Long-term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures.

We retrospectively reviewed 84 patients who underwent internal fixation of an intracapsular femoral neck fracture. The mean age was 58 years and the time from injury to operative treatment was 5.3 days. The mean follow-up was 4.7 years (range, 2-8 years). At the latest follow-up, in the 46 patients with undisplaced (Garden I, II) fractures, nonunion occurred in two patients and avascular necrosis of the femoral head in nine. Six of these nine patients had a good or excellent result, one had a fair result, and two had a poor result. Of 35 patients with no sign of avascular necrosis, 32 patients had a good or excellent result, two a fair and one had a poor result. In the group of 38 patients with displaced (Garden III, IV) fractures, nonunion occurred in six patients and avascular necrosis of the femoral head in 15. Of these 15 patients, 10 had a good or excellent result, two had a fair result, and three had a poor result. Of 17 patients with no sign of avascular necrosis, 14 had an excellent result and three patients a poor result. Overall only five of the 24 patients who developed avascular necrosis of the femoral head had undergone total hip arthroplasty. Internal fixation remains a simple and safe, method of treatment for both undisplaced and displaced femoral neck fractures in middle-age patients. Despite the relatively high rate of avascular necrosis after internal fixation of femoral neck fractures, only a few of these patients (20%) required further surgical treatment in the follow-up period of this study.

Degenerative spondyloarthropathy of the cervical and lumbar spine in jockeys.

This prospective study analyzed the long-term effects of horse riding on the cervical and lumbar spine of jockeys. Thirty-two jockeys were observed for 13 years. All jockeys had clinical and radiographic evaluation of the spine; three consecutive age groups were studied. Results were compared to age-matched, normal population control groups. The incidence of degenerative changes of the spine was higher in the jockeys compared with the control groups and was more prominent in the older age group for both the lumbar and cervical spine. These findings suggest that equestrian sports, particularly professional horse riding, apart from the increased risk of direct spinal injury caused by a fall from the horse, can lead to progressive spine degeneration as a result of repetitive trauma and increased physical stress on the spine.

Influence of orthotopic placement on the incorporation and mechanical strength of a loaded structural cortical graft: an experimental study in rabbits.

The biological and mechanical behavior of loaded cortical autografts were evaluated in an experimental study using 40 adult male New Zealand rabbits divided into 4 groups. A double osteotomy was performed on all animals at the mid-diaphysis of the right ulna. The bone segment (5 mm) in between the osteotomies was considered a cortical autograft and fixed with an intramedullary Kirschner wire. The graft was fixed in an orthotopic manner in groups A and C, and rotated 180 degrees in groups B and D. After the animals were sacrificed (at 2 months for groups A and B and at 4 months for groups C and D), bone mineral density, graft cross-sectional geometry, and SSI index were assessed. Mechanical testing of the grafted area was carried out using a three-point bending configuration, and the parameter fracture load was assessed. Graft union and incorporation also was studied in histologic sections. In group C (orthotopic graft placement--4 months), bone specimens showed statistically significantly higher values for fracture load, total cross-sectional area, volumetric total bone mass and density, and polar SSI (P values < or = .05) compared to the other groups. In the same group, union and incorporation of the graft was complete, the cortex showed low porosity, and the collagen fibers were mature and properly oriented. Structural cortical bone autografts placed in an orthotopic manner recognize the new mechanical environment as optimal and thus their biological and mechanical behavior are enhanced. Loaded structural cortical grafts should be placed in an orthotopic manner when used for the management of cortical bone defects.

Operative treatment for Maisonneuve fracture of the proximal fibula.

This study reviewed operative treatment of Maisonneuve fracture of the fibula in 26 patients. Operative treatment consisted of restoration of the fibular length, repair of the lateral and medial ankle ligamentous structures, and placement of one or two suprasyndesmotic screws. After average follow-up of 6.4 years, the clinical results were satisfactory in 23 (88.4%) patients. Operative treatment is the treatment of choice for Maisonneuve fractures, and a satisfactory outcome may be anticipated after appropriate management of any associated bony and syndesmotic injuries.

The significance of rotation in fracture-separation of the articular pillar of a lower cervical vertebra. A clinical and cadaveric study.

We report 13 fracture-separations of an articular pillar at the lower cervical spine in 12 patients. There were 9 men and 3 women with a mean age at injury of 32 years, with involvement of C4, C5 and C6 vertebrae. Neurological symptoms were present in 9 patients, 2 were classified as ASIA A and 7 as ASIA D. The average magnitude of rotation of the articular pillar was 24 degrees (10 degrees-36 degrees). 4 patients with neurologic deficit and a rotated articular pillar of more than 25 degrees were operated on, while 8 patients, 3 of which had a rotation of more than 25 degrees, had closed treatment. Patients were followed from 8 months to 15 years (mean 9 years). Patients who had closed treatment and/or with a rotated fractured articular pillar of more than 25 degrees had less satisfactory results. This observation was affirmed by cadaveric studies which showed that rotation of more than 25 degrees is an additional factor of instability in a fractured articular pillar.

[Treatment of pseudarthrosis of the clavicle by bone plate with screw fixation and autologous spongiosa graft]. / Traitement des pseudarthroses de la clavicule par plaque vissée et greffe spongieuse autogène.

PURPOSE OF THE STUDY: The authors review and evaluate the operative treatment of mid-shaft clavicular non-union by compression plate osteosynthesis and most frequently by decortication and autogenous bone grafting. MATERIAL AND METHODS: From 1979 to 1990, 11 consecutive patients, 9 males and 2 females, mean age 33.5 years, with symptomatic non-union of mid-shaft clavicular fracture were operated and followed-up for an average of 4 years. The pseudarthrosis was atrophic in 10 and hypertrophic in 1 patient. The initial treatment of the fracture was always conservative. RESULTS: All patients achieved bone union by 3-7 months post operatively. The functional results were excellent in 9 patients. The remaining two patients had mild symptoms such as occasional pain related to weather, soreness of the muscles with overhead lifting and discomfort of the shoulder. Minor complications were noted such as 1 delayed wound healing, 3 cheloid scars and 1 transient partial paresis of the brachial plexus. DISCUSSION: Symptomatic non-union of the mid-shaft clavicular is a rare complication, mainly after non-operative treatment (11 cases in 12 years in our series). Factors responsible for non-union are the initial high velocity injury, the cominution, the overlapping and great displacement, the paucity of cancellous bone at this site and the trapezius interposition. Internal fixation by compression plating, decortication and bone grafting in atrophic non-union often encountered is a safe reliable method allowing uncomplicated healing and acceptable functional results.

Old injuries of the lower cervical spine treated surgically.

The present study involves 16 surgically treated patients who had sustained an old injury of their lower cervical spine. This group represents the 29% of the 55 patients that were admitted in our Department with an old injury of the cervical spine. The aim of the present study is to see the effect of surgery on these old injuries in relation to clinical and radiological parameters. Operative treatment was indicated in the presence of instability and the resulting deformity or pain or, more important, in case of further deterioration (or development) of the neurological status. The patients were followed up for 1-14.4 years (mean 5.5 years). At follow-up, fusion was sound in all but 1 patient and the deformity was improved in 12 cases. As for the clinical evaluation, pain was still present in two patients and the neurological status was improved in all but one patient with complete tetraplegia. Surgical treatment is of value irrespective of time delay to avoid fixed deformities and/or permanent neurological lesions.

The values of some plasma components during the early phases of fracture healing in man.

A study of plasma components during the early phases of fracture healing in man showed no specific changes except a change of C-reactive protein to positive and a slight but non-significant increase of the plasma hydroxyproline.

Dorsal dislocation of the first metatarso-phalangeal joint. Report of four cases.

The anatomy of the first metatarso-phalangeal joint and of dorsal dislocation of the phalanx are described. As similar lesions in the hand, closed reduction is impossible because of interposition of the volar plate. Open reduction is essential and should be performed as soon as possible after the injury.

Effect of cortisone and an anabolic steroid upon plasma hydroxyproline during fracture healing in rabbits.

The effect of cortisone and an anabolic steroid on plasma hydroxyproline (HOP) was investigated in young male rabbits, following operative fracture of the radius. The action of these hormones was studied in three groups of animals, a cortisone (hydrocortisone sodium succinate 5mg/kg every day), an anabolic (norandronolone-19-phenylpropionate 5 mg/kg every other day) and a cortisone plus anabolic treated group. A fourth group of animals served as controls. Plasma HOP was found to increase during the fracture healing in control animals, particularly in the first week and during callus remodelling. Cortisone produced elevation of HOP level during the first two weeks followed by a decrease to low normal values. Animals treated with the anabolic did not present the initial rise but a sustained increase during callus remodelling. When both the anabolic and cortisone were administered, a curve similar to that of cortisone-treated animals was obtained. The initial increase of HOP is attributed to bone destruction and to a lesser degree to synchronous bone formation at the site of the fracture. This catabolic process seems to be enhanced by cortisone and inhibited by the anabolic. When, however, the two hormones are given together the protective anticatabolic effect of the anabolic is almost abolished.