Spontaneous hemarthrosis 6 years after total knee arthroplasty.

Spontaneous hemarthrosis is an uncommon complication of total knee arthroplasty. We report the case of a tense hemarthrosis developing 6 years after total knee arthroplasty as a result of a prominent superolateral femoral flare eroding through an atherosclerotic superior lateral genicular artery.

Distal femoral varus osteotomy for painful genu valgum. A five-to-11-year follow-up study.

From 1978 until 1984, 23 patients (24 knees) were treated with varus producing distal femoral osteotomy for painful, lateral compartment osteoarthrosis. Evaluation at five to 11 years (average, 8.3 years) included orthopedic examination, calculation of the Hospital for Special Surgery (HSS) knee score, and standing knee roentgenograms. Based on the objective knee scores, 71% of the patients had good or excellent results, with no difference in those followed for longer periods. Complications occurred in 63% of the cases, including nonunion (25%) and loss of correction (21%). Both complications were associated exclusively with staple fixation, which was performed during the period of this study and is now known to be inadequate to fix this osteotomy. Despite increasing morbidity rates, these complications did not appear to influence the ultimate result. A statistically significant prognostic factor was the severity of the disease as reflected by the pre- and postoperative knee scores. Further, the degree of correction was a function of the initial deformity. At follow-up evaluation 13% of the knees had been converted to a total knee replacement.

Subcapital fractures after open reduction and internal fixation of intertrochanteric fractures of the hip. Report of three cases.

Three cases of subcapital fractures were discovered after open reduction and internal fixation of intertrochanteric fractures of the hip. These fractures: (1) illustrate devices and methods that contribute to this complication; (2) occur typically in elderly patients with an osteoporotic type of bone; and (3) indicate measures necessary to avoid this complication.

Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment.

Twenty-seven shoulders (in 26 patients) that had surgical repair of a rupture of the long head of the biceps tendon between 1962 and 1981 were evaluated at three to 22 years after injury (mean, 13 years). Thirty similar patients had been treated nonsurgically and were evaluated two to 15 years (mean, 4.6 years) after tendon rupture. Biomechanical testing was performed on ten patients in the surgical group and 13 in the nonsurgical group. Residual arm pain was infrequent in both surgically and nonsurgically treated groups. Residual subjective weakness at the elbow was reported in four of the surgical group and in 20 of the nonsurgical group. Surgically treated patients returned to work later than nonsurgical patients; however, 11 in the nonsurgical group were not able to return to full work capacity, versus only two in the surgical group. On biomechanical testing, the nonsurgical group had lost a mean of 21% of supination strength and 8% of elbow flexion strength but had no weakness in grip, pronation, or elbow extension. The surgical group had lost no strength in any of these testing modes.

Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation. Results of second attempts to gain union.

A retrospective review was performed on 20 patients treated at the authors' hospital between 1961 and 1981 with noninfected nonunions following primary open reduction and internal fixation (ORIF) of intertrochanteric femoral fractures. All patients were available for follow-up examination. Each patient was interviewed at an average follow-up period of 6.6 (0.8-11.9) years. The group consisted of 15 women and five men with an average age at the time of fracture of 63 (36-86) years. Only one fracture was "stable" while 19 were "unstable" with loss of medial support. The initial fixation device was a sliding nail or screw in four patients, fixed nail plate in 11, Smith-Petersen in two, Deyerle pins in one, and was unrecorded in two. Of the 20 cases, it was possible to obtain the original postoperative roentgenograms in 12. Anatomic reduction had been achieved in four, medial displacement osteotomy had been used in two, varus positioning in one, and valgus positioning in five. Subsequent operative treatment for the nonunions consisted of three endoprostheses, six total hip arthroplasties, and 11 repeated attempts at ORIF. Of those treated with repeat ORIF, nine (82%) achieved radiographic union at an average time of six months. Of the remaining two who did not achieve union with the second ORIF, one achieved union following removal of internal fixation and bone grafting (five months) and one required a total hip arthroplasty. The postoperative functional results, as determined by a modified Harris hip score, were improved over the preoperative functional results for each treatment mode. Functional results were best in those patients who achieved union with a second surgical attempt.

Circumcision. A study of current practices.

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.

Hygienic care in uncircumcised infants.

A written questionnaire was used to determine the advice pediatricians give concerning hygienic care of uncircumcised infants. A telephone survey was conducted in which new mothers were asked what they had been told about genital hygiene and how they were caring for their infants. Pediatricians' advice concerning hygiene in uncircumcised infants varied greatly. Most counseled mothers to retract the foreskin and clean the child, but few (22%) knew when this could be readily accomplished. None of the mothers of uncircumcised children had been told when the foreskin could be expected to retract, and only half had been given any advice concerning hygiene. Mothers of infants whose foreskins had been manipulated by physicians felt this practice was traumatic. Both this and the stress of caring for their infants without adequate instruction caused 40% of the mothers to state they would choose to have the next child circumcised. Recommendations for hygienic care of uncircumcised infants are given.