The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review.

BACKGROUND: A long-term review of metal prosthetic radial head replacement in patients with radial head fractures associated with gross instability of the elbow has been performed. METHOD: Twenty patients were reviewed using a modified Mayo Clinic functional rating index system. The mean follow-up was 12.1 years, with a range from 6 to 29 years. RESULTS: Results were excellent in 12 patients, good in 4 patients, fair in 2 patients, and poor in 2 patients. A metal radial head replacement restored elbow stability when fracture of the radial head occurred in combination with dislocation of the elbow, rupture of the medial collateral ligament, fracture of the proximal ulna, and/or fracture of the coronoid process. CONCLUSION: We conclude that a metal radial head prosthesis has select indications. We advocate its use when the radial head cannot be reconstructed in the setting of a clinically unstable elbow. Results suggest that it functions well on a long-term basis.

The natural history of suspected scaphoid fractures.

Clinically suspected scaphoid fractures are common injuries. The authors prospectively followed up, by serial radiography and bone scanning, 23 patients who had a history of trauma to the carpus and associated localized tenderness to the anatomic "snuff box": in 15 patients the radiographs and bone scans were negative; in 5 the radiograph was equivocal and the bone scan positive. The authors concluded that patients with clinically suspected scaphoid fractures and negative radiographs can be treated symptomatically without immobilization in a cast. Patients with equivocal radiographs should be assumed to have a fractured scaphoid and treated accordingly.

Inadvertent extramedullary placement of Austin Moore prosthesis. A case report.

Virtually complete extramedullary insertion of an Austin Moore prosthesis is a rare complication. The prosthesis is seldom left in such a position once the complication has been recognized. To the authors' knowledge, this is the first reported long-term follow-up study of such a case in which the result could be considered reasonably well-tolerated. The prosthesis was revised to a total hip arthroplasty 15 years following implantation. That the reason for excision was acetabular wear indicates that the prosthesis was load bearing. This case raises the question of whether the concept of extramedullary fixation of hip prostheses could be valid.

Delayed union and nonunion of the tibia: experience in a community teaching hospital.

Delayed union and nonunion are frequent sequelae of high-energy tibial fractures, particularly compound ones. The authors studied 45 such cases; of these, 20 fractures were compound. The authors analysed the initial management but found no apparent correlation between the initial management of these fractures and subsequent delayed union or nonunion. The Phemister bone-grafting technique was used to achieve union and was considered a safe, efficacious method. Aggressive initial management of the soft-tissue component of tibial fractures is recommended to minimize the possible development of chronic osteomyelitis, a serious complication that occurred in eight patients and necessitated below-knee amputation in three.

Lumbar disc herniation in the elderly.

Thirty-two patients older than 60 years underwent surgical treatment for lumbar disc herniation over a 10-year period. Other causes of low-back pain and sciatica were investigated, and bony nerve root entrapment syndromes were not included. Sciatica was a predominant symptom and was present in all patients, with 81% showing positive nerve root tension signs. Motor deficit was found in more than half of the cases. A sequestrated disc was present in 50%. The follow-up ranged from 1 to 10 years with an average of 50 months. Eighty-seven percent of the patients had excellent or good results. There were no poor results and no one required reoperation. Lumbar disc herniation in the elderly is not a common problem, but surgery yields a high rate of satisfactory results if a proper investigation and correct diagnosis is obtained.

The Madreporic cementless total hip arthroplasty: short-term North American experience.

Forty-four Madreporic, cementless, total hip arthroplasties performed on 41 patients were reviewed, with special attention to overall clinical results and radiologic findings. Follow-up averaged 17 months (range from 6 to 27 months). Subjectively, 87% of patients rated the results of their operation as being excellent or good; objectively, 92.5% were in the excellent or good category, using the Harris hip scale rating system. Short-term radiologic findings were of major interest, with proximal medial calcar reabsorption (7 hips), thickening of the lateral cortex at the tip of the femoral stem (2 hips) and sclerosis at the tip of the femoral component (15 hips) all being present. Complications were associated with 11 operations, but adversely affected long-term results in only two hips. The authors conclude that short-term clinical results using Madreporic total hip replacement are satisfactory. However, long-term biomechanical effects of stress shielding and use of a large, rigid, femoral component in the uncemented total hip replacement are unknown. A long-term, follow-up study is necessary to demonstrate whether the early radiologic findings in this series are progressive and whether they will result in serious morbidity with time. The authors strongly believe that the Madreporic cementless total hip arthroplasty should be used only in centres dealing with a large volume of hip conditions where staff are committed to documenting and reporting the results of surgery regularly.

Acute spinal subdural hematoma. A case report and review of literature.

A case of acute spinal subdural hematoma is reported in a 24-year-old woman. Presentation occurred in the postpartum period, 4 days following epidural anesthesia. Emergency decompressive laminectomy attained partial recovery. Subsequent pathology demonstrated evidence of a low-grade ependymoma. Reported cases of spinal subdural hematomas are reviewed and compared with the characteristics of this unique case.

Cone arthrodesis of the first metatarsophalangeal joint.

The reliability and effectiveness of the treatment of hallux rigidus and symptomatic arthritis of the first metatarsophalangeal joint by the technique of cone arthrodesis are discussed. The authors reviewed the long-term results of cone arthrodesis in 51 patients with 60 operated feet. The average age was 55 years (range, 28 to 75 years) and the average length of follow-up was 39 months (range, 1 to 12 years). On questioning the patients regarding function, cosmesis, and pain, 41 of 51 patients were happy, eight of 51 patients were satisfied, and two of 51 were unhappy with their feet. No patient complained of persistent or recurrent hallux valgus deformity. Radiologically and clinically 58 of 60 first metatarsophalangeal joints were solidly fused. Two patients had a fibrous ankylosis which was functional and painless. Function with respect to gait and ability to walk on tiptoe and run was normal in all patients. In summary, the authors feel that this procedure is a reliable, effective treatment of painful arthritis of this joint.

Coracoacromial ligament division.

The object of this paper is to report on the findings of a retrospective study of 40 patients with 41 shoulders with persistent painful arc syndrome secondary to a chronic coracoacromial ligament inflammation who underwent simple coracoacromial ligament division at the Toronto East General and Orthopaedic Hospital between January 1973 and June 1979. Initial therapy was always nonoperative. Surgical intervention was reserved for patients who did not respond to conservative management and who had a painful arc with tenderness of the coracoacromial ligament. The aim of the coracoacromial ligament division was to relieve impingement by releasing the coracoacromial arch. Patients were carefully examined to rule out associated neck pathology, rotator cuff problems, and lesions of the acromioclavicular joint. Any patients with significantly large osteophytes under the anterior acromion were excluded. Forty patients (41 shoulders) were questioned and examined in followup. There were 29 males and 11 females. The ages ranged from 21 to 72 years (average 43.5 years). In 21 shoulders (51%), there was a history of trauma as the initiating factor. The follow-up ranged from 8 to 76 months (average 36.3 months). According to a described rating system, the results were satisfactory to excellent in 39 of 41 shoulders (95%) and unsatisfactory in two of 41 shoulders (5%). The back to work time ranged from 1 to 16 weeks (average 5.7 weeks).(ABSTRACT TRUNCATED AT 250 WORDS)

Femoral shortening by a step-cut osteotomy for leg-length discrepancy in adults.

The problem of leg-length discrepancy in the adult differs from that in children. The technique of shortening the femur by the step-cut osteotomy and Küntscher rod fixation to correct leg-length discrepancy in the adult was employed in 14 consecutive patients. There were seven male and seven female patients, ranging in age from 15 to 36 years (average, 22.7 years). The leg-length discrepancy ranged from 2.7 to 11.0 cm (average, 5.6 cm), and the shortening of the longer leg (and thus of the patient) ranged from 2.7 to 7.5 cm (average, 5.0 cm). There were no intraoperative or postoperative complications. All fractures were united clinically and radiologically three to four months after surgery (average, 3.6 months). The follow-up period ranged from two to 18 years (average, 8.9 years). The final leg-length discrepancy was 0 in six patients and ranged from 0.5 to 3.5 cm (average, 1.3 cm) under correction in seven. One patient was overcorrected by 0.5 cm. All patients were satisfied both cosmetically and functionally with the operation.

Combined vascular and neurogenic claudication.

Eight patients with combined vascular and neurogenic claudication were presented. In the adult with coexistent neurospinal and vascular disease, a careful history and examination often suggested the pathology more productive of symptomatology. Among patients presenting with predominately vascular claudication, six of six patients had calf pain as part of the pain pattern, and in three of six patients the pain was crampy. Five of six patients had a consistent exercise tolerance pain pattern and obtained relief of symptoms by resting the leg. Among patients presenting with mainly neurogenic claudication. Only four of eight patients had associated calf pain, and none experienced crampy pain. Five of eight patients had a variable exercise tolerance pain pattern and obtained complete relief of symptoms only by assuming the recumbent position. Doppler testing was very helpful as the initial step in the evaluation of the significance of an arterial lesion and in the follow-up assessment of these patients after vascular surgery. Lumbosacral-spine, cardiovascular, and neurologic examination was similar in the two groups of patients.

Fracture of the ipsilateral femur in patients wih total hip replacement.

The records of all patients who had had a total hip replacement complicated to a fracture of the ipsilateral femur in the intraoperative or postoperative period were collected from six London and Toronto teaching hospitals. Thirty-five patients (thirty-seven fractures) were studied to determine the effects of the fracture on the total hip replacement. The results of the total hip replacement ultimately were rated as satisfactory in fourteen patients (40 per cent) and unsatisfactory in twenty-one patients (60 per cent). Our study suggests that fractures proximal to the tip of the prosthetic stem that occur postoperatively should be treated conservatively if the prosthesis is intact. If subsequent symptomatic loosening develops, a revision can be done after the fracture has healed. Intraoperative fractures that occur proximal to the tip of the prosthesis and all fractures occurring at or distal to the tip should be stabilized surgically. The best results were obtained using a long-stem prosthesis supplemented with internal fixation of the fracture. If rigid fixation is not achieved at surgery, postoperative immobilization is required. Fractures entirely distal to the tip of the prosthesis do not result in prosthetic loosening and may be treated in a routine fashion if care is taken to avoid unnecessary areas of stress concentration.

Ganglion migrans of the proximal tibiofibular joint causing lesions in the subcutaneous tissue, muscle, bone, or peroneal nerve: report of three cases and review of the literature.

Three cases illustrate the variety of ways a ganglion may arise from the tibiofibular joint. In one case, the diagnosis was initially obscure because the swelling occurred under the muscles of the lateral compartment of the lower leg; the lesion was also intraosseous and extended into a tendon. In the second case, the ganglion had invaded the peroneal nerve, and in the third, the ganglion was a palpable subcutaneous tumor.

Intervertebral disc herniation in the adolescent.

Twenty-nine patients between 14 and 20 years of age underwent surgical treatment for intervertebral disc herniation over a 10-year period. Trauma was a significant factor in 59%. Back pain was a major complaint in all cases, and all but one had significant sciatic distress. Typical painful, restricted forward flexion was found in 22 cases. All patients had definite signs of nerve root tension. Nerve compression signs were present in 41%. Myelography was done in all cases, and discography was performed on 22 patients to aid in diagnosis and planning of definitive treatment. Twenty-three patients were followed over an average of 5.3 years. Excellent or good results were found in 89%. One patient required a further surgical procedure. Analyzing 12 procedures performed at the L5-S1 level demonstrated excellent results in all patients undergoing lumbosacral fusion combined with discotomy at this level in the presence of a normal L4-5 discogram.

Transient monoarticular synovitis of the hip joint in adults.

Clinical, laboratory, and radiological investigation of 6 cases of idiopathic monoarticular adult hip synovitis demonstrates that unlike the syndrome in children, in the adult the onset is very acute, short in duration, and followed by a short tapering off period with no sequelae to date. The ESR is the best index of the severity and course of the illness. Hip aspiration is of diagnostic value. Viral etiology was suspected, but not proven. Recognition of this syndrome in the adult will prevent an unnecessary arthrotomy for "septic arthritis" of the hip joint.

Diagnosis of occult fractures and dislocations.

The principles to be followed in the identification of occult injuries include: a good history and physical examination to arouse a high index of suspicion; high quality radiographs; radiographs of the whole bone and associated joints above and below, particularly in the lower cervical spine and hip; special views to delineate fractures, particularly oblique films, tangenital and axial views and stress films. Tomograms may also be helpful; follow-up and re-check films, especially with fractures and epiphyseal injuries. With early identification of fractures that are commonly missed, these injuries eventually cease to be occult and appropriate management can be instituted.