Contemporary orthopaedics最新文献

The management of a supracondylar fracture above a total knee arthroplasty requires a cautious surgical approach. Currently, the standard method of plate/screw internal fixation of this type of fracture has yielded only fair results. A new technique of retrograde intramedullary nailing through the femoral component using the GSH supracondylar nail is described in this report. A review of four series in which more than 50 patients were treated using the GSH nail indicates a significant difference in bone grafting (10% versus 75%), delayed union (7.2% versus 50%), nonunion (1.9% versus 10%), and surgical revision (0 versus 10%) compared to plate/screw fixation of similar fractures. The findings in this review indicate that the GSH supracondylar nail provides excellent biomechanical stability in these complex fractures, resulting in minimal complications and allowing early return of the patient to functional activities.

A study was performed to validate the effectiveness of a bone demineralization process with respect to its inactivation of viruses. The viruses selected for study included human immunodeficiency virus (HIV), duck hepatitis B virus (a model for human hepatitis B), bovine viral diarrheal virus (a model for human hepatitis C), human cytomegalovirus, and human poliovirus (a model for small nonenveloped viruses, e.g., hepatitis A). This study was performed in compliance with Good Laboratory Practice regulations using validation methodology similar to that used to ensure the safety of blood derivatives and other products. Use of the bone demineralization process described in this report resulted in a reduction in infectivity of greater than one million (10(6)) for all viruses and as much as one trillion (10(12)) for the poliovirus.

Vertebral osteomyelitis, an infectious disease with vague manifestations, can be difficult to diagnose. Although vertebral osteomyelitis represents only 2-4% of bone infections, the consequences are often grave and disabling, even fatal, when untreated. A series of 23 cases is reported in which patient records were reviewed to determine the etiology and appropriateness of diagnosis and management. Information on treatment and follow-up after discharge was obtained from outpatient progress notes, records from subsequent hospital admissions, and telephone interviews of patients. Pyogenic vertebral osteomyelitis was diagnosed by positive needle or open biopsy tissue cultures, positive blood cultures in the appropriate clinical setting, or diagnostic histopathology. Staphylococcus aureus was grown from 75% (15/20) of patient cultures, Escherichia coli from 15%, and Staphylococcus epidermidis from 10%. Overall, 87% (20/23) of these patients were disease-free at follow-up. The experience with this series of patients demonstrates that early diagnosis aided by MRI ensures a high cure rate and low complication rate.

Complications in removal of the Brooker-Wills tibial nail were encountered in eight patients, and breakage of the distal fins occurred in four of these patients. Although none of the patients experienced residual effects related to removal of the tibial nail, the procedure is associated with potential risks such as infection or nonunion. Three methods of nail removal are described.

A total of 64 patients with clinical and radiographic signs of bilateral knee arthritis were evaluated based on multiple associated variables including complications, community ambulatory levels, and timing of staged knee replacement. A pain/dysfunction categorization based on initial presentation was established so that temporal progression of symptoms could be documented. Two surgical groups were represented: simultaneous bilateral total knee replacement and staged bilateral knee replacement. The findings in this study indicate that a patient with equally painful knees should undergo simultaneous bilateral total knee arthroplasty. If a patient has bilateral disease but only one knee is symptomatic, surgery should be performed on only the painful knee. If both knees are symptomatic, but one knee is much more painful than the other, the choice of treatment must be individualized based on the patient's medical health, symptoms, type of fixation used, and Charnley activity classification.

Practice parameters or clinical policies and the future practice of medicine are covered in a series of three articles. In Part I, the term practice parameters is defined, and the background of practice parameters at the federal, AMA, and specialty society level is discussed. In Part II, the development, application, dissemination, and monitoring of practice parameters, including the clinical usage and impact, will be discussed. In Part III, the advantages, disadvantages, and legal implications of practice parameters will be reviewed.

A clinical study of the effects of nonischemic arterial injuries to the leg on tibial fracture healing is presented. In addition, the literature published during the past 100 years describing the vascular supply to the tibia is reviewed, and the San Francisco General Hospital treatment protocol for difficult open tibial fractures is outlined. Based on the finding that the delayed and nonunion rate is three times higher when one of the three arteries of the leg is disrupted, a modification of the Gustilo fracture classification is proposed.

Varus tension testing was performed on 26 matched pairs of tibias after high tibial osteotomy with three different fixation techniques--Coventry stepped staple, Mansat staple blade, and modified tension-band. Biomechanical testing revealed that in group I the Coventry stepped staple and Mansat staple blade yielded similar force at failure values of 132.44 +/- 29.29 and 137.34 +/- 40.84, respectively. In group II, the varus force at failure value was 170.45 +/- 83.95 for the modified tension band device versus 115.27 +/- 67.21 for the Coventry stepped staple device. In group III, the varus force at failure value was 180.26 +/- 82.36 for the modified tension band device versus 109.14 +/- 60.96 for the Mansat staple blade. The findings in this study suggest that the modified tension band technique provides a greater varus force at failure value, approximately 160-170%, compared to the other two techniques. In addition, this device is easy to apply and less expensive, and most orthopaedic surgeons are already familiar with its use.