Second-generation cephalomedullary nails in the treatment of reverse obliquity intertrochanteric fractures of the proximal femur.

Since 1996, in Tampere University Hospital, a second-generation cephalomedullary nail (CMN) has been the implant of first choice in reverse obliquity fractures of the proximal femur. Between 1996 and 1999 we treated 77 such fractures, of which 72 were fixed with the CMN. There were six re-operations (8.3%). An anatomic or nearly anatomic reduction and a properly placed implant were found in 47 cases with one failure. An unacceptable postoperative radiological result was seen in 25 cases resulting in five re-operations (P=0.029). In 12 of 14 open procedures a cable was added to stabilise the greater trochanter and none failed. Four of five fractures fixed with the sliding hip screw failed. Our results using the CMN in reverse obliquity intertrochanteric fractures compares favourably to the results in earlier reports where extramedullary implants are used.

Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. A prospective, randomized study.

BACKGROUND: Controversy continues with regard to the optimal postoperative care after open reduction and internal fixation of an ankle fracture. The hypothesis of this study was that postoperative treatment of an ankle fracture with a brace that allows active and passive range-of-motion exercises would improve the functional recovery of patients compared with that after conventional treatment with a cast. Thus, the purpose of this prospective, randomized study was to compare the long-term subjective, objective, and functional outcome after conventional treatment with a cast and that after use of functional bracing in the first six weeks following internal fixation of an ankle fracture. METHODS: One hundred patients with an unstable and/or displaced Weber type-A or B ankle fracture were treated operatively and then were randomly allocated to two groups: immobilization in a below-the-knee cast (fifty patients) or early mobilization in a functional ankle brace (fifty patients) for the first six postoperative weeks. The follow-up examinations, which consisted of subjective and objective (clinical, radiographic, and functional) evaluations, were performed at two, six, twelve, and fifty-two weeks and at two years postoperatively. RESULTS: There were no perioperative complications in either study group, but eight patients who were managed with a cast and thirty-three patients who were managed with a brace had postoperative complications, which were mainly related to wound-healing. Two patients in the group treated with a cast had deep-vein thrombosis. All fractures healed well in both groups. The difference between the two groups with respect to the complication rate was significant (p = 0.0005). No significant differences between the study groups were observed in the final subjective or objective (clinical) evaluation. At the two-year follow-up examination, the average score (and standard deviation) according to the ankle-rating scale of Kaikkonen et al. was 85 +/- 9 points for the group treated with a cast and 83 +/- 10 points for the group treated with a brace, and the average ankle score according to the system of Olerud and Molander was 87 +/- 8 points and 87 +/- 9 points, respectively. CONCLUSIONS: The long-term functional outcome after postoperative treatment of an ankle fracture with a cast and that after use of a functional brace are similar. Although early mobilization with use of a functional ankle brace may have some theoretical beneficial effects, the risk of postoperative wound complications associated with this treatment approach is considerably increased compared with that after conventional cast treatment. Thus, the postoperative protocol of treatment with a functional brace requires refinement before it can be generally advocated for use after operative treatment of an ankle fracture.

A randomized study of the compression hip screw and Gamma nail in 426 fractures.

A prospective, randomized study comparing the compression hip screw with the Gamma nail in the treatment of 426 intertrochanteric fractures is reported. The median patient age was 80 years, and 71% were women The compression hip screw operation took less time except in Evans Type 5 fractures. Blood loss generally was less in the compression hip screw group except in patients with Type 5 fractures. The most frequent surgical problem for patients in the Gamma group was problems with distal locking. Cephalic position of the femoral head screw and cut-out were seen more often in the Gamma nail group. The Gamma nail more frequently preserved the fracture position obtained perioperatively. Whether there was distal locking of the Gamma nail in unstable fractures did not seem to affect the healing rate. Additional fissures or fractures in the proximal femur occurred during five Gamma nail operations and two compression hip screw operations. Postoperative walking ability did not differ between the groups. At 6 months 88% of the fractures were healed. In less comminuted fractures, the compression hip screw method is the preferred method of treatment whereas the Gamma nail is an alternative treatment for more comminuted Evans Type 5 fractures.

Pancreatic pseudocystportal vein fistula manifests as residivating oligoarthritis, subcutaneous, bursal and osseal necrosis: a case report and review of literature.

Pseudocyst is a common complication of pancreatitis. Pseudocyst may rupture into the surrounding organs. Rupture into the portomesenteric vein is extremely rare with only seven cases being described in the English literature. pancreatic portal vein fistula is very difficult to verify. The aim of this study was to view the diagnostic methods of pancreatic portal vein fistula and to describe the results of high-dose corticosteroid treatment to our knowledge for the first time. We report here a case of pancreatic portomesenteric vein fistula that was manifest as subcutaneous fat necrosis, bursal necrosis, intramedullary aseptic bone necrosis and recidivating oligoarthritis. The literature of this unusual complication is reviewed. The results of high-dose corticosteroid treatment are also described. In patients with recidivating oligoarthritis, subcutaneous, bursal or osseal necrosis a pancreatic process should be included in the differential diagnosis even in cases of no abdominal signs or symptoms or previous abdominal history. Operative exploration of the pancreas should be performed in the early phase of the disease. To diminish the ongoing extrapancreatic manifestations after the closure of the fistula massive corticosteroid treatment may be attempted although the role of this therapy remains controversial.

Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques.

BACKGROUND: Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during nailing is thought to be a contributing cause of chronic anterior knee pain. The purpose of this prospective, randomized study was to assess whether the prevalence or the intensity of anterior knee pain following intramedullary nailing of a tibial shaft fracture is reduced by the use of a paratendinous incision for the nail entry portal. METHODS: Fifty patients with a tibial shaft fracture requiring intramedullary nailing were randomized equally to treatment with paratendinous or transtendinous nailing. Twenty-one patients from both study groups were followed for an average of three years after nailing. After fracture union, all but two patients had elective nail removal through the same surgical approach as was used for the nailing. At the follow-up evaluation, the patients used visual analog scales to report their level of anterior knee pain and the impairment caused by that pain. The scales described by Lysholm and Gillquist and by Tegner et al., the Iowa knee scoring system, and simple functional tests were used to quantitate the functional results. Isokinetic thigh-muscle strength was also measured. RESULTS: Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. CONCLUSION: Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.