The use of freeze-dried cancelous allograft in the management of impacted tibial plateau fractures.

The purpose of this study is to assess the behaviour of freeze-dried cancellous allograft used for supporting the reconstructed articular surface in impacted tibial plateau fractures. Freeze-dried cancellous allograft was used as metaphyseal defect filling agent in twenty-three patients (fifteen men and eight women, mean age 53 years), who suffered impacted tibial plateau fractures. According to Schatzker classification, ten fractures were classified as type II, six as type III, three as type V and four as type VI. All fractures were treated with open reduction-internal fixation after restoration of the tibial plateau surface and insertion of freeze-dried allograft chips for subchondral support. The mean follow-up was 13 months. The clinical and radiological outcome was assessed according to the modified Rasmussen system. The freeze-dried allograft incorporated soundly in all cases within 12 weeks from surgery and no complications that could relate to the graft were recorded. Freeze-dried allograft has specific advantages in comparison to autograft or other grafts and the results of the present study justify its use in the treatment of impacted tibial plateau fractures.

A new distal targeting device for closed interlocking nailing.

A new, image-intensifier mounted target device for closed interlocking nailing is described. The aim of locating the distal holes with the least radiation exposure is achieved. The proposed device has been designed to be mounted on the image-intensifier, is absolutely stable, eliminates the need for a specialised X-ray technician and allows the surgeon to be away from the radiation beam (direct or scattered). It also permits image intensification in the anteroposterior view, without losing the target. The device has proved its reliability in the operating room during closed interlocking nailing procedures.

The treatment of difficult proximal femoral fractures with the Russell-Taylor reconstruction nail.

The outcome of 30 proximal femoral fractures and pathological lesions in 29 patients treated with the Russell-Taylor reconstruction nail are reported. Four patients had fractures involving both the femoral neck and shaft (segmental). Fifteen patients had extensive comminuted fractures of the proximal femur and ten patients underwent nailing because of pathological fractures (one bilateral). In nineteen operations there were technical difficulties, nail insertion and proximal interlocking being the commonest. In the elderly there was a high post-operative complication rate. Three nails needed to be revised for failure of fixation. On review, all patients under sixty years of age regained full mobility and returned to their pre-fracture level of activities. Patients with per-trochanteric fractures over the age of sixty had less favourable results. No cancer patient returned to their prefracture mobility level. The Russell-Taylor reconstruction nail proved to be useful in the treatment of segmented and, in a lesser degree, pathological fractures. However, the surgical technique is demanding and there is a high incidence of post-operative complications in the patients over the age of sixty.

The treatment of selected fractures of the humeral shaft with the True-Flex nail.

The True-Flex nail was used in 23 selected non-pathological and eight pathological fractures/lesions of the humeral shaft. The overall fracture union rate was 69.5 per cent and the patients achieved a good range of movement of the shoulder and elbow. Nailing did not lead to union of established non-unions or fractures which were previously treated unsuccessfully by surgery despite bone grafting. All patients with pathological fractures/lesions regained good function of the arm and a good range of movement of the shoulder and the elbow. In one case the nail migrated proximally and impinged on the rotator cuff. This was revised. No other technical difficulties or complications were seen. The True-Flex nail is useful in the treatment of difficult and relatively recent humeral shaft fractures. Established non-unions or cases where previous surgery has failed should be treated by alternative methods.

Idiopathic multicentric osteolysis principally affecting the phalanges of the hands and feet.

The case of a 64-year-old man with idiopathic symmetrical osteolysis affecting both hands and feet is presented. The phalanges were principally affected, with relative sparing of the carpus and tarsus. The relevant literature has been reviewed and this reveals that the distribution of osteolysis in this case is unique. We suggest that this case represents a different disease entity, which has not been described previously.

Treatment of femoral fracture above a knee prosthesis. 18 cases followed 0.5-14 years.

We reviewed 16 patients who sustained 18 fractures above a total knee prosthesis. 5 fractures were undisplaced and were treated with either skeletal traction or a plaster cylinder. 3 did well, 1 patient suffered a cerebral vascular accident while still in plaster and 1 patient died of heart failure while on skeletal traction. 7 displaced fractures were treated initially with skeletal traction. 1 patient had a nonunion of the fracture and 2 a malunion and malfunction of the knee. 4 underwent various operations later because of malalignment and nonunion of the fracture with poor functional results. 6 displaced fractures were treated with immediate internal fixation. 5 recovered well and returned to pre-fracture activities. 1 patient's plate broke and further surgery was needed. We conclude that displaced fractures above a knee prosthesis should be treated with immediate stable internal fixation and early mobilization. Nonoperative treatment was satisfactory only for minor undisplaced fractures.

Preliminary clinical experience with a new fluted humeral nail.

The early clinical results of humeral nailing using a fluted intramedullary nail with a locking screw are reported. The True-Flex nail has been designed with a proximal cancellous screw to prevent 'back-tracking' and with flutes to give rotational control. The design features have proved to be successful in the authors' brief clinical experience in 12 patients with complicated fractures, non-unions or pathological lesions. Eight of the 10 fractures healed uneventfully, one by delayed union; one had to be revised because of loosening due to use of a nail which was too narrow. There were no serious complications. Return of function in the arm was good. This humeral nail may be suitable for fixation of some complicated and difficult fractures and lesions of the humeral shaft.

Technical note: modifications and improvements of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication.

A method for the reduction of anterior dislocations of the shoulder based on the Milch technique is presented. We have been using this method for the last 2 years (75 dislocations) with excellent results. The reduction is easy, produces minimal pain and discomfort for the patient, and the success rate is as high as 94.5%. The modified Milch technique is less troublesome for the patient and the physician and we strongly recommend it.