Rheumatoid arthritis of the ankle and hindfoot.

Rheumatoid arthritis frequently affects the hindfoot and ankle and may present a considerable source of dysfunction. Awareness of characteristic clinical and radiographic findings and other diagnostic modalities help the clinician to evaluate the progression of the disease and determine the best methods of management. A variety of nonoperative treatments may slow progression of deformities, improve function, and provide symptomatic relief. If these measures fail, surgical intervention, including soft-tissue procedures as well as a variety of arthrodesis techniques, can return patients to a more active lifestyle.

Allograft epiphysiodesis for slipped capital femoral epiphysis.

During this retrospective investigation, use of freeze-dried irradiated allograft for achieving epiphysiodesis in patients with Grade I or Grade II slipped capital femoral epiphyses was evaluated. The study reviewed 40 grafting procedures in 33 patients: 20 patients were boys and 13 were girls, whose average age was 13 years old. The group included 31 Grade I slips and 9 Grade II slips. Six were unstable and 34 were stable. Procedure time averaged 1 hour 57 minutes and blood loss averaged 360 ml. The average time to complete physeal closure was 28 weeks. An incomplete bony physeal bridge, apparent at an average 11 weeks, may impart earlier stability. Thirty-eight cases had followup averaging 3 years 6 months. At most recent evaluation, according to the Harris hip rating system, 35 hips had excellent ratings, 1 had a good rating, and 2 had fair ratings. Six patients were identified with major postoperative complications, including 1 case each of segmental avascular necrosis, chondrolysis, femoral neck fracture, subtrochanteric hip fracture, bilateral progressive coxa vara deformities requiring corrective osteotomies, and a unilateral progressive coxa vara deformity. The senior author (TLS) currently uses a fluoroscopically guided percutaneous lateral approach, a cannulated reaming system, and freeze-dried irradiated cortical allograft. The procedure promotes premature physeal closure. Allograft epiphysiodesis is an alternative operating technique for treating patients with a slipped capital femoral epiphysis.

The role of closed reduction in tibial shaft fractures.

Although several methods of treating difficult tibial shaft fractures have been introduced in the past few decades, closed reduction remains the cornerstone of treatment. The physician must be able to recognize those tibial fractures suitable for treatment by this method, as opposed to fractures that have the potential to cause problems and would be better handled initially by other means. Properly performed, closed reduction in conjunction with early weight bearing accomplishes the goals of solid bony union, normal function, and a cosmetically acceptable appearance. This nonoperative approach avoids the potential morbidity associated with surgery and has been shown to give excellent results in the hands of a number of different physicians.

The treatment of open tibial fractures using nonreamed flexible intramedullary fixation.

Many fixation methods for the treatment of open tibial fractures have been devised, studied, and compared, but controversy persists regarding the most suitable means of immobilization. Nonreamed flexible intramedullary fixation nails, such as Ender rods, have proved an excellent alternative for stabilizing a variety of open tibial fractures with varying degrees of soft-tissue damage. These nails act as an internal splint, which provides three-point fixation; preserves much of the primary blood supply of the tibia; allows for maintenance of length, alignment, and rotation; and facilitates healing of adjacent injured soft tissues. Their use deserves consideration in treating most open diaphyseal tibial fractures.