of the tibia with osteotomy of the fibula. The disadvantages of this technique are well known. Open wedge osteotomy from the medial side eliminates the risk of compartment syndrome and peroneal nerve injuries. A new fixation device (TomoFix) with an adapted surgical technique allows stable fixation of the osteotomy without the need to fill the osteotomy gap with bone grafts. In a prospective study, 92 consecutive cases were treated with this procedure. Bony healing with remodelling of the medial and posterior cortical bone was observed. Full weight-bearing was possible ten weeks after surgery. There were no implant failures. Complications included one delayed union, two revarisations and one deep infection.

Adolescent↗

PubMed2000

Open-door laminoplasty for cervical stenotic myelopathy: surgical technique and neurophysiological monitoring.

OBJECT: A modified technique of open-door laminoplasty for cervical stenotic myelopathy (CSM) is described, and the role of evoked potential monitoring in selecting patients for surgery and evaluating results is discussed. METHODS: Between October 1992 and October 1996, 33 patients with CSM underwent open-door laminoplasty. After surgery, in 27 patients (81.8%) different levels of clinical improvement were demonstrated, and in five of them (15%) full recovery was observed. The Japanese Orthopaedic Association score increased from 5 to 12 (mean 9.8) preoperatively to 8 to 14 (mean 11.6) postoperatively. At 1-year follow up, the N13 cervical response was restored in nine (75%) of 12 patients with isolated presurgical abnormality and in 57.1% of those with combined abnormalities of both N13 and P14 response. Although significant clinical improvement was observed in 82% of the cases, in 24 of 33 patients motor evoked potential abnormalities persisted at least at one explored level. CONCLUSIONS: Of several laminoplasty techniques, the one described here offers some advantages: preservation of biomechanical function of posterior muscular-ligamentous complex, prevention of laminar collapse, smaller degrees in reduction of range of cervical motion, stabilization of the spine with no postoperative malalignment, and maintenance of decompressive effect that avoids recurrent stenosis. Neurophysiological studies sometimes clarified neurological disorders that were only suspected on the basis of history and/or clinical examination, leading to early diagnosis.

Aged↗

PubMed1984

Current concepts of Paget's disease of bone.

Paget's disease of bone is a process of increased bone remodeling resulting in architecturally abnormal bone that may affect any area of the skeleton. Paget's disease may present with a wide variation in the clinical and radiographic picture. When symptoms arise, they depend on the site and the extent of skeletal involvement. The two major therapeutic agents available for medical treatment are calcitonin and diphosphonate. Surgical intervention in Paget's disease is indicated for (1) selected fractures, (2) severe disabling arthritis, and (3) extreme bowing deformities causing malalignment of weight-bearing joints.

Arthritis↗

PubMed1998

External fixation of lower limb fractures in children.

26 children with 29 lower limb fractures, between the age of 2 and 15 years, were treated with an external fixator. The average time to union and removal of the fixator was 71 days for femoral and 73 days for tibial fractures. Complications included pin problems in nine cases, two devices had to be replaced with a cast and one refracture. Leg length discrepancies were noted in five children and radiological malalignment in three. We recommend external fixation for all femoral shaft fractures and all open or dislocated tibial and tibia and fibula fractures beginning at the age of three to adolescence.

Child↗

PubMed1977

[Corrective osteotomy for malalignment of fractures of the distal radius (author's transl)].

Corrective osteotomy is indicated in young manual workers with significant malalignment after fracture of the distal radius without associated degenerative changes in the wrist joint. Chronic pain, limited motion and impaired power can be avoided and the cosmetic appearance of the hand improved, by restoration of the functional anatomy of the wrist. The operation consists of an opening-wedge osteotomy at the fracture site, sometimes combined with resection of the distal ulna. The approach may be dorsal or volar. A small iliac cortico-cancellous bone graft is inserted at the osteotomy site. Fixation is by an AO-small fragment-T-plate allowing early functional after-treatment.

Adult↗

PubMed1999

[Lisfranc arthrodesis after malunited fracture healing].

The causes of residual deformity with posttraumatic painful arthritis after tarsometatarsal (Lisfranc) fracture-dislocation with the need for correctional arthrodesis are in our experience (22 cases over 5 years) overseen injuries in one third, closed reduction and immobilisation or inadequate fixation technique with K-wires in another two thirds of cases. Foot malalignment and residual instability is assessed with weight-bearing radiographs of both feet, adduction/abduction stress films and CT scans for complex deformity. Correction is carried out via two longitudinal dorsal incisions, strict epiperiosteal preparation and debridement of the Lisfranc joint of all remaining cartilage, sclerosis and fibrous tissue. Reorientation begins, in the same manner as primary open reduction, with anatomical alignment of the second metatarsal base to the second cuneiform. Defects are filled with autologous bone grafting, stable fusion can be achieved with 3.5 mm cancellous compression screws. Full weight bearing is allowed in a modelled plaster shoe for 6 to 8 weeks. The functional medium-term results are convincing with 15 of 17 patients seen after 13 months of follow-up working full time. The Maryland Foot Score improved from 38.9 to 76.8 points in these patients.

Adult↗

PubMed1991

Intramedullary wiring for tibial shaft fractures in children before epiphyseal closure. Indications and technique--experience of 36 patients.

Between 1958 and 1987 36 children underwent intramedullary wiring for tibial shaft fractures. Of these, 29 presented with combined tibial and fibular fractures, and 7 showed isolated tibial shaft fractures. Fractures were simple in 22 and compound in 14 patients. Mean patient age was 13 years (4-16 years). Only bending fractures with and without splinters were wired. The wiring technique and the protocol for postoperative care are reviewed. Mean immobilization time in long-leg casts was 12 weeks; intramedullary wires were removed after a mean interval of 17.7 weeks. Patients were selected for intramedullary wiring because of compound fractures of variable severity (14 patients), brain injuries with associated fractures (1), relative separation of the fracture ends with the fibula intact (2), severe dislocation or expected instability following closed reduction (9), and secondary dislocation or unsatisfactory alignment on skeletal traction (9). Complications included infections of 2nd degree compound fractures (2 patients), transitory peroneal palsy (2) and delayed union (2). Non-union and damage related to immobilization were not seen. A total of 19 patients were available for follow-up. Mean follow-up time was 9 years. Posttreatment lateral displacement was found to be irreversible except in infants but had no functional relevance. Malalignment showed a tendency towards spontaneous correction, which decreased with increasing age. Correction surgery proved to be unnecessary. Differential longitudinal growth was not consistently evaluable because of the heterogeneity of the material; reported data on this parameter from the literature were equally inconclusive.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1986

Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques.

Seventy-six patients with severely comminuted distal radial fractures were treated at two institutions, of which the overwhelming majority were Frykman class VIII. Fifteen fractures were open. Thirty patients were seen at the University Hospital; 17 had pins and plaster and 13 had external fixation. Forty-six patients were seen at Kaiser Hospital; all had pins and plaster treatment. The complication rate for those with pins and plaster at the University Hospital was 53%; the complication for external fixation rate was 62%. The affiliated-hospital complication rate was 52%. All patients with ipsilateral forearm shaft and carpal fractures developed a nonunion of the carpal fracture. Few patients maintained anatomic reduction, and many had significant intra-articular malalignment. External fixation with threaded half pins did not obviate pin problems in our series. These methods may help manage severely comminuted distal radial fractures, but complications should be anticipated and alternative treatment considered, especially when ipsilateral carpal or forearm shaft fractures are present.

Adult↗

PubMed1993

Comminuted femoral shaft fractures treated by closed intramedullary nailing and functional cast bracing.

Eighty-one patients with comminuted femoral shaft fractures were treated by closed unlocked Küntscher nailing and functional cast bracing for 1 to 4 weeks postoperatively depending on the degree of comminution. The mean follow-up period was 27.6 months. The average time required for fracture healing was 14 weeks. There was one delayed union. One fracture united with more than 10 degrees of rotational malalignment; shortening of more than 1 cm was present in four cases. Two patients had more than 20 degrees of limitation of hip and knee movement.

Adolescent↗

PubMed1991

Neurologic complications of surgery for cervical compression myelopathy.

Neurologic complications resulting from surgery for 384 cases of cervical myelopathy (cervical soft disc herniation, spondylosis, ossification of the posterior longitudinal ligament) were reviewed. Surgical procedures performed included 134 anterior interbody fusions (Cloward or Robinson-Smith technique), 70 subtotal corpectomies with strut bone graft, 85 laminectomies, and 95 laminoplasties. Twenty-one patients (5.5%) sustained neurologic deterioration related to surgery. The deterioration was classified into two types on the basis of the neurologic signs observed: deterioration of spinal cord function or of nerve root function. Manifestations of the former varied from weakness of the hand to tetraparesis. Paralysis of the deltoid and biceps brachii muscles was an exclusive feature of deterioration in the nerve root group. Causes of this paralysis included malalignment of the spine related to graft complications, and a tethering effect on the nerve root following major shifting of the spinal cord after decompression. The causes of deterioration of the cord function included spinal cord injury during surgery, malalignment of the spine associated with graft complication, and epidural hematoma.

Cervical Vertebrae↗

PubMed2004

Risk factors for osteoarthritis: understanding joint vulnerability.

Joint damage occurs when structures protecting the joint fail. Because osteoarthritis consists of end-stage joint damage, I propose that risk factors for disease can be best understood as either impairments of joint protectors, increasing joint vulnerability, or as factors that excessively load the joint, leading to injury. I review current knowledge using this paradigm, separating factors into those increasing joint vulnerability (malalignment, muscle weakness, genetic and ethnic predispositions, aging) and those that cause excessive loading (obesity; certain physical activities). Osteoarthritis and cartilage loss can occur without pain. This review focuses separately on factors associated with pain in those with osteoarthritis. To identify sources of pain in osteoarthritis, recent studies have compared magnetic resonance imaging findings of people with osteoarthritis with and without pain, focusing on structures known to have nociceptive innervations. Those with pain are more likely to have effusions, bone marrow lesions, synovial hypertrophy, and tendinitis and bursitis around the joint. This review creates a new paradigm for understanding risk factors for osteoarthritis, using joint vulnerability and loading as a framework and focuses separately on the emerging investigative area of sources of pain.

Humans↗

PubMed1988

Fracture/dissociation of the polyethylene in metal-backed patellar components in total knee arthroplasty.

We encountered a complication that is unique to the use of a metal-backed patellar component in total knee replacement--namely, fracture and separation of the polyethylene bearing from its metal counterpart. The cases of seventeen patients who were treated at several institutions were studied. Patellar malalignment, especially in heavy patients who had a high level of activity, was a contributory cause of the complication, but we thought that deficiencies in the design of the prosthesis were also an important factor.

Aged↗

PubMed2004

Computer aided high tibial open wedge osteotomy.

High tibial osteotomy is a widely accepted treatment of medial compartment osteoarthritis as well as other lower extremity deformities. However, it is a technically demanding procedure. The lack of exact intraoperative real time control of the mechanical axis often results in postoperative malalignments, which is one reason for poor long term results. These problems can be addressed with the use of a surgical navigation system. Following exposure, dynamic reference bases (DRBs) are attached to the femur, and the proximal and the distal part of the tibia. After intraoperative measurement of the deformities and correction planning, the osteotomy is performed under navigational guidance. The wedge size, joint line orientation, and tibial plateau slope are monitored during correction. The in vitro evaluation with a plastic bone model suggests that the error of deformity correction is less than 1.7 degrees (95% confidence limits) in the frontal, and less than 2.3 degrees (95% confidence limits) in the sagittal plane, respectively. On a cadaver study of 13 legs, the mechanical axis intersected the Fujisawa line in 80.7% (range 77.5-85.8%). The preliminary clinical experience confirms these results. A novel computer tomography free navigation system for high tibial osteotomy has been developed that holds the promise of improving the accuracy, reliability, and safety of this kind of approach.

Adult↗

PubMed2005

Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy.

BACKGROUND: Functional loss and clinical evidence of hallux malalignment have been reported to follow isolated tibial sesamoidectomy. METHODS: Thirty-two patients with isolated tibial sesamoidectomies were identified. Patients with a diagnosis of peripheral neuropathy, diabetes mellitus, inflammatory arthropathy or previous foot surgery were excluded as were patients who had concomitant joint realignment procedures. Twenty patients were available for followup with the Short Form-36 (SF-36), Foot Function Index (FFI) disability scale, visual analog scale (VAS), and questionnaire at an average of 62 (range 10 to 157) months after surgery. Fourteen patients returned for physical examination, radiographs, and pedographic and isokinetic examination. RESULTS: Physical examination of the 14 patients did not reveal any significant change in clinical alignment, range of motion or tenderness. Preoperative and postoperative comparison radiographs did not reveal significant differences in the intermetatarsal (IM) angle, hallux valgus (HV) angle distal metatarsal articular angle (DMAA), or sesamoid alignment (sesamoid station). Postoperative outcome measurements (VAS, SF36, and FFI) for 20 patients found significant relief of pain and improved functional outcome. Computerized dynamic pedographic measurements (Performance Orthotic) for 12 patients did not reveal any altered plantar pressures in the region of the hallux metatarsophalangeal joint. Isokinetic measurements of ankle plantar flexion push-off strength in eight patients did not reveal significant differences in side-to-side measurements. Eighteen of 20 (90%) patients indicated that they were able to resume all preoperative activities; six (30%) had extreme difficulty or an inability to stand on tip toe, but this did not impact their activities of daily living or their athletic endeavors. Two patients (14.3%) developed transfer metatarsalgia, but only one was symptomatic. CONCLUSION: Isolated tibial sesamoidectomy is a safe and effective treatment for recalcitrant tibial sesamoiditis. Hallux malalignment and deformity resulting in functional loss and change in hallux alignment can be avoided by meticulous surgical technique with repair of the soft tissues.

Adolescent↗

PubMedDate not supplied

Lumbar spinal stenosis. Radiographic diagnosis with special reference to transverse axial tomography.

Spinal stenosis due to malalignment and/or hypertrophy of the bony margins of the spinal canal is a recognized cause of cauda equina compression and nerve root entrapment. The plain lumbosacral spine roentgenograms reveal the number of lumbar vertebrae, their alignment, their interpedicular distances, the height of the intervertebral disk spaces and the presence of osteophyte formation. It correlates poorly with encroachment on the spinal canal. The transverse axial tomogram directly demonstrates a cross-section of the spinal canal and will show abnormal areas of bone encroachment usually arising from hypertrophied lamina and articular processes. These narrow the posterior portion of the spinal canal and encroach on the lateral recesses. This examination does not demonstrate soft tissue hypertrophy and the stenosis may be even greater than what is apparent due to the bony encroachment. The myelogram expresses how the narrowed spinal canal affects the dural sac and its contained cauda equina. Not infrequently there is an associated herniated disk.

Constriction, Pathologic↗