Treatment of giant cell tumor of long bone.

From 1981 to 1991, sixty-eight patients with giant cell tumors of their long bones were treated and followed-up at Chang Gung Memorial Hospital. Thirty-three males and thirty-five females between the ages of 14 and 76 (average, 32 years) were followed for an average duration of 3.5 years (range, 2.5 years to 7.3 years). Forty-five primary lesions and 23 cases of recurrent lesions were diagnosed. Seventeen patients were classified as grade II while 51, as grade III. Surgical procedures included intralesional curettage and wide resection. The local recurrent rate following surgery was 13% (9/68). The overall outcome was 85% (58/68) good or excellent results. Complications included one superficial infection, 9 local recurrences and 3 fractures of fixation devices. In addition, one patient with a lung metastasis was noted. In the primary lesion group, there were 9 grade II and 10 grade III lesions treated by curettage and grafting. Of these 4 grade II and 5 grade III patients had local recurrences. The recurrent rate was 47% (9/19) following intralesional curettage with cancellous bone graft (8/16) or bone cement (1/3). The average period before local recurrence was 10.4 months. Seven of the 9 recurrent patients received radical resections and allograft reconstruction with good results at short-term follow-up. The other two patients were lost in follow-up. The cases in the curettage group had shown low recurrent rate (1/10) after 1989 and high recurrent rate (8/9) before 1989 (p < 0.001). The most important factor for local recurrence appeared to be inadequate curettage with similar recurrence rates regardless of the type of bone graft used. A careful approach to the surgical margin including use of a dental burr and local adjuvant treatment with phenol, the rate of local recurrence may be decreased. There were no recurrences in the wide resection group. Although radical resection yield a best chance for cure, the sacrifice of the joint with subsequent arthroplasty resulted a compromise of the joint function.

Fingertip reconstruction by the reverse digital artery island flap.

BACKGROUND: Fingertip injuries remain as one of the most common injuries in the hand. The ideal reconstruction for such injuries is to provide abundant tissue with similar qualities, preserve the length, maintain joint motion and restore fingertip sensation. Although many reconstructive methods are described in the literature, many disadvantages can be associated with these procedures. METHODS: An island skin on the side of the proximal phalanx, based on the ipsilateral digital artery, was elevated to resurface the defect of the fingertip. Six male patients with fingertip injuries were treated by using this flap from August 1993 to January 1994. Their ages ranged from 20 to 55 years. The average follow-up time was 8.5 months. RESULTS: Three of the six flaps were involved the middle fingers; two, for the index fingers and one, for the small finger. The sizes of the flaps varied from 1.5 by 2.0 to 2 by 3;. all the flaps survived. There was no vascular disturbance nor neurological deficit, and no limitation of joint motion. All the patients were pleased with the results. CONCLUSIONS: The advantages of the reverse digital artery island flap include using a single operative field on the injured digit, allowing for treatment of single or multiple fingertip injuries, providing abundant tissue with similar qualities and aesthetic improvement.

A follow-up study of porous-coated anatomic knee arthroplasty.

Ninety-four patients (105 knees) having a porous-coated anatomic total knee arthroplasty were retrospectively studied. The mean follow-up period was 5.8 years. The diagnoses were osteoarthritis (90.5%) and rheumatoid arthritis (9.5%). There were 80 women and 14 men. The mean age at operation was 58.5 years. Clinical evaluation, using the Hospital for Special Surgery knee score along with radiography, was used to assess knee status before and after surgery. The postoperative mean axial alignment was 3 degrees varus compared with 11 degrees varus before surgery. Placement of the prosthetic components was acceptable, with the femoral component in 6.5 degrees of valgus and the tibial component in 1.9 degrees of varus and 1.1 degrees posterior inclination. Complications included eight aseptic loosenings, four patellar maltrackings, one patellar fracture, eight wound problems, and one extension contracture. Most of the patients' knee function improved after surgery. The initial, postoperative range of motion improved in patients receiving continuous passive motion (CPM) immediately after surgery (P = .03) compared to patients without CPM application; however, the long-term follow-up data show no significance (P = .06) whether CPM was used or not. Age, body weight, degree of arthritic change, and modes of fixation yielded no significant influence on the final outcome. The porous-coated anatomic total knee arthroplasty is a valuable alternative procedure in the advanced arthritic knee when the proper candidates are selected, accurate surgical technique is executed and a suitable fixation mode is chosen.

Traumatic patellar tendon ruptures: a follow-up study of primary repair and a neutralization wire.

Thirty-five patients with traumatic patellar tendon ruptures treated with primary repair and with a neutralization wire were retrospectively reviewed. All the ruptures occurred in acute trauma; 12 of the patients (34%) had multiple injuries, and 19 had open wounds around the knee joints. The diagnostic clues included a high-riding patella by palpation or seen on roentgenograms, hemarthrosis, a palpable gap over the tendon, and inability of patients to extend the knee actively. Using the criteria of Siwek and Rao, at follow-up 57% of outcomes were rated as excellent; 28.6% as good; and 14.2% as unsatisfactory. None of the 35 patients had a rerupture of the tendon. We conclude that primary repair with a neutralization wire can be a treatment of choice for traumatic patellar tendon ruptures.

Traumatic patellar tendon ruptures--a follow-up study of primary repair and neutralization wire.

Thirty-five patients with traumatic patellar tendon ruptures treated with primary repair and neutralization wire were retrospectively reviewed. The length of follow up ranged from 1.5 years to 5 years with an average follow up period of 20 months. All the ruptures occurred due to acute trauma, twelve of them (34%) involved in a multiple injuries, and nineteen had an open wounds around the knee joints. The diagnostic clues included a high riding patella by palpation or by X-ray, hemoarthrosis, a palpable gap over the tendon; and being unable to extend the knee actively. Using the criteria of Siwek and Rao, at follow up 57% were rated as excellent, 28.6% good; and 14.2% unsatisfactory. None of the 35 patients had a rerupture of tendon. It is recommended that primary repair with a neutralization wire can be a treatment of choice for traumatic patellar tendon ruptures.

Simultaneous bilateral forearm revascularization.

A successful simultaneous bilateral forearm revascularization was performed on a 17-year-old boy. Functional recovery of both forearms was evaluated 42 months after injury. The patient can use both hands for the activities of daily living. So far, he has been employed and has no significant psychological problems. Temporary intraluminal silicone shunts are extremely helpful for reducing ischemic damage to the injured limb. The sufficient skeletal shortening of the upper limb replantation is crucially important. The wounds must be managed by aggressive and repeated debridement. Accurate primary nerve repair is essential, and the early postoperative rehabilitation is also important to achieve a satisfactory functional return. The functional replanted or revascularized upper extremity is superior to an amputation or prosthesis, especially in the cases of bilateral upper extremity amputation or devascularization.

The surgical treatment of complete acromioclavicular joint dislocation.

Forty-eight patients with complete acromioclavicular (A-C) joint dislocation were treated surgically and followed postoperatively for an average of 26 months. Nineteen patients were treated with simple temporary pinning without ligament reconstruction. Eight of these patients were found, on follow-up x-ray, to have some degree of loss of reduction. All 21 patients treated with Neviaser's operation and all four patients treated with pinning and coracoclavicular (C-C) ligament reconstruction maintained their position on follow-up. One patient treated with arthrodesis of the C-C joint with a wire sustained metallic failure, and another treated with arthrodesis with a screw sustained bone erosion of the clavicle. Although the radiographic results were not necessarily good, 94% (45/48) of patients obtained good or excellent functional results. Reconstruction of either the superior A-C ligament or the C-C ligament, besides temporary fixation of the A-C joint, is recommended for surgical treatment of complete A-C joint dislocation.

Intraosseous hypertension in osteoarthritis of the hip and ischemic necrosis of the femoral head.

Intraosseous hypertension is noted both in osteoarthritis of the hip and ischemic necrosis of the femoral head. The mean intraosseous pressure in osteoarthritis cases was 30.0 +/- 4.2 mmHg. The incidence of abnormal intraosseous pressure and positive stress tests was 39% and 26.7%, respectively. In patients with ischemic necrosis of the femoral head, intraosseous pressure was 45.6 +/- 19.4 mmHg, 79% of patients had abnormal intraosseous pressure, and 56.1% had positive stress tests. Intraosseous pressure studies indicated a statistically significant difference between patients with osteoarthritis and those with ischemic necrosis of the femoral head.