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FEMORAL-HEAD PROSTHESES. A REVIEW OF THREE HUNDRED AND FIFTY-SIX OPERATIONS AND THEIR RESULTS.
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TOTAL AND SUBTOTAL ARTHRODESIS OF THE WRIST.
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FRAGMENTATION AND RODDING IN OSTEOGENESIS IMPERFECTA.
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[Apropos of some laboratory findings in patients with delayed consolidation of fractures of the extremities].
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ARTHROPLASTY OF THE HIP. THEORETICAL AND PRACTICAL CONSIDERATIONS WITH A FOLLOW-UP STUDY OF PROSTHETIC REPLACEMENT OF THE FEMORAL HEAD AT THE MASSACHUSETTS GENERAL HOSPITAL.
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Posttraumatic atlanto-axial subluxation and myelopathy. Efficacy of anterior decompression.
Compression of the neuraxis may occur after displaced fractures of the dens. Nonunion or malunion increases the risk of developing neurologic complications because of the resulting atlanto-axial instability. Posterior decompression has generally been the surgical solution to myelopathy at this level. Two patients with cervical myelopathy due to displaced ununited dens fractures were treated with posterior fossa decompression and high cervical laminectomy. Both patients deteriorated after the surgery. Most of their neurologic deficits finally resolved after microsurgical transoral decompression (by resection of the dens). In those patients in whom atlanto-axial instability causes primarily anterior compression of the neuraxis, especially by a bony lesion, decompression posteriorly may not achieve the desired effect, and, instead, may cause a deterioration in the patient's condition. Anterior atlanto-axial subluxation effectively lengthens the bony spinal canal, which results in stretching of the relatively inelastic spinal cord over the bony deformity. If indirect methods of reduction fail to relieve the condition, then anterior transoral decompression is recommended.
The role of carpal instability in scaphoid nonunion: casual or causal?
We studied twenty consecutive scaphoid nonunions in twenty patients between the ages of eighteen and thirty-eight years. There were nineteen males and one female. The mean age was 25.2 years. Factors evaluated were fracture displacement, delay in treatment, and carpal instability. Fracture displacement and carpal instability were documented in patients by abnormal x-rays showing fragment displacement, abnormal scapholunate and radiolunate angles, etc., or by fluoroscopically controlled arthrography. We concluded that intercarpal ligamentous instability is consistently present and, therefore, the critical factor in wrists with ununited scaphoid fractures. Thirteen patients have been treated surgically; ligamentous disruption was confirmed at surgical exploration. In twelve patients, treatment of the nonunion included intercarpal ligamentous reconstruction. A satisfactory outcome was achieved in all twelve of these patients. One patient's treatment did not include ligament reconstruction. Although the scaphoid fracture united after a Russe bone graft, he remains symptomatic with persistent intercarpal instability. The remaining seven patients are being evaluated or awaiting surgery. Since ligamentous injury is so common in nonunion, we believe it is causal and that surgical care of nonunion involves ligamentous repair or other stabilization procedure. Prevention of nonunion involves early attention to the therapy of carpal instability when associated with scaphoid fracture.
UNILATERAL CONGENITAL GLAUCOMA, NEUROFIBROMATOSIS, AND PSEUDARTHROSIS.
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THE MANAGEMENT OF TRAUMATIC TISSUE LOSS IN THE LOWER LIMB, ESPECIALLY WHEN COMPLICATED BY SKELETAL INJURY.
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THE PROGNOSIS OF FEMORAL NECK FRACTURES WITH SPECIAL REFERENCE TO COMPLICATIONS AND OLD AGE.
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The natural history of scaphoid non-union.
We reviewed the clinical and roentgenographic findings of forty-seven non-unions of a fracture of the scaphoid in forty-six symptomatic patients in order to assess the incidence and severity of degenerative changes of the wrist. The duration of non-union ranged from five to fifty-three years. Three roentgenographic patterns were seen: twenty-three lesions had sclerosis, cyst formation, or resorptive changes confined to the scaphoid bone (Group I); fourteen had radioscaphoid arthritis (Group II); and ten had generalized arthritis of the wrist (Group III). The duration of Group-I non-unions averaged 8.2 years; Group-II, 17.0 years; and Group-III non-unions, 31.6 years. Fracture displacement and carpal instability correlated with the severity of degenerative changes. Lunate dorsiflexion of 10 degrees or more was a useful guide to carpal instability. Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. Based on the high probability of arthritis, we recommend that all displaced ununited scaphoid fractures be reduced and grafted, regardless of symptoms, before degenerative changes occur. Asymptomatic patients with an undisplaced, stable non-union should be advised of the possibility of late degenerative changes.
FEMORAL HEAD AND NECK RESECTION.
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Operative treatment of osteochondral nonunion of the distal humerus.
Three patients with ununited osteochondral fracture fragments of the distal humerus (2 anterior capitellum and trochlea; 1 posterior trochlea) who had debridement and realignment of the nonunion, autogenous cancellous bone graft, and internal fixation an average of 6 (range, 5-8) months after injury were studied. The preoperative arc of elbow flexion was 80 degrees, 35 degrees, and 25 degrees. All 3 fractures healed without implant related complications or osteonecrosis. At 28, 27, and 46 months after the index procedure for nonunion, the patients had 95 degrees, 90 degrees, and 115 degrees arcs of elbow flexion. The scores on the Mayo Elbow Performance Index were 80, 80, and 95 (2 good, 1 excellent). Based on this limited experience, it seems that operative treatment of ununited osteochondral fracture fragments can achieve union without osteonecrosis. Attempts to improve the function of the native elbow rather than salvage the situation with interpositional or prosthetic arthroplasty are worthwhile.
Mandibular fracture complications.
This paper presents the authors' experiences with 111 treated mandibular fractures and 16 cases of complication. Pertinent data on the fresh fractures are given, but the major part of the study deals with cause, diagnosis, and treatment of the complications of mandibular fractures. These are divided into four categories-infection, nonunion, malunion, and temporomandibular joint ankylosis, although only infection and temporomandibular joint ankylosis are included here. Unique mandibular fracture complications are reviewed.
The evaluation of a biphasic calcium phosphate ceramic for use in grafting long-bone diaphyseal defects.
The effectiveness of a sintered hydroxyapatite-tricalcium phosphate (HA-TCP) ceramic in bridging large diaphyseal defects in the canine ulna was studied. One-hundred percent morselized HA-TCP, a 50:50 mixture of morselized HA-TCP, and autogenous cancellous bone, and 100% autogenous cancellous bone were used to bridge 2.5-cm defects in the left ulnae of three groups of six dogs each. At 24 weeks the ulnae were explanted and studied by radiography, microradiography, mechanical testing, and histology. Pure HA/TCP was not osteoinductive, and four of six ulnae in this group progressed to a fibrous nonunion. The HA/TCP-cancellous bone mixture and pure cancellous bone were approximately equal in effect, leading to good callus formation at 4 weeks and strong bony union by 24 weeks, with no evidence of bioincompatibility. Morselized HA/TCP promises to be useful as a graft extender when mixed with autogenous cancellous bone.