Operative treatment of subcalcaneal pain.

Twenty of 21 consecutive patients (21 heels) with subcalcaneal pain retractory to conservative treatment managed by resection of the proximal attachment of the plantar fascia and the heel spur, if present, were reviewed retrospectively. The results, at a mean followup of 40 months (range, 12-102 months), using a 100 point scoring system, rated excellent in 8 patients, good in 10, fair in 1, and poor in 1 (90% satisfactory outcome). Time to maximal improvement often was prolonged, yet once reached was maintained over time. The only complication encountered was 1 superficial wound infection. Radiographically it was noted that, despite complete excision, subcalcaneal exostoses often reformed and the fascial transection never did precipitate collapse of the longitudinal arch of the foot. A combination of mucoid and fibrinoid degeneration of the plantar fascia, an acceleration of an age related process, was the principal histopathologic finding. It was concluded that the subcalcaneal pain unresponsive to conservative modalities can be treated effectively by the index procedure. The radiographic and histologic findings of this study suggest that changes within the fascia, rather than the spur, are primarily responsible for the pathogenesis of the syndrome.

Insufficiency stress fractures of the femoral neck in elderly women.

Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. All occurred in Caucasian women with severe osteoporosis. A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. The diagnosis was delayed in most cases because the clinical findings were minimal and the early roentgenographic features were absent or subtle. Bone scintigraphy was found more useful than roentgenography for diagnosing this entity. A completely displaced stress fracture of the femoral neck could not be distinguished clinically or roentgenographically from a traumatic subcapital femoral fracture. Internal fixation was the treatment method associated with the more favorable results. The histologic examination of removed femoral heads indicated that this entity is a dynamic metabolic process. Insufficiency stress fractures of the femoral neck in the elderly are not uncommon, but unless suspected, the condition can be easily overlooked, and if displaced, mistaken for trauma-induced subcapital femoral fractures.

Treatment of posttraumatic reflex sympathetic dystrophy syndrome (RSDS) with intravenous blocks of a mixture of corticosteroid and lidocaine: a retrospective review of 17 consecutive cases.

Seventeen consecutive patients with posttraumatic reflex sympathetic dystrophy syndrome (RSDS) were treated with one or more regional i.v. blocks of methylprednisolone sodium succinate and lidocaine HCL after physical therapy and oral medications had failed to produce satisfactory relief of their symptoms. In 12 of these patients the upper extremity was affected, and in five, it was the lower extremity. A fracture of the distal radius was the most frequent predisposing event. The average delay between injury and the manifestation of RSDS was 2.5 months (range 2 days to almost 6 months). The index treatment in all cases started within 3 months of the onset of symptoms. The number of i.v. blocks given ranged from one to four (average 2.4). The side effects and complications were negligible. The treatment, which in most cases was given exclusively on an outpatient basis, was well tolerated by all patients except one. Assessment of 16 of them at 6 months showed that 11 had total or almost total relief of their symptoms. When 15 of the patients were reassessed at an average follow-up of 28 months (range 12-48 months), it was noted that none of the patients with an early satisfactory response experienced recurrence of their symptoms. The condition of the symptomatic patients in the interim had improved overall. Analysis of the cases with an unsatisfactory outcome suggested that the primary reason for failure was inadequate treatment rather than ineffectiveness of the treatment used. It was concluded that this method is simple, safe, and well tolerated and should be regarded as a first choice for posttraumatic RSDS.

The Partridge nylon cerclage: its use as a supplementary fixation of difficult femoral fractures in the elderly.

We report on our early experience with the use of the Partridge nylon cerclage. This system was employed as a supplementary fixation in 18 femoral fractures in elderly patients (average age, 78 years). Indications of its use were reduction of comminuted fragments and enhancement of the grip of the main fixation device on osteoporotic femora or in femora with a prosthesis in situ. All fractures but one healed primarily. At an average follow-up time of 25 months, 15 of the 18 patients were ambulatory. Radiographic review showed that the cerclage did not cause cortical avascularity and that none of the straps used failed. We concluded that the internal fixation of difficult femoral fractures in the elderly can be easily and effectively strengthened by the use of this cerclage system.

Occult fracture-subluxation of the midtarsal joint.

In four women with occult fracture-subluxation of the midtarsal joint incurred in trivial accidents, the correct diagnosis was made promptly, assisted in one case by bone scintigraphy. Treatment was conservative, consisting of cast immobilization for six to eight weeks and a weight-bearing restriction. At the minimum follow-up time of 24 months, the functional results were rated good in three patients and fair in one. In the patient with a fair result, a compression fracture of the posterior facet of the calcaneus was diagnosed retrospectively. An occult fracture-subluxation of the mid-tarsal joint can be treated effectively by conservative means.

Long-term review of the McGoey-Evans high-friction uncemented total hip arthroplasty.

To assess the long-term clinical results of uncemented total hip arthroplasty with the McGoey-Evans bipolar high-friction hip prosthesis, the authors reviewed the findings in 86 such hip replacements. The minimum patient follow-up was 5 1/2 years (mean 9 years). Overall, satisfactory results were obtained in 46.5% of cases. There were no deep infections. In contrast to the experience with the cemented hip replacements, the authors found that the results were better in men than women and that most of the revisions were done within 5 years of the original operation. Tissue hypersensitivity resulted in implant loosening in only two cases and no harmful systemic effects arose from the use of this uncemented cobalt-chromium prosthesis. Although this particular hip prosthesis is not recommended because of its inferior design, the findings of the study could be useful in the current practice of uncemented hip arthroplasty.

Simultaneous fractures of the distal radius and scaphoid.

Simultaneous fractures of the distal radius and the scaphoid are uncommon. A study of seven male patients who had sustained this fracture combination revealed the most frequent cause of the injury was a fall from a height. The distal radial fracture, usually unstable and intra-articular, was the principle fracture in this complex injury. In contrast, most of the scaphoid fractures were stable. Four of the radial fractures were treated by closed reduction and cast immobilization. In the remaining three, an external fixator was used to maintain the reduction. Four scaphoid fractures were immobilized in a cast, two were internally fixed, and one was left untreated. At an average follow-up period of 20 months (range from 12 to 52 months), all seven patients had regained satisfactory use of their hands. (Three results were classified as excellent and four good.) All scaphoid fractures healed. Transient avascular necrosis was noted in one scaphoid, but cleared within 5 months. Advanced radiocarpal arthritis developed in one wrist, but its presence did not adversely affect the late functional result.

Stress fractures of the femoral neck. A report of seven cases.

The femoral neck is an uncommon location for stress fractures. In seven such fractures, three occurred in young adults, and four in elderly adults. The characteristic symptom was exertional hip pain. The clinical findings were generally minimal. Four of these fractures were of the transverse and three of the compression type. This radiologic differentiation is important for the planning of treatment. The transverse stress fracture is potentially unstable, and the recommended treatment is prompt internal fixation. The compression stress fracture has a benign prognosis. Restriction of weight bearing for a few weeks is usually sufficient to relieve symptoms. Prophylactic internal fixation should be considered only when the trabecular bone mass has been significantly weakened by internal (i.e., underlying disease) or external causes (i.e., medication-related).

Isolated volar dislocation of the fifth carpometacarpal joint. Case report.

A rare volar-ulnar dislocation of the base of the fifth metacarpal in a 73-year-old man was correctly diagnosed early and treated by closed reduction. The reduction was unstable and percutaneous skeletal fixation was applied to ensure stability. The functional results were excellent within four months of surgery.

Replacement of the radial head in the treatment of unstable elbow fractures.

The use of a radial head prosthesis for the treatment of fractures of the radial head associated with gross instability of the elbow is described. Seventeen fractures occurring in seventeen patients treated at the Toronto East General Hospital from 1966 to 1979 are analysed. Instability of the elbow occurs when fracture of the radial head is combined with dislocation of the elbow, fracture of the proximal ulna, fracture of a major portion of the coronoid process and rupture of the medial ligament. Stability can be restored in these injuries by inserting a radial head prosthesis which acts as a joint spacer. A metallic prosthesis which acts as a joint spacer. A metallic prosthesis was used in 15 patients and a silastic cap in 2. The results of this method of treatment for a difficult problem age good. We are not advocating the routine use of a prosthesis for simple fractures of the radial head. It is indicated for injuries where stability is poor after excision of the radial head. There is little information in the literature regarding the use of a prosthesis for radial head fractures.

Postirradiation sarcoma of bone: a perspective.

Ten cases of irradiation induced sarcoma of bone which fulfilled Cahan's criteria were seen in a twenty year period at the Princess Margaret Hospital. The overall incidence of this complication is 0.035% of all irradiated five year survivors. Combining our data with three other large series presented in the literature, a dose complication curve could be deduced. On the basis of the human and animal data reviewed, it was concluded that the risk of radiation induced sarcoma is so low in the dose range of modern radiotherapeutic practise that it does not represent a contraindication to the use of radiation therapy.