Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee.

OBJECTIVE: To identify the demographic and operative factors that determine outcome in supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. DESIGN: Clinical and radiologic review of a nonrandomized, consecutive one-surgeon series. SETTING: A university-affiliated, elective surgical referral centre. PATIENTS: Forty-nine consecutive patients with unicompartmental osteoarthritis of the knee, involving the lateral compartment, and of sufficient severity that the alternative surgical procedure would be total knee replacement. INTERVENTION: Supracondylar varus osteotomy stabilized with a blade plate. MAIN OUTCOME MEASURES: Knee function measured by the Knee Society Score and time to conversion to total knee replacement. RESULTS: A Knee Society Score greater than 80 was obtained in 81% of patients, but in the function portion of the measurement only 30% had a similar score. After discarding the patients who died, life-table analysis demonstrated the predicted survival before conversion to total knee replacement to be 87% at 7 years. There was no correlation with patient age or sex, femorotibial angulation, amount of correction or time after the intervention. Removal of the fixation device improved the clinical result. CONCLUSION: The role of supracondylar femoral osteotomy remains poorly defined, but the procedure can delay total knee replacement for considerable time in appropriate patients.

Microsurgical treatment of septic nonunion of the tibia. Quality of life results.

The outcome of microsurgical reconstruction of septic nonunion of the tibia was described. The series consisted of 15 patients, with Cierny Stage IVA or IVB septic nonunion of the tibia, who were treated in the microsurgical practice of a major tertiary care hospital. Patients with a documented end point of either union or amputation were eligible for inclusion. Patients were treated with wound excision followed by soft tissue and skeletal reconstruction. The outcome measures of interest included clinical measures (time to union or amputation, surgical complications, wound status) and health related quality of life measures (Short Form-36, Western Ontario and McMaster Universities Osteoarthritis Index, and patient satisfaction questionnaires). The average followup time was 3 years. There was 1 microvascular complication and no failures. Two of 15 patients (both Cierny IVB) required amputation after reconstruction. The time to union after bone grafting was an average of 6.5 months in May et al Type III legs (n = 12), 3 months in May et al Type IV legs (n = 1), and 16 months in May et al Type V legs (n = 2). Nine patients completed the questionnaires; Short Form-36 scores were below normative values for the same age group. Scores on the activity limitation component of the Western Ontario and McMaster Universities Osteoarthritis Index seem to be comparable with those of individual's scores after total knee replacement surgery. Despite relatively low scores on the questionnaires, most patients were either very or completely satisfied with the outcome of surgery. Patients often reported that satisfaction was related to preservation of the limb.

Influence of the Crowe rating on the outcome of total hip arthroplasty in congenital hip dysplasia.

Few studies have examined the relationship between the severity of congenital dysplasia of the hip (CDH) and the clinical outcome of total hip arthroplasty. The authors have used a prospective design to study this question, using the Crowe grade to assess the severity of CDH. There were 71 patients with CDH operated on using the S-ROM total hip (Joint Medical Products, Stamford, CT); the control group was composed of 22 patients without CDH operated on using the same implant during the same period as the CDH patients. The patients with mild CDH did not have a different outcome from the patients without CDH with respect to Harris hip score or limp. The higher the Crowe grade, the more complications occurred. It was also found that the patients in whom the true acetabulum was not used had a significantly higher incidence of limp.

In vivo diurnal variation in intervertebral disc volume and morphology.

STUDY DESIGN: Three-dimensional reconstructions of MRI scans measured volume, height, and diameter of intervertebral discs. These measurements were made in vivo. OBJECTIVES: This study documented diurnal change in lumbar disc volume and morphology. The authors studied the pattern of this change over the disc levels that were examined and documented individual differences. SUMMARY OF BACKGROUND DATA: There is a diurnal pattern of standing heights. The majority of this diurnal height change can be accounted for by height loss within the intervertebral disc, which bulges radially with loading. These studies have been performed in vivo. METHODS: Eight normal males were studied using two protocols. In one, the volunteers were in the supine position for 6 hours before MRI scanning. In the other, volunteers spent 4 hours standing and 3 hours sitting before MRI scanning. Three-dimensional MRI scanning was carried out on the L3-4, L4-5, and L5-S1 discs. RESULTS: Volume height and AP diameter of the lumbar intervertebral discs decreased significantly after the protocol of a day's activity. The mean decrease in disc volume at the L3-4 level after standing was 21.1%. At the L4-5 level, it decreased a mean of 18.7%, whereas at the L5-S1 level, there was a 21.6% mean decrease. CONCLUSIONS: The mean simulated diurnal volume decrease in the lower three lumbar discs is 16.2%. Most of the diurnal loss in disc height is due to volume loss. The effect of radial bulging is minimal.

Elderly patients with hip fractures: improved outcome with the use of care maps with high-quality medical and nursing protocols.

In a prospective cohort study, 51 patients were treated with standard nursing and medical treatment after sustaining a hip fracture. A second group of 55 patients was treated with high-quality medical and nursing protocols outlined on our care map. The patient groups showed no significant differences preoperatively in terms of the important variables of age, mental status, marital status, accommodation, ambulation, fracture type or fracture treatment. Postoperatively the patients were followed for a 6-month outcome. The outcome of return to their place of accommodation and their previous level of function was considered grade 1. In grade 2, the patients lost one level of function or one level of accommodation. In grade 3 they lost one level of accommodation and one level of function. In grade 4 they were dead. Overall we were able to show that the patients in the study group had a statistically significantly better outcome (p = 0.036). In addition, they had significantly fewer postoperative complications (p = 0.01) and a significantly greater number of the patients returned home within 14 days of their admission. We feel that the medical and nursing protocols outlined are generally applicable and could significantly improve the outcome overall for elderly patients with fractured hips.

A new scale for the clinical assessment of spinal cord function.

The systems currently used for grading the severity of neurologic injuries have serious limitations. The authors have developed a neurologic grading system to assess spinal cord function. This is a new, functionally oriented scale which can be used at the bedside and requires no special tests other than those done in a routine clinical neurological examination. This scale includes assessment of motor and sensory function, rectal tone, and bladder control. A major advantage of this scale is that motor function is assessed on a functional rating system. To evaluate the usefulness of this scheme, patients who have been previously entered into a prospective study on the surgical treatment of burst fractures were re-evaluated. A significant number of patients under our new reclassification system were noted to have had significant improvement which had been overlooked using the Frankel Grade system. The authors conclude that their new spinal cord assessment technique has many advantages and suggest that it be used by spinal cord injury centers.

Work status after posterior fixation of unstable but neurologically intact burst fractures of thoracolumbar spine.

Thirty nine patients with unstable burst injuries of the thoracolumbar junction who did not suffer neurological injury have been prospectively followed. There were 24 males and 15 females. Five patients were covered under the Workers' Compensation Board (WCB). The average patient age was 34 years (14-66). All patients were stabilised using the AO 'Fixateur Interne' and posterior fusion. The post-operative instrumented sagittal curve averaged six degrees of lordosis (-20 to +20). The length of follow-up averaged 24 months (range 12-24). Pre-operatively 28 patients were employed, 2 were housewives, 6 were students, and 3 were unemployed. At follow-up, all students and housewives had returned to their usual activities. No patient who was initially unemployed had found work. Of the remaining 28 patients who were employed before injury, 23 (82%) had returned to gainful employment, one had returned to school for job retraining, and 5 had not returned to work. Of the 23 patients who had returned to work, 5 returned to lighter duties, and 18 returned to their original occupation. Only 2 of the 5 WCB-covered patients did not return to work. Most neurologically intact patients undergoing surgery for unstable bursting injuries of the thoracolumbar spine can return to work.

Surgical anatomy of the sacrum. A guide for rational screw fixation.

Anterior sacral anatomy was studied to allow safe sacral screw placement. The study included 27 bony sacra. Intrapelvic dissections were performed. Cadaveric specimens were dissected and photographed. The position and angulation of the first sacral foramen was extremely variable. After the position of the L5 root, sacral roots, and iliac vessels, was considered, safe posterior sacral screw implantation could be assured through placement above the level of the first sacral foramen directed medially toward the promontory, parallel to the superior sacral end-plate. Complications of indiscriminate screw placement included L5-root damage, iliac vein penetration, and intractable perineal pain due to sacral root injury. Preoperative computed tomography with the scanner gantry tilted to parallel the superior sacral end-plate defined the great vessels, neural foramens, inclination of the superior sacral end-plate, and prominence of the posterior ileum. Surgical accuracy was evaluated after surgery with computed tomography.

Operative treatment of spinal fractures with the AO internal fixator.

A multicentered prospective trial to investigate the usefulness of the AO spinal internal fixator for the treatment of thoracolumbar fractures and fracture-dislocations was undertaken. This pedicle screw-rod system was effective in stabilizing a variety of unstable fracture patterns. It was effective in decompressing the canal of retropulsed bony fragments associated with burst fractures. By the use of this implant, sagittal plane deformity was easily corrected.

Evaluation of surgical treatment for burst fractures.

The authors instituted a prospective, randomized study of patients presenting with acute burst fractures of the thoracolumbar and lumbar spine. Patients were alternately treated by posterior distraction using pedicle instrumentation (AO fixateur interne) or anterior decompression and instrumentation (Kostuik-Harrington device). Forty patients are presented with a mean follow-up of 20 months. Preoperatively, there was significant canal compromise in 39 patients. This measured 44.5% in those patients undergoing posterior surgery and 58% in those patients undergoing anterior surgery. Postoperatively, this was reduced to 16.5% and 4%, respectively. There is a statistically significant difference between these two groups (P less than 0.0001). The mean preoperative kyphotic deformity was 18.7 degrees in those patients treated by anterior surgery and 18.2 degrees in the group treated by posterior surgery. At last follow-up, the mean improvement in kyphotic deformity was 9.3 degrees in the anterior group and 11.3 degrees in the posterior group. There is no statistically significant difference between these two groups. There were two implant failures of the anterior Kostuik-Harrington construct and two implant failures of the AO fixateur interne. Blood loss was significantly higher in the patients undergoing anterior surgery, but there were no complications from thoracotomy and anterior decompression of the dural sac. This study supports the hypothesis that posterior distraction instrumentation can effectively decompress the canal and correct kyphosis in patients sustaining burst-type injuries. Anterior surgery, however, results in a more complete and reliable decompression of the canal.

The role of external spinal skeletal fixation in the assessment of low-back disorders.

A variety of tests are currently used in an attempt to predict pain relief following arthrodesis of the lumbar and lumbosacral spine. External spinal skeletal fixation provides a means by which specific spinal motion units can be rigidly immobilized. A trial of temporary external fixation was investigated for its value in predicting the outcome of surgical fusion. Thirty-five patients with chronic low-back pain have been prospectively studied. The results show a statistically significant superiority of temporary external spinal fixation in predicting surgical result as compared with plain radiographs, discograms and facet blocks.