Showing papers in "Journal of Bone and Joint Surgery, American Volume in 1989"

Unicondylar knee arthroplasty.

Abstract: Etude des indications cliniques et fonctionnelles, ainsi que des techniques et resultats operatoires de l'arthroplastie unicondylienne pour arthrose unicompartimentale du genou

Early versus delayed stabilization of femoral fractures. A prospective randomized study.

Abstract: A prospective randomized study comparing the results of early with delayed reduction and stabilization of acute femoral fractures in adults was performed over a two-year period in 178 patients. Only patients who were more than sixty-five years old and had a fracture of the hip were excluded. Arterial blood gases, injury-severity score at the time of admission, pulmonary function, days in the hospital, days in the intensive-care unit, and hospital costs were recorded for all patients. The patients were divided into two groups: those who had an isolated fracture of the femur and those who had multiple injuries. When stabilization of the fracture was delayed in the patients who had multiple injuries, the incidence of pulmonary complications (adult respiratory-distress syndrome, fat embolism, and pneumonia) was higher, the hospital stay was longer, and the number of days in the intensive-care unit was increased. The cost of hospital care showed a statistically significant increase for all patients who had delayed treatment of the fracture compared with those who had early stabilization.

Fractures of the coronoid process of the ulna.

Abstract: A review of thirty-five patients who had a fracture of the coronoid process of the ulna revealed three types of fracture: Type I--avulsion of the tip of the process; Type II--a fragment involving 50 per cent of the process, or less; and Type III--a fragment involving more than 50 per cent of the process. A concurrent dislocation or associated fracture was present in 14, 56, and 80 per cent of these patients, respectively. The outcome correlated well with the type of fracture. According to an objective elbow-performance index used to assess the results for the thirty-two patients who had at least one year of follow-up (mean, fifty months), 92 per cent of the patients who had a Type-I fracture, 73 per cent who had a Type-II fracture, and 20 per cent who had a Type-III fracture had a satisfactory result. Residual stiffness of the joint was most often present in patients who had a Type-III fracture. We recommend early motion within three weeks after injury for patients who have a Type-I or Type-II fracture. Reduction and fixation, followed by early motion when possible, may be the preferred treatment for patients who have a Type-III fracture.

Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius.

Abstract: The results in sixteen patients who had a displaced, comminuted intra-articular fracture of the distal end of the radius and who were treated by open reduction and internal fixation were retrospectively reviewed. At a mean follow-up of 4.8 years, 81 per cent of the patients had a rating of good or excellent by the scoring system of Gartland and Werley, but only 56 per cent had such a rating when the modified scoring system of Green and O'Brien was used. All of the fractures healed at an average of nine weeks. A step-off of two millimeters or more in the distal radial articular surface at the time of healing was important, because the four patients in whom the fracture healed with this amount of incongruity all had post-traumatic arthritis at follow-up, compared with only three of twelve in whom the incongruity was less than two millimeters.

Contact pressures from an instrumented hip endoprosthesis.

Abstract: A pressure-measuring Moore-type endoprosthesis was implanted in a seventy-three-year-old patient who had sustained a displaced fracture of the femoral neck. The measurement and telemetry of contact pressures in the hip began in the operating room, and data were acquired periodically for more than thirty-six months. Unexpectedly high localized contact pressures between the acetabular cartilage and the prosthesis were recorded. Early in the period of recovery, activities such as using a bedpan or performing isometric exercise produced pressures that were close to those recorded during normal walking. The highest pressure, eighteen megapascals, was recorded one year postoperatively, while the patient was rising from a chair. High pressures occurred in the superior and posterior aspects of the acetabulum.

Epidemiology of fractures of the distal end of the radius in children as associated with growth

Abstract: We determined the annual incidence of fracture of the distal end of the radius for patients of all ages and both sexes in the province of Saskatchewan, using two data sets: data on hospital admissions for 1970 through 1984, and data on physician billing for 1978 through 1985. The rate of occurrence of this fracture in children, by age and sex, was compared with longitudinal data on the velocity of growth that was collected during the same time for children from the same population. We compared the incidences of the fracture with the results of studies on the levels of activity in children and adolescents during growth. We also compared the age-specific incidence of the fracture in children with the incidence in adults. For both data sets, the age at the peak incidence of fracture of the distal end of the radius almost perfectly matched the age at which peak velocity of growth in height occurs for boys and girls. For girls, the peak incidence occurred between the ages of 11.5 and 12.5 years and for boys, between 13.5 and 14.5 years; these ages corresponded to the mean peak velocity of growth at 11.9 years for girls and 14.3 years for boys. The age-adjusted incidence of the fracture in male subjects was highest at fourteen years and was not exceeded by that in female subjects until fifty-three to fifty-four years.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteochondral fractures of the dome of the talus.

Abstract: Twenty-four patients who had an osteochondral fracture of the dome of the talus were examined by plain radiography, magnetic resonance imaging, computerized tomography, and, when indicated, scintigraphy. When plain radiographs of the ankle are relied on for the diagnosis of an osteochondral fracture of the talus, many lesions remain undiagnosed. Stage-I osteochondral fractures show no diagnostic changes on plain radiographs, and Stage-II lesions are usually subtle and, therefore, are often overlooked by both radiologists and clinicians. The use of scintigraphy as a screening procedure and of magnetic resonance imaging for patients who have positive scintiscans showed that osteochondral fractures are more common than has previously been indicated in the literature. Scintigraphy should be used to assess patients when there is clinical suspicion of an osteochondral fracture but the plain radiographs appear to be negative. Patients who have positive scintiscans should be assessed by magnetic resonance imaging. Patients who have abnormal plain radiographs will derive no major benefits from magnetic resonance imaging; for all but one of these patients, computerized tomography was adequate for staging the fracture.

Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment.

Abstract: Seventeen patients who had recalcitrant chronic adhesive capsulitis were operated on between 1979 and 1986 and were followed for an average of 6.8 years. At operation, the major cause of the restricted glenohumeral movement was found to be contracture of the coracohumeral ligament and rotator interval. Release of the contracted structures relieved pain and restored motion of the shoulder in all patients. Histological study showed fibrosis, hyalinization, and fibrinoid degeneration in the contracted connective tissues, as well as fibrosis of the subsynovial tissue and an absence of the synovial cell layer on the joint side of the rotator interval. The contracture of the coracohumeral ligament and rotator interval appears to be the main lesion in chronic adhesive capsulitis. Resection of these structures, combined with appropriate exercise, will relieve pain and restore motion to the shoulder.

Development of an osteogenic bone-marrow preparation.

Abstract: The osteogenic effect of bone marrow was tested in rabbits, using chambers that had been implanted in the peritoneal cavity (ectopic site) and in a delayed-union model (orthotopic site). Osteogenesis was accelerated in both sites after concentration of marrow elements by centrifugation, but not after unit gravity sedimentation. Chambers that were implanted with marrow that had been processed by simple and isopyknic centrifugation demonstrated a more pronounced increase in deposition of calcium compared with whole-marrow implants of equal volume (101 compared with 193 per cent). Orthotopic grafting of a rabbit delayed-union model with whole marrow and marrow that had been processed with simple centrifugation significantly increased osteogenesis, as measured biomechanically and biochemically. Significantly improved healing was evident radiographically at five weeks after grafting with bone marrow that had been concentrated by simple centrifugation.

An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability.

Abstract: Between 1976 and 1985, we repaired avulsion of the glenohumeral ligaments in sixty-three shoulders (sixty-one patients) that had traumatic anterior glenohumeral instability. We describe the indications for operation, the operative technique, and the findings at the time of operation. We located thirty-seven patients (thirty-nine shoulders) for clinical follow-up (average, 5.49 years). One patient had recurrent anterior dislocation four years postoperatively, but no patient needed reoperation. The average range of motion was 171 degrees of forward elevation and 84 degrees of external rotation in abduction. According to the criteria of Rowe et al., 97 per cent of the results were good or excellent.

Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up.

Abstract: One hundred and eleven consecutive patients who had acute injuries to the knee that included rupture of the anterior cruciate ligament, as shown by physical examination with the patient under anesthesia and by diagnostic arthroscopy, were randomized to three treatment groups: simple repair of all injured structures, repair of all injured structures and augmentation of the anterior cruciate ligament with a strip of the iliotibial band, and repair of all injured structures except the anterior cruciate ligament. In all other respects, the knees were treated in an identical fashion. Of the 111 patients, 107 were re-examined forty-five months or more after operation. At the most recent follow-up, the knees that had been treated by repair and augmentation of the anterior cruciate ligament were significantly more stable and had had significantly fewer subsequent meniscal tears. Sufficient instability to necessitate late reconstruction was also less frequent in the patients who had had an augmented repair. These patients had better function of the knee and a higher level of activity than the patients in the other two groups. Sixty-four per cent of these patients who had a rupture of the anterior cruciate also had a meniscal tear, and primary care was indicated for more than 50 per cent of the tears. Therefore, we believe that early arthroscopic examination is essential for patients who have an acute rupture of the anterior cruciate ligament.

Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna.

Abstract: A retrospective study was done of eighty-seven patients who had 129 diaphyseal fractures of either the radius or the ulna, or both, and who were treated with fixation using an AO dynamic-compression plate. Open fractures were internally fixed primarily, and both comminuted and open fractures routinely had bone-grafting. Ninety-eight per cent of the fractures united, and 92 per cent of the patients achieved an excellent or satisfactory functional result. The rate of infection was 2.3 per cent. Refracture occurred after removal of a 4.5-millimeter dynamic-compression plate in two patients, but there were no refractures after removal of a 3.5-millimeter plate. The 3.5-millimeter-plate system gave excellent results in patients who had a fracture of the forearm, and it minimized the risk of refracture. Our results demonstrated that immediate plate fixation of an open fracture of the forearm, with a low rate of complications, is possible.

Corrective shoes and inserts as treatment for flexible flatfoot in infants and children

Abstract: We performed a prospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment with a Helfet heel-cup; or Group IV, treatment with a custom-molded plastic insert. All of the patients in Groups II, III, and IV had a minimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstrated a significant improvement in all groups (p less than 0.01), including the controls, and no significant difference between the controls and the treated patients (p greater than 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

Posterior subluxation of the glenohumeral joint.

Abstract: Twenty-four patients who had posterior subluxation of the glenohumeral joint were assigned to one of two groups on the basis of the severity of the symptoms. The sixteen patients in Group I, who had less severe symptoms, were treated with a physical therapy program that was based on exercises to strengthen muscles. The eleven patients in Group II (three of whom had no success with physical therapy when they were originally in Group I) had a posterior capsulorrhaphy, with or without a bone block. According to an over-all rating, Group I had a rate of success of 63 per cent, and Group II had a rate of success of 91 per cent. The patients who had more severe ligamentous laxity were not more likely to fail either of the treatment programs. Although voluntary subluxation may be a subtle but important indicator of underlying emotional difficulties, it appears that, in the patient who is emotionally stable, the ability to voluntarily subluxate the shoulder posteriorly is not associated with a negative prognosis for either non-surgical or surgical treatment. Patients who have moderately disabling posterior subluxation of the shoulder should be treated with an intensive program that is designed to strengthen muscles. Patients who have symptoms that are severely disabling or who have had no success with non-operative treatment should be treated with posterior capsulorrhaphy. When the posterior aspect of the glenoid is severely deficient and when the posterior portion of the capsule or the infraspinatus tendon is attenuated, a bone block should augment the reconstruction.

Two-stage reconstruction of a total hip arthroplasty because of infection.

Abstract: From 1969 to 1985, eighty-one patients (eighty-two hips) who had an infection after a previous total hip arthroplasty were treated with a resection arthroplasty, followed by delayed reconstruction in the form of a repeat total hip arthroplasty. For all of the reconstructions, the femoral and acetabular components were fixed to bone with cement that did not contain antibiotics. An average of 5.5 years (range, 2.0 to 13.6 years) after reimplantation, infection had recurred in eleven hips (13 per cent). The presence of retained cement at the time of the resection arthroplasty appeared to be associated with recurrent sepsis, as three of seven patients who had retained cement had a recurrent infection, compared with only eight (11 per cent) of seventy-five patients from whom the cement had been completely removed (p less than 0.01). The twenty-six patients (twenty-six hips) who had the reimplantation less than one year after the resection arthroplasty had seven recurrent infections (27 per cent), while the fifty-six patients who had reimplantation more than one year after the resection arthroplasty had only four recurrences (7 per cent) (p less than 0.001). Three of the seven patients in whom the infection was caused by gram-negative bacilli and group-D streptococcal organisms (which are considered highly virulent) and who received systemic antimicrobial therapy for less than twenty-eight days had a recurrence. In contrast, only one of the thirteen patients in whom the infection was caused by a virulent organism and who were treated for longer than twenty-eight days had a recurrence (p = 0.055). The two-stage reconstruction is an effective, safe technique even when the infection is caused by a virulent organism.

Femoral fracture during non-cemented total hip arthroplasty.

Abstract: A study of the data on 1,318 consecutive non-cemented total hip-replacement arthroplasties revealed thirty-nine intraoperative fractures of the femur (3 per cent), only half of which were diagnosed intraoperatively. The fractures occurred in the proximal region of the femur or at the tip of the stem of the prosthesis. Most were incomplete and minimally displaced, and they did not jeopardize the stability of the femoral component. All complete proximal fractures were stabilized with a four-fifths-coated or fully coated prosthesis to provide distal fixation, and, when diagnosed intraoperatively, were fixed with cerclage wiring. When an incomplete fracture near the tip of the stem was discovered postoperatively and the posterior part of the femoral cortex was intact, a spica cast was applied, and the patient was instructed in protected weight-bearing. For a complete fracture at the tip of the stem, we recommend open reduction and internal fixation. No statistical difference was found with respect to residual pain, the score for walking, or the stability of the implant when we compared the results for the patients who had a fracture with those for the patients who did not. Modifications in surgical technique resulted in a decrease in the incidence of fractures (p less than 0.05).

The effect of lateral meniscectomy on motion of the knee.

Abstract: With the use of a five-degrees-of-freedom testing apparatus, we studied changes in the motion of the knees of cadavera after isolated resection of the lateral meniscus, with section of the anterior cruciate ligament and resection of the medial meniscus. Primary anterior and posterior translations were not affected by lateral meniscectomy. When lateral meniscectomy was done in addition to resection of the anterior cruciate ligament, anterior translation did not increase compared with that measured after isolated section of the anterior cruciate ligament. However, when the means of the paired differences in anterior translation were compared, a significant increase was found. This differed from the results after excision of the medial meniscus and section of the anterior cruciate ligament; in that situation, medial meniscectomy resulted in significantly more anterior translation.

Resurfacing of the knee with fresh osteochondral allograft.

Abstract: Fifty-nine fresh osteochondral allografts were consecutively transplanted into the knees of fifty-eight patients. The preoperative diagnoses were chondromalacia or degenerative arthritis of the patella, osteochondritis dissecans, a traumatic defect or osteonecrosis of the femoral condyle, a painful healed depressed fracture or traumatic defect of the tibial plateau, and unicompartmental traumatic arthritis of the knee. All of the patients had disabling pain after the failure of previous attempts to correct the problem surgically. Thirty-nine patients (forty knees) were available for follow-up at two to ten years after the allograft was transplanted. Nine transplants (22.5 per cent) failed and thirty-one (77.5 per cent) were successful. The result was rated excellent after thirteen of the successful transplants, good after fourteen, and fair after four. Transplantation of a fresh osteochondral allograft proved to be a satisfactory intermediate procedure for the treatment of the disabling conditions, except unicompartmental traumatic arthritis, in the young patients in this series. For the patients who had unicompartmental traumatic arthritis, the rate of success was only 30 per cent.

Aseptic loosening in total hip arthroplasty secondary to osteolysis induced by wear debris from titanium-alloy modular femoral heads.

Abstract: Since 1984, we have used components made of titanium alloy for total joint arthroplasty. Recently, two patients needed revision hip arthroplasty, approximately three years after the initial procedure, because of aseptic loosening secondary to severe osteolysis that had been induced by metallic debris. Although implants made of titanium alloy have many favorable qualities--most importantly, superb biocompatibility--the alloy is more susceptible to wear by particles of acrylic cement and tends to generate more polyethylene wear than do components made of stainless steel or chromium-cobalt. A new process of implanting ions has reportedly improved resistance to wear as well as fatigue properties and has enhanced the resistance to corrosion of the implants. Although, to our knowledge, only in vitro studies of this process have been reported to date, we recommend avoiding the use of components made of titanium alloy in which ions have not been implanted. We suggest considering the possibility of osteolysis secondary to appreciable metallic debris in patients who have aseptic loosening of titanium-alloy components that were not implanted with ions.

Cervical kyphosis and myelopathy. Treatment by anterior corpectomy and strut-grafting.

Abstract: Between 1976 and 1984, fourteen patients who had severe cervical kyphosis and myelopathy were treated with anterior decompression and arthrodesis. Eight had had spondylosis; five, a traumatic injury; and one, a benign intradural tumor. In eight of the fourteen patients, the severe kyphosis and myelopathy had developed after a laminectomy of three, four, or five cervical vertebrae. The laminectomy had been done for the treatment of spondylosis in five patients, of a traumatic lesion in two, and of a tumor in one. Considering all fourteen patients, an average of 2.25 vertebral bodies was removed from each, and the average extent of the subsequent fusion was 3.25 levels. Eight patients (six of whom had spondylosis; one, a traumatic lesion; and one, a tumor) were treated with a fibular graft that spanned an average of 4.10 levels, and six patients (four of whom had a traumatic lesion and two, spondylosis) were treated with an iliac graft that spanned an average of 2.70 levels. Of the five patients who had a traumatic lesion, four were treated with anterior decompression and arthrodesis, combined with posterior arthrodesis that was performed during the same period of anesthesia. In three patients, the anterior graft dislodged during the immediate postoperative period. Two of the three patients had posterior instability due to a prior laminectomy, and in the third the graft dislodged because of technical difficulties. Two of these grafts were revised to restore stability. At the latest follow-up, twelve of the fourteen fusions were solid. In the other two patients, who died six and ten months postoperatively, the fusion had been solid, as shown by radiographs, before the time of death. The average amount of correction of the kyphotic deformities was 32 degrees, a reduction from an average of 45 degrees to an average of 13 degrees. All but one patient had some recovery of neural function; nine had complete and four, partial recovery. The remaining patient had relief of pain, but he continued to be completely quadriplegic although he had some sensory sparing. Of the four patients who had been unable to walk preoperatively, three were able to walk postoperatively. No patient lost neural function after the anterior decompression and arthrodesis. We concluded that, in the presence of severe cervical kyphosis and myelopathy, adequate anterior decompression of the spinal cord, correction of the kyphosis, and anterior arthrodesis using a strut graft can yield excellent results without undue risk.

Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis.

Abstract: The case of eighty-one patients who had tuberculosis of the spine that was treated by debridement and anterior arthrodesis were reviewed eight years or more postoperatively. We studied the progression of the kyphosis and evaluated the function and fate of the bone grafts that were used. At eight years, the results with respect to the progression of the kyphosis were classified as excellent or good in forty-eight patients (59 per cent), all of whom had had minimum destruction of the vertebral bodies; limited surgical excision of bone, resulting in a small post-debridement defect that needed only a short graft; marked intraoperative correction of the deformity; and involvement of lower lumbar segments. Fifteen patients (19 per cent) had a fair result and eighteen (22 per cent), a poor result. An increase in the deformity was common in patients who had extensive involvement of the vertebral bodies that had resulted in a large post-debridement defect necessitating a graft spanning more than two disc spaces. Lesions of the thoracic vertebrae were associated with many of the poor results, and patients who had a marked kyphosis before treatment also did not do well. A stable graft that provided structural support was observed in only thirty-three patients (41 per cent), and failure of the graft due to slippage, fracture, absorption, or subsidence was seen in forty-eight patients (59 per cent). The length of the graft also played a role: the graft failed most often in patients in whom it spanned more than two disc spaces. We concluded that it is unwise to rely solely on the graft to prevent vertebral collapse in patients in whom the length of the graft exceeds two disc spaces. These patients may benefit from additional measures, such as an extended period of non-weight-bearing, posterior arthrodesis after six to twelve weeks, and prolonged use of a brace until complete consolidation is evident.

Spondylolysis and spondylolisthesis in children and adolescents.

Abstract: Etiology, symptoms, radiographic aspects and treatment of spondylolysis and spondylolisthesis

Non-operative treatment of meniscal tears.

Abstract: In a retrospective review of the results of 3,612 arthroscopic procedures that were performed for the treatment of an acute or a chronic meniscal lesion, with or without an associated ligamentous lesion, we identified eighty meniscal tears (in seventy-five patients) that had been assumed to be stable. Seventy were vertical longitudinal tears and ten were vertical radial tears. The seventy longitudinal tears included fifty-two lateral and eighteen medial meniscal lesions. All of the radial tears were in the lateral meniscus. Of the seventy-five patients, fifty-two had been followed for two to ten years. At the time of follow-up, only six of these fifty-two patients had needed additional intervention because of symptoms that were related to the meniscal tear. Four of them had the intervention after a sports-related traumatic extension of a stable tear, and two, because persistent symptoms were caused by the original meniscal lesion. A repeat arthroscopy was performed on thirty-two patients (twenty-six of whom had a longitudinal tear and six of whom had a radial tear), at an average of twenty-six months after the original arthroscopy. Seventeen of the twenty-six longitudinal tears had completely healed. Five of the six radial tears had no evidence of healing and one had extended. Neither ligamentous laxity nor a meniscal tear that was chronic at the time when it was discovered appeared to preclude healing of the stable longitudinal tears. No localized degenerative changes in the adjacent articular cartilage were found in association with any of the stable vertical longitudinal or radial meniscal lesions. Excluding the six patients who had had additional surgical treatment, none of the fifty-two patients who filled out a questionnaire reported that they had symptoms of a meniscal lesion, and none of the forty-two patients who were re-examined two years or more after the operation had signs of a meniscal lesion. Stable vertical longitudinal tears, which tend to occur in the peripheral vascular portions of the menisci, have great potential for healing. The tear should be left alone unless it is the only abnormality that is found and it is causing symptoms that warrant treatment. Stable radial tears, which tend to occur in the avascular inner one-third of the meniscus, have little potential for healing. Whether it is best to leave these lesions alone or to fashion an intact rim by contouring the meniscus was not established by this study.

Mechanical considerations for the syndesmosis screw. A cadaver study

Abstract: The purpose of this study was to examine the mechanical necessity of using a syndesmosis screw to supplement rigid internal fixation of the fibula and medial malleolus in the treatment of pronation-external rotation fractures. The legs of thirty embalmed and five fresh cadavera were dissected and mounted through the tibia to a frame so that multiple radiographs could be made with a constant relationship between the specimen and the x-ray apparatus. A standardized pronation-external rotation load was applied to the foot, and widening of the syndesmosis was studied on mortise radiographs that were made after each experimental step. On the basis of previous investigations, we developed a model for pronation-external rotation injuries that included disruption of the syndesmosis and interosseous membrane up to the level of the fibular fracture. Accordingly, multiple repaired fibular fractures could be simulated at several levels in the same specimen by incremental proximal division of the interosseous membrane. Specimens were separated into two groups. Group I consisted of thirteen specimens in which the deltoid ligament, syndesmosis, and interosseous membrane were serially sectioned in 1.5-centimeter increments. Group II (ten sections) was subjected to the same protocol, except that the deltoid ligament was kept intact until the final step. The five fresh specimens were sectioned in the same way as those in Group I. In Group I, since the simulated pronation-external rotation injury included a deltoid tear, rigid medial fixation was not possible; accordingly, there was rigid fibular fixation only.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up after fractures of the tibial and fibular shafts.

Abstract: Thirty-seven patients who sustained a closed or a Grade-I open tibial and fibular fracture were evaluated an average of twenty-nine years after injury. All of the patients had had uncomplicated treatment with a plaster cast. Clinically, 78 per cent of the ankles were rated good or excellent, and 92 per cent of the knees were rated excellent. Radiographic assessment for osteoarthritic changes revealed a good or excellent result for 76 per cent of the ankles and an excellent result for 92 per cent of the knees. The clinical and radiographic outcomes were unaffected by the amounts of anterior or posterior and of varus or valgus angulation, as well as by the level of the fracture. The length of immobilization, which did not exceed one year, also did not affect the outcomes.

Salvage of the limb in the treatment of malignant pelvic tumors.

Abstract: From 1970 through 1985, at the Mayo Clinic, sixty patients had operative treatment, with salvage of the limb, for a primary malignant tumor of the pelvis. Chondrosarcoma, osteosarcoma, and fibrosarcoma were common diagnoses. There were twenty-three iliosacral, twenty-five acetabular, and twelve ischiopubic lesions. Most of the resections were done with a wide margin and disruption of femorosacral continuity. Reconstruction included ten iliosacral, fourteen iliofemoral, and three ischiofemoral arthrodeses, and approximately 50 per cent of the procedures resulted in fusion. The average length of follow-up exceeded five years. Seventeen per cent of the patients, primarily those in whom an iliosacral lesion extended into the sacrum or along the spinal column, had a local recurrence. Twenty-one patients (37 per cent) had metastasis. The best functional results were seen after resections in which femorosacral continuity was maintained or reconstructed. If satisfactory margins can be achieved by the excision of a pelvic tumor, salvage of the limb is justified from both an oncological and a functional standpoint.

The effect of alignment of the implant on fractures of the patella after condylar total knee arthroplasty.

Abstract: The results in thirty-six knees that had a fracture of the patella after a total condylar arthroplasty were reviewed, and were analyzed according to the type of fracture and the alignment of the implant and the limb. Most of the fractures occurred two years or less after the initial operation. Fourteen knees were rated fair or poor and twenty-two, good or excellent. None of the thirty-six implants had been aligned in the neutral range. In sixteen knees, the alignment had a minor variation from the neutral range--that is, the knees were in minor malalignment. In general, these knees had the least severe fractures and the best over-all results. All had a good or excellent result except one, which was revised because of a loose patellar component. That knee was rated as fair at the latest follow-up. There was a major discrepancy in the alignment of twenty implants. These knees had more severe fractures and less satisfactory results than those in the other group. In two of these knees, the fracture was treated non-operatively; one had a good and the other, a poor result. Twelve of the remaining knees, which were treated surgically, were rated as fair or worse. Two knees that had revision of three components and restoration of alignment to the neutral range had an excellent result. The results of this study indicate that the alignment and fit of a component are important in determining the severity of a fracture of the patella after condylar total knee replacement and the long-term results after treatment of the fracture.

Defects of early fracture-healing in experimental diabetes.

Abstract: Diabetes has been implicated as a cause of impaired fracture-healing. To test this hypothesis, we tested the tensile strength of femora from normal rats and from untreated and insulin-treated diabetic rats two weeks after the production of a closed fracture. One week before the fracture, diabetes was induced by administration of streptozotocin (sixty-five milligrams per kilogram of body weight). The concentration of serum glucose increased from 6.1 +/- 0.3 millimoles per liter (110 +/- 5 milligrams per deciliter) in the control animals to 31.1 +/- 0.8 millimoles per liter (560 +/- 15 milligrams per deciliter) in the untreated diabetic animals. After two weeks of healing, fracture callus from the untreated diabetic animals had a 29 per cent decrease in tensile strength and a 50 per cent decrease in stiffness compared with the controls. Treatment of the diabetic animals with insulin resulted in a mean concentration of serum glucose of 14.4 +/- 0.6 millimoles per liter (260 +/- 10 milligrams per deciliter) and restored the tensile strength and stiffness of the callus to a value that was not statistically different from that of the controls. Between the fourth and eleventh days of healing, there was a 50 to 55 per cent decrease in the collagen content of the callus of the untreated diabetic animals compared with the controls. In addition, on the fourth day of healing, DNA content, an indicator of cellularity of the callus, was decreased 40 per cent in the untreated diabetic group. Between the fourth and eleventh days of healing, the collagen-to-DNA ratio, which was determined as an indicator of net collagen synthesis per cell, was decreased 15 to 50 per cent in callus from the untreated diabetic animals.

Acute compartment syndrome of the thigh. A spectrum of injury.

Abstract: Twenty-one compartment syndromes of the thigh in seventeen patients were identified for retrospective review. Ten of the compartment syndromes were associated with an ipsilateral femoral fracture; five of these femoral fractures were open. In five patients, the syndrome followed femoral intramedullary stabilization. The remaining eleven syndromes followed blunt trauma to the thigh, prolonged compression by body weight, or vascular injury. The patients who were awake and alert at the time of the examination complained of intense pain in the thigh, and they had neuromuscular deficits. For the patients who could not cooperate with a subjective physical examination because they were under general anesthesia or because of associated injuries, the measurement of compartment pressure assumed a more important diagnostic role. All of the patients had tense swelling of the involved thigh. The predisposing risk factors for the development of compartment syndromes of the thigh, which are common in the multiply injured population, include: systemic hypotension, a history of external compression of the thigh, the use of military antishock trousers, coagulopathy, vascular injury, and trauma to the thigh, with or without a fracture of the femur. In approximately one-half of these patients, a crush syndrome developed, with myoglobinuria, renal failure, and collapse of multiple organ systems. Eight patients (47 per cent) died as a result of multiple injuries. Of the nine patients (ten compartment syndromes) who survived, infection developed at the site of the fasciotomy in six. Follow-up examination revealed marked morbidity, including sensory deficit and motor weakness of the lower extremity.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal cord monitoring.

Abstract: Inventaire des differentes techniques avec description des zones stimulees et des sites d'enregistrement: potentiels evoques somatosensoriels corticaux, potentiels evoques medullaires, potentiels evoques moteurs, stimulation d'un dermatome