Accurate limb-length equalization during total hip arthroplasty.

A method of equalization of limb lengths during total hip arthroplasty (THA) was developed that uses the concept of precise reproduction of the position of the femur in space (abduction/adduction) by use of a carpenter's level. Precise reproduction of the femoral position allows accurate measurement of the distance between the pelvis and femur before hip dislocation and after trial component placement allowing accurate measurement of the change in the distance between the femur and pelvis. Accordingly, limb length can be maintained or adjusted to match the contralateral side with increased accuracy. A prospective study was performed with 117 consecutive patients undergoing THA to assess the accuracy of an intraoperative limb-length measuring device. Patients were sequentially randomized into two groups. Group A patients underwent THA without the use of the measuring device, and group B underwent THA using the device. Radiographic assessments of limb lengths were measured using the method of Williamson and Reckling. The hips in group B had a statistically significant decrease in limb-length inequality after THA compared with group A (P<.01). Average postoperative limb-length inequality was 8.8 mm and 3.4 mm for groups A and B, respectively. Three (5%) of 58 group B patients and 18 (31%) of 59 group A patients had a radiographic postoperative limb-length inequality >12 mm (P<.01). Eighty-four of group B patients had limb lengths within 6 mm of the contralateral side compared with 30% of group A patients. Twenty-four percent of group A patients and 7% of group B patients had a symptomatic limb-length inequality that required a heel lift (P<.01).

The potential use of human recombinant erythropoietin in orthopedic surgery.

Human recombinant erythropoietin has been approved by the Food and Drug Administration for treatment of anemia due to chronic renal failure or malignancy and in zidovudine-treated patients with the human immunodeficiency virus. It is highly effective in reducing the anemia commonly seen in these patients, with minimal adverse effects. Approximately 20% of patients undergoing elective orthopedic procedures are not able to donate adequate amounts of autologous blood prior to surgery. Additionally, patients who cannot donate 3 or more units of blood prior to large procedures are at increased risk for receiving a homologous transfusion despite the use of intraoperative and postoperative blood conservation techniques. Investigational use of this drug as an adjuvant to autologous blood donation has been shown to increase the amount of blood donated by patients prior to surgery and, therefore, will decrease homologous blood transfusions after surgery. Perioperative use of this drug, dosage, route of administration, and clinical indications are currently being evaluated in multicenter clinical trials.

Femoral artery and nerve compression by bulk allograft used for acetabular reconstruction. An unreported complication.

Absent pulses in the ipsilateral limb and a femoral nerve palsy occurred after revision total hip arthroplasty. Emergent arteriogram revealed an occlusion of the femoral artery inferior to the inguinal ligament. The femoral artery was found to be compressed by the bulk allograft bone used for reconstruction of an anterior segmental acetabular defect. No laceration or thrombosis of the artery was present. A high-speed burr was used to remove the anterior portion of the offending allograft. Pulses were immediately restored and the patient had no long-term vascular sequelae. The femoral nerve palsy has slowly resolved over 2 years.

Long-term outcome of 42 knees with chronic infection after total knee arthroplasty.

The outcome of treatment in 40 patients (42 knees) with chronic infections after total knee arthroplasty was reviewed. Eighteen knees were treated with a 2-stage reimplantation. Sixteen of these 18 knees were treated with antibiotic-containing beads between debridement and reimplantation, and 7 of these were also treated with antibiotics in the cement at reimplantation. Infection did not recur in any of these 18 knees. Clinically, the 2-stage reimplantation group averaged a score of 90 points on the Knee Society Clinical Rating System. Average function score was 86.5 points, with average range of motion from 2 degrees to 109 degrees. Sixteen knees were treated with an arthrodesis: 9 with a 1-stage technique with a uniplanar external fixator and 7 with a 2-stage technique with intramedullary nail internal fixation. Infection did not recur in 6 of 9 knees treated with the 1-stage technique, but only 2 had a solid arthrodesis. All 7 treated with the 2-stage intramedullary nail technique had no recurrence of infection and achieved a solid fusion. Reimplantation or arthrodesis was not attempted in 8 other knees because of recalcitrant infection, vascular complications, or medical infirmity. Of the 42 knees, 11 (26%) had a severely morbid outcome. The infection could not be eradicated in 7 knees: 6 required amputation and 1 had a solid fusion but chronic drainage. In 3 knees, the infection was cured but resection arthroplasties were required, and in 1 patient an amputation was needed as a result of an intraoperative vascular complication.

Vein, silastic, and polyglycolic acid fine mesh: a comparative study in peripheral nerve repair.

We investigated three sheathing materials (autogenous vein, silastic, and polyglycolic acid fine mesh) using the rat model. Forty rats were divided into five groups of eight animals each. Group A animals underwent transection of the sciatic nerve but had no repair. In Group B, a standard epineural repair was performed. In Groups C, D, and E, the nerve was repaired as in Group B with the addition of autogenous vein, Silastic, and polyglycolic acid fine mesh sheaths, respectively. Nerve regeneration and function were assessed using sciatic functional index, nerve conduction studies, and light microscopy. Sheathing methods showed no statistically significant advantage to standard epineural repair without a sheath.

Transpedicular convex anterior hemiepiphysiodesis and posterior arthrodesis for progressive congenital scoliosis.

Nine children with progressive congenital scoliosis underwent bilateral posterior spinal fusion supplemented with transpedicular convex anterior hemiepiphysiodesis. The average preoperative curve was 52 degrees. The average age at surgery was 9 years and 1 month and the average follow-up period was 3 years and 6 months. Curve progression was arrested in all cases, and curve correction greater than 10 degrees was achieved in four patients.

Superficial temporal artery laceration. A complication of skull tong traction.

Complications associated with the use of skull tongs are not uncommon. We report a case of superficial temporal artery injury as a complication of Gardner-Wells tong application. Chronic recurrent episodes of pulsatile bleeding from the pin site necessitated arterial ligation to control the bleeding.

A preliminary experience with the Russell-Taylor reconstruction nail for complex femoral fractures.

Eleven cases of complex femoral fractures were seen from November 1987 to November 1989; five ipsilateral femoral neck and shaft fractures and six comminuted subtrochanteric fractures. High-energy accidents accounted for most of these injuries. There were numerous associated injuries, many requiring operative procedures. All of the fractures were treated with Russell-Taylor reconstruction nails. All fractures united, but there were two delayed unions. There was no delay in diagnosis of the femoral neck fractures, and all healed without avascular necrosis. Malalignment occurred in one case, shortening of the femur occurred in two cases, and in two cases only one screw could be placed in the femoral head. In three patients technical errors related to nail insertion led to fracture complications. The use of the Russell-Taylor reconstruction nail is technically demanding. However, we conclude that in complex femoral fractures, this device offers superior stabilization over other currently used methods of internal fixation.

Laryngeal manifestations of Wegener's granulomatosis: case reports and review of the literature.

We report two patients with laryngeal manifestations of Wegener's granulomatosis to demonstrate the marked variability of presentation in this disease. The reported literature is reviewed and shows a similar spectrum with early and late onset of laryngeal granulomata, subglottic in location. Of all the patients with Wegener's granulomatosis reviewed, 8.5% will eventually develop a subglottic lesion. Therapy depends upon response to steroids, cytotoxic drugs, and radiation therapy. Usually surgical therapy will be necessary.