Showing papers in "Journal of Bone and Joint Surgery, American Volume in 1978"

Dislocations after total hip-replacement arthroplasties.

Abstract: In a series of 300 total hip replacements, nine (3 per cent) dislocated. Precise measurements of the orientation of the acetabular cup were made and it was found that anterior dislocations were associated with increased acetabular-component anteversion. There was no significant correlation between cup-orientation angle and posterior dislocation. The dislocation rate for cup orientation with anteversion of 15 +/- 10 degrees and lateral opening of 40 +/- 10 degrees was 1.5 per cent, while outside this "safe" range the dislocation rate was 6.1 per cent. Other factors that were documented include time after surgery (with the greatest risk in the first thirty days) and surgical history (with a greater risk in hips that have had prior surgery).

The Bankart procedure: a long-term end-result study.

Abstract: Of 161 patients with 162 shoulders operated on during a thirty-year period (1946 to 1976), 124 were re-examined and twenty-one answered a questionnaire. The lesions found at surgery were separation of the capsule from the anterior glenoid rim in 85 per cent, a Hill-Sachs lesion of the humeral head in 77 per cent, and damage to the anterior glenoid rim (including fracture) in 73 per cent. There were five recurrences (3.5 per cent) after repair by the method described in the 145 shoulders that were followed. Only one of the forty-six patients with dislocation on the dominant side and one of the thirty-one with dislocation on the non-dominant side failed to return to the competitive athletic activities in which they participated prior to injury. The results at follow-up were rated excellent in 74 per cent, good in 23 per cent, and poor in 3 per cent. Ninety-eight per cent of the patients rated their result as excellent or good. Sixty-nine per cent of the shoulders had a full range of motion, and only 2 per cent of these shoulders redislocated. A fracture of the rim of the glenoid did not increase the risk of recurrence, while a moderate to severe Hill-Sachs lesion increased the risk only slightly. We concluded that with the meticulous technique of the Bankart repair as described, postoperative immobilization is not necessary, early return of motion and function can be expected, and resumption of athletic activities with no limitation of shoulder motion is possible for most patients.

Atlanto-axial arthrodesis by the wedge compression method.

Abstract: Fifteen patients with atlanto-axial instability (secondary to os odontoideum in three, nonunion of an odontoid fracture in seven, acute odontoid fracture in three, and rheumatoid arthirtis in two) were treated by wedge compression arthrodesis of the atlanto-axial joint. One patient died at home eight weeks after fusion with the cause of death never established. Of the two patients with rheumatoid arthritis (ankylosing spondylitis), one had a non-union and in the other the posterior arch of the atlas fractured and the fusion had to be extended up to the occiput and down to the third cervical vertebra. The procedure is rarely indicated in patients with long-standing rheumatoid arthritis or severe osteopenia.

Resection and reconstruction for primary neoplasms involving the innominate bone

Abstract: Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.

Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension.

Abstract: The kinematics of the wrist during radial-ulnar deviation and flexion-extension were studied in several ways. In six fresh cadaver wrists, the forearm was fixed in full pronation, each motion was constrained to one plane, and two metal markers were placed in each of the finger metacarpals, as well as in the radius and all of the carpal bones except the pisiform and greater multangular. Radial ulnar and flexion-extension movements in these wrists were studied roentgenographically. In the wrists of six normal volunteers, a similar roentgenographic analysis was carried out and the trajectories of wrist motions also were studied using light-emitting diodes. Finally, roentgenographic measurements were made on 100 wrists of normal subjects. From these studies, it was concluded that: (1) during each of these motions, rotation occurs about a fixed axis located within the head of the capitate, and the location of each axis is not changed by the position of the hand in either plane; (2) the distance from the base of the third metacarpal to the distal articular surface of the radius (the carpal height), measured along the proximally projected axis of the third metacarpal on posteroanterior roentgenograms, is constant throughout radial-ulnar deviation of the normal wrist and can be used as a measure of carpal collapse; and (3) the perpendicular distance of the fixed axis of rotation for radial-ulnar deviation from the distally projected longitudinal axis of the ulna can be used as a quantitative measurement of the amount of translation of the carpus in pathological conditions.

Total hip arthroplasty.

Abstract: A review of 333 consecutive Charnley total hip arthroplasties four to seven years after operation showed that twenty-eight patients had died, and three deaths were directly related to the surgery. The survivors had an average improvement of 46.6 points in their evaluation scores to a level of 91.3 points. Four deep infections occurred for which removal of the prosthesis was required. Thirteen hips dislocated postoperatively, and five of them required additional surgery. Three were four sciatic-nerve injuries and all but one resolved. Wear of the acetabular component was evident in seventeen hips, measuring two millimeters in six and one millimeter in eleven. With the marking system used, accurate measurement of wear was not possible. Roentgenographic evidence of loosening of the femoral component was found in 24 per cent of the hips, atributable more often to the quality of cement fixation than to the position of the components (varus-valgus). Varus loosening of two millimeters or more was associated with lower evaluation scores.

Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.

Abstract: Seventy-one fractures through the neck of the talus were clinically evaluated and classified on the basis of roentgenographic appearance. The follow-up interval averaged 12.7 years. Good or excellent results were achieved in 59 per cent of the fractures. Accurate anatomical reduction of displaced fractures, if necessary by open reduction and internal fixation, is recommended. Avascular necrosis of the talar body occurred in 52 per cent of the fractures (in two of thirteen non-displaced fractures, in half of the fractures with subluxation or dislocation of the subtalar joint, and in sixteen of nineteen fractures with complete dislocation of the body of the talus). Many patients with avascular necrosis treated conservatively had satisfactory results. The complications of avascular necrosis, malunion, subtalar arthritis, and infection required twenty-five secondary procedures. Triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.

Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter.

Abstract: Intracompartmental pressures were measured by the wick catheter technique in sixty-five compartments of twenty-seven patients who were clinically suspected of having acute compartment syndromes. A pressure of thirty millimeters of mercury or more was used as an indication for decompressive fasciotomy. The range of normal pressure was from zero to eight millimeters of mercury. Eleven of these patients were diagnosed as actually having compartment syndromes and in these patients, twenty-seven compartments were decompressed. Only two patients had significant sequelae. In the sixteen patients (thirty-eight compartments) whose pressures remained less than thirty millimeters of mercury, fasciotomy was withheld and compartment syndrome sequelae did not develop in any patient. Intraoperatively the wick catheter was used continuously in eight patients to document the effectiveness of decompression. Fasciotomy consistently restored pressures to normal except in the buttock and deltoid compartments, where epimysiotomy was required to supplement the fasciotomy. Continuous intraoperative monitoring of pressure by the wick catheter technique allowed us to select the few cases in which primary closure of wounds was appropriate and to decide which patients were best treated with secondary closure.

In vivo knee stability. A quantitative assessment using an instrumented clinical testing apparatus.

Abstract: Twenty-eight male and twenty-one female subjects with no history of previous injury to their knees were examined using a newly developed clinical testing apparatus designed to record anterior-posterior tibial force versus displacement and varus-valgus moment versus angulation during manual manipulation of the knee. Joint stiffness and laxity were measured from test tracings made with the knee muscles relaxed and tensed. Agreement between these measurements and those made previously on thirty-five fresh cadaver knee specimens was very good. Anterior-posterior laxity averaged 3.7 millimeters in full extension, 5.5 in 20 degrees of flexion, and 4.8 millimeters in 90 degrees of flexion, while the mean varus-valgus laxity was 6.7 degrees in full extension. The common clinical assumption that normal right-left differences are negligible was found to be invalid. Individual right-left differences averaged 26 to 35 per cent for laxity and 19 to 24 per cent for stiffness. There was no discernible tendency for one knee to be more stable than the other; random interchanges of relative stability between the right and left knees were observed for each individual at different knee positions. When requested to tense the knee muscles, these subjects were able to increase their knee stiffness an average of two to four times while knee laxity was reduced to 25 to 50 per cent of the normal value.

Scoliosis: incidence and natural history. A prospective epidemiological study.

Abstract: A prospective study was carried out of the incidence and natural history of adolescent idiopathic scoliosis in 26,947 students. Data were obtained on 1,122 students with idiopathic scoliosis. The incidence of idiopathic scoliosis was 4.5 per cent. The female-to-male ratio was 1.25:1.0 over-all, but the ratio varied directly with the severity of the curve--that is, 1:1 for curves of 6 to 10 degrees, and 5.4:1 for curves of more than 20 degrees. Progression of the curve was determined by a two-year follow-up of 603 patients. Progression was observed in 6.8 per cent of the students and in 15.4 per cent of the skeletally immature girls with scoliosis of more than 10 degrees at the initial examination. In 20 per cent of the skeletally immature children with curves of 20 degrees at the initial examination, there was no progression. Spontaneous improvement of the curve occurred in 3 per cent and was seen more frequently in curves milder than 11 degrees. Treatment was required in 2.75 students per 1,000 screened.

Survival and ambulation following hip fracture.

Abstract: A retrospective analysis of the outcomes in 360 patients with fractures of the hip showed return to preinjury ambulatory status in 51 per cent. One year after injury 27 per cent of the patients had died and 22 per cent were non-ambulatory. For the first eight months after injury the death rate in the fracture population exceeded that of the population at large, while afterward it was the same. Factors that increased the probability of death and non-ambulation included advanced age, preoperative presence of cerebral dysfunction, and male sex.

Subtrochanteric fractures of the femur.

Abstract: The results of treatment of fifty-six patients with subtrochanteric fractures of the femur are presented and a new classification of these fractures is described. In forty-seven fractures treated with internal fixation there were nine failures of fixation. One type of lesion, the three-part spiral subtrochanteric fracture, occurred eighteen times and accounted for eight of the failures of fixation.

Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair.

Abstract: Recurrent anterior subluxation of the lateral tibial plateau is a common type of chronic knee instability resulting from trauma. It can be reproduced by the clinical test described and corrected by a surgical procedure called the sling and reef operation, in which a strip of iliotibial tract is used to create a sling and to reef the posterolateral capsule. From 1971 to 1978, eighty-four patients were operated on, of whom fifty had been evaluated at one to six and one-half years after operation. The results were: forty-one good, six fair, and three poor. The lesions found in the thirty-seven knees in which arthrotomy was performed included a tear of the anterior cruciate in every case, a tear of the medial meniscus in fifteen and of the lateral meniscus in eleven, a notch in the articular surface of the lateral femoral condyle in fifteen, and a lateral marginal tibial (Segond) fracture in three. No definite lateral capsular tears were visualized--only stretching comparable to that seen in recurrent dislocation of the shoulder.

The Jones fracture revisited.

Abstract: Twenty-two patients with twenty-three fractures of the proximal part of the diaphysis of the fifth metatarsal, an injury originally described by Jones, are reported. The average follow-up was 3.5 years. Delayed union occurred in twelve (66.7 per cent) of eighteen patients treated conservatively. Four patients were operated on within two weeks of injury. The clinical picture in nine of the twenty-two patients suggested that the injury was a stress fracture. Force-platform analysis in eleven cases confirmed that the injury results from vertical and mediolateral forces concentrated over the fifth metatarsal and that it is not caused by inversion. Thirteen of the twenty-three fractures were in young athletes, often occurring during training and causing significant disability. In this group of patients, and in a select number of recreational athletes and non-athletes with delayed union, intramedullary screw fixation of the fracture is advised.

Unicompartmental tibiofemoral resurfacing arthroplasty.

Abstract: Thirty-seven patients with unicompartmental osteoarthritis were treated by replacement arthroplasty using the Marmor modular prosthesis and each patient was followed for at least two years. Despite rigid preoperative criteria for the selection of cases, the over-all results were definitely inferior to those seen after either bicompartmental or tricompartmental replacement arthroplasty. Complications included recurrent pain and degeneration of the other compartment, often associated with abrasion of the remaining cartilaginous surfaces caused by polyethylene particles. There was also more settling of the tibial component in these patients than in patients treated by bicompartmental replacement arthroplasty. Because of these findings, we no longer use unicompartmental replacement of the medial side of the knee. The results after the three lateral compartment replacements, on the other hand, were good, and use of this procedure for post-traumatic arthritis is still under investigation.

Proximal strain distribution in the loaded femur. An in vitro comparison of the distributions in the intact femur and after insertion of different hip-replacement femoral components.

Abstract: The distribution of strain in the proximal part of loaded cadaver femora was measured in vitro using strain gauges applied to the cortex The loading conditions simulated single-limb stance and the strains were recorded first with the femora intact and then with the femoral components of six different designs inserted Each femur served as its own control After insertion of a femoral component, the pattern of strain in the proximal part of the femur was reversed compared with that in the intact femur, in that the maximum strain occurred around the tip of the prosthesis rather than at the calcar femorale A massive decrease in stress in the region of the calcar femorale was found when the implants were in place, and it was concluded that this decrease could contribute substantially to the calcar femorale resorption sometimes observed in patients after total hip replacement Transfer of load directly to the calcar femorale through a larger collar in direct contact with the cortical bone restored 30 to 40 per cent of the normal strain to the calcar femorale and shifted the strain pattern toward normal Compared with the less stiff stems tested, the larger, stiffer stems, which provide more protection against fatigue failure, did not affect the strain pattern adversely

The abnormal lateral patellofemoral angle: a diagnostic roentgenographic sign of recurrent patellar subluxation.

Abstract: On roentgenograms made with the patient supine, the knees flexed 20 to 30 degrees, the x-ray tube between the ankles, and the cassette held proximal to the knees and perpendicular to the x-ray beam, it was found that a line between the femoral condyles and a line between the margins of the lateral facet of the patella formed the lateral patellofemoral angle, an angle that was of diagnostic value in patients with subluxation of the patella. In 100 clinically normal patients, these lines were parallel in three and formed an angle open laterally in ninety-seven. In thirty patients with subluxation of the patella, the lines were parallel in twenty-four and formed an angle open medially in six. In 100 patients with chondromalacia of the patella, however, the roentgenographic study was of no diagnostic value since the lines were parallel in ten and formed an angle open laterally in ninety.

Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies.

Abstract: Postmortem studies of ten normal full-term infants and of three children, seven, nine, and fourteen years old, showed that the acetabular cartilage complex is a unit that is triradiate medially and cup-shaped laterally and is interposed between the ilium, ischium, and pubis. This complex is composed of epiphyseal growth-plate cartilage adjacent to these bones, of articular cartilage adjacent to these bones, of articular cartilage around the acetabular cavity, and, for the most part, of hyaline carilage. Interstitial growth within the triradiate part of the cartilage complex causes the hip socket to expand during growth. The concavity of the acetabulum develops in response to the presence of the spherical femoral head. The depth of the acetabulum increased during development as the result of interstitial growth in the acetabular cartilage, of appositional growth at the periphery of this cartilage, and of periosteal new-bone formation at the acetabular margin. At puberty, three secondary centers of ossification appear in the hyaline cartilage surrounding the acetabular cavity. These centers are homologous with other epiphyses in the skeleton. The os acetabuli, which is the epiphysis of the os pubis, forms the anterior wall of the acetabulum. The epiphysis of the ilium, which has been called the acetabular epiphysis, forms a good part of the superior wall of the acetabulum. A small epiphysis of the ischium was seen in the oldest patient, who was fourteen years old. The bone in these epiphyses expands toward the periphery of the acetabulum and thus contributes to its increase in depth.

Results of reduction and stabilization of the severely fractured thoracic and lumbar spine.

Abstract: From 1962 to 1976, ninety-five patients with fracture-dislocations of the spine were treated with Harrington instrumentation and fusion within ninety days of injury. This report presents the results of this procedure related to reduction, stabilization, return of neural function, and total hospital stay. Mean follow-up was twenty-one months. Reduction and stabilization were attained without a substantial number of complications, but no more return of neural function in the patients was evident than has been reported in the literature for patients treated with postural reduction and bed rest. Total hospital stay averaged 107 days from day of injury.

The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff.

Abstract: In sixteen patients with massive tears of the rotator cuff of the shoulder, bridging of the defect with a freeze-dried graft of a rotator cuff from a cadaver produced a satisfactory repair in all cases. A good or excellent functional result was obtained in all but two patients, with a definite decrease or absence of nocturnal pain in all sixteen. The operative technique includes avoidance of a complete acromionectomy and an adequate suture of the deltoid muscle to the acromion after an acromioplasty.

Revision with gentamicin-impregnated cement for deep infections in total hip arthroplasties.

Abstract: Seventy-seven total hip arthroplasties complicated by deep infection were treated by reoperation and fixation of a new prosthesis with gentamicin-containing cement. The infection was proved in each case by positive bacterial cultures. Systemic antibiotic treatment was continued for six months postoperatively. Sixty hips were considered healed; the patients had no pain and had normal sedimentation rates and roentgenograms. Nine still had pain or an abnormal sedimentation rate and were classified as doubtful with regard to eradication of the infection. Eight were still infected. The patients were followed for six months to three and one-half years after reoperation.

The natural history of "idiopathic" frozen shoulder.

Abstract: The natural history of "idiopathic" frozen shoulder. R Grey; The Journal of Bone & Joint Surgery

Kinematics of the wrist. II. Clinical applications.

Abstract: A reproducible method of measuring carpal height and carpal-ulnar distance and expressing them as ratios of these distances to the length of the third metacarpal, as reported in a previous paper9, was applied to serial roentgenograms of seventeen patients with rheumatoid disease and six patients with Kienbock's disease. These ratios provide an accurate expression of the extent of carpal collapse and of ulnar translation. However, once carpal collapse has occurred, the trajectory of hand motion becomes flattened, and, as a result, the carpal height ratio will vary as the wrist moves from maximum radial to maximum ulnar deviation. These ratios may be of use in predicting a patient's clinical course, but a larger clinical study is necessary before use of the measurements for this purpose can be recommended with assurance.

Somatosensory evoked potentials during Harrington instrumentation for scoliosis.

Abstract: The somatosensory evoked potential can be obtained in the anesthetized patient during corrective surgery on the spine. The techniques of anesthesia and somatosensory evoked potential recordings described herein were utilized in fifty-five patients during surgical correction of scoliosis with Harrington instrumentation and spine fusion. No detectable complications were encountered and no neurological morbidity ensued in our series. This method may prove to be of significant value when potential injury to the spinal cord may be encountered during correction of spinal deformities.

Mechanical response of the lumbar intervertebral joint under physiological (complex) loading.

Abstract: Nineteen fresh, intact lumbar intervertebral joints (two vertebrae and the intervening joint) from twelve spines were loaded in a materials testing machine to determine their mechanical behavior. The loads applied were pure axial compression and complex loading conditions simulating physiological states. The measurements made included vertical load deflection, disc bulge, and strains in both the anterior and the lateral aspects of the vertebral body and in one lamina. The results showed that the posterior elements transmit considerable force during quasistatic complex loading, particularly in extension and frontal shear. When a healthy specimen is subjected to complex loading, "yielding or failure" occurs in the vertebral body and not in the annulus fibrosus of the disc.

Failure of total knee arthroplasty due to loosening and deformation of the tibial component.

Abstract: A series of 100 consecutive UCI knee replacements showed a 7 per cent incidence of reoperation due to loosening of the prosthesis associated with permanent deformation of the tibial component. Analysis of the clinical data, roentgenograms, and removed implants showed associations between failure and radiolucency at the cement-bone interface, prosthetic obliquity, collapse of trabecular bone, change of the alignment of the extremity, and permanent deformation of the tibial component. Although no one of these factors by itself can be responsible for the mechanical failure of the arthroplasty, a predominant failure pattern exists. We think that the sequence of events is as follows: implantation of the tibial component with medial or lateral tilt; lack of firm skeletal stabilization; continual microtrabecular fractures; change in alignment of the extremity; and permanent deformation of the plastic component.

Morphology of the acetabulum in congenital dislocation of the hip gross histological and roentgenographic studies

Abstract: At autopsy, the hips of six infants who died soon after birth and had unilateral congenital hip dysplasia were found to have a cartilaginous ridge in the acetabulum which separated the hip socket into two sections. In two of the hips with a moderate degree of dysplasia and in one completely dislocated hip the ridge was formed exclusively by a bulge of acetabular cartilage. In three completely dislocated hips the ridge was formed by a bulge of acetabular cartilage covered by the inverted labrum. The acetabular cartilage showed signs of degeneration whereas the triradiate cartilage was normal. Examination of many newborn infants indicated that hip "clicks" are common and are not diagnostic of hip dysplasia. This diagnosis should be made only when the femoral head slides with a jolt over the acetabular ridge, causing a true positive Ortolani sign. Scattered ossification centers in the acetabular cartilage were seen on the roentgenograms of nearly half of fifty-nine hips with congenital dislocation reduced after the child was two years old, but less frequently in hips reduced at an earlier age.

Improved fixation of the femoral component after total hip replacement using a methacrylate intramedullary plug.

Abstract: When the distal part of the medullary canal of the femur was plugged with a bolus of methylmethacrylate prior to the insertion of cement and femoral component, fixation of the prosthesis was improved in vitro. A special syringe was devised to introduce the plug at the desired level. When the plug was used, the penetration of the cement into the trabecular bone lining the canal was increased, and subsequent push-out tests showed that the force necessary to disrupt the methacrylate from the bone was significantly greater. Casts of the methacrylate from femora with and without plugged canals showed that the surfaces of the casts made with the canal plugged conformed much more completely with the irregularities of the bone and provided more intimate contact at the cement-bone interface.