Versatility of TSRH spinal instrumentation system. Experience in 67 patients with trauma and spinal deformities.

We evaluated the effectiveness of the TSRH (Texas Scottish Rite Hospital) spinal instrumentation system in treating patients with spinal deformities and trauma to the spine. 38 patients (29 women) with spinal deformities and 29 (13 women) with trauma to the spine underwent fusion using the TSRH implant system. In patients with idiopathic scoliosis, the amount of curve correction achieved varied depending on the curve pattern, where patients with single thoracic (type III) or single extended thoracic (type IV) curves showed an improvement of 54% and 63%, respectively, compared to patients with King type II curves in which correction averaged only 45%. We found the TSRH spinal system to be effective for correcting the scoliotic curve. The fact that no neurologic complications were observed and that patients demonstrated a rapid ability to stand and walk as compared to the lengthy immobilization required with more traditional methods, suggests that the TSRH system is superior for scoliotic curve correction.

Two-stage treatment of flexor tendon ruptures. Silicon rod complications analyzed in 109 digits.

Complications during two-stage flexor tendon reconstruction may jeopardize the function of the repaired tendons. We reviewed complications encountered in 89 patients (109 digits) treated with a two-stage flexor tendon reconstruction using either silicone or Hunter rods. The complications could be distinguished according to the stage of reconstruction in which they occurred. Complications during stage I included rod buckling, rupture of the distal end of the rod, rod migration, synovitis and infection, and during stage II included distal rupture of the graft juncture, loose graft, tight graft, bowstringing, and flexion deformity of the PIP and DIP joints. The commonest complication was a flexion deformity of the PIP and/or DIP joint which was related to the surgical procedure. These deformities could easily be corrected in all cases with night splints.

Scaphoid nonunion treated with bone graft and Herbert screw. 23 of 28 fractures healed.

We retrospectively reviewed 28 patients with symptomatic, established nonunion of the waist of the scaphoid who were treated with bone grafting and Herbert screw fixation. A volar approach was used in 20 patients, and a dorsal in 8. Grafting was performed with cancellous bone from the radius in 16 patients and a iliac wedge graft in 12 patients. At a mean follow-up of 3 (1-6) years. 5 of the 28 patients had not united. The surgical approach, the type of graft applied, and the duration of postoperative immobilization played a role for the final outcome. The volar approach appeared to be associated with a better outcome which may be attributed, in part, to the relatively better view of the nonunion achieved with this incision compared to the dorsal approach. The iliac wedge graft was more effective for reduction of the deformity and initial stabilization. We believe that the relatively long period, 3 months, of postoperative immobilization negatively effected the postoperative function because of stiffness.

Surgical management of tibial plateau fractures.

From 1992 to 1996, 49 patients with 49 tibial plateau fractures underwent operative treatment at the First Orthopaedic Department of the General Hospital of Athens. There were 3 type I fractures, 12 type II, 5 type III, 9 type IV, 5 type V and 15 type VI according to Schatzker's classification. 7 of the type VI fractures were open (5 grade II and 2 grade IIIA). All fractures were managed with open reduction and internal fixation and were followed to complete healing which averaged 4 months. 28 patients had excellent results, 13 good, 6 fair and 2 poor results. The fair and poor results were in polytrauma patients and in patients with open (grade II and grade IIIA) type VI fractures. Open reduction and internal fixation, when not strongly contraindicated, was found to be the preferred treatment in displaced tibial plateau fractures.

School-screening for scoliosis. A prospective epidemiological study in northwestern and central Greece.

A two-year prospective study was done to assess the prevalence and distribution of various parameters associated with scoliosis in schoolchildren in northwestern and central Greece. A total of 82,901 children (41,939 boys and 40,962 girls) who were nine to fourteen years old were screened for scoliosis. Five thousand eight hundred and three children had clinical signs of scoliosis and, of these, 4185 were referred for posteroanterior radiographs (to be made with the patient standing) because they had a positive result on the forward-bending test (a difference of more than five millimeters between the two sides of the torso as measured in the thoracic or thoracolumbar region with use of a ruler and a level plane) at the time of a second screening. The prevalence of scoliosis (defined as a curve of 10 degrees or more) was 1.7 per cent (1436 of 82,901 children), and most of the curves (1255; prevalence, 1.5 per cent) were small (10 to 19 degrees). The ratio of boys to girls was 1:2.1 over-all but varied according to the magnitude of the curve (1:1.5 for curves of less than 10 degrees, 1:2.7 for curves of 10 to 19 degrees, 1:7.5 for curves of 20 to 29 degrees, 1:5.5 for curves of 30 to 39 degrees, and 1:1.2 for curves of 40 degrees or more). Thoracolumbar curves were the most common type of curve identified, followed by lumbar curves; specifically, of the 1436 children who had a curve of at least 10 degrees, 493 (34.3 per cent) had a thoracolumbar curve, 475 (33.1 per cent) had a lumbar curve, 261 (18.2 per cent) had a thoracic curve, and 207 (14.4 per cent) had a double curve. Although most (753) of these curves were to the left, the left:right ratio varied according to the location of the apex of the curve (1:3.1 for thoracic curves, 2.0:1 for thoracolumbar curves, and 3.2:1 for lumbar curves). The cost of the screening process was negligible (estimated at thirty cents per child); however, the decreased number of operative procedures performed in children from the geographical area of our University Hospital, the identification of a large number of previously undiagnosed curves (eleven of which were treated operatively and 170 of which were treated with a brace), and the identification of children who were at high risk for progression were considered important benefits of the school-screening program.

Idiopathic osteonecrosis of the medial femoral condyle. Classification and treatment.

Idiopathic osteonecrosis of the medial femoral condyle is a well recognized cause of spontaneous, sudden onset of severe pain, usually at the anteromedial aspect of the knee joint. At the Department of Orthopaedic Surgery of the University of Ioannina, 105 knees in 101 patients were evaluated and treated for idiopathic osteonecrosis of the medial femoral condyle. The disease was found to follow a four-stage course, which consisted of a progression from no radiographic findings (Stage I), to a slight flattening of the medial condyle (Stage II), followed by the appearance of a radiolucent lesion (Stage III), and finally, articular cartilage collapse (Stage IV). Although Stages I and II potentially were reversible, Stages III and IV were associated with irreversible destruction of the subchondral bone and articular cartilage. Although bone scan is a nonspecific diagnostic modality, it was helpful in establishing diagnosis in the early stages of the disease. Conservative treatment was found appropriate for the first two stages, whereas surgical management was effective for patients with Stages III and IV. Specifically, osteotomy was useful for patients younger than 60 years of age with limited necrotic lesions, whereas unicompartmental arthroplasty was effective in older patients with more extensive lesions. Total knee arthroplasty can be reserved for cases where the disease has expanded to the lateral compartment.

Surgical treatment of malleolar fractures. A review of 144 patients.

Malleolar fractures are one of the most common fractures faced in orthopaedic surgery. The results from a consecutive series of 144 malleolar fractures during a 10-year period that were classified and treated according to the AO system are presented. Assessment of outcome was done using the scoring system of Baird and Jackson, which is based on subjective, objective, and radiographic criteria. Excellent and good results were achieved in 107 of the 144 patients surgically treated. Overall, excellent and good results were obtained in almost all unimalleolar fractures, but were significantly less in bimalleolar fractures. There was no difference in outcome achieved between Weber C and Weber D fractures. The presence of a large bony fragment or dislocation also significantly affected the final outcome. Posttraumatic osteoarthritis was found to be associated significantly with poor clinical results, bimalleolar fractures, and unsatisfactory surgical reduction.

Scoliosis elasticity assessed by manual traction: 49 juvenile and adolescent idiopathic cases.

We assessed preoperative curve elasticity in 49 consecutive patients with juvenile or adolescent idiopathic scoliosis who were operated on with Harrington distraction rods. Preoperatively, the curve was determined from posteroanterior radiographs taken in the standing position and in the supine position, with traction. In the latter, the radiographs were taken at the moment of maximal traction when one technician applied traction to the ankles and another to the wrists. The scoliotic curve in the 10 patients with juvenile scoliosis averaged 59 degrees and 32 degrees in the standing and supine positions with traction, respectively. Immediately postoperatively, the curve averaged 19 degrees. 39 patients with adolescent scoliosis had a scoliotic curve which averaged 58 degrees in the standing position and 32 degrees in the supine position with traction. The mean postoperative measurement was 21 degrees. These findings suggest that manual traction is a simple and reliable means of predicting the minimal correction of the scoliotic curve to be expected, using Harrington distraction rods.

Transpositional microsurgery in multiple digital amputations.

In 34 of the 62 patients treated for complete multiple digital amputations, the severed part was not replanted in its anatomical position, but in the place of the most useful stump. This procedure is defined as transpositional digital microsurgery and refers to the transposition and replantation of any digit to another stump which plays a more significant role in the function of the hand. Twenty-eight patients had transposition of a digit, while six patients underwent thumb transposition. All except six of the transposed digits survived, while all of the thumbs survived the surgical procedure. The cosmetic appearance of the hand with a transposed digit or thumb was acceptable to the patients. Two-point discrimination was assessed to be 10-14 mm for the transposed digits, and the functional ability of the transplanted digit was comparable to digits which were replanted in their anatomical position. In conclusion, transpositional digital microsurgery remains a useful alternative for the treatment of multiple digit amputations, particularly in patients with severely damaged non-replantable amputated parts.

Major limb replantation in children.

After the first successful replantation of a completely amputated extremity in a 12-year-old boy undertaken by Ronald Malt at the Massachusetts General Hospital in 1962 (Malt and McKhann, Journal of the American Medical Association, 189:716-722, 1964) numerous series of major limb replantations have been reported in adults. The reports of major limb replantation in children are relatively rare and are usually included in adult series. During the last 14 years, 18 children with major limb amputations were treated at the Microsurgical and Replantation Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School. Of these, 13 were complete amputations (11 upper extremity and 2 lower extremity), while 5 were incomplete nonviable amputations (3 upper extremity and 2 lower extremity). The success rate following replantation of the complete amputations was 76.9%, while for the incomplete, nonviable amputations success was 80%. Preoperative evaluation, operative management, postoperative care, and the results of this difficult but rewarding procedure are analysed and discussed in this review.