Lower extremity fractures in paraplegics: pattern, treatment, and functional results.

Eighty-seven lower extremity fractures in 71 paraplegics were retrospectively evaluated to determine adequacy of treatment, functional result, and range of motion of the hip and knee. Most fractures treated closed healed without difficulty, but with a complication rate of 19%. Length of hospitalization averaged almost 3 months in the group treated closed, and residual hip and knee stiffness was the major complication. This was not a problem except in high demand patients, such as wheelchair athletes, in whom decreased range of motion was a significant limitation. Treatment with circular casts produced a high number of complications and is not recommended for patients with insensate skin. Open reduction and internal fixation is recommended for a small subgroup of paraplegics: wheelchair athletes, hip fractures, and those in whom autonomic dysreflexia and/or uncontrollable spasticity due to fracture manipulation is a significant hazard.

The weight-bearing shoulder. The impingement syndrome in paraplegics.

The cases of ninety-four patients who had complete paraplegia were studied to determine whether they had complaints about the shoulder during transfer activities. Thirty-one patients reported pain on transferring, and twenty-three of these patients were found to have a chronic impingement syndrome with subacromial bursitis. Arthrography of the shoulder was done for each of these twenty-three patients, and fifteen were found to have a tear of the rotator cuff. Five of the thirty-one patients were found to have aseptic necrosis of the head of the humerus. We also measured the intra-articular pressure in the shoulder in five patients during different activities, including transfer from wheelchair to bed, and found that this pressure exceeded the arterial pressure by two and one-half times. We believe that this high pressure, in conjunction with abnormal distribution of stress transmitted across the subacromial area during transfer or propulsion of a wheelchair, contributes to the high rate of problems about the shoulder in paraplegics.

A clinical and electrophysiological investigation of anterior transposition for ulnar neuropathy at the elbow.

Previous studies have shown good clinical results following anterior transposition of the ulnar nerve for compression neuropathy. However, no studies have examined all patients pre- and post-operatively with both clinical and electrophysiological studies to determine if a correlation exists. Twenty-three of 24 (96%) anterior transpositions performed consecutively over 6 years were followed up at a mean of 33.2 months with clinical and electrophysiological examinations. All patients were male "blue-collar" workers with a mean age of 52.1 years. The mean duration of preoperative symptoms was 11.3 months. Preoperatively, 30% were graded moderate and 70% severe. The motor conduction velocity (MCV) across the elbow and electromyography (EMG) correlated with the severity of the clinical findings. Postoperatively, 70% of patients improved, with 40% having a good result and 30% fair, and the MCV improved to a highly significant degree (P less than 0.0005). Thirty percent had a poor result with no clinical improvement, yet the MCV improved to a significant degree (P less than 0.05). There was no correlation between the clinical result and the distal motor or sensory latencies, MCV below the elbow, or EMG. Advanced age, duration of preoperative symptoms, diabetes, hypertension, alcoholism, etiology, type of transposition, tourniquet time, and atrophy did not correlate with a poor result, either clinically or electrophysiologically. Severe clinical findings confirmed by electrophysiological studies do not contraindicate surgery and have a reasonable success rate. In conclusion, preoperative electrophysiological studies correlate with the clinical findings but postoperative ones do not, including the MCV. The MCV improves after anterior transposition of the ulnar nerve regardless of the clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior transposition for advanced ulnar neuropathy at the elbow.

Previous studies have shown good clinical results after anterior transposition of the ulnar nerve for compression neuropathy. However, it has been suggested that younger patients with a shorter duration of preoperative symptoms benefit most from surgical therapy. To determine what factors adversely affect the prognosis in patients with advanced disease, 23 of 24 anterior transpositions performed consecutively over 6 years were observed at a mean of 33.2 months. The mean age was 52.1 years. Symptoms were present for a mean of 11.3 months. Before the operation, 30% were graded moderate and 70% severe. After the operation, 70% of the patients improved, with 40% having a good result and 30% fair. Advanced age, duration of preoperative symptoms, diabetes, hypertension, alcoholism, etiology, type of transposition, tourniquet time, or atrophy did not predict a poor outcome. Severe clinical findings confirmed by electrophysiologic studies did not contraindicate surgery or preclude a reasonable rate of success in this small but relatively homogeneous group of patients.

The treatment of spinal fractures with Harrington compression rods and segmental sublaminar wiring. A dangerous combination.

The increasing use of more rigid internal fixation constructs for spinal fractures, especially in association with spinal cord injury, has led surgeons to combine sublaminar segmental wiring with Harrington instrumentation systems. Two clinical cases whose neurologic condition deteriorated postoperatively were shown to have sustained direct cord injury by the combination of Harrington compression rods with segmental sublaminar wiring. Myelographic and surgical evidence of hook protrusion into the spinal canal with direct cord injury is presented. Laboratory spine simulations duplicating the clinical situation did demonstrate that sublaminar wiring of the Harrington compression rod system caused the standard hooks to protrude dangerously into the spinal canal. Caution should be exercised not to combine Harrington compression rods with segmental sublaminar wiring.

Complete sensory and motor recovery from anterior spinal artery syndrome after sprain of the cervical spine. A case report.

A patient sustained C7-C8 incomplete myelopathy with dissociated sensory loss after a whiplash injury. Cervical radiograms showed no fracture or dislocation but separation of the C4-C5 and C5-C6 spinous processes and anterior tilting on C5 on C6 vertebral body only in the head-neck flexed position. Complete sensory and motor recovery occurred after neck immobilization. The patient's transient neurologic deficits were probably caused by vascular insufficiency of an anterior radicular artery at the C5-C6 intervertebral foramen.

Tobramycin in bone cement. An in-depth analysis of wound, serum, and urine concentrations in patients undergoing total hip revision arthroplasty.

In this prospective clinical study, ten patients were treated by revision of total hip arthroplasties utilizing tobramycin-impregnated bone cement. After the operation, serum, urine, and wound suction drainage concentrations of tobramycin were determined serially by radioimmunoassay. Although high local wound concentrations, 5.7 micrograms/ml, were maintained for as long as 48 hours, serum concentration never reached even normal therapeutic ranges (greater than 2.0 micrograms/ml). There were no immediate postoperative infections; all patients are pain-free and ambulate without external support two years after surgery. One patient who had had a preoperative infection was successfully treated for late manifestation of infection 24 months after revision. Based on the evidence obtained in this study, tobramycin in bone cement is currently acceptable for clinical use.