Salvage of Lisfranc's tarsometatarsal joint by arthrodesis.

Sixteen patients with fractures or fracture-dislocations of the tarsometatarsal (Lisfranc) joint who failed initial treatment were salvaged by arthrodesis using a technique of rigid internal fixation. Preoperative symptoms included local pain in all patients, progressive flatfoot deformity with forefoot abduction in 12 patients, and ankle or lateral impingement pain in five. The technique involved exposing the joint, denuding it of cartilage and scar, and reduction and fixation with lag screws. A total of 49 joints were fused. When significant deformity was present, reduction was performed before arthrodesis. Clinically symptomatic and radiographically proven nonunion occurred in four sites in three patients. One healed after revision. Good to excellent results were obtained in 11 patients (69%). Five patients had a fair or poor results. All but one of the patients were subjectively improved. Four patients were symptom free and returned to their preinjury lifestyles. Accurate reduction and early treatment had a significant positive relationship with outcome. Injuries that occurred in the workplace and those that incurred a long delay until treatment showed a significant negative correlation to outcome. Neither the age of the patient nor the number of joints fused had a significant impact on result.

Fractures and fracture-dislocations of the tarsometatarsal joint.

We are reporting the results in a consecutive series of forty adults in whom, between 1978 and 1984, forty-one tarsometatarsal fracture-dislocations were treated with open reduction followed by temporary internal fixation with AO screws. Ninety per cent of the patients had an intra-articular or a periarticular fracture. An anatomical or nearly anatomical reduction was achieved in all but a few patients, and there was no loss of fixation or displacement. For thirty-four patients (thirty-five injuries), the length of follow-up averaged 3.4 years, and a good or excellent functional result was obtained in all but two of the thirty in whom an anatomical reduction had been achieved. Of the six patients who had a fair or a poor result, five had an associated grade-II or grade-III open injury. The development of post-traumatic arthritis was directly related to damage to the articular surfaces or to inadequate reduction, or to both.

Treatment of unstable femoral shaft fractures with closed interlocking intramedullary nailing.

From 1979 to 1982, 64 femoral shaft fractures in 62 patients were treated by closed interlocking nailing at Harborview Medical Center, Seattle, WA, U.S.A., and Parkland Memorial Hospital, Dallas, TX, U.S.A. Twenty-nine patients sustained multiple system injuries and 29 of the involved extremities (45%) had at least one additional injury. There were 17 (26%) open fractures. Static mode nailing was used to treat 52 fractures; dynamic mode nailing was performed for 12 fractures. Patient follow-up averaged 17 months (range 7-41 months). The average time to union was 13.5 weeks. Normal femoral length within 1 cm was achieved in 97% of cases. Knee range of motion averaged 127 degrees. Complications (9%) included two delayed unions, one nonunion, two cases of shortening or lengthening of more than 1 cm, and one case of malunion with angulation or more than 10 degrees. The delayed unions and nonunions healed after one additional procedure. This study shows that closed interlocking nailing is a safe, effective technique that provides stable fixation in most unstable femoral shaft fractures. This technique represents a major advance in the treatment of difficult femoral shaft fractures that would be poorly suited for standard closed nailing.

Adolescent bunions treated by the modified Lapidus procedure.

The modified Lapidus procedure with rigid internal fixation was used to correct adolescent bunion deformities in 20 patients (32 feet). All patients were female and skeletally mature at surgery. Their average age was 18 years. Preoperatively, 100% had bunion pain and trouble with shoe wear, and 93% had a hypermobile first ray. Sixteen patients (24 feet) were available for follow-up examination and radiographs. The average follow-up time for the entire group was 24.3 months (range 3-72 months). Excellent or good results were obtained in 91% of patients. One recurrence required reoperation with first metatarsal osteotomy and MTP joint debridement. In our experience, the modified Lapidus procedure is the procedure of choice for the adolescent bunion with a hypermobile first ray.

Treatment of failures after plating of tibial fractures.

Eighteen patients with tibial fractures treated by plating that had failed were treated by intramedullary nailing. Nine patients had a broken plate or screw that had pulled out. In seven, the plate and screws were intact but no healing was evident, and in two patients the plate was intact but one or more screws were broken. The plate and screws were removed from all patients and immediate limited open intramedullary nailing was done with a Küntscher nail after the bone was reamed. In one patient the method failed, while in fifteen patients the fracture united and in the two remaining patients who could not be contacted union was thought to be in process when they were last seen, five and ten months postoperatively. Two bone grafts were used in one patient. Six fibular osteotomies were performed in conjunction with the intramedullary nailing.

Ipsilateral fractures of the femur and tibia. A report of fifty-seven consecutive cases.

We treated fifty-seven consecutive ipsilateral fractures of the femur and tibia in fifty-four adults from 1968 through 1978. Twenty-one patients had concomitant life-threatening injuries, and in thirty-three extremities the fractures were open. All but one of the femoral fractures and about half of the tibial fractures were internally fixed. The length of hospitalization averaged five weeks. Local complications included one below-the-knee amputation, three deep infections, and four ununited fractures. A fat embolism syndrome was diagnosed in 13 per cent of the patients. At the last follow-up examination, at an average of 40.5 months after injury, the mean range of motion of the knee was 129 degrees. Over-all, a good or excellent functional result was achieved in about 80 per cent of the patients. The best results were achieved when both fractures were stabilized surgically.

Compartmental syndromes in children.

Compartmental syndromes are reported in 24 children after injuries and surgery. In these cases, increased tissue pressure compromised local perfusion and neuromuscular function. Compartmental syndromes occurred in the interosseous compartments of the hand, the volar and dorsal compartments of the forearm, and the four compartments of the leg. The most common etiologies were fracture, vascular injury, and tibial osteotomy. In many instances, clinical data were sufficient to establish the diagnosis. However, in young patients or in patients with neurologic or vascular injuries, tissue pressure measurement helped to resolve otherwise ambiguous findings. The most significant determinant of the quality of the end result was the duration of the compartmental syndrome prior to surgical decompression. We conclude that prompt diagnosis and decompression of compartmental syndromes can minimize the sequela from these conditions.

Recurrent Anterior Compartmental Syndromes.

Vigorous exercise may raise compartmental pressure enough to compromise blood flow. Recurrent compartmental syndromes may be treated by altering the exercise program, but serious athletes require surgical decompression.