The use of cortical allograft struts for fixation of fractures associated with well-fixed total joint prostheses.

Nineteen patients with 19 fractures around or below a well-fixed femoral stem, were treated by open reduction and internal fixation using massive cortical allograft struts and cerclage wires or cables. The first procedure was performed in 1982 and the last in 1990. Follow-up averaged 28 months. Seventeen patients united their fractures and returned to their preoperative functional status at an average time of 41/2 months. Sixteen healed anatomically. There was one mild malunion and there were two nonunions, both requiring further surgery.

Humeral head replacement for acute, four-part proximal humerus fractures.

Twenty-eight patients with acute, four-part proximal humerus fractures and fracture dislocations were treated with humeral head replacement. At an average follow-up of 37 months (range 12 to 96 months) one author examined 24 patients and evaluated them according to the criteria of the American Shoulder and Elbow Surgeons. There were no infections. One patient had subsequent surgery for joint contracture. Nine (38%) patients had no pain, eight (33%) had occasional slight pain, three (13%) had pain with unusual activity, and four (17%) had moderate pain. No patient had marked pain or pain at rest. Average active forward elevation was 110°, average passive forward elevation was 139°, average active external rotation was 31°, and average passive internal rotation was to the L1 level. Active forward elevation of patients younger than 60 years old was significantly greater than that of older patients. Functional outcome was variable. Although most patients could perform activities below the shoulder, only about one half could perform activities at or above the shoulder level. Eighty-nine percent of patients were satisfied with their treatment. Humeral head replacement for acute, four-part fractures reliably prevented the development of shoulder pain. Functional outcome varied and was dependent on patient age, individual functional requirements, and rotator cuff integrity.

Laterally comminuted fracture-dislocation of the ankle.

Laterally comminuted fracture-dislocations of the ankle are highly unstable injuries in which anatomical reduction of the talus and restoration of fibular length and rotation are difficult. To our knowledge, no descriptions of the fracture pattern of these injuries and the surgical technique for treating them are available, and surgical results with this fracture have been disappointing. Discontinuity of the fibula as a result of comminution makes accurate assessment of fibular length and rotation impossible if the fibula is reduced first. Anatomical stabilization of the talus beneath the tibia is achieved by reduction and fixation of the medial malleolus. The fibular malleolus is then anatomically positioned in the lateral articular facet of the talus and fixed in this position. The osseous discontinuity of the fibula is grafted with bone. Clinical and radiographic results of the technique were highly satisfactory after a mean length of follow-up of thirty-four months.