Corrective Osteotomy for Intra-Articular Distal Humerus Malunion.

BACKGROUND: An intra-articular distal humerus malunion can be disabling. To improve function, reduce pain and/or prevent further secondary osteoarthritis an intra-articular corrective osteotomy can be considered. Herein we present the indications, practical guidelines for pre- operative planning and surgical technique. Subsequently, we provide long-term results in a small series. METHODS: We included six consecutive patients operated for intra-articular distal humerus malunion. Mean follow-up was 88 months. At lastest follow up elbow function was assessed according to standardized questionnaires and classification systems. RESULTS: All six patients healed their osteotomies. Three patients had a postoperative complication which were treated succesfully. Range of motion improved significantly and all patients were satisfied with the outcome. The elbow performance scores were good to excellent in all. Correlation analyses showed that age and level of osteoarthritis are very strong predictors for the long-term elbow function and quality of life. CONCLUSION: An intra-articular corrective osteotomy for a malunited distal humerus fracture is a worthwhile procedure. Based on our results it should particularly be considered in young patients with minimal osteoarthritis and moderate to severe functional disability and/or pain.

WITHDRAWN: Different functional treatment strategies for acute lateral ankle ligament injuries in adults.

BACKGROUND: Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified. OBJECTIVES: The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test. MAIN RESULTS: Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences. AUTHORS' CONCLUSIONS: The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Reconstructive osteotomy of fibular malunion: review of the literature.

The treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion to reconstruct. The most frequent malunions of the fibula are shortening and malrotation resulting in widening of the ankle mortise and talar instability, which may lead to posttraumatic osteoarthritis. The objective of this article is to review the literature concerning the results of osteotomies for correcting fibular malunions and to formulate recommendations for clinical practice. Based on available literature, corrective osteotomies for fibular malunion have good or excellent results in more than 75% of the patients. Reconstructive fibular osteotomy has been recommended to avoid or postpone sequela of posttraumatic degeneration, an ankle arthrodesis or supramalleolar osteotomy. The development of degenerative changes is not fully predictable; therefore, it is advisable to reconstruct a fibular malunion soon after the diagnosis is made and in presence of a good ankle function. Recommendations were made for future research because of the low level of evidence of available literature on reconstructive osteotomies of fibular malunions.

The long-term fate of the hip arthrodesis: does it remain a valid procedure for selected cases in the 21st century?

Even in current orthopaedic practice, some cases are still not suitable candidates for hip replacement and hip fusion remains the only option in these highly selected patients. In this retrospective study we describe the long-term clinical outcome, quality of life and radiological evaluation of all adjacent joints in a cohort of 47 hip fusions. The main objective of our study was to show the long-term effects of a fusion. Thirty patients were analysed after an average of 18.2 years (range 6.2-30.5 years) with a mean SMFA of 31.2 (range 9-70). The VAS for pain for the fused hip was an average 1.9 (range 0-8), for the contralateral hip 2.0 (0-8), for the ipsilateral knee 2.0 (0-8), for the contralateral knee 1.8 (0-8) and for the lower back 3.6 (0-8). Average walking distance was 115 minutes (range 10-unlimited). Although the hip arthrodesis has lost popularity, it still is an option for the young patient with severe hip disorders, while leaving the possibility to perform a THA at a later stage. If the arthrodesis is performed with an optimal alignment of the leg, complaints from the adjacent joints are minimal, even in the long-term, and an acceptable quality of life can be obtained. We believe that in highly selected cases a hip fusion, even in current practice, is still a valid option.

Osteotomy and autograft lengthening for intra-articular malunion of the proximal ulna: a case report.

An osteotomy with interposition of iliac crest bone graft and lengthening of the proximal ulna can be used to restore ulnohumeral congruency after a malunited comminuted olecranon fracture treated with figure-of-eight tension band wiring.

Intra-articular osteotomy for distal humerus malunion.

Intra-articular osteotomy is considered in the rare case of malunion after a fracture of the distal humerus to restore humeral alignment and gain a functional arc of elbow motion. Traumatic and iatrogenic disruption of the limited blood flow to the distal end of the humerus resulting in avascular necrosis of capitellum or trochlea is a major pitfall of the this technically challenging procedure. Two cases are presented which illustrate the potential problems of intra-articular osteotomy for malunion of the distal humerus.

Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia. Surgical technique.

BACKGROUND: Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia. METHODS: From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively. RESULTS: A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two. CONCLUSIONS: A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Cemented hip revision surgery in severe acetabular defects using a semirigid acetabular reinforcement ring--a 5- to 25-year follow-up study.

Between 1978 and 1998, a total of 38 consecutive acetabular component revisions were performed in 38 patients. Average age was 67 years, and 87% of patients had severe uncontained segmental acetabular defects of more than 50%. We describe the operative technique of acetabular component revisions performed with bone grafting and a steel, semirigid acetabular reinforcement ring (Eichler), and long-term results are presented. After an average of 11.2 years follow-up, 1 cup was revised after 0.8 years for mechanical loosening, but the ring remained stably fixed. Remodeling (partial) of autografts occurred in all cases. The average HHS was 72.5. The Eichler reinforcement ring is a viable option for segmental acetabular defects in revision hip surgery, allows for restoration of pelvic bone, and makes future revisions feasible.

Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia.

BACKGROUND: Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia. METHODS: From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively. RESULTS: A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two. CONCLUSIONS: A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Small stem total hip arthroplasty in hypoplasia of the femur.

UNLABELLED: Total hip arthroplasty in hypoplastic femurs is technically difficult and the incidence of complications and aseptic loosening is relatively high. Cemented, uncemented, off-the-shelf, and custom-made stems all have been advocated in these cases. From 1978 to 1997, we performed 86 total hip arthroplasties in 77 patients with a hypoplastic femur using a cemented, off-the-shelf, small, curved, cobalt-chromium stem. We hypothesized results equaled those of the identical but larger-sized stems in normal-sized femora which were used as comparisons. Clinical and radiographic evaluations were performed. Minimum followup was 4.2 years (mean, 12 years; range, 4.2-20.3 years); mean Harris hip score was 88, and mean hip flexion was 104 degrees . Six stems were revised: four because of aseptic loosening, one after a femoral fracture, and one because of malpositioning. Complications included one perforation and one fracture of the femur, one fracture, one nonunion of the greater trochanter, and one deep infection. Implant survivorship for all hips at 15 years with aseptic revision of the stem as the end point was 90% (confidence interval, 82-99) which equaled results of the larger stems. The small off-the-shelf cemented Weber stem has a high long-term survival and a low complication rate. Survival compares favorably with other small-sized total hip systems. LEVEL OF EVIDENCE: Level III, therapeutic study, case-control.

Is the long-term outcome of cemented THA jeopardized by patients being overweight?

Although the effect of being overweight on the long- and short-term outcome of THA remains unclear, the majority of orthopaedic surgeons believe being overweight negatively influences the longevity of a hip implant. We asked whether complications and long-term survival of cemented THA differed in overweight patients (body mass index [BMI] > 25 kg/m2) and obese patients (BMI > 30 kg/m2) compared with normal-weight patients (BMI < 25 kg/m2). We retrospectively analyzed 411 consecutive patients (489 THAs) treated with cemented THA between 1974 and 1993. Except for cardiovascular comorbidity, we observed no differences in demographics among these weight groups. We found no differences in the number of intraoperative or postoperative complications. The survival rates for the three BMI groups were similar. The 10-year survival for any revision was 94.9% (95% confidence interval, 91.6%-98.2%), 90.4% (95% confidence interval, 85.6%-95.2%), and 91% (95% confidence interval, 81.2%-100%) for normal-weight, overweight, and obese patients, respectively. Cox regression analysis showed BMI and weight had no major influence on survival rates. The differences in mean Harris hip score at final followup were 4.8 between normal-weight and overweight patients and 7.1 between normal-weight and obese patients. Being overweight and obesity had no influence on perioperative complication rates in this cohort and did not negatively influence the long-term survival of cemented THA.

Nonunion of the femoral neck: possibilities and limitations of the various treatment modalities.

Nowadays in cases of nonunions of the femoral neck, the surgeon is tempted to perform prosthetic replacement of the hip, more so if there is also evidence of avascular necrosis of the head of femur. This provides rapid pain relief and allows early mobilization. However, long-term results of hip arthroplasties, especially in younger people and in the presence of osteopenia, are not always as expected; and a less radical approach is worth considering. The intertrochanteric valgization osteotomy, described by Pauwels, is an excellent alternative for healthy patients up to 65 years of age with a nonunion of the femoral neck. A union rate of 80-90% of the nonunion is described by most authors. Leg length inequality, rotational and angular deformities can be corrected at the same time. During the period 1973-1995, we performed valgization osteotomy according to Pauwels in 66 patients of, 18-72 years old (mean 49.5 years). 24 (37%) of our patients died 4 months to 24 years (mean: 9.5 years) after the operation. Union of the femoral neck was achieved in 58 (88%) of the 66 patients; union of the osteotomy in 65 patients (99%). A good or excellent result was achieved in 62% (23 uneventful and 13 with healed, necrosis/arthrosis without need for further treatment) of our patients. However, the method has its limits. We feel if there is too little bone stock inside the femoral head, a valgization osteotomy does not give good result. The radiographic signs of avascular necrosis in patients over 30 years of age is considered a contraindication for an osteotomy. However our results show that it is worthwhile trying to save the joint of young patients even in case of a segmental collapse. In the race between revascularization and collapse, often revascularization is the winner. We deliberately give nature its chance and don't rely on the result of bleeding from drill holes in the head, nuclear scans and other methods to estimate vascularity. A secondary total hip replacement if necessary because of avascular necrosis or osteoarthritis is considerably postponed; and better milieu for hip replacement can be achieved by the development of sclerotic bone in the subchondral areas of the acetabulum and femoral head. Between 65 and 80 years of age, a total hip replacement is probably the best option for fit patients. We treat fresh femoral neck fractures with a hemiarthroplasty in patients over the biological age of 80 years. Logically the same choice will be made for patients with a nonunion. During the period 1973-1995 we performed hemiarthroplasty (n = 34) in patient with low general condition. Their mean age was 79 years. The average survival in these patients was less than three years and that explains probably the low late complication rate: in this group. Total hip replacement was performed in 37 younger patients with a mean age of 69 years. They were not considered for a valgization osteotomy because of age being over 70 years, severe osteoporosis or a total collapse of the femoral head. In this group, we observed one aseptic cup revision and two extractions of the prosthesis because of a deep infection.

Surgical treatment of intra-articular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years.

BACKGROUND: The short-term results of open reduction and internal fixation of intra-articular distal humeral fractures are good to excellent in approximately 75% of patients, but the long-term results have been less well studied. This investigation addressed the long-term clinical and radiographic results of surgical treatment of intra-articular distal humeral fractures (AO Type C) as assessed with use of standardized outcome measures. METHODS: Thirty patients were evaluated at an average of nineteen years (range, twelve to thirty years) after open reduction and internal fixation of a fracture of the distal part of the humerus to assess the range of elbow motion and the functional outcome. Twenty patients had an olecranon osteotomy, and all had fixation with plates and/or screws and/or Kirschner wires. No ulnar nerve was transposed. RESULTS: Excluding one elbow salvaged with an arthrodesis and counted as a poor result, the average final flexion arc was 106 degrees and the average pronation-supination arc was 165 degrees. The average American Shoulder and Elbow Surgeons (ASES) score was 96 points, with an average satisfaction score of 8.8 points on a 0 to 10-point visual analog scale. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 7 points, and the average Mayo Elbow Performance Index (MEPI) score was 91 points. Including the patient with the arthrodesis, the final categorical ratings were nineteen excellent results, seven good results, one fair result, and three poor results. The presence of arthrosis did not appear to correlate with pain or predict disability or function. Subsequent procedures were performed in twelve patients (40%). CONCLUSIONS: The long-term results of open reduction and internal fixation of AO-Type-C fractures of the distal part of the humerus are similar to those reported in the short term, suggesting that the results are durable. Functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis.

Apparently isolated partial articular fractures of the radial head: prevalence and reliability of radiographically diagnosed displacement.

The purpose of this study was to measure the prevalence and reliability of the radiographic diagnosis of displacement of apparently isolated partial articular radial head fractures and use these factors to assess treatment considerations. Among 119 radiographically visible partial fractures of the radial head not associated with other wrist, forearm, or elbow injury, 101 were classified as Mason type 1 (85%), 11 as borderline between Mason type 1 and Mason type 2 fractures (9%), and 7 as Mason type 2 fractures (6%) according to Broberg and Morrey's modification of the Mason classification. The intraobserver reliability of the classification of Mason type 1 and type 2 fractures was excellent (mean kappa, 0.85), but the interobserver reliability was only moderate (multirater kappa, 0.45). Because apparently isolated, stable partial fractures of the radial head are infrequently displaced and observers have moderate disagreement regarding the diagnosis of displacement, it is likely that displacement is overdiagnosed.

Correction of lateral tibial plateau depression and valgus malunion of the proximal tibia.

OBJECTIVE: Improvement of joint congruency in malunited lateral tibial plateau fractures, reduction of pain, prevention of osteoarthritis. INDICATIONS: Valgus malalignment of the proximal tibia combined with intraarticular depression of the tibial plateau. CONTRAINDICATIONS: Patients in poor general condition. Severe loss of knee function Elderly patients (> 65 years). Chronic infection. Soft-tissue problems, Inability to perform non-weight bearing after the operation SURGICAL TECHNIQUE: Oblique osteotomy of the middle third of the fibula. Straight lateral or parapatellar approach to the lateral proximal tibia. Lateral arthrotomy of the knee joint. Proximal open wedge osteotomy of the tibia. Intraarticular correction of the depressed lateral tibial plateau through subchondral impaction of cancellous bone grafts. Evaluation of leg alignment. Interposition of bicorticocancellous bone grafts to maintain the open wedge osteotomy. Internal fixation, if necessary. POSTOPERATIVE MANAGEMENT: Continuous passive motion to 90 degrees of flexion from the 1st postoperative day. After application of a stabilizing brace, patients are allowed toe-touch weight bearing for 8 weeks. After radiologic bony healing has occurred, patients are allowed to increase weight bearing stepwise. RESULTS: Between 1977 and 1998, 23 patients were operated on. There were two failures resulting in one arthrodesis and one total knee arthroplasty. After an average of 14 years (5-26 years) 21 patients were followed up. Two patients suffered from severe progression of osteoarthritis after the osteotomy, four had some progression of cartilage degeneration, and 15 presented without changes in osteoarthritis. Mean difference in pre- and postoperative tibiofemoral angle was 8.6 degrees (range 13-4.4 degrees), mean difference in pre- and postoperative depression 6 mm (range 4-9 mm), and mean difference in pre- and postoperative range of motion 12 degrees (range 0-20 degrees). There were no nonunions.

Reporting of outcomes in orthopaedic randomized trials: does blinding of outcome assessors matter?

BACKGROUND: Randomization, concealment of treatment allocation, and blinding are all known to limit bias in clinical research. Nonsurgical studies that fail to meet these standards have been reported to inflate the differences between treatment and control groups. While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold: (1) to examine the reporting of outcome measures in orthopaedic trials, (2) to determine the feasibility of blinding in published orthopaedic trials, and (3) to examine the association between the magnitude of treatment differences and the blinding of outcome assessors. METHODS: We identified and reviewed thirty-two randomized, controlled trials published in The Journal of Bone and Joint Surgery (American Volume) in 2003 and 2004 for the appropriate use of outcome measures. These trials represented 3.4% of all 938 studies published during that time-period. All thirty-two trials were reviewed by two authors for (1) the outcome measures used and (2) the blinding of outcomes assessors. We calculated the magnitude of the treatment effect of the use of blinded compared with unblinded outcome assessors. RESULTS: Ten (31%) of the thirty-two randomized controlled trials used a modified outcome instrument. Of the ten trials, four failed to describe how the outcome instrument was modified. Nine of the ten articles did not describe how the modified instrument was validated and retested. Sixteen of the thirty-two randomized controlled trials did not report blinding of outcome assessors when blinding would have been possible. Among the studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects than blinded outcomes assessment (standardized mean difference, 0.76 compared with 0.25; p = 0.01). Similarly, in the studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects than blinded outcomes assessments (odds ratio, 0.13 compared with 0.42; p < 0.001). The ratio of odds ratios (unblinded to blinded outcomes assessment) was 0.31, suggesting that unblinded outcomes assessment was associated with a potential for exaggeration of the benefit of the effectiveness of a treatment in our cohort of studies. CONCLUSIONS: In future orthopaedic randomized controlled trials, emphasis should be placed on detailed reporting of outcome measures to facilitate generalization and the outcome assessors should be blinded, when possible, to limit bias.

Open-wedge osteotomy of the lateral femoral condyle for extensor mechanism instability.

OBJECTIVE: To achieve extensor mechanism stability in postpatellectomy patients by elevating the lateral femoral condyle, thus creating a deeper trochlear groove. INDICATIONS: Instability of the quadriceps tendon after patellectomy and other realignment interventions, including but not limited to the release of the lateral patellofemoral ligaments, advancement of the vastus medialis obliquus muscle and, in some cases, transfer of the tibial tubercle. Stabilization of a normal dislocating patella in presence of a hypoplastic lateral femoral condyle. CONTRAINDICATIONS: Medical conditions precluding surgery. SURGICAL TECHNIQUE: An open-wedge osteotomy of the lateral femoral condyle is performed. Predrilling at the osteotomy level is followed by a multiple-step curved-type osteotomy starting laterally, directed upward to the trochlea. Bone wedges are inserted under the levered bony fragment and the intrinsically stable osteotomy is secured with one or more countersunk screws. POSTOPERATIVE MANAGEMENT: A removable splint is applied in 30 degrees of knee flexion. With patellectomy, the splint is applied in 90 degrees of knee flexion for the first 3 days. Continuous passive motion and partial weight bearing are started 4 days after surgery in all patients. Use of the splint is advocated for 6 weeks in total. RESULTS: Eight knees (six patients) with extensor mechanism instability underwent this procedure. In five knees patellectomy had been performed earlier, one patient underwent an osteotomy combined with patellectomy bilaterally, in one patient a normal patella was left in situ. No instability was reported after surgery (average follow-up 8 years, range 2-17 years). Modified Lysholm Knee Scores showed two excellent, two good, and four fair results. Follow-up radiographs showed a healed osteotomy and an increase in trochlear depth.