A technique of percutaneous multidrilling osteotomy for limb lengthening and deformity correction.

We have recently developed a technique of per-cutaneous multidrilling osteotomy for limb lengthening and deformity correction. The bone is drilled percutaneously, using a special drill guide, and osteotomy is accomplished by connecting the multiple drill holes with a small chisel. The bone segments are subjected to slow progressive distraction with an external fixation device. We have lengthened 33 limbs in 22 patients with congenital or post-traumatic limb shortening and/or bone deformities. All the patients underwent the proposed lengthening and/or correction of the bone deformities through a single-treatment procedure. None of the lengthened segments resulted in nonunion. This technique can prevent undesirable bone cracks and preserve soft tissue around the osteotomy site, and is also applicable to other fields of orthopedic surgery.

Salvage of failed resection of the distal ulna. Case report.

A 45-year-old woman completely lost the ability of active supination of the forearm after a Darrach resection for malunited fracture of the distal radius. A three-component reconstruction was performed to stabilise the distal stump of the ulna and prevent convergence between the two forearm bones. The procedure combined advancement lengthening osteotomy of the ulna, longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, and dorsal transfer of the pronator quadratus through the interosseous space. Four months after the salvage procedure she again had full active supination of the forearm and she returned to work two months later.

Dynamic traction for unstable fractures of the distal radius.

We have designed a flexible distracter through which dynamic traction is applied to fractures of the distal radius. The distraction is maintained during flexion and extension as well as radial and ulnar deviation. The results in 30 patients showed that the majority of the fractures maintained reduction during the period of dynamic traction. In several patients the radiological variables even improved during dynamic traction. The median radial shortening was 0 mm, the palmar angulation 7 degrees, and the radial inclination 23 degrees. Continuous dynamic traction applied to fractures of the distal radius did not lead to redisplacement of the fracture, and the overall functional results were good.

Open tibial fractures treated with the Ex-fi-re external fixation system.

Fifty open tibial fractures were treated with the Ex-fi-re external fixation system from 1987 to 1994. According to the Gustilo and Anderson classification, there were 12 Grade I, 14 Grade II, 10 Grade IIIA, 13 Grade IIIB, and 1 Grade IIIC injuries. Eight fractures were segmental. The average patient patient age was 39 years (range, 16-85 years). With the reduction unit of the system, displaced tibial fractures could be reduced by the functions of the device in contrast to the manual reductions needed with other unilateral devices. Compression could be applied even to oblique fractures. The reductions were performed by this unit in all cases and were classified as exact in 28 of 41 cases. Exact reduction was defined as a reduction in which there was no more than 2 mm of translational displacement. The 8 segmental fractures were not classified according to reduction. Forty-three fractures healed with no secondary procedure. Three secondary bone graftings, 4 fibulotomies, and 3 renamed intramedullary fixations were performed in 6 patients. Thirty-two skin grafts were performed. There was 1 fracture site infection, and 1 curettage and 1 sequestrectomy were performed after union. At 1 year followup there were no signs of infection. Median time to union was 20 weeks, and median time to full unprotected weightbearing was 22 weeks. Fractures with an exact reduction had a median time of union of 19 weeks, compared with a median of 31 weeks in reductions with greater than 2 mm translational displacement. The exact reduction and translational compression applied in oblique fractures appeared to contribute to early consolidation.

11 femoral fractures with vascular injury: good outcome with early vascular repair and internal fixation.

We reviewed 11 consecutive cases with combined femoral fracture and vascular injury presenting with acute ischemia. 6 cases had ischemia exceeding 8 hours and 4 of them developed massive muscle necrosis in the lower leg. 5 cases with ischemia less than 8 hours had no muscle necrosis. Vascular repair preceded fracture stabilization in 5 cases; there were no vascular complications during the subsequent fracture stabilization. 6 fractures treated with internal fixation had uneventful fracture-healing, whereas the 4 which were treated with external fixation needed later reoperations to obtain fracture-healing. We conclude that the limb must be reperfused within 6-8 hours. Vascular repair should be the first procedure, and fracture fixation by internal fixation is then preferred.

[Surgical treatment of fractures of the acetabulum]. / Operativ behandling av acetabularfrakturer.

Since January 1988, 18 patients with acetabular fractures were operated on. Seven fractures were "both columns", six were posterior wall fractures, four were of the transverse/single column types, and one was unclassified. Four patients were operated by ileo-inguinal incision alone, three by combined ileo-inguinal and posterior Kocher-Langenbeck, ten by Kocher-Langenbeck, and one by triradiate incision. Early complications were 1 DVT and 1 infection (subsided after removal of the plate from crista iliaca). One patient with brain injury developed cerebral infarction, and one multi-traumatized patient died of lung embolus after transfer to another hospital. 11 patients are back at work, one has retired, and two are seeking new education after the injury. We conclude that operative treatment is indicated for these fractures, and that the results and rate of complications are acceptable. This treatment should be centralized.

Improved external skeletal fixation for unstable fractures.

A novel external fixation device (EX-FI-RE) is described with which it is possible to manipulate fracture fragments under complete control of stability. EX-FI-RE is a unilateral, telescopic, single-frame device, consisting of two functionally separate components, the correction unit and the fixation unit. The correction unit allows reduction of angular, parallel, and longitudinal dislocations. Sustained transverse compression of an oblique fracture is a special feature. After reduction has been achieved, pin retainers and transcutaneous pins can be transferred to the fixation unit without change of position of the fracture fragments. Its mechanical behavior under load is analyzed and compared with that of a Hoffman-Vidal Adrey quadrilateral system. In axial loading, the two systems were similar within the loading range of 0-1000 N. In the anteroposterior plane, the stiffness ratio of the EX-FI-RE was significantly higher. In lateral bending and axial loading, the two systems were comparable. The turning moment required to induce a 5 degree angular deformation of the quadrilateral system was 4.8 +/- 0.6 Nm; the corresponding figure for the unilateral system was 8.8 +/- 0.4 Nm. After more than two years of clinical experience with this new device, closed atraumatic reduction, sustained transverse compression, and early weight-bearing were found to promote union. There were no pin tract infections or mechanical failures in more than 70 cases treated.

Organic acid profiles of human tissue biopsies by capillary gas chromatography-mass spectrometry.

A method is described to determine the organic acid content of tissue specimens comparable in size to those obtainable by closed biopsy. The method involves solvent extraction of tissue homogenates followed by analysis of trimethylsilyl derivatives of the organic acids by combined capillary gas chromatography-mass spectrometry. Organic acid profiles of human liver, pancreas, kidney and muscle are shown.

Application of glass capillary-column gas chromatography-mass spectrometry to the studies of human diseases.

Open-tubular glass capillary columns have been used in gas chromatography in combination with mass spectrometry (GC-MS) and computer methods to study human diseases. Patients with maple syrup urine disease excrete not only alpha-keto and alpha-hydroxy acids but also six other metabolites which hitherto have been overlooked. The GC-MS methods demonstrated that a group of patients suffering from hereditary progressive loss of hearing have an impaired metabolism of leucine, leading to the accumulation of 3-hydroxyisovaleric acid and 3-methylcrotonylglycine. GC using the capillary columns proved suitable for mapping of the carbohydrate profile of human seminal fluid and for the analyses of organic compounds accumulating in human adipose tissue. The high resolving power and long life of the glass capillary columns suggest that they will be valuable in the diagnosis and study of human disorders.

The development of a computer-assisted search for anomalous compounds (CASAC).

An automated system for the recognition of anomalies in multi-compound mixtures is described. The mixtures to be investigated are injected into a combined gas chromatograph-mass spectrometer and low resolution spectra are acquired by repetitive scanning. Using an on-line computer, all of these spectra are compared with a pre-recorded file of spectra obtained by identical analyses of a "normal" mixture. The matching procedure has been designed to allow for differences in retention times. The CASAC program calculates and plots the degree of coincidence and in this way determines whether the sample spectrum contains fewer or more fragments than the corresponding library spectrum. The system has been applied to studies on pathological urine samples.