Fixation of femoral shaft fractures with a flexible bundle-type nail.

In a prospective study, 31 consecutive patients with a femoral shaft fracture were treated with the Marchetti-Vicenzi intramedullary flexible bundle-type nail. Open reduction of the fracture was necessary in 25 of the 31 patients (81%). Twenty-five of the 31 fractures (81%) united within 2.5 to 6 months after the operation (mean, 4.2 months). Nonunion occurred in one patient (3.2%). Other complications included delayed union in five patients (16%), femoral shortening in five (16%), breakage of the distal pins in two (6.5%), and severe varus malunion in two patients (6.5%). Because of the high complication rate in this series, the authors no longer use the Marchetti-Vicenzi flexible nail for treatment of femoral shaft fractures.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device.

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

Surgical treatment of 35 volar Barton fractures. No need for routine decompression of the median nerve.

35 patients with volar Barton fractures were treated operatively from 1985-1994. The injury was due to a high velocity motor vehicle accident in 20 patients. All fractures were closed without major carpal injuries. 11 fractures were type B3.1, 21 type B3.2 and 3 type B3.3. according to the AO classification. All fractures were openly reduced and internally fixated by small buttress plates and screws. In 31 cases, the median nerve was unaffected by the injury and was not explored or decompressed during surgery. The patients were assessed clinically and radiographically after mean 6 (2-10) years. According to the criteria of Pattee and Thompson (1988), 23 patients had excellent results, 10 good and 2 fair. Posttraumatic arthrosis was found in 12 patients and was related to the congruency of the articular surface achieved at surgery. We conclude that the median nerve, when not damaged or compressed, should not be explored or decompressed during surgery.

Results of surgical treatment of tibial plafond fractures.

To clarify which factors influence the final result of surgical management of plafond or pilon fractures, 66 patients with 67 pilon fractures treated at the Orthopaedic Department of the University of Athens between 1978 and 1993 were reviewed. There were eight (11.95%) Type I, 33 (49.25%) Type II, and 26 (38.8%) Type III fractures according to the Ruedi-Allgower classification. Eleven (16.4%) were open injuries. Fifty of the 67 fractures were treated by internal fixation following the AO principles, whereas minimal osteosynthesis was performed in nine cases, and the remaining eight cases were managed by external fixation. The final outcome of the treatment was evaluated after 2 to 17 years followup (mean, 8.1 years) and was based on the subjective, objective, and radiographic results of each case, using the method of Burwell and Charnley. The findings indicate that three parameters significantly influenced the outcome of plafond fracture management. Specifically, the results of surgical management were affected by the clinical type of the fracture, the quality of reduction achieved at surgery, and the specific surgical procedure by which the fracture was managed.

Early detection of progression in adolescent idiopathic scoliosis by measurement of changes in back shape with the Integrated Shape Imaging System scanner.

STUDY DESIGN: A retrospective study of 78 patients with right thoracic idiopathic scoliosis was done. OBJECTIVES: To evaluate the reliability of the integrated Shape Imaging System scan (Oxford Metrics Ltd, Oxford, UK) in detecting progression of scoliosis and the use of back shape data in predicting scoliosis progression. SUMMARY OF BACKGROUND DATA: At first presentation and every 3-6 months during the follow-up period, all patients underwent integrated Shape Imaging System scans and radiographic examinations, from which the Cobb angle was measured. The follow-up period was 18-49 months (mean = 31.4 months). METHODS: Patients were divided into three groups according to the severity and progression of the Cobb angle. The spinal fusion, brace, and observation groups were compared using analysis of variance and the student's t test to detect significant differences among groups in the progression of deformity as measured by the integrated Shape Imaging System parameters and the Cobb angle. RESULTS: Three of the Integrated Shape Imaging System parameters detected significant progression in the spinal fusion group 1 year earlier than the Cobb angle. Only one of the Integrated Shape Imaging System parameters detected a significant difference in progression between the brace and observation groups. CONCLUSIONS: The Integrated Shape Imaging System technique demonstrated significant changes in this group of patients with progressive scoliosis. Serial measurements of back surface shape, particularly the size of the rib hump, may be predictive of progression. Serial Integrated Shape Imaging System scanning has advantages over serial radiography in the management of idiopathic scoliosis in addition to the avoidance of exposure to ionizing radiation.

Operative treatment of type C intra-articular fractures of the distal humerus: the role of stability achieved at surgery on final outcome.

We report the results of 75 patients with type C intra-articular fracture of the distal humerus treated operatively by two methods and followed up for a mean period of 48.2 months. Minimal osteosynthesis and joint immobilization was used in 21 cases while the remaining 54 patients were treated according to AO recommendations. Good or excellent results were found in 38 per cent after minimal osteosynthesis and in 77.8 per cent following the AO technique. 87.8 per cent of the cases with stable osteosynthesis and early mobilization had a good or excellent result as compared with 41.2 per cent of the cases after unstable fixation and immobilization of the joint (P < 0.01). The type of fracture was found to be an important factor in achieving stable fixation (P < 0.01).

Closed interlocked nailing in comminuted and segmental femoral shaft fractures.

One hundred eight femoral shaft fractures in one hundred six adults were treated by closed intramedullary interlocked nailing. Ninety-two fractures were severely comminuted and 16 fractures were segmental. The procedures were done with the patients in the supine position. A modification of the cylinder guide for fixation of the distal screws is described. All the fractures healed in an average of 18 weeks (range, 12-24 weeks). Dynamization was performed in 15 fractures. There were two postoperative complications, which did not ultimately affect the clinical results. No infections or delayed unions were observed. Closed intramedullary interlocked nailing seems to be the treatment of choice for comminuted and segmental fractures of the femoral shaft provided that all the technical details are followed by the surgeon.

Surgical treatment of acetabular posterior wall fractures.

This is an analysis of 52 fractures of the posterior wall of the acetabulum treated operatively and reviewed 2-15 years after injury. In 48 cases the fracture was associated with posterior dislocation of the hip, which was treated by closed reduction soon after the injury. In all but two of the cases there was a displaced single or comminuted fragment resulting in a large defect in the posterior acetabular wall; they were treated by open reduction and internal fixation to restore joint congruity and stability. In the remaining two cases, the fragment was small but trapped in the joint and was excised. A strict correlation was found between accurate reduction of the fracture and the clinical and radiological results, which were excellent or very good in 85 per cent and 87.5 per cent of the patients, respectively. Surgical and late complications were peroneal palsy in four patients, ectopic ossification restricting hip movement in two cases, aseptic necrosis in three, and osteoarthritis in another three cases.

Ipsilateral fractures of the femur and tibia.

From October 1987 to September 1990, 32 patients with ipsilateral fractures of the femur and the tibia were treated. There were 20 men and 12 women with a mean age of 27 years (range 18-75 years). All were caused by road accidents. There were 7 femoral and 22 tibial open fractures. The management of the fractures was partially the same. The tibial fractures were reduced and stabilized by a unilateral external fixator, while in 29 out of 32 femoral fractures, a closed intramedullary nailing was performed. The remaining three patients with an open grade III fracture were initially treated by external fixation, with two of them converted into nailing. The time of hospitalization ranged from 12 to 105 days (mean 30 days). The femoral fractures healed in an average of 15.5 weeks, while the tibial fractures healed in 18.5 weeks. The evaluation of our results was made according to Karlstrom and Olerud's criteria. We achieved 81 per cent excellent or good results and 19 per cent acceptable or poor, in a follow-up time of 19.5 months.

Surgical treatment of central acetabular fractures.

Surgical treatment is indicated in most displaced acetabular fractures in young adults. The fractures are generally intraarticular and almost invariably involve the weight-bearing area of the acetabulum. Complete or near anatomic reduction is essential for an excellent and long-standing recovery of the hip joint, and this is extremely difficult to accomplish by conservative management. Fifty-eight displaced central acetabular fractures treated surgically were followed from one to 12 years. They were evaluated by anteroposterior and oblique roentgenograms and classified according to the Judet-Letournel system. Although surgical treatment was somewhat delayed and the experience in approaching and dealing with these fractures was limited in many of the early cases, excellent or satisfactory reduction to a less than 3-mm displacement at the articular surface was achieved in 81% of cases. A close agreement was found between the quality of surgical reduction and clinical results as well as between roentgenographic and clinical results at the final follow-up examination, which were satisfactory in 72% and 74%, respectively. The surgical complications were infection in 2% of cases, peroneal nerve palsy in 8.5%, and moderate to severe ectopic ossification in 10% of the patients.

Effect of hip dislocation on the blood supply to the femoral head. An experimental study in rabbits.

This work consists of a series of experiments which were made in order: a) to examine the possible alterations of blood flow to the reduced femoral heads of rabbits, after inducing a closed dislocation of their hips and b) to determine the influence of the early or late reduction of the dislocated femoral heads on their blood flow. The estimations of blood flow to the normal and reduced femoral heads were made using radioactive microspheres. The findings are as follows: a) The blood flow of the femoral heads of the reduced hips was never interrupted completely. b) The initially decreased femoral head blood flow progressively increased, in association to the time elapsed from the reduction. c) No statistically significant difference was found in the femoral head blood flow between hips reduced in early and those reduced late. d) Pure traumatic dislocation of the hip can only rarely be the cause of aseptic necrosis of the femoral head.

Double or multiple level fractures of the spine.

Over a period of 5 years, 231 patients with nonpathological fractures of the spine were admitted to the Orthopaedic Department of Athens University. Eighteen (7.79 per cent) were found to have double or multiple level fractures of the spine which means that these injuries are not so uncommon. We define double level fracture as those which are separated by an intact spinal unit, not related at least at one end to a fractured vertebra. These fractures, if overlooked, may cause serious complications.

Bone lesions in pigmented villonodular synovitis.

Seven cases of pigmented villonodular synovitis with invasion of the bone are described, four affecting the hip and the remaining three involving the knee, shoulder and ankle joint, respectively. The pathogenesis of the bone changes and the radiographical appearance of the involved joints are described. The methods of treatment are discussed.

Avulsion of the triceps tendon.

Two cases of the rare injury of avulsion of the triceps tendon are presented. The difficulties in clinical diagnosis and proper evaluation of the roentgenographic findings whenever present are discussed and the treatment is outlined.