Management of different forms of varus deformity during total knee arthroplasty

Varus deformity of the lower limb is a common association of knee arthritis. The deformity-and more precisely its apex-is usually situated at the level of the joint and results from wear of the articular cartilage and subchondral bone underneath. Less commonly this deformity-due to non-united fracture, or malperformed osteotomy-maybe situated away from the joint line along the axes of the tibia or the femur. Two types of varus knee deformity in knee arthritis are therefore distinguishable, the intraarticular and the extra-articular types. Each of these types requires and deserves special attention and different way of correction during replacement of the knee joint. In this article three groups of varus osteoarthritic knees are presented, evaluated and compared. The first group comprised 82 knees with intraarticular deformity that ranged from 17 to 32 degrees and treated with total replacement of the joint after adequate soft tissue release. In the second and third groups 22 osteoarthritic knees with extraarticular varus deformity that ranged from 18 to 35 degrees were presented and differentiated according to the mode of surgical correction of the varus deformity. In one group compensatory bone cuts were carried out ignoring and compensating for the extraarticular deformity and correcting at the same time the overall limb alignment and the inclination of the joint line. In the other group, a single stage procedure that included a separate osteotomy away from the joint level corrected the deformity prior to replacement of the knee. Comparison of the three groups in this study demonstrated that total knee arthroplasty in knees with intra-articular varus deformities was relatively a simpler procedure and had superior results to the arthroplasty of the knees with extraarticular varus deformity. This procedure however, necessitated special attention to soft tissue balancing and special care in the repair of the released tissue. In the groups with extraarticular deformity limb alignment was a major concern. The worst results however, were obtained when compensatory bone resection was the technique of correction of the extraarticular varus and this was mainly due to ligament laxity. In this group tibial compensatory resection had better results than femoral compensatory resection. It is therefore concluded that during total knee arthroplasty extraarticular varus deformity is best managed independently through a separate osteotomy situated at the apex of the deformity. Careful soft tissue release and adequate repair of the released tissues were necessary for the stability after total knee arthroplasty in knees with intraarticular varus deformity

Surgical management of trapezio-metacarpal joint arthritis. Comparison of two techniques

Osteoarthritis at the base of the thumb affecting the trapeziometacarpal [TMC] joint is a common, painful and disabling condition that severely compromises function of the entire hand. Successful treatment is based on an understanding of the specific anatomy and the unique functional attributes of the human hand and thumb. Surgical procedures for this problem include extra articular ligamentous reconstruction, partial or complete resection of the trapezium with or without tendon interposition arthroplasty, arthrodesis of the trapeziometacarpal joint, osteotomy of the thumb metacarpal, silicone interposition arthroplasty and total joint arthroplasty. The results of this prospective study were represented in which qualitative and quantitative outcomes were assessed clinically and radiographically in 47 thumbs in 40 patients with thumb basal joint arthritis affecting the trapeziometacarpal joint treated with beak ligament reconstruction with tendon interposition arthroplasty [LRTI] [group I including 25 thumbs] or with arthrodesis of the TMC joint [group II including thumbs]

Retrograde closed unreamed interlocking nailing for multiple-level femoral fractures

In a prospective study for the treatment of multiple-level femoral fractures, the results of retrograde, closed unreamed, interlocking technique through the inter-condylar notch of the femur were evaluated. Russell-Taylor tibia1 nail was used in all cases. There were twelve fractures [five were open] in twelve patients; ten were males and two were females. Nine patients had other skeletal trauma and one had rupture of the spleen. The average operative time was 65 minutes [range 45 to 100 minutes]. Blood loss was minimal [average 150 ml]. The average follow up was 19 months [range 11-32 months]. Union occurred without additional surgery within 17 weeks in all, but one patient needed autogenous bone grafting about the most proximal fracture site at the twentieth week. All patients regained full knee motion within four weeks. No cases of infections, screw or nail failures, patellofemoral [PF] problems or problems about the hip were recorded. In most of cases [8 out of 10], simultaneous management of other skeletal or non skeletal trauma was possible. At the terminal follow up, it was evident that retrograde closed unreamed interlocking nailing is a competent method in the treatment of multiple-level femoral fractures, especially in those with multi system and/or multiple skeletal trauma

Experience with interlocking nail fixation for humeral shaft fractures and its surgical spectrum

This is a prospective study of 23 patients who had 23 fractures of the humeral shaft fixed with closed unreamed interlocking nailing using the Russell-Taylor humeral nails. All fractures were of traumatic origin and of different morphological varieties The fractures occured at different levels of the humeral shaft extending from a point one inch distal to the inferior margin of the articular surface of the proximal humerus to a point two inches above the superior margin of the olecranon fossa. A closed technique of nailing was followed in all cases over a guide wire inserted in an antegrade manner into the medullary canal of the humerus after reduction of the fracture. There was no attempt at reaming the medullary canal and the used nail was of 8 mm diameter. In all cases but two the nail was locked at either end using a self tapping 4 mm cortical screw. Union was assessed radiologically by denoting bridging callus at the fracture site. In all cases but two healing progressed steadily. These two cases showed some delay in union but eventually united without further interventions. The average time of union was 16 weeks. The complications in this series was pain and limitation of shoulder movement in five patients, one of them also had limitation of elbow extension. latrogenic radial nerve palsy that recovered at 14 weeks postoperatively occurred in one patient, delayed union in two patients and few technical pitfalls related to the nail length and diameter or the locking screws occured in 6 patients. This study has shown that the technique of closed and locked medullary nailing of humeral shaft fractures is a reliable one. The rate of union is quite satisfactory if the technique and principles of the procedure are followed properly. Most important however is the wide spectrum of use of this technique that includes all sorts of fractures that extend from one inch below the humeral head to less than two inch above the olecranon fossa [Fig. 14]