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Results for “Bone Malalignment”

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PubMed1987

Interfragmentary screw fixation of fractures of the tibial shaft.

The records of 54 patients treated with interfragmentary screws were reviewed a mean of 2 years after surgery. Fifty-one fractures were of moderate severity (Ellis, 1950), 31 had a ratio of fracture length to tibial diameter of 2 or more and 17 were comminuted. An anatomical reduction, achieved initially in 44 fractures, was lost before union occurred in 14 (32 per cent), despite plaster splintage. Excellent results, with anatomical healing, were achieved in 30 patients (55 per cent) and good results with less than 5 degrees malalignment in 6 (11 per cent). There was a statistically highly significant association of satisfactory results with initial anatomical operative reduction of the fracture, a ratio of fracture length to tibial diameter of 2 or more and the absence of comminution. The orientation and number of screws, delayed operation, the degree of initial displacement of the fracture and the patient's age were not shown to affect the outcome. Delayed union occurred in 4 patients (7.4 per cent) and non-union in 3 (5.5 per cent). Deep infection occurred twice (3.7 per cent). As more satisfactory results could be expected for these fractures using other techniques, we conclude that this method cannot be recommended.

Adolescent↗

PubMed2006

[Fracture of the tibial head].

Fractures of the tibial head are severe injuries, characterized by enormous variety. Fractures can be classified into fractures of the tibial plateau, luxation fractures, and comminuted fractures. Due to the mechanism of injury luxation fractures are frequently associated with lesions of the menisci and intra- and extra-articular ligaments. Multiple factors can be etiologic for post-traumatic gonarthrosis: nonanatomic reduction of the joint surface, malalignment, and unaddressed associated injuries. Therefore in addition to diagnostic steps such as X-ray, CT scan, and MRI a sophisticated therapeutic regime is necessary. In cases with severely damaged soft tissue or unstable patients, the fracture should initially be reduced and fixed with an external fixator and the definite fixation should be performed in a second setting. Arthroscopically assisted treatment is reserved for fractures of the tibial eminence, crack fractures, and impression fractures. Comminuted and bilateral fractures can be addressed via different incisions. New locking plates with angular stability allow avoidance of bilateral plating in most situations. In specific cases such as compound fractures and for patients with low compliance, a hybrid fixator may be a well-chosen alternative.

Arthroscopy↗

PubMed2002

[Retrograde locking nail osteosynthesis of distal femoral fractures with the distal femoral nail (DFN)].

Non-operative treatment with immobilization or isometric traction has been abandoned as treatment for fractures of the distal femur at the end of the 1960ies. The technique of open reduction and internal fixation with a condylar plate as suggested by the AO has been the golden standard since the 1970ies. However, anatomic reconstruction of the condylar region with interfragmentary screw fixation and axial realignment of the femur shaft with a plate are challenging procedures especially in the presence of severely compromised soft tissues and put periosteal blood supply at risk. Soft tissue complications, axial malalignment and delayed fracture healing times led to the consideration of alternative techniques, such as intramedullary nailing which has been practiced with success since the 1940ies by Gerhard Küntscher and colleagues for femoral shaft fractures with minimal complication rates and improved results after closed reduction. The era of retrograde femoral nailing began with the systematic approach through the intercondylar notch by Green. This paper reviews the biomechanical properties, indication, technique as well as potential hazards and pitfalls of fracture management with the AO "distal femoral nail" (DFN). With appropriate application this technique is suitable for all fractures of the distal third of the femoral shaft including highly instable bicondylar fractures without damage to the soft tissues and the knee joint.

Biomechanical Phenomena↗

PubMedDate not supplied

No association between residual forefoot adduction and the position of the navicular in clubfeet treated by posterior release.

Medial displacement of the navicular has been considered a major explanation for residual forefoot adduction (FFA) in congenital clubfoot and also a frequent reason for dissatisfaction after limited surgery. In this study, it was hypothesized that there would be an association between the degree of medial displacement of the navicular and residual FFA in clubfeet. The position of the navicular was retrospectively measured by ultrasonography in 49 clubfeet in 35 children at ages 3 to 6 years and correlated to residual FFA measured on footprints and radiographs (talo-first metatarsal angle). In the 49 clubfeet, the navicular was significantly more medially displaced toward the medial malleolus than in the 21 contralateral normal feet (P < 0.001). However, there was no correlation between the degree of medial displacement of the navicular and the degree of FFA measured on footprints (P = 0.690) or on radiographs (P = 0.390). Thus, there were clubfeet with straight forefoot and a medially displaced navicular, that is, "spurious correction," and clubfeet with FFA and the navicular in correct position in relation to the head of the talus. Both patient satisfaction and foot score declined with larger FFA. The results support the view that ultrasonography is a helpful tool for assessing the position of the navicular. The critical issue for analysis is whether the FFA is due to malalignment in the talonavicular joint or more distally.

Adolescent↗

PubMed2006

Retrograde nailing for distal third femoral shaft fractures: a prospective study.

PURPOSE: To evaluate the postoperative knee function and results of unreamed retrograde nailing for distal third femoral shaft fractures. METHODS: Between January 2002 and 2003 inclusive, a consecutive series of 27 patients (with 28 fractures) who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified Knee Society Knee Score. Correlations between union time and other variables were also studied. RESULTS: In these patients 26 (93%) of the 28 fractures achieved union, of which 5 underwent dynamisation; the mean union time for the other 21 fractures was 4.4 months. Angular malalignment was present in 4 patients and shortening in 4 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 26 patients. 19 patients had anterior knee pain and 10 had instability. By the end of one year, excellent or good scores for pain and function were recorded in 77% and 73% respectively, of the 26 patients. CONCLUSION: In view of such favourable union rates but significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.

Adult↗

PubMed2001

Surgical treatment of tibial plateau fracture in elderly patients.

This retrospective study involves 22 patients with displaced tibial plateau fractures who were treated surgically from July 1993 to April 1996. All the patients were over 60 years old (mean 66.3 years old, range 61-80 years). All of the patients were treated by open reduction and internal fixation with AO/ASIF buttress plates (Synthes, Bochum, Switzerland). Additional small fragment plate or inter-fragmental screws were used in some of them as indicated. Two patients died during follow-up of causes unrelated to the fractures. The average follow-up time was 49.8 months (range 36-68 months). The other 20 patients were interviewed at the outpatient clinic, and radiographs of bilateral standing knees were taken. By comparison with the uninjured side on radiographs, condylar joint space depression was noted in 6 patients. However, joint depression greater than 4 mm was not found. Malalignment with varus or valgus greater than 5 deg was not demonstrated in any case. Their range of motion was restored in all patients, with more than 120 deg of flexion and without extension lag except for the one who suffered a superficial wound infection. No complication required further surgical management. During the period of follow-up, no accelerated degenerative change in the operated knee joint resulted in total knee arthroplasty. Two patients needed occasional medical treatment for residual knee joint pain. Only two patients needed canes for assistance during walking due to old age and minor stroke. The results justify surgical treatment for displaced tibial plateau fractures in elderly patients.

Activities of Daily Living↗

PubMed2003

Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis.

In children and young adults who seek medical treatment for high-grade isthmic dysplastic spondylolisthesis, common clinical symptoms are referable to the lumbosacral spine and/or the lower extremities. Pain in the lumbosacral spine may be secondary to altered lumbosacral alignment and biomechanics. It also may be caused by malalignment of the entire spinal-pelvic axis as a result of anterior sagittal imbalance. Lower extremity radiculopathies involving the L5 nerve root(s) may be present, and in severe forms of spondylolisthesis crisis, marked entrapment of the cauda equina at L5-S1 may occur. High-grade isthmic dysplastic spondylolisthesis are treated surgically and should include appropriate central and foraminal decompressions at the L5-S1 level, followed by lumbosacral fusion. Partial reduction aiming at improving the slip angle (lumbosacral kyphosis) is more beneficial and provides less risk to the L5 nerve roots than complete reduction of the translational component of the slip. Solid anterior and posterior spinal fusion at L5-S1 appears to provide the best long-term results.

Adolescent↗

PubMed2006

[Early results of medial opening wedge osteotomy in varus gonarthrosis].

OBJECTIVES: We evaluated the efficacy and short-term results of medial opening wedge high tibial osteotomy with the use of a Puddu plate in patients with medial compartment gonarthrosis. METHODS: The study included 15 knees of 12 female patients (mean age 50.6 years; range 45 to 63 years) who were treated with medial opening wedge high tibial osteotomy for varus knees with medial compartment gonarthrosis. The osteotomy sites were fixed with a Puddu plate followed by allograft application. The mean follow-up period was 30.7 months (range 19 to 40 months). RESULTS: The mean consolidation time was 7.1 weeks (range 6 to 9 weeks). The mean preoperative and postoperative Lysholm scores were 54.1 (range 30 to 60) and 82 (range 67 to 95), respectively. The mean preoperative femorotibial angle was 3.5 degrees in varus malalignment (range 3 degrees valgus to 9 degrees varus). It was 7.3 degrees valgus postoperatively. The mean correction of the mechanical axis was 10.7 degrees , with no loss of correction during the follow-up period. No adverse effects were observed associated with allograft use. The lateral cortex was broken in one patient (6.7%) who was then treated with an Ilizarov external fixator due to pseudoarthrosis. All but this patient were satisfied with the treatment. CONCLUSION: Compared with other osteotomy models, medial opening wedge osteotomy with the use of a Puddu plate offers advantages in terms of ease of application and maintenance of correction in the early follow-up period. With allograft application, consolidation is obtained without interfering with the rehabilitation period.

Bone Plates↗

PubMed1983

Angular and torsional deformities of the lower limbs in children.

Angular and torsional malalignments of the lower extremity in children are common problems for which parents seek orthopedic advice. Calcaneal valgus of the foot, internal tibial torsion, genu varus, genu valgus, and femoral anteversion are normally observed in infants and usually are corrected with growth. The majority of angular deformities are physiologic; however, it is important to distinguish those requiring further evaluation and treatment. Accurate examination and knowledge of the natural history of rotational and angular deformities allow accurate assessment of the child and sound advice to the parents. There is a trend away from the use of shoe modifications, Denis-Browne-type bars, and twister cables in treating these deformities. Surgical treatment is occasionally required, but the prerequisites in each case should be carefully observed.

Adolescent↗

PubMed1998

[Fractures of the pediatric foot].

Some 13% of fractures in children are in the foot. Of these fractures, 50% involve the metatarsals and the phalanges. These are treated conservatively and do not cause therapeutic problems in general. In contrast, fractures and dislocations of the midfoot and hindfoot occur very rarely, so profound therapeutic expertise is lacking. The present paper takes stock and provides a critical assessment of the therapeutic concepts presented hitherto and new approaches to different problematic fractures. The long-term results of the literature and our own follow-up of dislocated intraarticular talus and calcaneus fractures which were not reduced anatomically has shown important problems in terms of pain, limited range of motion and malalignment in adolescence. In contrast to the findings in adults, no arthrosis was apparent in the radiological examinations. The findings were similar in mishealed Chopart dislocation and Lisfranc dislocation. The treatment of complex foot trauma is a multidisciplinary team approach. These challenging injuries should be treated only in centers where vascular and plastic surgeons are constantly available. The precise scientific assessment of foot fractures in children is confronted with the problem that so far too few cases have been evaluated. Rare problematic fractures (i.e. talus, calcaneus) require scientific work-up to establish a "gold standard" for operative and conservative treatment. This can only be accomplished in a multicenter study.

Adolescent↗

PubMed2004

Tibial lengthening over nails in children using modified Ender nails: preliminary results of a new treatment.

Tibial lengthening over nails, using modified Ender nails, was performed in nine children whose mean age at surgery was 12.8 years. The prerequisite for using this technique was the absence of axial malalignment and an indication for tibial lengthening only. Lengthening was not performed in one case due to the development of a compartment syndrome after the tibial osteotomy. Breakage of one interlocking screw without loss of alignment or length was observed in one case. Superficial pin tract infections were observed in two cases. An average of 4.1 cm (range 3-4.5 cm) lengthening of the tibia was achieved in eight of the nine cases. The modified Ender nails used permitted locking at both ends after achieving the desired distraction and permitted early removal of the external fixator. The advantage of this technique is that it permits early removal of the fixator and thus decreases the incidence of fixator related problems and facilitates early rehabilitation.

Adolescent↗

PubMed2000

Supracondylar osteotomy of the femur with use of compression. Osteosynthesis with a malleable implant.

BACKGROUND: The goal of treatment of a valgus deformity of the knee that is secondary to osteoarthritis of the lateral compartment is to obtain axial correction of the malalignment of the extremity. Osteosynthesis of the osteotomized femur with use of internal fixation and a stiff implant has not been as successful as expected. We evaluated the accuracy and maintenance of correction and the stability of fixation with a malleable plate after a supracondylar osteotomy of the distal aspect of the femur that was performed to correct a valgus deformity of the knee. METHODS: We performed an incomplete oblique osteotomy of the distal aspect of the femur in nineteen patients (twenty-one knees) and stabilized the osteotomy site with a malleable semitubular plate, which was bent to form an angled plate, and lag-screws. Postoperatively, the patients were immediately encouraged to walk, with partial weight-bearing on the affected extremity. The mean age of the patients was fifty-seven years (range, thirty-nine to seventy-one years), and the mean duration of follow-up was five years (range, two to twelve years). RESULTS: In seventeen knees, the osteosynthesis withstood the mechanical loading that occurred during the postoperative functional rehabilitation program. Prolonged use of crutches or immobilization, or both, was necessary after the operation in three knees. The osteosynthesis failed in one knee. The loss of correction in eighteen knees, after bone-healing, averaged 1.7 degrees (range, 0 to 4 degrees). CONCLUSIONS: Our method of achieving osteosynthesis is based on the concept that inherent endogenous stability mechanisms can be mobilized by circumferentially compressing the two cortical tubes with the cut ends congruently apposed to each other. We believe that our technique provides an alternative to osteosynthesis with use of a stiff implant such as a fixed-angle blade-plate device.

Activities of Daily Living↗

PubMed2006

Expandable cylindrical cages in the cervical spine: a review of 22 cases.

OBJECT: Expandable cylindrical cages (ECCs) have been utilized successfully to reconstruct the thoracic and lumbar spine. Their advantages include ease of insertion, reduced endplate trauma, direct application/maintenance of interbody distraction force, and one-step kyphosis correction. The authors present their experience with ECCs in the reconstruction of the cervical spine in patients with various pathological conditions. METHODS: Data obtained in 22 patients were reviewed retrospectively. A standard anterior cervical corpectomy was performed in all cases. Local vertebral body bone was harvested for use as graft material. Patients underwent pre- and postoperative assessment involving the visual analog scale (VAS), Nurick grading system for determining myelopathy disability, and radiographic studies to determine cervical kyphosis/lordosis and cage subsidence. Fusion was defined as the absence of motion on flexion-extension x-ray films. Sixteen patients presented with spondylotic myelopathy, two with osteomyelitis, two with fracture, one with tumor metastasis, and one with severe stenosis. Fourteen patients underwent supplemental posterior spinal fusion, seven underwent single-level corpectomy, and 15 patients underwent multilevel corpectomy. No perioperative complications occurred. The mean follow-up period was 22 months. In 11 patients with preexisting kyphosis (mean deformity +19 degrees), the mean correction was 22 degrees. There was no statistically significant difference in subsidence between single- and multilevel corpectomy or between 360 degrees fusion and anterior fusion alone. The VAS scores improved by 35%, and the Nurick grade improved by 31%. The fusion rate was 100%. CONCLUSIONS: The preliminary results support the use of ECCs in the cervical spine in the treatment of patients with various disease processes. No significant subsidence was noted, and pain and functional scores improved in all cases. Expandable cylindrical cages appear to be well suited for cervical reconstruction and for correcting sagittal malalignment.

Adult↗

PubMed1997

The effects of distal radius fracture malalignment on forearm rotation: a cadaveric study.

Seven fresh cadaveric specimens were used to determine the loss of forearm rotation with varying distal radius fracture malalignment patterns. Uniplanar malunion patterns consisting of dorsal tilt, radioulnar translation, or radial shortening were simulated by creating an osteotomy at the distal end of the radius, orienting the distal fragment position using an external fixator, and maintaining the position with wedges and a T-plate. Rotation of the forearm was produced by fixing the elbow in a flexed position and applying a constant torque to the forearm using deadweights. Forearm rotation was measured with a protractor. Dorsal tilt to 30 degrees and radial translation to 10 mm led to no significant restriction in forearm pronation or supination ranges of motion. A 5-mm ulnar translation deformity resulted in a mean 23% loss of pronation range of motion. Radial shortening of 10 mm reduced forearm pronation by 47% and supination by 29%.

Biomechanical Phenomena↗

PubMed2002

[The extraarticular proximal tibial fractures].

Operative stabilization of proximal tibial fractures by use of conventional osteosynthesis is still problematic. The choice of the osteosynthetic treatment is strongly influenced by the situation of the surrounding soft tissue. Additional problems in this particular location may occur with malalignment in the fracture site after operation. Primary intraoperative malalignment may occur due to dislocating muscle forces or to the operative approach itself. Secondary dislocation is mainly due to the unstable fixation of the proximal fragment by the implant. Today many different implants with specific biomechanical properties are available. Each system requires a particular operative technique and can lead to individual implant-related problems. The new angle stable implant systems (e. g. LISS = "less invasive stabilization system"), offer significant advantages over conventional plate osteosyntheses and external fixation systems. Improvement of the geometry of standard intramedullary osteosyntheses and introduction of angle stability in the proximal interlocking screws (PTN = "proximal tibial nail") seemingly make this system the optimal solution, concerning biomechanics. On the background of our own clinical experiences and biomechanical investigations, the article discusses solutions for this particular problem.

Adult↗

PubMedDate not supplied

[Emergencies in the knee joint surgery].

Anatomy of the knee joint is one of the most complicated when compared to other joints in the human body. Due to high demands and strong forces acting on the knee joint, it is also one of the most injured joints. Every structure in the joint can be damaged and some of the damages demand earlier treatment. Except intraarticular fractures, stress fractures of the proximal tibia, as a result of lower extremity malalignment, need earlier treatment to prevent the dislocation of the fragments. Damage to the articular cartilage needs earlier treatment due to its tendency to involve wider area of the joint. Meniscus rupture is not an indication for earlier treatment, except a "bucket handle" rupture due to its potential to block the movements of the knee joint. Collateral ligament injury needs early treatment to prevent chronic laxity of the joint. Anterior cruciate ligament early reconstruction in top athletes results in their complete rehabilitation and return to the previous level performance. Total knee replacements may result in a number of complications, some of which need prompt treatment. Septic arthritis is a condition that requires prompt treatment, without any hesitation. Failure of earlier or prompt treatment of the conditions of the knee mentioned in this chapter may result in permanent damage to the knee joint.

Arthroplasty, Replacement, Knee↗

PubMed2005

Implementation, accuracy evaluation, and preliminary clinical trial of a CT-free navigation system for high tibial opening wedge osteotomy.

OBJECTIVE: The objectives of this study are to design and evaluate a CT-free intra-operative planning and navigation system for high tibial opening wedge osteotomy. This is a widely accepted treatment for medial compartment osteoarthritis and other lower extremity deformities, particularly in young and active patients for whom total knee replacement is not advised. However, it is a technically demanding procedure. Conventional preoperative planning and surgical techniques have so far been inaccurate, and often resulting in postoperative malalignment representing either under- or over-correction, which is the main reason for poor long-term results. In addition, conventional techniques have the potential to damage the lateral hinge cortex and tibial neurovascular structures, which may cause fixation failure, loss of correction, or peroneal nerve paralysis. All these common problems can be addressed by the use of a surgical navigation system. MATERIALS AND METHODS: Surgical instruments are tracked optically with the SurgiGATE((R)) navigation system (PRAXIM MediVision, La Tronche, France). Following exposure, dynamical reference bases are attached to the femur, tibia, and proximal fragment of the tibia. A patient-specific coordinate system is then established, on the basis of registered anatomical landmarks. After intra-operative deformity measurement and correction planning, the osteotomy is performed under navigational guidance. The deformities are corrected by realigning the mechanical axis of the affected limb from the diseased medial compartment to the healthy lateral side. The wedge size, joint line orientation, and tibial plateau slope are monitored during correction. Besides correcting uni-planar varus deformities, the system provides the functionality to correct complex multi-planar deformities with a single cut. Furthermore, with on-the-fly visualization of surgical instruments on multiple fluoroscopic images, penetration of the hinge cortex and damage to the neurovascular structures due to an inappropriate osteotomy can be avoided. RESULTS: The laboratory evaluation with a plastic bone model (Synbone AG, Davos, Switzerland) shows that the error of deformity correction is <1.7 degrees (95% confidence interval) in the frontal plane and <2.3 degrees (95% confidence interval) in the sagittal plane. The preliminary clinical trial confirms these results. CONCLUSION: A novel CT-free navigation system for high tibial osteotomy has been developed and evaluated, which holds the promise of improved accuracy, reliability, and safety of this procedure.

Arthroscopy↗

PubMed2007

[Severely displaced radial neck fractures after minimally invasive joystick reduction and Prévot nailing: long-term course in childhood].

Significantly displaced radial neck fractures in children are at risk for functional problems due to malaligned healing or growth disturbances at the proximal growth plate. Anatomic reduction is needed, especially in older children (aged 10+ years). Elastic stable intramedullary nailing (ESIN) (1993 Metaizeau) is the preferred method. When closed reduction is not possible, we use a joystick technique to fully reduce the radial head. The aim of this study was to challenge the hypothesis that this manipulation leads to secondary complications by affecting blood flow. Also, we asked the question to which extent an additional injury to the growth plate leads to functional problems concerning range of motion in the elbow joint. We undertook a retrospective analysis of children with severely displaced radial head fractures that occurred as isolated incidents or in combination with complex elbow fractures who had been treated by us with this technique between 1998 and 2004. We collected data on the clinical and radiological healing process.

Adolescent↗