Acute fractures and dislocations of the cervical spine in children and adolescents.

We reviewed the records of 143 patients, two months to fifteen years old, who were seen at the Mayo Clinic between 1950 and 1991 because of an injury to the cervical spine. There was a clear demarcation between the characteristics of the injury of two age-groups. Children who were less than eleven years old had fewer injuries as a group, were most often injured in falls, tended to have a predominance of ligamentous injuries of the cephalic portion of the cervical spine, and had a high rate of mortality as a consequence of injury to the spinal cord. Children who were eleven through fifteen years old had more injuries as a group, were most often injured during sports and recreational activities, had a higher male-to-female ratio, were more frequently injured in the caudal portion of the cervical spine, and had a pattern of injury similar to that of adults. The age and sex-adjusted incidence was 7.41 per 100,000 population per year.

Dislocation of the knee.

The results of treatment for vascular and ligamentous injuries in 17 patients who suffered complete dislocation of the knee were reviewed. Eight patients had 23 associated injuries. All nine patients who had injuries of the popliteal artery had arterial reconstruction with saphenous vein bypass grafts, which were successful in eight (89%). Intraoperative arteriography after vascular repair showed a narrowed anastomosis requiring revision in two (22%) of the nine patients and distal thrombi requiring removal in five (55%) patients. Delay in arterial repair was responsible for the one failure. Eleven patients had satisfactory results after early open ligament repair. The results were less favorable in the patients not treated with early ligament repair.

Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study.

The first prospective series of nonoperatively treated Neer type II fractures of the lateral third of the clavicle with concomitant rupture of the coracoclavicular ligaments is reported. Among ten patients with an average follow-up of 14.3 months, there were seven healed fractures and three nonunions. None of the three patients with a nonunion desired surgery. Six of the seven patients with healed fractures were satisfied. Eight of the ten patients returned to full activities, although all three patients with nonunions experienced at least occasional discomfort in the affected shoulder. Based on the results in this series of patients, the authors conclude that nonoperative treatment is an effective alternative to surgical management of Neer type II distal clavicle fractures.

Type II distal clavicle fractures: a retrospective review of surgical treatment.

We retrospectively reviewed cases of 19 of 35 patients who underwent operative treatment for type II fractures of the distal clavicle over 7 years. The average age was 21.5 years. There were 15 males. Ten of the fractures occurred in vehicular accidents and eight in sports. Ten of the fractures were comminuted. All fractures were closed. Thirteen patients were treated with transacromial Kirschner wires and six by other methods. There were 10 satisfactory and nine unsatisfactory results. All six nonunions and five of the six deep infections occurred in those treated with transacromial wires. Our results indicate that transacromial wire fixation may not be the treatment of choice for this uncommon fracture.

Pulmonary embolism as a complication of arthroscopic surgery.

Thromboembolic disease is a rare complication of arthroscopic procedures. Two case reports of pulmonary embolus following arthroscopic surgery are presented with an emphasis on the factors that increased the patients risk for this complication.

Treatment of unstable tibial diaphyseal fractures with minimal internal and external fixation.

We prospectively studied 20 patients whose selected unstable tibial diaphyseal fractures were treated with the combined techniques of minimal internal fixation and external fixation. Five fractures were closed and 15 were open (six Grades I and II, nine Grade III). Seventeen were due to high-energy injuries. The minimum followup was 2 years. All fractures healed, one with malalignment. Time to union averaged 12 weeks in closed fractures and 19 weeks in open fractures. All high-energy fractures underwent bone grafting. The external fixation was removed by dynamization. Thirteen complications occurred in nine patients, all with open fractures. Three of 120 pins became infected (2.5%). Early bone grafting and dynamization of the external fixation prevented the malunions and nonunions reported previously with this technique.

Prosthetic replacement of the femoral head for fracture of the femoral neck in patients who have Parkinson disease.

A retrospective study was performed of forty-nine patients (fifty fractures of the femoral neck) who had Parkinson disease and who had had an endoprosthetic replacement of the femoral head. The average age of the patients was seventy-four years (range, forty-seven to ninety-two years). All of the fractures were Garden Stage III or IV. An anterolateral surgical approach was used in twenty-five hips; a posterior approach, in twenty hips; and a transtrochanteric approach, in five hips. An adductor tenotomy was required in five patients to release an adduction contracture. Ten patients died by the sixth postoperative month. The remaining thirty-nine patients were followed for a minimum of two years (average, 7.3 years). Common postoperative complications were infection of the urinary tract (20 per cent) and pneumonia (10 per cent). There was only one dislocation. At the time of writing, nineteen (80 per cent) of the surviving patients could walk.

Condylar total knee arthroplasty after failed proximal tibial osteotomy.

Data were collected retrospectively on thirty-five patients who had a failed osteotomy of the proximal part of the tibia for unicompartmental osteoarthrosis of the knee that was treated with a cruciate condylar, total condylar, kinematic condylar, or cemented porous-coated anatomical total knee prosthesis. The patients were evaluated clinically and roentgenographically before and after the arthroplasty. The minimum period of follow-up was twenty-nine months (mean, forty-four months). On the basis of the knee-rating scale of The Hospital for Special Surgery, 89 per cent of the patients had either an excellent or a good result after the arthroplasty. No result was a failure. One patient had loosening of the patellar component, but no other loosening was identified. The results of total knee arthroplasty after osteotomy of the proximal part of the tibia were found to be comparable with the results after arthroplasty in knees that had not had a prior osteotomy. The intraoperative and postoperative rates of complications were not higher, and no untoward technical difficulties were encountered at surgery. These data support the clinical impression that an osteotomy of the proximal part of the tibia does not "burn any bridges" insofar as a future successful arthroplasty is concerned.

The use of external fixation in the reconstruction of complex posterior cruciate injuries.

Proper immobilization of the knee after repair or reconstruction of the posterior cruciate ligament is difficult because of the tendency of the tibia to sag posteriorly, placing tension on the repaired structures. We describe the use of external fixation to immobilize the knee after repair or reconstruction of the posterior cruciate ligament. In seven patients, external fixation devices were used postoperatively for immobilization. Ail three patients with acute injury had repair of the avulsed ligament and associated ligamentous injuries. Of the four patients with chronic injury, three underwent reconstructive surgery because of significant injury to other ligaments. The average length of immobilization in the fixator was 45.4 days. The range of motion at last followup averaged 5.7° to 103.5°, and followup was from six to 20 months. Two patients had three complications: one had decreased flexion and the other had a pin tract infection and lacked flexion beyond 90°. All patients were satisfied with the result of surgery: three patients had a 1 + posterior drawer and four had a stable posterior cruciate ligament at folfowup examination. External fixation may be useful in complex knee injuries involving rupture of the posterior cruciate ligament.