Orthopaedic review最新文献

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 indicated below. The final clinical and roentgenographic differential diagnoses are presented on the following pages.

We report the occurrence of a previously undescribed combined Monteggia and Galeazzi fracture pattern of the left forearm in an 8-year-old boy. Previous reports do not address the combined injury described in this article, which consists of a left radius shaft fracture with dislocation of the distal radioulnar joint, and a left ulna shaft fracture with anterior dislocation of the radiohumeral joint. An excellent result was obtained with closed reduction. Radiographic evaluation is crucial in these disorders for both diagnosis and for treatment decisions. A review of the literature is provided with specific emphasis toward the classifications, mechanisms of injury, diagnosis, associated injuries, and treatment.

Nonunion of the ulnar styloid is a relatively common injury that can often be ignored. In patients presenting with pain, compromised range of motion, and decreased grip strength, careful physical examination, and dynamic radiographic evaluation may document distal radioulnar joint instability. Mitek anchors provide a simple, effective means of triangular fibrocartilage complex reattachment, providing stabilization of the distal radioulnar joint.

An algorithmic approach to the treatment of Paget's disease of the spine is based on the authors' collective experience in managing 70 patients and a review of the literature. For patients with active disease, even if asymptomatic, cyclical treatment with etidronate is recommended until normalization of biochemical parameters is achieved. For patients with back pain and/or neurologic dysfunction, cyclical etidronate treatment in the blastic and mixed phase is advocated. Those who fail to respond to calcitonin in the lytic phase should be given the new generation of bisphosphonates and gallium nitrate. No antipagetic drug therapy is indicated for the sclerotic phase. Surgery for complications of Paget's disease should be preceded by intravenous therapy to minimize intraoperative bleeding. For cases of spinal stenosis with impending paraplegia, the new bisphosphonates, mithramycin (plicamycin), or gallium nitrate should be used. If conservative treatment fails, surgery should not be delayed.

A prospective study was conducted to investigate and compare the analgesic effect of morphine and bupivacaine injected intra-articularly following elective knee arthroscopy performed under general anesthesia without the use of a tourniquet. Cost-effectiveness of these agents was also evaluated. Patients in Group 1 (n = 41) received 30 cc of 0.25% bupivacaine with 1:200,000 epinephrine; while Group 2 (n = 40) received 2 mg morphine (1 mg/cc) in 28 cc normal saline (total volume 30 cc). Postoperative pain scores and the amount of supplemental analgesic agents used in a 24-hour period were recorded. Results showed that patients in Group 2 reported significantly less pain overall (P < .006) and significantly lower analgesic requirements (P < .0004) at a lower average patient cost than Group 1. We conclude that intra-articular morphine reduces postoperative pain and analgesic requirements more effectively and at a lower average patient cost than bupivacaine.

Fourteen patients with 15 open tibial fractures were examined retrospectively to compare postoperative infection rates of asymptomatic patients who tested positive or negative for the human immunodeficiency virus antibody (HIVab). All patients were treated with a standard open-fracture protocol. All of the HIVab-positive patients developed postoperative infections. There were five postoperative infections in 4 patients; 3 of the 4 patients were HIVab-positive and 2 of these patients developed chronic osteomyelitis. The only other infection, in an HIVab-negative patient with insulin-dependent diabetes, resolved without complication. All other HIVab-negative patients had no complications. The infection rate for asymptomatic HIVab-positive patients with open tibial fractures was higher than that for HIVab-negative patients in our study. These data suggest that the HIV status of patients with open tibial fractures is relevant to treatment outcome.

Fifty consecutive patients undergoing posterior lumbar fusion by a single surgeon were prospectively randomized in a study designed to evaluate the efficacy of using a pneumatic oscillating gouge to obtain posterior outer table iliac crest bone graft versus the standard method of using osteotomes and gouges. Variables analyzed included graft harvesting time, blood loss, weight of graft obtained, and graft site morbidity. Mean graft harvesting time with the pneumatic gouge was 1 minute 44 seconds (range, 1 min 5 sec to 3 min 15 sec) compared with the standard method time of 4 minutes 4 seconds (range, 2 min 15 sec to 8 min 56 sec) (P = 0.0001). Blood loss was also less, with a mean of 25.4 cc for the pneumatic gouge compared with 65.2 cc using the standard method (P = 0.0001). There were no complications with the graft site in either group. We conclude that the pneumatic gouge is a viable alternative to standard bone graft harvesting techniques. Benefits include shorter operative time and decreased blood loss without an increased morbidity.

The use of minimally invasive techniques for the treatment of articular and periarticular fractures is becoming more popular, especially when formal open reduction and internal fixation is contraindicated because of associated soft-tissue compromise and swelling. Cannulated screws are frequently effective in these situations and can be inserted by way of limited open or percutaneous techniques in many cases. Accurate fracture reduction can be attained through insertion of cannulated screws over a guide pin, resulting in provisional stability of the fracture. In most instances, such methods of fracture reduction are adjunctive and require the addition of external fixation, limited internal fixation, and cast bracing or orthotic considerations. Applications of cannulated screw fixation in specific trauma injuries are discussed as are indications, contraindications, advantages, and disadvantages of such methods.

A retrospective analysis of postoperative fracture collapse was performed using data from 142 patients with intertrochanteric hip fractures fixed anatomically with sliding screws. Of the 142 patients, 80 had unstable, three- or four-part hip fractures. Significant collapse (as defined by strict radiographic criteria relating the height of the femoral head to the greater trochanter and by Doppelt's criteria) was seen in 26 of the unstable fractures. The degree of collapse was classified as type I (minimal), type II (moderate), and type III (severe). Average follow-up was 31 months. An in-depth clinical and radiographic analysis was performed evaluating pain, limp, abductor weakness, and leg-length discrepancy. The numerical degree of both vertical and horizontal fracture collapse was also analyzed. Of the patients with moderate or severe collapse, 93% had a poor functional result, whereas all the patients with minimal collapse remained asymptomatic. Although postoperative fracture impaction of hips fixed with sliding screws may promote early healing, a high rate of union, and a low rate of hardware failure, excessive collapse is a problem that needs to be addressed.