Bilateral fracture of the tibial shaft with intact fibulae.

We report the case history, treatment, and follow-up of a 16-year-old girl who sustained symmetrical fractures of the right and left tibia without fractures of the fibulae. Although a fracture of the tibia with an intact fibula is not an uncommon fracture pattern, a bilateral fracture of this type is quite rare, and we have been unable to find such a reported case in our review of the literature. The management of a fracture of the tibia with an intact fibula is controversial, with potential complications of delayed union and varus malunion. For this reason, as well as the bilateral nature of the injury, we felt operative treatment to be indicated.

Cochlear gene delivery through an intact round window membrane in mouse.

Cochlear gene transfer studies in animal models have utilized mainly two delivery methods: direct injection through the round window membrane (RWM) or intracochlear infusion through a cochleostomy. However, the surgical trauma, inflammation, and hearing loss associated with these methods lead us to investigate a less invasive delivery method. Herein, we studied the feasibility of a vector transgene-soaked gelatin sponge, Gelfoam, for transgene delivery into the mouse cochlea through an intact RWM. The Gelfoam absorbed with liposomes and adenovirus, but not with adeno-associated virus (AAV), was successful in mediating transgene expression across an intact RWM in a variety of cochlear tissues. The Gelfoam technique proved to be an easy, atraumatic, and effective, but vector-dependent, method of delivering transgenes through an intact RWM. Compared with the more invasive gene delivery methods, this technique represents a safer and a more clinically viable route of cochlear gene delivery in humans.

Patellofemoral resurfacing at total knee arthroplasty.

A retrospective review of 268 primary total knee arthroplasties (TKAs) with a mean follow-up of four years is presented. The patellae were resurfaced in all cases. There were six complications (2.2%) referable to the patellofemoral articulation: three subluxations, one patellar fracture, one loosening of a metal-backed patellar component, and one patellar tendon avulsion. Successful patellofemoral resurfacing (PFR) can be accomplished with minimal complications if the following technical considerations are met: 5-7 degrees of valgus alignment; medial placement of the patellar component; taking care not to increase either the AP diameter of the knee or the thickness of the patella; avoiding internal rotation of either the tibial or femoral components and proper soft tissue balancing. A thorough review of patellofemoral complications after TKA is presented, and technical considerations relevant to the successful performance of PFR are discussed.

Heterotopic ossification following primary total knee arthroplasty.

Heterotopic ossification is a rare complication following primary total knee arthroplasty and may be symptomatic if massive enough. The authors retrospectively reviewed 158 primary total knee arthroplasties from 1985 to 1989 and found 6 cases (3.8%) of heterotopic ossification. Patients were graded before and after surgery according to the Hospital for Special Surgery total knee arthroplasty score and their histories were reviewed for the presence of recognized risk factors for heterotopic ossification and whether a manipulation under anesthesia was performed. This report describes the incidence of, appearance of, and clinical risk factors for heterotopic ossification following primary total knee arthroplasty in this series. A radiographic grading system is proposed.

Works in progress #7. Clinical experience with the Accu-Path threaded acetabular cup. A preliminary report.

Clinical experience with the Accu-Path threaded titanium hemispheric cup is presented. A series of 62 cases was followed for an average of 28.1 months (range, 6 to 48). Primary surgery was performed in 50 cases and revision surgery in 12. The surgical technique is described in detail. Preoperative Harris scores improved from 28 to 93 in primary cases and from 24 to 84 in revision cases. Complications included 3.2% dislocation, 3.2% loss of cup position, and 1.6% recurrent subluxation. The overall reoperation rate was 8% (8% in primary surgery and 8.3% in revision surgery). Roentgenographic analysis is discussed. The importance of preservation of the subchondral plate and a rim fit in the use of this implant is stressed. It is not indicated in those with loss of the plate due either to prior surgery (as in revision) or in aggressive over-reaming in primary cases. Although the overall results were encouraging, caution was recommended--especially in revision surgery or in the patient with severe osteopenia.

Management of ipsilateral femoral shaft fractures following hip arthroplasty.

Femoral shaft fractures following hip arthroplasty can be difficult to manage, particularly in elderly patients. Nine patients were treated with open reduction and rigid internal fixation using cement augmentation for screw fixation in the distal shaft. The stability achieved allowed all patients to be mobilized in the immediate postoperative period. No incidences of reduction loss or implant failure occurred, and all fractures had healed by the time of review. The results obtained support this method of treatment for ipsilateral femoral shaft fractures when prosthetic stability has not been compromised.

Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly.

The results of primary Bateman-Leinbach bipolar prosthetic replacement for comminuted intertrochanteric fractures of the hip in the elderly are examined. In an effort to avoid the postoperative complications seen in open reduction and internal fixation of severely comminuted fractures with osteoporotic bone, and to avoid postoperative restrictions when fixation is suboptimal, a group of 58 patients were treated with a bipolar Bateman-Leinbach prosthesis. They were followed for an average of 28 months. Surgery was performed using an anterolateral approach, which is recommended. A detailed description of the surgical approach and operative technique are provided. Eighty-eight percent of patients were able to ambulate within the first week, weight bearing as tolerated with no postoperative restrictions, except for a simple abduction pillow for 2 weeks while in bed. Ninety-one percent of patients ambulated prior to discharge. Morbidity and mortality was no greater in this group than in groups treated by open reduction and internal fixation for these types of fractures. Complications were few. Primary Bateman-Leinbach bipolar prosthetic replacement is recommended as the preferred treatment of selected unstable comminuted intertrochanteric fractures in the elderly.

Infected uncemented hip arthroplasty. Preserving the femoral stem with a two-stage revision procedure.

Revision of an infected uncemented hip arthroplasty can be significantly complicated by the presence of extensive bony ingrowth. Although removal of the prosthesis is desirable, technical difficulties in extracting a well anchored prosthesis can be extreme. Femoral windowing or splitting may be necessary. In these cases, treatment alternatives that avoid destruction of the femoral cortex are desirable. A 47-year-old man presented with a deep infection of a virtually fully coated porous implant two years postoperatively. Radiographs revealed extensive bony ingrowth and an arthrogram revealed no dye tracking down the femoral canal. The infecting organism was Staphylococcus epidermis. In order to avoid the possible complications of extraction of this fully coated stem, treatment was carried out initially with removal of the bipolar head, joint debridement, and placement of antibiotic impregnated beads. After seven weeks of intravenous antibiotic therapy with the patient in tibial pin traction, a revision was undertaken and the acetabulum was revised with a threaded uncemented acetabular component. The patient recovered and at 18 month follow-up is without evidence of infection and back to full function. Revision with a two-stage femoral stem preserving procedure is presented as an alternative in the management of infected uncemented hip arthroplasty.

The pathology and treatment of metastatic disease of the femur.

Two hundred eighty-three pathologic fractures and 23 impending fractures of the hip and femur were analyzed and compared after surgical treatment. One hundred ninety-six fractures were treated by internal fixation or prosthetic replacement and the adjunctive use of methylmethacrylate, and 110 were treated by surgery without the use of methylmethacrylate. Pain relief, ambulatory activities and survival rates were all enhanced in the methylmethacrylate group. The six failures of fixation in the nonacrylic group might have been prevented by the use of bone cement. Breast carcinoma was the most common metastasis, comprising 56% of the series. Kidney metastases, when treated aggressively, showed many long-term survivors. Lung metastases gave the worst prognoses. The overall series survival rates were 59% at six months and 48% at 12 months. The incidence of complications including infection were not related to the use of methylmethacrylate or preoperative radiation. Although many authors have reported the advantages of methylmethacrylate in stabilization of pathological fractures, none have compared the results by analyzing pain relief, ambulatory ability and survival times in those treated with and without bone cement. This study appears to clearly indicate that methylmethacrylate enhances the stability of the pathological fracture and contributes to achieving the goals of treatment in these severely compromised patients.

Subcutaneous lateral retinacular release for chondromalacia patellae: a preliminary report.

When chondromalacia patellae is caused by lateral capsular and retinacular tightness, subcutaneous lateral release affords relief of pain. The operation, performed at the time of arthroscopy, causes minimal morbidity, and it is advantageous when cosmetics are of concern. Range-of-motion exercises are begun on the second postoperative day to keep the retinaculum open. In the postoperative examination of 25 knees at 24 to 45 months in 15 patients, there were 20 excellent and five good results; none was made worse. There were two postoperative hemarthroses. The procedure is most effective in the carefully selected patient with demonstrable tightness of the lateral capsule and retinaculum. Abnormal attachments of the iliotibial band and synovial plicae are also significant in the etiology of this syndrome.

Spontaneous and simultaneous rupture of both quadriceps tendons.

The seventh case known to be reported in the literature on simultaneous rupture of both quadriceps tendons occurred in a 60-year-old man with diabetes mellitus. The patient was treated by surgical repair of both tendon ruptures with a satisfactory return of function. Diabetes mellitus may be a predisposing condition for the bilateral rupture, but does not prevent either the tendon or wound from healing.