Scaphoid nonunion treated with vascular bone grafts pedicled on the dorsal supra-retinacular artery of the distal radius.

BACKGROUND: Nonunion and avascular necrosis (AVN) are frequent complications of scaphoid fractures. We describe the operative technique and long-term results of treatment with pedicle vascularized bone grafts (VBGs) of the distal radius in patients with scaphoid fractures in whom nonunion and AVN developed. METHODS: During a 4-year period (1997-2000), VBGs pedicled on either the first and second or second and third compartments of the supraretinacular artery of the distal radius were in our hospital used to treat 11 patients with symptomatic scaphoid nonunion involving AVN of the proximal fragment (one with perilunate transscaphoid fracture dislocation and 10 with displaced scaphoid fractures with nonunion). Nine of these 11 patients received fixation with divergent K-wires fixation and two received Herbert screws fixation. RESULTS: Osseous union was achieved in all 11 patients treated with VBGs within an average period of 13 weeks. Functional results of treatment, which were measured using the modified Mayo Wrist Score, were encouraging in all patients in this series (four excellent, six good, and one fair). The deformity of ununited scaphoid was well corrected. CONCLUSIONS: The index study suggests that this treatment can be used not only to revascularize necrotic scaphoid, but also to correct humpback deformity and the resulting carpal instability.

Percutaneous screw fixation for unstable scaphoid fractures.

BACKGROUND: The technique of percutaneous screw fixation, with increasing popularity, has been successfully conducted in non-displaced, stable scaphoid fractures resulting in shortened immobilization duration and prompt functional retrieval. The purpose of this study was to evaluate the surgical technique and to explore the potential benefits of using percutaneous screw fixation in unstable scaphoid fractures. METHODS: Eleven of 97 patients with scaphoid fractures surgically treated between 1994 and 2002 were enrolled in this study. All were acute unstable fractures and underwent closed reduction and percutaneous screw fixation. All the records were meticulously reviewed and reported, including the complete radiographic examination before and after operation, time to fracture union, wrist motion, grip strength, and time of return to work, as well as overall patient satisfaction at the time of the most recent follow-up. RESULTS: Eleven fractures in an equal number of patients were followed up for a mean period of 1.6 years. All fractures acquired radiographic union in an average of 10.6 weeks. The modified Mayo Wrist score averaged 88.2. The functional result was ranked as excellent in 6 patients, and good in 5 patients. All returned to work or the pre-injury level of activity, and were satisfied with the surgical outcome. CONCLUSION: The technique of percutaneous screw fixation was successfully used to treat 11 unstable scaphoid fractures. The encouraging outcome of this treatment option and the prompt functional recovery deserve further investigation. Further randomized prospective studies to explore the specific indications and ubiquitous benefits of the technique presented herein are recommended.

Arthroscopic-assisted reduction with bilateral buttress plate fixation of complex tibial plateau fractures.

PURPOSE: Our aim was to determine the outcome of arthroscopic-assisted reduction with bilateral buttress plate fixation for the treatment of closed complex tibial plateau fractures. TYPE OF STUDY: Case series. METHODS: 18 consecutive patients (12 men, 6 women) with complex tibial plateau fractures were enrolled in this prospective study. All patients underwent arthroscopic-assisted bilateral buttress plate fixation of closed complex tibial plateau fractures. The average age at operation was 35 years (range, 23 to 45 years). The follow-up period ranged from 39 to 69 months, with an average of 48 months. Using the Schatzker classification, there were 11 type V and 7 type VI fractures. The clinical and radiological outcomes were determined according to Rasmussen's system. RESULTS: All of the 18 fractures united. Overall, 4 (22%) patients were rated as excellent, 12 (67%) good, and 2 (11%) fair. Secondary osteoarthritis appeared in 3 injured knees (16.7%). One patient had a wound dehiscence (3 cm long) of the medial incision. Condylar joint surface depression was noted in 3 patients without functional instability. Two patients had valgus alignment between 10 degrees and 15 degrees. Two patients had the paresthesia over the lateral calf. There were no complications directly associated with arthroscopy in any of the 18 patients. No deep vein thrombosis, infection, or knee stiffness was found at final follow-up. CONCLUSIONS: Arthroscopic-assisted reduction with bilateral buttress plate fixation for complex tibial plateau fractures allows accurate fracture reduction, diagnosis, and treatment of associated intra-articular lesions, and less dissection than open reduction internal fixation.

Arthroscopically assisted osteosynthesis for tibial plateau fractures.

BACKGROUND: Options for management of tibial plateau fracture are numerous, and the outcome depends on several factors. With the inherent advantages of arthroscopy, the results of tibial plateau fracture have been greatly improved. METHODS: Thirty-one patients were treated with arthroscopically assisted reduction for tibial plateau fracture, with an average follow-up period of 3 years. Evaluations were performed with the Hospital for Special Surgery knee score clinically, and with the Ahlbäck scale for osteoarthritis radiographically. RESULTS: Eighty percent of cases were Schatzker type II, III, or IV, and over half (52%) of the patients had concomitant intra-articular lesions. Twenty-nine patients (93.5%) had satisfactory results according to the Hospital for Special Surgery knee score, and only one patient developed degenerative arthritis during the period of follow-up. CONCLUSION: The arthroscopically assisted reduction of tibial plateau fracture is a safe and promising procedure. The results are comparable to traditional methods of open reduction.

Surgical approaches for nonneurogenic elbow heterotopic ossification with ulnar neuropathy.

BACKGROUND: Few reports are available concerning elbow heterotopic ossification (HO) and its optimal management in nonneurologic or nonburn patients after repetitive elbow manipulation. The unique anatomic relationship of the ulnar nerve at the elbow renders it rather vulnerable to injury when elbow HO occurs medially or posteromedially and extends into the vicinity of the cubital tunnel. METHODS: A total of 16 consecutive patients without neurologic injury were diagnosed with heterotopic ossification formation in the elbow and referred to the Upper Extremity Unit of Chang Gung Memorial Hospital. All 16 patients were diagnosed with ulnar palsy, and 14 were found to have sensory dysfunction and muscle wasting for an average of 5.2 months. RESULTS: Fourteen of 16 patients achieved functional range of motion or more after surgery. The final gain in range of motion averaged 80.3 degrees. All except one had complete neurologic recovery postoperatively. The patient who had ulnar palsy for 1 year presurgery did not achieve any neurologic recovery. CONCLUSION: Forceful and repetitive manipulation may add further damage to an already stiffened elbow and should be avoided in an elbow after immobilization or surgery. Early surgical resection of HO and ulnar nerve decompression followed by gentle and aggressive physical therapy terminate the vicious cycle and yield encouraging results.

Arthroscopically assisted osteosynthesis of complex intra-articular fractures of the distal radius.

BACKGROUND: Complex intra-articular fractures of the distal radius pose a great challenge in orthopedic surgery. Conventional open reduction and internal fixation generally yields poor functional outcome. The technique of arthroscope-assisted surgery allows more accurate reduction of the articular surface and treatment of soft tissue lesions, both of which are necessary for regaining anatomic structure and satisfactory function. METHODS: Twenty wrists in 18 patients with intra-articular fracture of the distal radius received arthroscopic surgery and percutaneous pinning with or without external skeletal fixation and bone grafting. A new traction method was designed that allows arthroscopic surgery and fluoroscopic monitoring to be performed simultaneously. Postoperative follow-up averaged 24.7 months. RESULTS: All except one of these patients returned to work within 3 to 6 months after surgery. Later collapse with minimal articular step-off was noted on radiographs before osseous union in two patients who did not undergo bone grafting. Decreased radial height because of subsequent displacement at the metaphyseal fracture was noted in one patient who did not receive external skeletal fixation initially. CONCLUSION: The technique of arthroscope-assisted surgery, despite a steep learning curve, is an invaluable method. Results using this technique are promising and few complications are encountered in the treatment of complex radius platform fractures. The bone grafting procedure augments osseous union, shortens the duration of external skeletal fixation, and thus lessens joint stiffness.

Management of scaphoid nonunion with avascular necrosis using 1, 2 intercompartmental supraretinacular arterial bone grafts.

BACKGROUND: Poor reduction or neglect of an unstable carpal scaphoid fracture may lead to scaphoid nonunion or avascular necrosis. When pre-operative suggestion of avascular necrosis of the proximal pole is confirmed by intra-operative evaluation, conventional bone graft is not enough and a vascularized bone graft is strongly recommended. METHODS: Five patients with nonunion of scaphoid fractures associated with avascular necrosis based on results of radiography and further confirmed by magnetic resonance images and intra-operative findings were operatively managed with 1, 2 intercompartmental supraretinacular arterial (1, 2 ICSRA) vascularized bone graft combined with supplemental cancellous bone grafts from the radius. Follow-up periods were at least 18 months. The functional outcomes and radiographs were analyzed. RESULTS: In four of the five patients, the nonunion sites united within 4 months after surgery. The other patient had a superficial pin tract infection and bone healing was complete 6 months after the operation. The functional results were good in all five patients. CONCLUSION: 1, 2 ICSRA is superficial to the retinaculum and runs directly into the bony tubercle. It is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

Conditions before collapse of the contralateral hip in osteonecrosis of the femoral head.

BACKGROUND: Osteonecrosis of the femoral head is a disease which may cause rapid femoral head collapse in relatively young patients. Clinical results of prosthesis replacement in osteonecrosis patients are generally poorer than in age-matched patients with other diagnoses. The ultimate goal in treating these patients is therefore to preserve not replace the involved femoral head. The purposes of this study were to analyze outcomes by examining osteonecrotic hips before collapse and to justify the role of early surgical intervention for osteonecrosis of the femoral head. METHODS: Between 1993 and 1997, there were 275 consecutive patients with osteonecrosis of the femoral head who received joint replacement on 1 side. Among these patients, 100 contralateral hips with evidence of osteonecrosis in the stage before collapse were included in this study. Demographic information, laboratory data, and radiographs were reviewed and compared between patients whose collapse time was less than 1 year, between 1 and 2 years, and more than 2 years, and those who had no collapse at the latest follow-up. RESULTS: At the final follow-up, the overall collapse rate was 78%, and the collapse time was generally within 2 years. Patients with younger age (less than 50 years old), higher activity levels, and higher serum triglyceride levels were at higher risk of rapid collapse. CONCLUSION: In conclusion, we found that the disease progression rate is high in patients who have bilateral femoral head involvement. Early surgical intervention to preserve the femoral head should be adopted to prevent early femoral head collapse in these patients. In addition, risk factors such as high activity levels and abnormal lipid metabolism should also possibly be addressed in the therapeutic modality.

Early surgical management for heterotopic ossification about the elbow presenting as limited range of motion associated with ulnar neuropathy.

BACKGROUND: The formation of heterotopic ossification (HO) about the elbow after traumatic injury has been well documented in the literature. The optimal treatment, however, for ectopic bone associated with restricted range of motion and ulnar nerve entrapment syndrome has not been established. METHODS: Seven elbows with HO in 7 patients admitted to Chang Gung Memorial Hospital from April 1998 to January 1999 presented with limited range of motion and associated ulnar nerve neuropathy. All of these patients received early surgical excision of HO combined with release of the encased ulnar nerve and anterior transposition, followed by early gentle passive physical therapy and active exercise within the pain-free range of motion postoperatively. RESULTS: Almost full range of motion and complete functional ability following surgery were recovered in 6 of the 7 patients, while I patient who suffered from multiple traumatic injuries had limited improvement from 45 degrees ankylosis to 10 degrees approximately 90 degrees of a flexion-extension motion arc. CONCLUSION: Our results suggest that early surgical management combined with gentle physical therapy postoperatively is a feasible modality for treating patients with post-traumatic HO about the elbow presenting as limited range of motion and associated ulnar nerve compression syndrome.