Résumé
An intra-articular fracture of the distal tibia or a fracture of the tibial plafond is a relatively uncommon but the most difficult fracture to manage. There are many treatment options and many authors have reported good results after open reduction and rigid internal fixation to restore the length with articular surface and bone-graft followed by early motion and prolonged non-weight bearing. But in the fractures with severe comminution or with severe soft tissue injury, tries for internal fixation with plate and screws in the distal tibia will result in extensive soft tissue stripping of the wound with precarious blood supply, high rates of wound breakdown, superficial and deep infection, and osteomyelitis. The purpose of this study is to evaluate the results of treatment of severely open (open type III-A and more by Gustilo and Anderson) or comminuted plafond fractures (fracture type III and more by Ovadia and Beals) with an Ilizarov method with a minimum follow up of one year (average: 27.9 months) and we have reviewed 12 cases from December 1990 to October 1995. The results were as follows. 1. The average time of bone union were 17.5 weeks (range: 6-42weeks). 2. The radiological results of the treatment were excellent in 4 patients (33.3%), good in 4 patients (33.3%) and poor in 4 patients (33.3%) by radiological assessment of Crutchfield and the clinical results of the treatment were excellent in 4 patients (33.3%), good in 5 patients (41.7%) and poor in 3 patients (25.0%) by functional rating scaie of Crutchfield. 3. It seems that prognosis depends on severity of comminution at the time of injury. 4. The complications were bony collapse of the distal tibia in 2 patients, nonunion in 1 patient, degenerative arthritis of the ankle joint in 2 patients and chronic osteomyelitis in 2 patients. 5. Ilizarov technique is an useful method in the management of severely open or comminuted plafond fracture of the tibia and it would be preferable to apply buttress plate or bone graft after improvement of skin condition to prevent the late collapse.
Sujets)
Humains , Articulation talocrurale , Études de suivi , Technique d'Ilizarov , Fractures articulaires , Arthrose , Ostéomyélite , Pronostic , Peau , Traumatismes des tissus mous , Tibia , Transplants , Plaies et blessuresRésumé
Interlocking and Ender nail fixations have been widely used for the surgical treatment of diaphyseal fractures of femur. Interlocking nail could give advantage of high stability to unstable, cominuted fractures. It requires, however, advanced technique and exposure to radiation harzard, often complicated by further comminution, displacement, breakage of drill bit or loosening of locking screws. Ender nail, on the contrary, is easier in procedure without reaming, thereby maintaining endosteum and requiring short operation time. It, however, cannot avoid complications of shortening, rotational deformity, migration of nails, etc. This study aimed at comparative evaluation of the clinical results of two different nailings(23 Interlocking and 19 Ender nails) performed from March 1987 to March 1993. The study materials were 42 femoral fractures out of 41 adult patients with the followed-up between one and seven years(average 3.5 years). The results are summarized as below: 1. Fracture occurred mostly in the mid-diaphysis(81%) and the Type III comminution(63%) was most common according to the Winquist-Hansen classifiaction. 2. The operative time averaged ninty five minutes in Interlocking nailing, while sixty minutes in Ender nailing. The blood loss was negligible in both techniques. 3. Fluoroscopic assessment after insertion of the nails revealed that Interlocking gave superior stability to Ender nail, while Ender nail produced earlier callus formation(7.5 weeks in average) than Interlocking nail(9.0 weeks in average, p 0.05). 4. Interlocking nail was complicated by loosening of locking screws in two, angulation in one, breakage of drill bit in one cases. Ender nail showed protrusion in two, limb shortening in three, rotational deformity in three cases respectively. There was neither operative infection nor nonunion.
Sujets)
Adulte , Humains , Cal osseux , Malformations , Membres , Fractures du fémur , Fémur , Durée opératoireRésumé
Twenty-eight patients with 20 tibia fractures and 8 femur fractures were treated with external fixation. The average age at fracture was 10 years 10 months ranging from 5 years to 17 years 6 months. Of 28 fractures, 6 were closed fractures and 22 were open fractures. The average follow-up of these children was 23 months. Monofixators were used in 12 fractures and Ilizarov fixators in 16 fractures. The average time to healing of the fractures was 14.6 weeks(range, 6 to 44 weeks). Seven segmental bone defects(range, 2 to 17cm) were treated with the Ilizarov method of internal bone transport using the transport ring and bone grafting at the docking site. The average healing index for callus distraction was 25 days per centimeter. Seven patients had 10 major complications that necessitated additional operative procedures. There were 4 nonunions. Three patients had an infected nonunion, which was treated with the Ilizarov fixator and polymethyl-methacrylate antibiotic beads. One patient had a hypertrophic nonunion which was treated with plate fixation. Three patients who had an epiphyseal injury had shortening with angular deformity, which was treated by callus distraction. Three patients had a joint contracture, which was treated by the percutaneous tenotomy and Ilizarov fixator. The selection of the type of external fixator depends on the fracture pattern and the Ilizarov fixator is recommended for complicated fracture with severe comminution or segmental bone loss.
Sujets)
Enfant , Humains , Transplantation osseuse , Cal osseux , Malformations , Contracture , Fixateurs externes , Fémur , Études de suivi , Fractures osseuses , Fractures fermées , Fractures ouvertes , Technique d'Ilizarov , Articulations , Procédures de chirurgie opératoire , Ténotomie , TibiaRésumé
Thirty-six femoral heads with non-traumatic osteonecrosis(ON) at precollapse stage in 32 patients were studied with repeated magnetic resonance(MR) imagings at three-month intervals to reveal the occurrence of marrow edema of the proximal femur in early stage ON. Eighteen hips were randomly selected for the core decompression and the remaining 18 hips were treated conservatively. The criteria of marrow edema in this study were signal abnormalities of low signal intensity in T1-weighted image, and isointensity or hyperintensity in T2-weighted image which involved the femoral head beyond the necrotic zone, extending to the neck and trochanteric area. Eight femoral heads demonstrated marrow edema at the initial MR imaging and seven out of eight were associated with pain for one to six weeks before the first MR study. Core decompression was performed on four out of those seven symptomatic femoral heads with marrow edema after the first MR imaging. The symptom was relieved promptly in three out of four core decompressed hips. The remaining one core decompressed case showed reccurrent marow edema on follow-up MR imagings. Out of 28 hips free of marrow edema at the initial MR study, 14 hips underwent core decompression after the first evaluation and the remaining 14 hips were treated conservatively. One out of 14 core-decompressed hips and three out of 14 nonoperated hips showed marrow edema in follow-up MR studies. Two cases experienced hip pain while two cases remained symptomless at the presence of marrow edema. Four femoral heads under-went core biopsy and three cases received total hip arthroplasty at the presence of marrow edema. In those four hips which underwent core decompression during the presence of marrow edema, intraosseous pressure(IOP) ranged from 36 to 60 (mean; 49) mmHg. In the remaining 14 core decompressed hips, the IOP ranged from 16 to 52 (mean; 37) mmHg. The histology of those four core biopsies and three resected femoral heads showed a collection of eosinophilic plasma-like fluid in the marrow space around the necrotic zone, a finding compatible with marrow edema. This study suggests that marrow edema of the proximal femur may occur during the progression of the ON of the femoral head and is frequently associated with increased intraosseous pressure and pain. Core decompression can relieve marrow edema and associated pain promptly. But the effect is temporary, and core decompression does not prevent marrow edema permanently.
Sujets)
Humains , Arthroplastie prothétique de hanche , Biopsie , Moelle osseuse , Décompression , Oedème , Granulocytes éosinophiles , Fémur , Études de suivi , Tête , Hanche , Imagerie par résonance magnétique , Cou , Ostéonécrose , Études prospectivesRésumé
Fixation with screws of Cotrel-Dubousset instrumentation was applied to replace the hooks in the treatment of scoliosis thoracic spine from 1987 by authors. The purpose of this study is to compare the result of treatment of the idiopathic scoliosis patient with pedicle screws and that with hooks and to clarify the advantages of pedicle screws in the treatment of idiopathic is scoliosis. The materials were 164 idiopathic scoliosis patients treated from 1987 to 1991 with average follow-up of 36 months(ranged 24 to 52 months). They were divided into three groups according to the fixation implants used. Forty-seven patients were treated with hooks only(hook group), 76 patients with screws and hooks(mixed group), and 41 patients with screws only(screw group). In the frontal curve correction, the hook group showed 49% of correction(preop. 59° to postop. 30°), the mixed group 60% of correction(preop. 58° to postop. 23°), and the screw group 63% of correction(preop. 51° to postop. 19°). For the patients with preoperative kyphosis less than 15°, there were significant improvement of sagittal curve in all groups from 3° to 19°. In the normokyphotic patients, there was no significant change. In rotational deformity, measured by Perdriolle method, the hook group 19% of correction, mixed group 20%, the screw group 24%. Hooks were dislodged in 17 cases and screws were found out of pedicle in 5 cases, but any neurologic complications or significant adverse effect on curve correction and loss of correction were not observed. Soft tissue infection was occurred in one patient, who was treated onservatively. In conclusion, screws fixation on the thoracic spine can be applied in the treatment of scoliosis without neurologic complications, and the screws provide rigid fixation and immediate stability after insertion with better correction in frontal, sagittal and less neurologic risk due to its extracanal placement and rigid fixation in derotation, and it makes the instrumental technique simpler, so the operation time shorter.
Sujets)
Humains , Malformations , Études de suivi , Cyphose , Méthodes , Vis pédiculaires , Scoliose , Infections des tissus mous , RachisRésumé
No abstract available.