Closed reduction of posterior hip dislocation: the Rochester method.

This paper describes a new technique of closed reduction for a dislocated normal hip or a dislocated prosthetic total hip. The Rochester method is unique in that it can usually be done by one trained medical care provider, whereas many other reduction techniques require one or more assistants. The patient is placed in the supine position and reduction is performed while the patient is sedated, although some patients may require an anesthetic. The medical care provider uses his or her non-dominant arm for pelvic counterforce, while the other arm provides longitudinal traction and rotation control. Most reductions can be done in the emergency department.

The use of staples in hand surgery.

Staples can be used in a variety of surgical procedures on the hand. They provide excellent retraction of skin flaps for which sutures would normally be placed, and their use often decreases the need for manual retraction.

Flexor tendon lacerations in zone V.

Twenty-three patients with zone V flexor tendon lacerations rehabilitated by the Kleinert protocol were studied at an average of 46 months after trauma. Hand function was subjectively normal in only eight. Of fourteen patients who were employed at the time of injury, eight returned to their original occupations. Eight others were working at other jobs, and we considered six more capable of employment. Only one had a poor functional result that precluded occupational use of the hand. Pinch/grip strengths recovered to 85%/79% of the uninvolved side. Independent flexor digitorum superficialis/flexor digitorum profundus action was present in only seven patients. Sixteen regained full digital flexion. Extension loss averaged 25% at the wrist and 10% in each digit. As assessed by static two-point discrimination, sensibility was poor after associated median and ulnar nerve transections; this did not preclude good objective functional results. Complications included two tendon ruptures, proximal interphalangeal hyperextension in the presence of an unrepaired flexor digitorum superficialis, and limited motion in two patients after poor compliance in therapy. Tenolysis was needed in 4 of the 23. We now use a modified Duran technique for noncompliant patients and in those who are unable to extend their PIP joints because of weak intrinsic muscles.

Autogeneic cancellous bone grafting following transtrochanteric hip arthroplasty. An attempt to facilitate union of the greater trochanter.

A technique involving the use of autogeneic cancellous bone to facilitate union of the greater trochanter following hip arthroplasty via a transtrochanteric approach is presented. This technique has not been previously reported for a large series of patients. Two hundred thirty-five patients were treated with 286 hip arthroplasty procedures via a transtrochanteric approach. All trochanters were advanced 1-2 cm distally and reattached using a three-wire technique. In 111 procedures, cancellous bone taken from the excised femoral head or neck was placed at the inferior aspect of the osteotomy site. In the remaining 175 procedures, no bone grafting was performed. Retrospectively, the incidences of trochanteric nonunion at two-year follow-up evaluation for the nongrafted versus the grafted groups were as follows: 5.7% (10 of 175) versus 2.7% (3 of 111) overall incidence, 4.3% (6 of 139) versus 1.2% (1 of 85) in patients with no previous hip surgery, 8.7% (2 of 23) versus 0% (0 of 10) in patients with previous hip surgery (excluding previous hip arthroplasty), and 15.4% (2 of 13) versus 12.5% (2 of 16) in patients following revision arthroplasty. There was no significant difference in incidence of nonunion between the grafted versus nongrafted groups in any of these categories (chi-square analysis). However, a lower incidence of trochanteric nonunion was found for the patients with autografts in each category, which may indicate a beneficial effect of cancellous bone grafting following trochanteric osteotomy.

Hip flexion deformity secondary to acute pyogenic psoas abscess.

The data from ten patients who underwent incision and drainage of an acute pyogenic abscess were studied with respect to the presence of an associated hip flexion deformity prior to incision and drainage of the abscess, bacteria cultured intraoperatively, treatment of any persistent hip flexion deformity postoperatively, and any additional sequelae noted at an average follow-up of seven years (range, one to 17 years). Six of the ten patients presented with an associated hip flexion deformity. In three patients, the deformity had resolved spontaneously and completely--in one by the third postoperative day and in two by the 45th postoperative day. Follow-up of these patients at up to 17 years revealed no residual flexion deformity. The flexion deformity in two of the six patients improved following incision and drainage, but residual flexion deformities of 10 degrees and 15 degrees were noted at three- and six-year follow-up, respectively. The sixth patient was treated with skin traction both preoperatively and postoperatively, but it was ineffective in totally correcting the deformity. Follow-up of this patient at one year revealed a residual 15 degrees hip flexion deformity. All six patients had normal ambulation at follow-up examination. Bacteria cultured intraoperatively did not appear to affect either the initial development of the flexion deformity or the time to resolution following incision and drainage of the abscess. Of 183 patients with an acute pyogenic psoas abscess reviewed in 14 series from the literature, 96% (176/183) presented with an associated hip flexion deformity. A hip flexion deformity in a patient with fever and pain on attempted extension of the thigh is therefore a reliable sign for the diagnosis of an acute pyogenic psoas abscess. Treatment may be indicated for a persistent deformity following incision and drainage. Skin traction is the most commonly used and successful method of treatment. Persistence of the hip flexion deformity postoperatively may be secondary to fibrosis within the psoas sheath or actual substance of the muscle, or both. A mild residual flexion deformity may be present years after incision and drainage but apparently will cause no functional abnormality.

The juvenile fracture of Tillaux.

The juvenile fracture of Tillaux is an ankle joint avulsion fracture of the anterior distal tibial tubercle in adolescents, produced by external rotation force applied to the foot. Data from five patients with the juvenile fracture of Tillaux were reviewed. In four of the patients, an initial closed reduction was unsuccessful and had to be followed by open reduction and internal fixation of the displaced fragment. The fifth patient's treatment was nonoperative. All patients had an excellent functional and radiographic result at follow-up evaluation one to nine years after the injury. Results were compared with data from five major series of patients who had sustained this fracture. Nonoperative treatment was indicated for the undisplaced fractures but may give less than optimal results in initially displaced fractures. In cases where there was displacement of the fragment after closed reduction, open reduction and internal fixation of the displaced fracture gave excellent functional result.

Intraarticular corticosteroids in treatment of osteoarthritis.

The history of the use of intraarticular corticosteroids in the treatment of osteoarthritis and the various available corticosteroid preparations, their possible mechanism of action, side effects, and results of treatment are presented. The longest-lasting effects in the alleviation of joint symptomatology are produced by the tertiary-butyl acetate esters of the various corticosteroid preparations. The effect produced by triamcinolone appears to be of the longest duration. The anti-inflammatory action of corticosteroids seems to be responsible for the alleviation of joint symptomatology in osteoarthritis. Significant adverse effects, such as steroid arthropathy and tendon rupture, may result from excessive intraarticular use. Infection is an uncommon complication when adequate skin preparation is performed. The major disadvantage of intraarticular corticosteroids is their short duration of action, averaging two to three weeks. However, a small percentage of patients with osteoarthritis may sustain prolonged relief from one or two injections. Acute self-limited disorders, such as trigger finger and inflamed bursae, seem to lend themselves best to this form of therapy.