Non-traumatic lesser trochanter avulsion: a report of three cases.

Avulsion fractures of the lesser trochanter in adults are almost always due to metastatic bone disease. Familiarity with this characteristic association can lead to early diagnosis and assist the orthopaedist in implementing effective management. We report three patients with avulsion of the lesser trochanter due to neoplasm. In one patient, this was the first sign of metastatic disease; in another patient, there was no history of a primary neoplasm and the avulsion was the first evidence of disease.

Assessment of the AO/ASIF fracture classification for the distal tibia.

OBJECTIVES: The purpose of this study was to assess the interobserver reliability and intraobserver reproducibility of the AO/ASIF and Rüedi and Allgöwer classifications for fractures of the distal tibia, and to determine the benefit of a computed tomography (CT) scan and experience on observer agreement for several fracture characteristics, including classification. METHODS: The radiographs of forty-three fractures of the distal tibia, fourteen of which had CT scans, were assessed by groups of experienced and less-experienced observers. Each case was classified according to the AO/ASIF and Rüedi and Allgöwer systems. Several other fracture characteristics also were assessed. The kappa coefficient of agreement was calculated and used to compare the interobserver reliability and intraobserver reproducibility of the classification systems and to determine the benefit of experience and CT scans. The intraclass correlation coefficient was used to assess noncategoric data. RESULTS: Interobserver and intraobserver agreements were good when classifying fractures into AO/ASIF types and significantly better than that for the Rüedi and Allgöwer system. However, agreement was poor when classifying the fractures into AO/ASIF groups. For most assessments, the experienced group tended to have higher levels of interobserver agreement, but not intraobserver agreement. Viewing the CT scans improved agreement on the percentage of articular surface involved, but it did not improve interobserver reliability or intraobserver reproducibility for either of the classification systems. CONCLUSION: The AO/ASIF classification for fractures of the distal tibia has good observer agreement at the type level, but poor agreement at the group level. Experience tends to improve interobserver agreement, but not intraobserver agreement. Viewing CT scans does not improve agreement on classification, but it tends to improve agreement on articular surface involvement.

Supracondylar fractures of the femur treated by external fixation.

OBJECTIVE: To determine the results and complications of treating supracondylar fractures of the femur with external fixation. DESIGN: Retrospective follow-up from the time of injury (inception cohort) to an average of thirty-one (range thirteen to seventy-two) months after injury. SETTING: Tertiary care university hospital. PATIENTS: All thirteen adult patients with supracondylar femur fractures treated with the method described were included. There were seven closed and five open fractures and five vascular injuries that required repair. Fractures were chosen for this technique on an individual basis by the treating surgeon. INTERVENTIONS: The femoral condyles were reduced percutaneously or via a medial arthrotomy and stabilized with 6.5-millimeter cannulated screws. Fixator pins were placed from lateral to medial in the condyles and in the shaft above the fracture. The monolateral fixator was applied laterally and stabilized the reduced condyles to the shaft. Initial grafts of bone were used in five fractures. External fixation time averaged 127 days. OUTCOME MEASURES: During treatment we determined the occurrence of complications at the pin sites and the fracture site, the time of healing, and the angular alignment at healing. At the latest follow-up we determined the range of motion of the knee, knee stability, a standardized knee score, and on radiographs the occurrence of arthrosis. RESULTS: Twelve fractures healed primarily. One patient had a fracture site infection and required further treatment before healing. Knee flexion was restricted while in the fixator but rapidly recovered after frame removal. At follow-up (average thirty-one months), the range of knee flexion averaged 111 degrees (range sixty-five to 140). The Iowa Knee Score averaged 87 points (range 75-93 points). Four femurs healed with angular malalignments, shortening, or both. Twelve knees had no detectable arthrosis. CONCLUSIONS: We concluded that in select supracondylar femur fractures, monolateral external fixation is a satisfactory treatment alternative.

Long-term follow-up of patients with chronic back pain treated in a multidisciplinary rehabilitation program.

STUDY DESIGN: The study evaluated the long-term outcomes of 129 chronic low back pain patients who had completed a multidisciplinary rehabilitation program. OBJECTIVES: Two major outcome issues were addressed--one related to the effectiveness of the program as measured by return to work, use of the medical system, and sense of well being, and the other concerning the stability of the outcome effect over time. SUMMARY OF BACKGROUND DATA: Other outcome studies have established the short-term effectiveness of rehabilitation programs such as the present one with between 50% and 75% of patients. However, long-term follow-up--i.e., 1 1/2 to 2 years or more--has been lacking to determine what happens later. METHODS: Graduates of the program were contacted by telephone to complete a 23-item questionnaire. Every effort was made to include all who had completed the program. Many had moved away or were inaccessible, but few of those contacted refused to participate. RESULTS: An attempt was made to classify the job outcome into good, fair, and poor outcomes by weighting return to work, remaining at work, and continuing to look for work. Forty-nine percent of the sample attained a good job outcome, 13% a fair job outcome, and 38% a poor job outcome. Regarding general well-being, 53% reported doing better or much better, 27% reported being about the same, and 20% reported being worse or much worse at follow-up. CONCLUSIONS: The results provide support for the efficacy of programs such as this.

Meniscus-like synovial fold in the atlantoaxial (C1-C2) joint.

Some of the synovial joints in the human body have a fibrocartilaginous disc interposed between the joint surfaces to absorb or evenly distribute loads. Examples of fibrocartilagenous discs include the intervertebral disc, knee joint meniscus, and triangular fibrocartilages in the distal radioulnar joint and the acromioclavicular joints. The joint capsule and the surrounding tissue from nine cervical spines (18 C1-C2 joints) were dissected and prepared for gross examination and histology. We found meniscus-like synovial folds in 13 of the 18 atlantoaxial joints. These folds were located at the anteromedial and posteromedial aspect of the joint. Each synovial fold was of semilunar shape, with a thickened outer edge and thin inner edge giving a wedge-shape cross section. In one case, the synovial fold was grossly similar in appearance to a knee joint meniscus, and on histological examination there was evidence of cartilagenous metaplasia in part of the fold. The findings are compared with the limited data reported in the literature.

Isolated L4-L5 fusions using the variable screw placement system: unilateral versus bilateral.

Thirty-six patients were retrospectively followed an average of 25.1 months to evaluate the relative effectiveness of unilateral (16 patients) versus bilateral (20 patients) variable screw placement (VSP) instrumentation in isolate L4-L5 fusions. Demographic variables and preoperative diagnoses were similar between treatment groups. Outcome was assessed primarily through evaluation of plain roentgenograms and self-report questionnaires. Use of VSP instrumentation at the L4-L5 level with autogenous posterolateral grafting achieved a successful fusion rate of 97% with minimal complications. Fusion results with unilateral instrumentation were nearly identical to those of bilateral; in both cases, results were better than most historical controls for noninstrumented fusions in situ. Clinical outcome, as obtained through standardized measurement techniques of pain and function, demonstrated 69% excellent and good results. Clinical outcome was similar between treatment groups yet was not significantly related to the fusion status obtained at follow-up.

The importance of positive bacterial cultures of specimens obtained during clean orthopaedic operations.

Microbiological cultures of specimens of tissue and of fluids from the wound in forty patients who had had consecutive clean, elective orthopaedic operations (excluding total joint replacements) and had not received antibiotics preoperatively were analyzed. Of the forty patients, twenty-three (58 per cent) had a positive culture on at least one of the media that were used and seventeen (43 per cent) had negative cultures. Of the forty specimens that were obtained from swabbing of the wound, eight (20 per cent) were positive on culture, compared with twenty (50 per cent) that were obtained from biopsy of tissue. Of these twenty-eight positive cultures, thirteen (46 per cent) were on routine blood-agar plates and fifteen (54 per cent), in broth only. Of the thirty-three bacterial organisms that were identified in the twenty-eight positive cultures of the wound, nineteen (58 per cent) were coagulase-negative Staphylococcus; eight (24 per cent), Propionibacterium acnes; two (6 per cent), Peptostreptococcus; and four (12 per cent), miscellaneous organisms. In all of the positive cultures on the blood-agar plates, except in those showing Propionibacterium acnes, there were five colonies or fewer. One patient had a clinical infection with Staphylococcus aureus that developed later, but the initial cultures of the wound had been positive for Staphylococcus epidermidis only. None of the bacteria that grew on culture were Staphylococcus aureus or the less common pathogenic gram-negative bacteria, such as Escherichia coli, Pseudomonas, or Klebsiella.(ABSTRACT TRUNCATED AT 250 WORDS)

Stimulation of dorsal root ganglia and degradation of rabbit annulus fibrosus.

The authors sought to determine whether narrowing of the intervertebral neural foramen, by itself and in association with vibration, would stimulate the mechanosensitive dorsal root ganglia and result in degradation of proteoglycan and collagen of the annulus fibrosus, as proposed in their working model of dorsal root ganglia-neuropeptide-mediated degeneration of the spinal motion segment. Degradation of proteoglycan and collagen of rabbit annulus was observed when there was narrowing of the neural foremen and the degradation process was accelerated by vibration. Vibration alone, in the absence of structural abnormalities of the spinal motion segment, did not induce matrix degradation probably because of a less pronounced stimulation of the dorsal root ganglia. Biological events similar to those postulated here, fomented by a combination of structural abnormalities and environmental factors, could be involved in human disc degeneration.

Early clinical experience with the Syracuse I-Plate: an anterior spinal fixation device.

Sixteen patients were treated with a new anterior internal fixation device after thoracolumbar or lumbar decompression, and fusion with bone grafting. Ten patients had acute burst fractures, four had metastatic tumors, and two had old, healed fractures with deformity. In the acute fracture group, eight patients had neurologic deficits and seven patients experienced improvement. Six patients had lesions of the conus medullaris, all of which improved. The four patients with metastatic tumors underwent surgery for back and leg pain and all gained significant relief. Two patients had correction of old fracture deformity with satisfactory outcome. Complications were minimal. The new anterior stabilization device provided early stability, allowed early patient mobilization, was easy to insert, and has a low profile. Late collapse, non-union, and kyphotic deformity have not been noted thusfar.