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PubMed1989

Management of the traumatized joint of the finger.

Selection of the reconstructive technique for the traumatized joint requires a careful consideration of the condition of the injured and adjacent joints, the needs and desires of the patient, and an understanding of the advantages and disadvantages of the available options. The MP joint is the key to a useful arc of motion, providing 77 per cent of the total arc of flexion. Every effort should be made to preserve its maximum pain-free movement. PIP joint motion, although important in maintaining grip strength, can more readily be sacrificed to provide stability when MP joint motion is normal. Arthrodesis provides a pain-free stable joint with a sacrifice of motion. It may be indicated in young patients in whom heavy loading is likely; in joints with a fixed, painful deformity, instability, or loss of motor; and in the salvage of failed implant arthroplasty. Arthrodesis is generally contraindicated where physes are open. PIP joint arthrodesis is well tolerated in the index finger with minimal morbidity. Motion of MP joints and PIP joints of the long, ring, and small fingers, however, should be preserved using other techniques when possible. Resection arthroplasty may be useful in selected cases of post-traumatic arthroplasty where other treatment techniques are not available. Soft tissue interposition techniques are useful in specific cases. Eaton volar plate arthroplasty provides good results where 50 per cent of the articular surface is preserved. The technique, however, requires precision to avoid rotational malalignment. Perichondrial resurfacing provides a reasonable alternative in patients younger than 40 years of age who have a relatively well maintained joint contour, preferably involving a single joint surface. Prior infection is a relative contraindication. MP joints generally produce better results than PIP joints. Swanson interposition arthroplasty remains the most widely accepted implant technique, providing improved stability and earlier motion than simple resection arthroplasty. Reported arcs of motion range from a minimum of 29 degrees to a maximum of 85 degrees, with results generally better for MP than for PIP joints. Complications are common and include implant fracture, lateral instability of the PIP joint, and, occasionally, synovitis. Patient satisfaction, however, has been consistently reported as high. The use of Swanson arthroplasty in acute cases remains controversial, although several authors report favorable results. Silicone arthroplasty is contraindicated in joints with open physes. Allograft small joint reconstruction provides replacement bone and articular surface without donor site morbidity. Experience with the technique, however, has been limited. Increasing concern over the transmission of infectious diseases may make this option less desirable.(ABSTRACT TRUNCATED AT 400 WORDS)

Arthroplasty↗

PubMed1998

[Torsional abnormalities and length discrepancies after intramedullary nailing for femoral and tibial diaphyseal fracture. Computerized tomography evaluation of 189 fractures].

PURPOSE OF THE STUDY: We retrospectively determined by computed tomography torsionnal abnormalities and length discrepancies after diaphyseal tibial and femoral fractures treated by intramedullary nailing. MATERIAL: Eighty femoral fractures and 89 tibial fractures were evaluated after healing. All these patients were treated by Grosse-Kempf intramedullary locked nail. AO classification was used: there were 16 type A, 32 type B and 32 type C, femoral fractures. Tibial fractures were 48 type A, 29 type B, and 12 type C. Reaming was systematic, 90 per cent of the nailing were static. METHODS: We measured comparatively length and torsion of tibias and femurs after bone healing and tried to find statistical correlation between clinical, epidemiological, anatomical factors and CT measurements. RESULTS: For the femur the mean difference in torsion was 9.9 degrees (max. -21 degrees min. +45 degrees) 52.5 per cent had the same measurements in intact and fractured side. For tibias the mean torsionnal value was 6.84 degrees. Seventy three per cent of patients had the same torsion in intact and fractured side. The mean femoral length discrepancy was 6.3 mm (max. -25 mm min. +19 mm) and 4.1 mm (max. -19, min. 20 mm) for the tibia. There were no statistical correlation. DISCUSSION: Even though there is no clinical sign after torsionnal abnormalities in our patients, hip, knee or ankle arthrosis is possible after nailed shaft fracture. A long term follow-up is necessary. A prospective study will be necessary in order to assess the exact frequency of these malalignements.

Adolescent↗

PubMedDate not supplied

High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. A two- to seven-year follow-up study.

We assessed short-term treatment results of younger patients with varus malalignment and chronic anterior cruciate ligament deficiency. Forty-one patients (mean, 32 years; range, 16 to 47) underwent a high tibial osteotomy. Because of giving way symptoms, 14 also had a lateral iliotibial band extraarticular procedure at the time of the osteotomy and 16 had an intraarticular anterior cruciate ligament allograft reconstruction after the osteotomy. All returned for followup (mean, 58 months; range, 23 to 86), which included KT-1000 arthrometer testing and evaluation by our knee rating system. Statistically significant (P < 0.05) improvements were found in the mean overall rating scores for pain, swelling, and giving way. Preoperatively, 30 (73%) had pain with activities of daily living or with any sports activity; 11 (27%) could perform only light sports activities without pain. At followup, 32 patients (78%) had no pain with activities of daily living or light sports. Ten of 15 patients with advanced medial tibiofemoral arthrosis (subchondral bone exposure) had significant improvements in symptoms. Patient satisfaction was high: 88% stated they would undergo the procedure again and 78% felt their knee condition was improved. Patients who had the allograft reconstruction had significantly lower (P < 0.05) anterior-posterior displacements at followup than those who had the extraarticular procedure. We concluded that osteotomy should be performed early in the disease process for younger athletes who experience symptoms with activity. It may be unrealistic, however, to expect continuation of sports beyond light recreational, given the joint arthrosis that is usually present and the high in vivo joint loadings with athletes. Anterior cruciate ligament reconstruction should be considered when giving way previously occurred and the patient plans to resume athletics. However, patients with advanced arthrosis can avoid anterior cruciate ligament surgery by reducing athletic activities.

Adolescent↗

PubMed1989

Carpal malalignment in Colles' fractures.

Thirty-two unilateral Colles' fractures were reviewed after one year to assess the evidence for carpal malalignment. Various radiographic parameters on the injured and uninjured wrists were correlated with a functional score. There was significant correlation with respect to the angles measuring carpal alignment on the late films and the functional score which was not present on either the initial or post-manipulation films. The carpus aligns in a dorsal instability pattern. Radial angulation or shortening was not found to be as significant in either the early or late films. This suggests that dorsal instability as the cause of morbidity after Colles' fracture is far commoner than originally thought.

Aged↗

PubMed1986

Supracondylar fracture of the femur after total knee arthroplasty.

We reviewed the data on thirty-six supracondylar fractures of the femur (in thirty-four patients) that occurred after total knee arthroplasties that were done between April 1974 and December 1981. Patients who had osteoporosis, rheumatoid arthritis, one or more previous arthroplasties of the knee, or inadvertent breeching of the anterior aspect of the femoral cortex at operation appeared to be particularly at risk for a supracondylar femoral fracture. Malalignment of the component could not be implicated as a cause. Twenty-six fractures (in twenty-five patients) were treated by non-operative methods. Seventeen of them (65.4 per cent) healed and required no surgical treatment. Fourteen of the seventeen were followed for more than two years; they had no significant difference in the knee score and lost less than 10 degrees of motion. The nine remaining knees required revision of the arthroplasty because of non-union in four knees, malunion in two, loosening of the component in two, and extension lag in one. At an average of forty months after revision, the nine knees were rated as having one excellent, four good, three satisfactory, and one failed result. In contrast, only three of the five fractures that were treated by early open reduction and internal fixation had a satisfactory result, and one of them required a second bone-grafting procedure. One patient died perioperatively and another required an above-the-knee amputation because of sepsis. Of the three fractures that were initially treated by external fixation, one had an excellent and two had a good result at an average of forty-five months after fracture. We have found that supracondylar fractures that occur after total knee arthroplasty can be managed by either traction or application of a cast, or both, which usually results in healing of the fracture and a satisfactory outcome of the arthroplasty. Patients who have a poor arthroplasty result after non-operative treatment of the fracture usually can undergo a revision arthroplasty with the expectation of a satisfactory outcome. Operative treatment of the fracture should be reserved for patients who do not have osteopenia and in whom stable fixation can be achieved, for those who demand a highly functional arthroplasty, and for those in whom adequate closed reduction cannot be maintained.

Aged↗

PubMed1997

Plaster cast versus percutaneous pin fixation for comminuted fractures of the distal radius in patients between 46 and 65 years of age.

OBJECTIVE: To compare the results of treating unstable distal radius fractures either by percutaneous pinning and casting, or by traditional closed reduction and casting. DESIGN: Prospective, randomized. SETTING: University hospital. PATIENTS: Forty patients with unstable Frykmann III-VIII distal radius fractures resulting from a fall. INTERVENTIONS: Twenty patients were treated with closed reduction, consisting of manipulation, under local anesthesia, followed by casting. Twenty patients were treated with percutaneous fixation using K-wires, followed by casting. MAIN OUTCOME MEASUREMENTS: Initial displacement, quality of reduction, carpal malalignment, articular step-off. Range of motion and grip strength were measured using a scoring system reported by Home et al. (10). RESULTS: Functional results in the pinning group were better (excellent, 12; good, 6; fair, 2) than in the plaster group (excellent, 3; good, 8; fair, 5; poor, 4). Anatomic results also were better in the pinning group. CONCLUSION: The best anatomic and functional results were obtained by percutaneous pinning. Although the cost of pins and plaster treatment is significantly greater than plaster treatment, the author believes that the positive end result justifies the cost.

Aged↗

PubMed2005

Focal dome osteotomy for the correction of tibial deformity in children.

Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.

Adolescent↗

PubMed2003

Limb salvage: the infected retrograde tibiotalocalcaneal intramedullary nail.

Tibiotalocalcaneal arthrodesis utilizing a retrograde intramedullary nail has been used for nearly a decade. The indications for retrograde intramedullary nailing to achieve a tibiotalocalcaneal arthrodesis have expanded from systemic arthritides and post-traumatic arthritis to use in diabetic patients with severe Charcot neurarthropathy and hindfoot malalignment. Results with this procedure have been good, with low infection rates when used in nonimmunocompromised hosts. As indications have expanded to include diabetic deformities, infection rates may increase. We report on the results of a salvage technique and management plan utilized in the treatment of infected tibiotalocalcaneal arthrodesis in five high-risk (immunocompromised) patients. The majority of these patients had diabetes with Cierny-Mader IVB osteomyelitis, and would have required an above-knee or below-knee amputation due to their infection.

Adult↗

PubMed2006

Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation.

BACKGROUND: There are strong advocates for both operative and nonoperative treatment of distal-third diaphyseal fractures of the humerus, but there are few comparative data. We performed a retrospective comparison of these two treatment methods. METHODS: Fifty-one consecutive patients with a closed, extra-articular fracture of the distal one-third of the humeral diaphysis were identified from an orthopaedic trauma database. Forty patients were followed for at least six months or until healing of the fracture. Eleven patients were excluded because of inadequate follow-up. Nineteen patients had been managed with plate-and-screw fixation, and twenty-one had been managed with functional bracing. RESULTS: Among the operatively treated patients, one had loss of fixation, one had a postoperative infection, and one required tendon transfers for the treatment of a preoperative radial nerve palsy that did not resolve. Three new postoperative radial nerve palsies developed, and one had not resolved when the patient was last evaluated, three months after surgery. All operatively treated fractures healed with <10 degrees of angular deformity, and one patient lost 20 degrees of shoulder or elbow motion. Among the nonoperatively treated fractures, two were converted to plate fixation because of the treating surgeons' concern regarding alignment and radial nerve palsy. Only one patient had >30 degrees of malalignment in any plane. Two patients had development of skin breakdown during treatment and completed treatment in a sling. Two patients lost >/=20 degrees of elbow or shoulder motion. CONCLUSIONS: For extra-articular distal-third diaphyseal humeral fractures, operative treatment achieves more predictable alignment and potentially quicker return of function but risks iatrogenic nerve injury and infection and the need for reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but function and range of motion are usually excellent.

Adult↗

PubMedDate not supplied

Screw fixation of closed oblique and spiral fractures of the tibial shaft.

The difficulty of reducing and holding fractures of the tibial shaft, especially those of oblique configuration, is well known. A high incidence of malalignment after closed treatment of fractures of the distal third of the tibial shaft, as compared with fractures in more proximal sites, has also been reported. In 29 of 37 fractures in the present study treatment by closed methods had failed. In highly selected cases of closed tibial shaft fractures, notably those in the distal third and at the middle third-distal third junction with an oblique or a spiral configuration and an unacceptable position after closed reduction, simple screw fixation followed by plaster immobilization provides an effective treatment alternative.

Adolescent↗

PubMed1980

[Osteosynthesis in the area of the hand. 168 cases of single and combination osteosyntheses].

In the years 1970-76 we have performed 168 cases of AO (ASIF) internal fixation of closed and compound fractures of the hand. The study gives a classification of fractures. The indications were as follows: Where closed manipulation did not give accurate reduction; where fragment dislocation was imminent and where malalignment of the fragments is already manifest. We also confirmed the value of internal fixation on compound fractures with associated injuries of nerves, vessels and tendons. A survey of our results is given using different methods and AO materials (screws, screwed plates, and combined methods) with or without K-wires for internal fixation, applied to different types of fractures in the hand. We also describe the preoperative preparation of the patient, the methods of anaesthesia, the follow-up treatment and the salutary effects of therapy on a mainly out patient basis.

Adolescent↗

PubMed1995

Calcaneocuboid joint deformity in talipes equinovarus: an overview and update.

The calcaneocuboid joint is significantly malaligned in some clubfeet. Calcaneocuboid deformity appears to be a combination of medial angulation of the calcaneocuboid joint with medial subluxation of the cuboid on the calcaneus. In moderate and severe cases, incomplete treatment of this deformity may result in rotary valgus of the hindfoot. One hundred consecutive cases of clubfeet requiring operative intervention, all treated at the Medical College of Wisconsin at Milwaukee between 1984 and 1988 were reviewed for incidence and treatment of calcaneocuboid abnormalities. A radiographic system of evaluation was devised, encompassing a normal grade of 0 and three grades of deformity based on the extent to which the midpoint of the cuboid had deviated from the longitudinal axis of the calcaneus or beyond the tangent defined by the edge of the calcaneus. The author's preferred surgical technique is described. Grade 1 deformity does not require operation; grade 2 deformity required extensive soft tissue release, and grade 3 deformity required a bone procedure in addition to extensive soft tissue release. The results demonstrated that partial release of the calcaneocuboid cuboid joint is never indicated because it may produce valgus of the hindfoot. Based on this sample, approximately 25% of all patients requiring operation will require calcaneocuboid release. Operation should be performed without placing undue pressure on the joints, which may produce late fusion; plantar release may be indicated as a means of reducing pressure on the joint surfaces. Operation before ossification of the cuboid should be avoided.

Child, Preschool↗

PubMed2005

Neglected femoral diaphyseal fracture.

Femoral diaphyseal fractures usually result after trauma of high magnitude and because of this, can be life-threatening injuries or may result in considerable physical disability if not treated with care and caution. Nonoperative treatment of these fractures continues to be popular among the patient population in the Indian subcontinent, which in majority of cases, leads to healing in malalignment, shortening of the limb, chondromalacia patellae, and loss of knee motion. Although the majority of these fractures are being treated by operative methods today, success of the treatment depends largely on the surgeon's familiarity with the procedure or the type of fracture pattern (comminuted or segmental) particularly in a polytraumatized patient. Delayed union and nonunion of femoral-diaphyseal fractures and implant failures usually result after these procedures or the type of injury. The purpose of this study is to discuss various types of neglected femoral diaphyseal fractures and to review the literature on their treatment.

Adolescent↗

PubMed1991

[The surgical treatment of calcaneus fractures].

The treatment of intra-articular fractures of os calcis has so far been controversial. For reconstruction of static and dynamic conditions of the foot, complex deformities must be corrected. Besides intra-articular malformation of the talocalcaneal joint that is supposed to lead to posttraumatic arthritis, there are malalignments like lateral displacement, widening and shortening of the heel, depression of talocalcaneal angles and deviation of talocalcaneal or talocuboidal axes. Even if perfect reconstruction of the talocalcaneal joint is not attained, reconstruction of form will provide a better chance for later function. ORIF is therefore superior to conservative techniques. For indication and planning of the procedure fracture analysis including CT is necessary. A lateral approach allows reconstruction and plate fixation of all intra-articular fracture types. For repositioning, temporary lateral external distraction by external fixation is recommended. The operative technique and results are discussed.

Adult↗

PubMed1992

The computed tomographic evaluation of patellofemoral joint in patellar fractures treated with open reduction and internal fixation.

In this study, we examined 97 patella fractures in which open reduction and internal fixation had been performed at the 1st Orthopaedics and Trauma Clinic of Social Security Ankara Hospital between January 1983 and December 1988. After 24 to 96 months, on an average of 48.4 months follow-up period, the cases were evaluated clinically for knee function complaints and by CT and roentgenography for patellofemoral articulation. In 11 of the patients (11.5) there was patellar displacement, 2 of the patients had patellar tilt (2.1%) and in 14 patients (14.5%) there was malalignment in which 1 patient (1.1%) had both patellar tilt and displacement. This data was obtained by measuring femoral trochlear angle (FTA) and patellar tilt angle (PTA) by CT at various degrees of knee flexion. Thirty-three patients (34%) had slight and 19 patients (19.6%) had severe degenerative changes in the patellofemoral articulation. It is found that there is close relation between the variability of the pain complaints of the patients and the type of the fracture and the time of management and the postoperative rehabilitation.

Adult↗

PubMed1996

[Extra-articular proximal femur fracture in the elderly--dynamic hip screw or intramedullary hip screw for fracture management?].

Over a 6-year period we treated 119 pertrochanteric fractures using dynamic hip screws (DHS). During the following 3 years we stabilized 112 per-, sub- and intertrochanteric, as well as "trochanter-associated" fractures by means of intramedullary hip screws (IMHS) or gamma nails (GN). Within comparable patient groups we encountered the following complications: DHS vs IMHS/GN: secondary varus malalignment of the collum femoris with "cut out": 1.7% vs. 1.8%; secondary varus malalignment without "cut out": 0.8% vs. 1.8%; infections: 5.0% vs. 2.7%; hematomas needing revision operations: 2.5% vs. 0%; torn out plate: 1.7% vs. 0%; intraoperative fissures of the shaft: 0% vs. 1.8%; intraoperative perforations of the shaft: 0% vs. 0.9%. Thus, the rate of reoperation for complications within the DHS series was 11.8%, while the rate within the IMHS/GN series was 6.3%. For stable pertrochanteric fractures we therefore acknowledge DHS as the ideal implant in our opinion, while for all other extraarticular proximal fractures of the femur we recommend IMHS or GN.

Adolescent↗

PubMed1998

Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators.

OBJECTIVE: To compare unreamed intramedullary nailing (IMN) with external fixation (EF) in patients with Type II, IIIA, and IIIB open fractures of the tibial shaft. DESIGN: An inception cohort of consecutive patients with Type II, IIIA, and IIIB tibial fractures incurred between January 1988 and March 1993 were systematically allocated into one of two treatment groups. Patients were treated and followed with a prospectively designed protocol. PATIENTS AND SETTING: All patients were skeletally mature and had incurred a fracture of the tibial diaphysis within twenty-four hours of presentation to the tertiary care hospital, a Level I Trauma Center. One hundred seventy-four fractures in 168 patients were stabilized with either IMN (104) or half-pin EF (70). There were 132 men and thirty-six women, with an average age of thirty-three years (range, 14 to 77 years). INTERVENTION: Except for the selection of the fixation device, open fracture care was similar in the two treatment groups. All patients underwent emergent irrigation and debridement with concomitant skeletal stabilization. Cephalosporin antibiotics were administered perioperatively for twenty-four to forty-eight hours. No wounds were closed primarily. Delayed primary closure, skin grafting, and/or myoplasty were performed between three and ten days after injury. MAIN OUTCOME MEASURES: The main outcome measures were final fracture alignment, presence of infection or inflammation, hardware failure, time to union, and the number of operative procedures. RESULTS: The IMN group had significantly fewer incidences of malalignment than did the EF group [8 vs. 31 percent; p = 0.00005; confidence interval (CI) = 0.18, 0.76] and had significantly fewer subsequent procedures (mean of 1.7 vs. mean of 2.7 per fracture; p = 0.001; CI = 0.45, 1.59). IMN resulted in fewer infections/ inflammatory problems than did EF at the injury site (13 vs. 21 percent; p = 0.73; CI = -0.63, 0.45) and significantly fewer at surgical interfaces (i.e., pin sites, nail and interlocking screw insertion sites; 2 vs. 50 percent; p = 0.000; CI = 0.39, 0.60). No significant difference was found in the healing rates for the two implant groups. The more severe Gustilo injury types had longer healing times regardless of the type of fixation. CONCLUSIONS: Results suggest that unreamed interlocking intramedullary nails are more efficacious than half-pin external fixators, in particular with regard to maintenance of limb alignment. However, the severity of soft tissue injury rather than the choice of implant appears to be the predominant factor influencing rapidity of bone healing and rate of injury site infection.

Adolescent↗

PubMed1991

Rotationplasty for limb salvage in the treatment of malignant tumors at the knee. A follow-up study of seventy patients.

Seventy patients who had a rotationplasty for treatment of a malignant tumor in the region of the knee (the femur or the tibia) between 1974 and 1987 were followed for two to thirteen years (mean duration of follow-up, four years). Forty-seven patients had a stage-IIB osteosarcoma; the remaining twenty-three patients had a malignant fibrous histiocytoma, a chondrosarcoma, a Ewing sarcoma, or a giant-cell tumor. The most severe postoperative complication was occlusion of the reanastomosed vessels (seven patients), leading to amputation proximal to the knee in three patients. Other complications were problems with wound-healing (eight patients), transient nerve palsy (five patients), irreversible nerve palsy (two patients), pseudarthrosis (four patients), and rotational malalignment (one patient). Late complications included eight fractures, two infections, two delayed unions, and one lymphatic fistula. More than half of the patients were free of complications related to the operative procedure. Forty-four of the patients who had a stage-IIB osteosarcoma could be followed, and their data were analyzed for survival statistics. These patients had a 58 percent rate of disease-free survival and a 70 per cent rate of over-all survival. One patient had a local recurrence five years after the operation.

Adolescent↗