A multicenter, prospective study was conducted to assess the efficacy of an unreamed, double-locked tibial nail for the acute management of open and/or unstable tibial fractures. Seventy-seven acute unstable and/or open tibial fractures in 74 patients were treated from December 1986 to February 1989. Forty fractures were closed and 37 were open; 25% occurred in polytraumatized patients and 39% of the patients had additional fractures. All closed tibial fractures healed at an average of 14.2 weeks; 94.6% of the open tibial fractures healed at an average of 20.1 weeks. There were no infections in the closed tibial fracture group. There were 4 infections among the 37 patients (11%) in the open tibial fracture group, 2 superficial and 2 deep. There were 7 problems intraoperatively (8.4%) with fin deployment: 2 fins bent during nail insertion, 4 fins penetrated the cortex, while 1 set of fins only partially deployed. Difficulty was encountered with proximal screw insertion in one third of the cases. Considering the high energy of these injuries, the treatment of open and/or unstable tibial fractures with an unreamed, double-locked tibial nail can offer the surgeon a high rate of union (97%) with minimal complications. The low infection rate found in this series indicates that this nail may be of particular benefit in the treatment of closed and select open tibial fractures.
To detect the incidence of preoperative and postoperative deep vein thrombosis (DVT) in elderly patients with hip fracture, 100 patients aged 65 years and older with either a subcapital or intertrochanteric hip fracture were evaluated by duplex beta-mode ultrasonography. Treatment was based on each scan result: if evidence for DVT was seen, the patient was therapeutically anticoagulated; lacking signs of DVT, patients were treated prophylactically. Before their operation, 77 patients (77%) had normal results of their scans, while DVT was diagnosed in 12 patients (12%). An additional 11 patients (11%) developed DVT after the operation. The total incidence of DVT in this series was 23%.
Orthopaedic surgeons may be confronted with a variety of medical problems that demand recognition and treatment. These may range in severity from a mild case of rheumatoid arthritis to a life-threatening pulmonary embolism. Rhabdomyolysis is a serious problem that must be recognized early to avoid grave renal consequences. This disorder is characterized by significant muscle injury giving rise to nephrotoxic breakdown products in the bloodstream. As many as 33% of these patients will suffer acute renal failure. Many orthopaedic patients may be at high risk for rhabdomyolysis, and the orthopaedic surgeon should be familiar with its diagnosis and treatment.
Despite the crucial nature of a biopsy for the diagnosis and treatment of a musculoskeletal tumor, the basic tenets of biopsy technique are frequently not respected. Unfortunately, catastrophic errors in biopsy technique occur frequently. Examples of the more common errors and the correct surgical techniques are discussed.
A technique is described whereby a small island of bone at the posterior midline of the tibia is preserved during total knee replacement to protect the insertion of the posterior cruciate ligament.
As the success rate for repair of hip fractures continues to increase, emphasis is shifting to outcomes beyond the simple fracture repair to include restoration of function. The orthopaedist's role is critical in understanding, assessing, and determining patient prognosis with respect to functional outcome. Multiple factors are predictive of outcome following hip fracture; these factors may facilitate the orthopaedist's decision making in providing care that will maximize restoration relative to a patient's premorbid ability to walk and live independently. This review of past research summarizes our current knowledge of hip-fracture outcomes and prognostic indicators.
One hundred consecutive patients with full-thickness tears of the rotator cuff were prospectively evaluated by glenohumeral arthroscopy to determine the incidence of associated intra-articular lesions. Seventy-four of the 100 patients had coexisting intra-articular abnormalities.
The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopaedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on the first two pages. The final clinical and roentgenographic differential diagnoses are presented on the following pages.
Penetrating wounds, stings, and inoculation of venom are common marine injuries to unwary walkers during the summer season. In many circumstances, foreign bodies such as wood splinters or small shards of glass can be removed readily with fine-pointed forceps. Other times, objects may not be noticed until radiographic examination of the injured area. With deeply penetrated foreign bodies, attempts at removal must often be weighed against the likelihood of continued symptoms and damage should the object be left in the foot. This review presents methods of prevention and treatment for common sources of marine foot injuries.
This paper reviews the treatment alternatives for acute and chronic lateral ankle ligament sprains. Inadequately treated ankle sprains can result in chronic lateral ankle instability, disabling pain, and the early onset of osteoarthritis. There are a multitude of reconstructive techniques used for chronic lateral ankle instability. Morbidity associated with present techniques includes loss of proprioception, stiffness following cast immobilization, loss of subtalar motion, loss of internal rotation of the talus during ankle plantar flexion, and recurrent instability. In addition, this paper reviews the reconstructive techniques used for chronic lateral ankle instability, addresses the shortcomings of current reconstructive techniques, and proposes alternatives that may help decrease associated morbidity.
The case of an adolescent Olympic-level gymnast with insidious onset shoulder pain is presented. Radiographic evaluation revealed bilateral physeal irregularities of the proximal humerus similar to those seen in Little Leaguer's shoulder. Roentgenograms of the involved shoulder also demonstrated Salter-Harris type I displacement at this physis and a slipped capital humeral epiphysis was diagnosed. A discussion reviewing proximal humeral physeal injury follows the case presentation.
Tibial stress fractures are common in an athletic population. The patient is usually an athlete who is involved in highly repetitive impact activities that have increased in intensity, and who develops pain over the anterior tibia that is felt with exercise and relieved by rest. Physical examination usually reveals focal bony tenderness. Plain roentgenograms initially tend to be normal, and bone scan is the gold standard for diagnosis. Most tibial stress fractures are transverse or oblique. The authors present the first reported case of an activity-related longitudinal stress fracture of the distal tibia in a previously healthy, premenopausal woman. A discussion of this unusual presentation, its radiographic appearance, and its response to treatment is presented.
Acute pyogenic osteomyelitis in children continues to be a problem in orthopaedics. The causes of acute hematogenous osteomyelitis are not adequately known, but the histologic progression of the disease has been described. Early diagnosis with culture of an aspiration specimen is of paramount importance. Treatment with antibiotic agents is often successful unless pus is obtained on aspiration. In patients with an established abscess, surgical drainage is often required in addition to antibiotic therapy. Oral antibiotics appear to be as effective as parenteral antibiotics, provided adequate serum bactericidal titers can be demonstrated. Staphylococcus aureus is the most common causative organism, although other organisms are often found in special circumstances, such as in neonates, patients with sickle-cell disease, and those with puncture wounds of the foot.
An understanding of the anatomy and biomechanics of the lateral ankle ligaments is essential to make a proper diagnosis in patients with ankle sprains. Specific radiographic stress tests can aid in differentiating single-versus double-ligament injuries and in determining their severity. Inadequately treated ankle sprains can result in chronic pain, instability, and early osteoarthritis. Thus, the proper diagnosis and initial treatment are important. This paper reviews the essential features of the anatomy, biomechanics, diagnosis, and natural history of lateral ankle sprains.
The open reduction and internal fixation of complex acetabular fractures generally require some amount of sustained intraoperative traction. This traction can be provided by either specialized traction tables or scrubbed assistants. Both methods have their advantages and disadvantages. Specialized traction tables provide excellent controlled traction but are costly. Interested assistants are less costly, but at many institutions an adequate number of them are unavailable. We describe the design, construction, and use of a simple intraoperative traction device to aid in the open reduction and internal fixation of acetabular fractures.
Treatment of atraumatic osteonecrosis of the femoral head is presently based not on disease prevention, but instead on the end-stage changes of bone associated with the necrotic lesion. Current diagnostic modalities are limited, by both cost and efficacy, in their ability to diagnose early-stage osteonecrosis. While many studies have assumed the cause of osteonecrosis is vascular occlusion, recent work suggests that alternate processes are primarily involved in the pathogenesis. By examining these concepts, a better understanding of osteonecrosis of the femoral head may lead to earlier diagnostic modalities and treatment protocols to prevent this devastating process from developing.
