Tendon interposition in a juxta-epiphyseal fracture of the proximal phalanx.

Juxta-epiphyseal fractures of the proximal phalanx are relatively common. A case report and literature review calls attention to the possibility of entrapment of either a flexor or extensor tendon in this type of fracture.

Influence of health status and the timing of surgery on mortality in hip fracture patients.

The purpose of the study was to determine the relationship of preoperative health status and time to surgery to mortality and late functional outcome in hip fracture patients. The records of 168 consecutive patients who had operations for 171 intertrochanteric or femoral neck fractures were reviewed retrospectively. Preoperative health status was assessed by the American Society of Anesthetists (ASA) classification. Postoperative outcome was determined by mortality and ambulatory status. The follow-up period for survivors averaged 33 months. The overall mortality was 14% at 1 year, which rose to 26% at 2 years, and 33% at 3 years. The 3-year mortality was significantly less for ASA I and II patients (23%) than for ASA III, IV, and V patients (39%). There was also a significant difference in mortality between patients having surgery within 24 hours of admission (20%) and those having surgery beyond 24 hours of admission (50%). Even when only the healthy subgroup of ASA I and II patients were considered, the relative risk of death was 4.5 times greater if surgery occurred after 24 hours from admission. These data support the concept that hip fracture patients are not a homogeneous group with respect to mortality and that the ASA classification is a good predictor of mortality. Patients who had surgery within 24 hours of admission had a significantly lower mortality rate than did patients having surgery beyond 24 hours of admission, regardless of their preoperative ASA classification.

Destructive spondyloarthropathy of the cervical spine in patients with chronic renal failure.

STUDY DESIGN: Eleven patients with chronic renal failure and destructive spondyloarthropathy of the cervical spine were evaluated with plain radiographs, flexion-extension views, computed tomography myelogram, or magnetic resonance imaging to determine the results of surgical and nonsurgical treatment. OBJECTIVES: To determine if cervical spine fusion is an effective method of treatment for patients with chronic renal failure and destructive spondyloarthropathy. SUMMARY OF BACKGROUND DATA: Several reports have described the pathogenesis and appearance of this condition, but little has been reported about the orthopedic management of destructive spondyloarthropathy of the cervical spine. METHODS: Three patients had no spinal surgery, three patients had laminectomies alone, three patients had laminectomies with anterior fusions, and two patients had laminectomies with posterior fusions. Radiographs, computed tomography myelograms, and magnetic resonance images were evaluated to determine the results of treatment. Histologic examinations were performed in two patients. RESULTS: Patients with laminectomy alone had no improvement in pain or neurologic function (one died in the immediate postoperative period), one of three patients with anterior fusions had some improvement (one died in the immediate postoperative period), and both of those patients with posterior fusions improved, although both died within a year of surgery from unrelated causes. CONCLUSIONS: Even though the osteopenia present in patients with chronic renal failure tends to allow wire pull-out and makes internal fixation of the spine difficult, successful cervical spinal fusion can relieve pain and improve neurologic deficits in selected patients with chronic renal failure and destructive spondyloarthropathy, allowing them to remain more active for longer periods of time.

A modular endoprosthetic system for tumor and non-tumor reconstruction: preliminary experience.

Though originally designed to facilitate the management of primary malignant bone tumors, the indications for the Howmedica Oncology modular endoprostheses have expanded to include the reconstruction of metastatic lesions, failed internal fixation of difficult trauma problems, and failed conventional and custom tumor endoprostheses. Between July 1989 and August 1992, 24 patients underwent 25 procedures, either proximal humeral replacement (7), proximal femoral replacement (5), distal femoral replacement (9), or total femoral replacement (4). Diagnoses included primary bone tumor (6), metastases (5), and failed previous orthopedic intervention (14). Two early and four late complications in five patients were all treated successfully with surgical or nonoperative treatment. Preliminary functional results indicate very satisfactory results. Modular endoprostheses appear to be effective in the treatment of a wide range of diagnoses, not limited to the reconstruction following primary malignant bone tumor resections.

Urethral carcinoma metastatic to bone: a case report and literature review.

Distant urethral carcinoma metastasis is a very rare event. The following discussion presents a unique case of urethral carcinoma (adenocarcinoma) metastatic to bone and reviews the literature regarding this condition.

Heterotopic ossification following total knee arthroplasty requiring surgical excision.

We present a case of progressive heterotopic ossification (HO) after cementless total knee arthroplasty causing painful stiffness that was treated with surgical excision. The patient had few risk factors associated with HO, including minimal anterior notching and dissection of the distal femoral cortex. The patient did undergo manipulation; however, this occurred after the diagnosis of HO was made. This report documents a rare case of HO following total knee arthroplasty that required surgical excision.

Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation.

Seven patients (average age, 26.3 years) with traumatic knee dislocations were retrospectively evaluated more than 2 years (average, 51 months) after having fresh-frozen allograft anterior and posterior cruciate ligament reconstructions. All patients were treated consecutively at an average of 9.6 days after injury. Two patients had arterial injuries and three patients had or developed common peroneal nerve palsy. Five patients had 20 additional injuries. All patients were enlisted in an early, aggressive physical therapy regimen with early protected weightbearing. Four patients required a manipulation under anesthesia for arthrofibrosis at an average of 16.8 weeks postoperatively (range, 6 to 33 weeks). At followup, only one patient had significant pain, three patients had rare or occasional giving way, and all seven were able to return to school or to the workplace. The functional grading was excellent in three patients, good in three patients, and fair in one patient. No patient had a significant flexion contracture; the average flexion arc was 118 degrees (range, 105 degrees to 135 degrees). Knee dislocation is a very traumatic injury, often resulting in a painful, dysfunctional knee. Anterior and posterior cruciate ligament reconstructions in young, active patients can minimize pain and optimize functional outcome. Arthrofibrosis is a common occurrence in these patients, and manipulation under anesthesia is frequently required.

Radiographic analysis of tibial fracture malalignment following intramedullary nailing.

Intramedullary nailing of the tibia was performed on 145 tibiae (137 patients) for fracture or nonunion from 1985 to 1992. There were 133 cases available for radiographic analysis of postoperative tibial alignment. Of the 133 nailings, 16 (12%) were malaligned (12 acute fractures and 4 nonunion-malunions). Malalignment was defined as 5 degrees angulatory deformity in any plane. Malalignment was seen in 58% of proximal third fractures, 7% of middle third fractures, and 8% of distal third fractures. Of the malaligned fractures, 83% were either segmental or comminuted. Thirteen percent of the reamed tibiae were malaligned as compared with 9% of the unreamed tibiae. There was no relationship between nail insertion site and degree of angulation. The medial entrance angle averaged 9.5 degrees and contributed to a valgus deformity in 4 proximal third tibial fractures. The average anterior bow deformity of 5 proximal third fractures was 7 degrees (range, 5 degrees-12 degrees). Careful attention to operative technique and entrance angle, particularly with proximal third or comminuted fractures, is recommended to prevent angular deformity and malunion after tibial nailing. Proximal third tibial fractures may require a neutral or slightly lateral entrance angle to ensure a more anatomic reduction and centromedullary nail orientation to offset the tendency for valgus angulation.

Total knee replacement including a modular distal femoral component in elderly patients with acute fracture or nonunion.

Distal femoral fracture or nonunion in elderly patients with osteopenic bone and coexisting gonarthrosis poses a difficult treatment challenge. Open reduction and internal fixation with or without the use of bone cement may not provide sufficient stabilization, requires a prolonged period of weightbearing restrictions, and does not address preexisting knee arthrosis. We report five patients, three with distal femoral nonunion, two with acute distal femoral fracture, and all with concomitant gonarthrosis treated with total knee replacement including a modular distal femoral component [distal femoral replacement (DFR)]. In this group of patients, modular DFR provided immediate pain relief and allowed early weightbearing and aggressive rehabilitation. We recommend this treatment modality in selected osteopenic elderly patients with difficult distal femoral reconstructive problems and coexisting gonarthrosis.

Automotive airbag-related upper extremity injuries: a report of three cases.

Automotive airbag technology has reduced the number of injuries and fatalities resulting from motor vehicle crashes. With the increasingly frequent application of this safety feature in automobiles, recent reports of airbag-associated injuries have emerged, including ocular and non-lethal cardiac trauma. We report three cases of airbag-related upper extremity injuries seen at a level-I trauma center over a 6-month period. A heightened awareness of this type of injury in patients injured in motor vehicle crashes with airbag deployment is recommended. The awareness, identification, and management of these high energy injuries will take on added meaning as the airbag technology becomes universally applied.

The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head.

The chevron osteotomy is one of the most widely used distal metatarsal osteotomies for the treatment of hallux valgus in adults. Because the osteotomy interrupts the intraosseous blood supply to the metatarsal head, there has always been a concern that the operation could produce osteonecrosis of the metatarsal head, particularly if the important extraosseous blood supply was also damaged. We used latex injection and a modified Spalteholz technique in cadaveric specimens to demonstrate the effect of the chevron osteotomy, with and without lateral capsular release, on the vascular supply to the first metatarsal head. We found an extensive network of extraosseous vasculature to the metatarsal head both proximal and distal to the site of the osteotomy. Both of these vascular networks were preserved when the osteotomy was done properly. Also, an extensive plantar and plantar lateral network of vessels provided circulation to the head. Potential technical flaws in the performance of the osteotomy included cutting of the first dorsal metatarsal artery by overpenetration of the saw blade and incorrect placement of the proximal arms of the osteotomy inside the joint capsule. These technical errors, alone or in conjunction with extensive capsular stripping, can result in damage to the vessels that supply the metatarsal head.

Ipsilateral hip and knee dislocation.

Hip and knee dislocations individually are two of the relatively limited orthopaedic emergencies. Long-term results of treatment of these two types of injury are associated with avascular necrosis of the femoral head, knee instability, and knee stiffness. Correct early diagnosis, including arteriography in the case of knee dislocation, is crucial. Prompt treatment consisting of closed or open reduction of the dislocations is necessary. Additional treatment involving knee ligament reconstruction is warranted to maximize knee function in healthy, active patients. Simultaneous occurrence of ipsilateral hip and knee dislocations is a particularly morbid injury. We report such a case to emphasize that early, aggressive treatment and extensive physical therapy can result in a functional and painless lower extremity.

The radiographic resolution of beads from porous coated joint prostheses.

While there have been reports of the 750 microns chrome-cobalt beads disassociating from the PCA type prosthesis, failure of the 200 microns bead has not been documented despite reports of failed prosthesis, which use the smaller bead. As a result of the negative reports, the hypothesis was posed as to the limit of resolution in the image of the standard clinical radiographical film. To test the hypothesis, chrome-cobalt beads, ranging in size from 200 to 700 microns, in differing configurations were placed adjacent to a femoral prosthesis that had been implanted into a cadaveric specimen. Using standard clinical radiographic technique, differing exposures were made of the configurations. The results demonstrated that beads or a conglomerate of beads smaller than 300 microns could not be resolved and were therefore invisible and unrecordable. The clinical significance is to question whether all porous-coated prostheses shed metal alloy particles, some of which are radiographically undetectable due to the limitations of their resolvable size.