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PubMed2002

Orthopaedic crossfire--can we justify unicondylar arthroplasty as a temporizing procedure? in opposition.

The indications for unicompartmental arthroplasty are quite specific. Overall, there should be involvement of 1 tibiofemoral compartment, mild malalignment, and ligamentous stability. In a review of 250 osteoarthritic knees, these pathologic findings were present in 19 patients (8%). Technique, despite improvement in instrumentation, still is more demanding than tricompartmental knee arthroplasty, and failure to achieve an optimal arthroplasty occurs more frequently. In the literature, long-term results with unicompartmental arthroplasty have been inferior to tricompartmental arthroplasty. The concept that unicompartmental arthroplasty is a temporizing procedure is not a valid one in that the patient has to undergo another arthroplasty with all the risks of revision arthroplasty surgery. Many of these revision procedures require bone grafting or component augmentation. Tibial osteotomy remains the procedure of choice in younger, active patients with unicompartmental arthritis (in highly selected patients), and tricompartmental arthroplasty is preferred in older, lower demand patients.

Arthritis↗

PubMed2002

Surgical treatment for chronic radial head dislocation.

BACKGROUND: The treatment of chronic radial head dislocation remains controversial. High rates of redislocation and complications have been reported after surgery. In our view, correction of malalignment with ulnar osteotomy is the key to a good surgical result. METHODS: Since 1975, twenty-two patients were treated surgically for chronic radial head dislocation at our hospital. The procedure consisted of open reduction of a dislocated radial head followed by radial and/or ulnar osteotomy, with or without reconstruction of the annular ligament or by reconstruction of the annular ligament alone. The ages of the patients ranged from four to twenty years. In 1991, we modified the surgical technique by performing an oblique ulnar osteotomy with angulation and elongation and rigid plate fixation. Bone-grafting at the osteotomy site was also performed if necessary. A cast was applied with the forearm in neutral rotation and was worn for two to four weeks. Nine patients were treated with this modified technique. RESULTS: The mean interval between the initial injury and the reconstructive surgery was ten months. There were no serious surgical complications. Of the thirteen patients treated before 1991, four had a good reduction and seven had redislocation. Seven patients had restricted forearm rotation postoperatively. Of the nine patients treated with the modified osteotomy since 1991, seven had a good reduction. Two patients, who had had slight radial head deformity preoperatively, had subluxation postoperatively. Two patients had restricted forearm rotation. CONCLUSIONS: Since we modified our technique for ulnar osteotomy, good reduction of the radial head has been achieved without causing serious contracture. Both angulation and elongation of the ulna are required to allow the radial head to reduce.

Adolescent↗

PubMed2002

[Intramedullary nailing of adult femoral fractures].

OBJECTIVES: We evaluated the results of treatment of adult femoral fractures treated by intramedullary nails. METHODS: Sixty-two patients (15 females, 48 males; mean age 29 years; range 16 to 62 years) with 64 femoral fractures were treated by intramedullary nailing. Eighty-three percent of the fractures was closed and 17% was open. According to the Winquist (W) classification, there were 16 (25%) W0, 22 (34%) W1, nine (14%) W2, nine (14%) W3, and eight (13%) W4 fractures. The mean duration between trauma and surgery was 18 days (range 4 to 130 days), and the mean hospital stay was 25 days (range 11 to 142 days). Open and closed techniques were employed in 62 (97%) and two (3%) fractures, respectively. Nine fractures were unlocked; dynamic and static locking were performed in 39 and 16 fractures, respectively. In the open technique, secondary procedures involved grafting in 14 cases, cerclage in eight cases, grafting and cerclage in 10 cases, and grafting and screw fixation in one case. The results were assessed according to the criteria by Thoresen et al. The mean follow-up was 28 months (range 7 to 62 months). RESULTS: Fifty-one patients (80%) had satisfactory, 13 patients (20%) had poor outcome. All proximal locking screws (n=20) were successfully inserted, whereas 23 (24%) of 95 distal screws missed the nail holes. Complications included superficial infection (n=3), osteomyelitis (n=4), trochanteric bursitis (n=1), irritation of the skin by the distal screws (n=4), heterotopic ossification (n=6), shortening more than 1 cm (n=8), rotational malalignment greater than 10 degrees (n=2), migration of the nail through the knee joint (n=2), drill breakage while preparing the distal holes (n=2), knee range of motion below 100 degrees (n=6), and delayed union (n=2). CONCLUSION: Intramedullary nailing should be the primary indication for stable and unstable femoral fractures.

Adolescent↗

PubMed1984

Malalignment of the scaphoid after lunate dislocation.

The author emphasizes the sequelar displacement of the scaphoid which may follow reduction of perilunar dislocations. Horizontal tilting of the scaphoid with its proximal pole maintained in contact with the posterior rim of the radius, may be due scapholunate dissociation, and immobilization of the wrist in flexion after reduction. Surgical reduction should be accomplished through a dorsal route and may call for division of the posterior rim of the radius.

Carpal Bones↗

PubMed1985

[Late results following femoral shaft fractures in childhood].

The results of 102 children with fractures of the femur shaft treated by osteosynthesis with dynamic compression plates (DCP) in comparison to 87 children which underwent a conservative treatment by extension are presented. Of 329 patients in a 15-years period, 238 children had a follow-up examination with evaluable data and 49 patients were excluded because of a different therapy such as plaster traction, cast, osteosynthesis with screws or nails etc. The children were divided into two groups: series I from 1968 to 1977 and series II from 1978 to 1982. 19.6% of the patients had a residual difference of more than 1 cm in the length of the legs. Operated children were twice as often afflicted as the conservative group. The amount of difference in the length depended on the duration of instability and increased when several repositions were required in the conservative group, or when an operation was carried out secondary to inadequate traction therapy. Axial deviation was found to be much more common in the extended group (16.1%) than in the operated group, in which only 4% axial deviations persisted in series II when DC-plates were used exclusively. Predominant in the conservative group was a persisting antecurvation in 13 of 14 children. Residual rotation malalignment of significant degree was found only in the group treated by extension, while the operated group averosed at minor torsion deformities. Children with closed epiphysis on the date of examination, who had a persisting rotation failure, had been treated nearly exclusively by extension (50% versus 15%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1977

The risk of neurologic damage with fractures of the vertebrae.

The incidence of spinal cord injury with spine fractures and dislocations is approximately 14% of the total as ascertained from a survey of these injuries in Northern California, and 17% of traumatic spinal cord injuries gave no overt radiographic evidence of vertebral injury. Patients sustaining fractures of the vertebral bodies and posterior elements with some degree of malalignment of the spine had a 61% incidence of neurologic deficit. Injuries to the cervical spine most often produced neurologic damage, the incidence of neurologic deficit being 39%. Motor vehicle collisons continue to be the major cause of these injuries and the victim is usually a young adult male.

Acute Disease↗

PubMed1996

Treatment of deformity of the lower limb in adults who have osteogenesis imperfecta.

The Ilizarov method of lengthening was used to correct deformities of the lower extremity in six patients who had type-1 osteogenesis imperfecta, as categorized by Silence et al. The average age was thirty-one years (range, fourteen to fifty-one years). The deformities included shortening of four tibiae and three femora as well as an angular malalignment (average, 28 degrees; range, 20 to 40 degrees) of all four tibiae and one femur. One patient also had a non-union of the right femur. The average angular correction was 23 degrees (range, 20 to 30 degrees). The seven limb segments gained an average of 6.6 centimeters (range, two to eleven centimeters) in length. All limb-length discrepancies were corrected to within two centimeters of the length of the contralateral limb. At an average of three years and four months (range, one year and seven months to six years), the roentgenographic appearance of the fully matured bone was comparable with that of the original bone. There was no fractures or increases in the angulation of the segment of new bone. Two patients had pain when walking; it was related to a chronic pin-track infection in one and to osteoarthrosis of the ankle in the other. The functional status of four patients was improved and that of the other two patients was unchanged. All six patients were pleased with the outcome of the procedure. There was eighteen complications: stiffness of the knee in two patients; a peroneal nerve palsy in two; a superficial pin-track infection in three; and a deep pin-track infection, greater-than-normal loss of blood intraoperatively, loosening of two pins, worsening of the instability of the knee, and an infection in the knee in one patient each. In another patient, a Rush rod that had been placed before correction of the deformity migrated proximally and had to be removed after completion of the correction. There were five fractures.

Adolescent↗

PubMed1984

Pediatric foot surgery.

Muscle balance involves increasing or decreasing the relative strength of a muscle. It also includes redirection of muscle tendons to change their mechanical retrograde pull. Tendoachilles lengthening, gastrocnemius lengthening, anterior tendon teno-suspension, and the Kidner procedure exemplify this method. Muscle balancing is necessary whenever an imbalance exists. However, muscle balancing is usually only able to mildly effect joint position. It is important to eliminate a deforming muscle force and restore the balance of muscle power. Osteotomy to change internal bone shape is effective in pediatric foot surgery since malshape of the osseous structures is a major problem. The osteotomy is becoming a more important part of surgical treatment as a better understanding and recognition of the biomechanics of the foot and leg develops. The arthroerisis procedure for subtalar joint balance using implants is rapidly advancing. The concept that the subtalar joint can be balanced satisfactorily has been demonstrated. However, the lifetime implications are still unexplored. Joint stabilization with some motion still available at the subtalar is a leading concept in treating the foot. Fusion procedures are meant to realign malaligned joints and prevent further motion. They are applicable to pediatric foot surgery only in extreme conditions and in the growing foot at adolescence.

Adolescent↗

PubMed2000

Dia-metaphyseal distal tibial fractures--treatment with a shortened intramedullary nail: a review of 15 cases.

Fifteen patients were reviewed retrospectively with distal tibial fractures treated with a reamed intramedullary nail which had approximately 1 cm removed just distal to the lowermost locking screw. There were 15 patients (nine males and six females). All patients had returned to normal activities of daily living. Eleven patients could perform all leisure activities with no symptoms and three had only minor discomfort, which did not preclude sport. All fractures united, 12 uneventfully and three after a secondary surgical procedure. Three patients had malalignment defined as varus-valgus angulation or recurvatum of 5 degrees or greater. Whilst technically challenging, intramedullary nailing for dia-metaphyseal distal tibial fractures represents a safe and reliable method for managing these injuries. This represents the first report in the English Language literature specifically examining treatment with a shortened tibial nail.

Adult↗

PubMed1998

The role of fixation of the fibula in open fractures of the tibial shaft with fractures of the ipsilateral fibula: indications and outcomes.

To determine the indications for fibular fixation in cases of combined fractures of the tibia and fibula and the effect of fibular fixation on tibial healing, a retrospective study of open fractures of the tibial shaft with concomitant fibula fractures was conducted at a level one trauma center. Apparent indications for fibular fixation included the presence of a syndesmotic injury and location of fracture within the distal third of the fibula. No significant differences were found in the healing rates, incidence of nonunion and malalignment, or in the number of required subsequent procedures between patients who did and did not undergo fibular stabilization. These results suggest that fixation of the fibula in open fractures of the tibia and fibula has no effect on fracture healing or alignment. A randomized, prospective study is needed to properly validate these findings.

Fibula↗

PubMed2004

Percutaneous reduction of incipient malunion of phalangeal neck fractures in children.

PURPOSE: In this article we describe our treatment of partially healed malaligned fractures of the phalangeal neck in children. METHODS: This was a retrospective study of 8 pediatric patients with phalangeal neck fractures who presented late for care to Children's Hospital in Boston. All patients were diagnosed clinically and radiographically with advanced partial healing of their fracture in a malunited position of extension. The 8 patients were followed up until fracture healing and restoration of normal motion and function were achieved. RESULTS: A K-wire was inserted into the fracture site through the dorsal callus and used to mobilize the fracture fragment by breaking down the fracture callus and partially healed bone. The wire then was used as a lever arm for fracture reduction. A separate wire was used to pin the fracture percutaneously. CONCLUSIONS: This treatment corrects the loss of flexion that occurs with a malunion in the phalangeal subcondylar fossa. It is a minimally invasive procedure that avoids the soft-tissue dissection of an open procedure.

Adolescent↗

PubMed1998

Arthrodesis of the ankle: a critical analysis.

Arthrodeses of 81 ankles performed by a single surgeon were reviewed after a 12- to 74-month follow up. Average time to union was 13.8 weeks, and 71 (88%) of 81 ankles healed without a second surgery. Ten (12%) of the 81 ankles failed to unite. Of the 10 nonunions, two developed a dense fibrous union without screw failure, and eight underwent revisional surgery. Seven of the revisions united and one has a persistent nonunion. The transfibular approach was utilized, and specific factors related to this approach were assessed. A greater resection of the medial malleolus correlated to a longer healing time and to an increased rate of nonunion. Sixty (96%) of the 63 patients who returned for follow up had no signs or symptoms attributable to malalignment. The average postoperative score for ankle-hindfoot on the AOFAS evaluation was 74 points, and rate of the patient satisfaction was 65 (89%) of the 73 patients. There was no correlation between outcomes and patients ages. Greater tarsal mobility correlated with a higher postoperative score and to higher level of satisfaction.

Adult↗

PubMed2004

Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity.

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1-4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.

Adolescent↗

PubMed1993

K-wire fixation of supracondylar humeral fractures in children: results of open reduction via a ventral approach in comparison with closed treatment.

The morbidity and functional outcome of K-wire fixation of dislocated supracondylar humeral fractures in children after open reduction through a ventral approach were studied, using the results after closed reduction as a golden standard. A series of 49 children were evaluated retrospectively. Of these, 46 children could be included in the study, of whom 35 were treated with closed reduction (group A) and 11 were treated with open reduction via a ventral approach (group B). All fractures were splinted in plaster for 3 weeks postoperatively. Thereafter free active motion of the elbow was permitted. Our data show that open reduction via a ventral approach carries no morbidity. The time for full functional recovery was equal in both groups. Only one out of 11 patients showed mild varus deformity after open reduction, while this slight malalignment occurred in five of 35 patients after closed reduction. The final anatomical and functional results did not differ between the two groups. It can be concluded that K-wire fixation of dislocated supracondylar fractures in children gives excellent results and that open reduction via a ventral approach is a logical, safe and elegant alternative, if closed reduction fails.

Adolescent↗

PubMedDate not supplied

Supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning.

During the period from 1973 to 1978, 38 children with displaced supracondylar fractures of the humerus were treated at The Children's Hospital of Philadelphia by closed reduction and percutaneous pin fixation. The technical details of the procedure include (1) reduction under general anesthesia with adequate relaxation; (2) insertion of crossed pins from the medial and lateral side with the elbow in acute flexion; (3) and intraoperative clinical and roentgenographic examination of the pinned fracture with the elbow in extension to determine the adequacy of the reduction, with particular attention to the carrying angle. By Flynn's criteria acceptable results were obtained in 19 of the 25 patients studied. Three results were unacceptable due to cubitus varus of 2 degrees, 5 degrees, and 10 degrees, respectively, and three to loss of flexion. Although rotational malalignment occurred in 19 patients, as manifested by a change in shoulder rotation, in no patient was it clinically significant, either cosmetically or functionally. There were no neurologic or vascular complications from the treatment. This is a safe and reliable technique for obtaining and maintaining an excellent reduction in this difficult fracture while preserving vascular function.

Bone Nails↗

PubMed2000

Posterior locked lateral compression injury of the pelvis: report of three cases.

Lateral compression injuries to the pelvis typically result in a rotationally unstable and vertically stable condition including an impaction and compression fracture of the posterior pelvic ring. The operative and postoperative management, as well as the morbidity and mortality, of these fractures differs significantly from vertical shear injuries to the pelvis, which are characterized by vertical and rotational instability. We report on three unusual lateral compression injuries to the pelvis, resulting in a complete disruption of the pelvic ring with vertical and rotational instability, by definition. Nevertheless, in these patients, locking of the posterior pelvic ring with medial translation of the iliac wing anterior to the sacrum resulted in a pseudostable condition. Their high rate of fracture-related associated injuries and possible complications, as well as the malalignment of the pelvis, required surgical restoration of the pelvic ring. Fracture reduction was successfully performed through an anterior approach in one patient and a posterior approach in two patients; the posterior approach was preferred. Open reduction and internal fixation of these pelvic ring fractures can result in a satisfactory outcome if the associated injuries are successfully dealt with.

Adolescent↗

PubMed1986

Flexible medullary nailing of acute tibial shaft fractures.

In a nonrandomized prospective study, 111 tibial shaft fractures (55 closed, 56 open) were treated with flexible intramedullary nails. Open injuries were nailed immediately following irrigation and debridement in the vast majority of cases. Ninety-four percent of the fractures united in an average time of 18.8 weeks. There were seven nonunions (6.3%), all of which healed following a secondary procedure. Six patients demonstrated delay in union but healed their fractures within 26 weeks (5.4%). Five patients developed angulatory malunions between 6 degrees and 10 degrees after nailing (4.5%). Three patients had rotational malalignment requiring treatment (2.7%). There were four deep wound infections, which required irrigation and debridement (3.6%). In two cases the nails were retained and in two they were replaced with an external fixator. In one patient, chronic osteomyelitis developed. Flexible medullary nailing extends the indications for intramedullary fixation of tibial shaft fractures because maintenance of length, alignment, and rotation are usually possible.

Adolescent↗

PubMed2006

Double plating of unstable proximal tibial fractures using minimally invasive percutaneous osteosynthesis technique.

BACKGROUND: Double plating of proximal tibial fractures with traditional open osteosynthesis gives a stable fixation, but may be complicated by wound healing problems. Minimally invasive methods have been recommended to decrease the wound complication rates. We report the efficacy of double plating of proximal tibial fractures using a minimally invasive percutaneous technique. PATIENTS AND METHODS: 23 proximal tibial fractures in 23 patients (mean age 54 (36-78) years) were treated with double plating using a minimally invasive percutaneous technique. Functional and radiographic results were evaluated by a modified Rasmussen scoring system. RESULTS: All fractures healed. The average time for fracture healing was 19 (10-32) weeks. 21 patients had excellent or good clinical and radiographic results. 2 patients had a fair clinical result because of associated knee injuries. Complications included 1 case of shortening (1 cm) and 2 cases of mild malalignments (varus less than 10 degrees ). There was 1 case of superficial infection that healed after removal of the plate. No deep infections occurred. INTERPRETATION: Double plating using minimally invasive percutaneous technique can provide favorable results in the treatment of proximal tibial fractures.

Adult↗