Proximal femur fractures after free vascularized fibular grafting to the hip.

The management of symptomatic femoral head osteonecrosis in young, active patients is troublesome and controversial. At the authors' institution, 707 consecutive free vascularized fibular grafts were performed for femoral head osteonecrosis between October 1979 and October 1995. Patients who underwent this procedure were at increased risk for proximal femur fractures because of the 16 to 21 mm core drilled through the lateral femoral cortex for removal of the avascular bone and placement of the fibular graft. An ongoing prospective database of patients who underwent this procedure was accessed to determine the incidence of and factors associated with postoperative subtrochanteric femur fractures. Eighteen subtrochanteric fractures occurred for an overall incidence of 2.5%. All fractures occurred through the core decompression site in the lateral femoral cortex. The treatment was nonoperative in seven patients and operative in 11. Fourteen of 18 fractures (77%) healed with an average of 4.1 months until radiographically documented union. Four fractures had nonunions develop, three of which later healed with bone grafting and internal fixation, whereas the fourth eventually required conversion to total hip arthroplasty. Twelve fractures in 251 patients occurred when the weightbearing regimen was touchdown weightbearing for the first 6 weeks and five fractures in 456 patients occurred when the weightbearing regimen was changed to nonweightbearing. The results indicate that nonweightbearing in the immediate postoperative period is associated with the lowest fracture rate.

Plantar fibromatosis: treatment of primary and recurrent lesions and factors associated with recurrence.

Plantar fibromatosis is a benign but often problematic foot disorder which, when surgically treated, is difficult to eradicate. The purpose of this investigation was to identify epidemiologic factors associated with disease recurrence and to determine which method of treatment most successfully eliminated recurrence. A retrospective review of surgical pathology reports and clinical histories from 1979 to 1993 was performed to identify all patients who underwent surgery for plantar fibromatosis at our institution during that time. Thirty-three feet of 30 patients were identified with a minimum 2-year follow-up. Seventeen feet underwent surgery for primary lesions, and 4 of 10 that had local excision, 1 of 3 that had wide excision, and 2 of 4 that had subtotal fasciectomy (with or without skin grafting) had recurrence. All 16 feet in patients presenting with recurrent lesions had undergone prior local excision at other institutions. When combined with patients from our institution who underwent a second procedure, 21 feet had surgery for recurrent plantar fibromatosis. Of these, three of four had further recurrence when treated with local or wide excision. In feet with recurrences treated with subtotal fasciectomy, only 4 of 17 had recurrence after the first attempt at such treatment. Average follow-up for all patients was 7.7 years, and all patients with postoperative recurrences showed evidence of disease within 14 months after surgery (mean, 6.9 months). Factors identified with an increased risk for recurrence were multiple nodules, bilateral lesions, and positive family history. In treating recurrent disease, subtotal fasciectomy was more effective than local or wide excision. This study identified factors associated with a significant likelihood of postoperative recurrence in treating plantar fibromatosis and found subtotal fasciectomy to provide the most successful treatment in eradicating disease in recurrent cases.

Acute hematogenous osteomyelitis of a closed fracture with chronic superinfection.

Acute hematogenous salmonella osteomyelitis is rare among immunocompetent adults. In this study, the authors reported an unusual case of salmonella enteriditis osteomyelitis of the humerus complicated by methicillin-resistant Staphylococcus aureus superinfection and eventual chronic osteomyelitis in an immunocompetent host. Resection of the humeral head and a significant portion of the humeral shaft coupled with numerous surgical debridements and intravenously administered antibiotics led to resolution of symptoms. This case provides a rare example of acute hematogenous osteomyelitis complicating a closed fracture and demonstrates the difficulty associated with eradication of these specific organisms while emphasizing the principle of aggressive surgical debridement in cases of chronic osteomyelitis.

The incidence and significance of the posterior gastric artery in human anatomy.

This study examines the incidence of the posterior gastric artery in a series of 75 adult cadavers. We clearly identified the posterior gastric artery in 36 (48%) cadavers as a 1- to 2-mm vessel arising from the cranial border of the splenic artery within 3 cm of the celiac trunk and coursing dorsally to the posterior parietal peritoneum where it forms a fold before supplying the upper part of the posterior gastric wall. Identifying this vessel is difficult during surgery that compromises vascular tributaries of the stomach, and the obscure course and high incidence of this vessel necessitates awareness that, in a 75-85% gastrectomy, the short gastric artery or branches of the left gastric artery should be preserved since the posterior gastric artery will be sacrificed in 13% of these cases.

Examination of collateral flow and anomalies of the left renal vein with clinical correlations.

The anatomy of the left renal vein, especially knowledge of collateral flow, is extremely important to the modern surgeon, since division of the left renal vein is common to many procedures. This study examines the left renal venous drainage system in 20 human cadavers for evidence of collateral flow and anomalies. Ten cadavers underwent dissection of the tissues surrounding the left renal vein, except for the left suprarenal and left gonadal veins, and 10 did not. Water and methylene blue were injected into the left renal vein to check for extravasation, and the veins were subsequently divided. There was no evidence of additional tributaries off the left renal vein as no extravasation occurred, and opening of the left gonadal and left suprarenal veins did not reveal any direct connections to the inferior vena cava. Thus, this experiment did not demonstrate evidence of a systemic collateral flow system draining the left kidney once the left renal vein was divided. Anomalies of the left renal venous drainage system occurred in six of 20 (30%) of cadavers, with one anomaly of the left renal vein itself (5%) manifested as a supernumerary left renal vein. The other anomalies included bifurcation of the gonadal vein, bifurcation of the suprarenal vein, the inferior phrenic vein draining into the left renal vein distal to the superior mesenteric artery, and the presence of a lumbar vein draining into the left renal vein in two cadavers. The lumbar veins may perhaps represent a normal variant.