Contemporary orthopaedics最新文献

A ten-year retrospective review of extremity long bone gunshot fractures treated operatively at the Elmhurst City Hospital Center, New York, was performed to examine the operative outcomes with regard to immediate, intermediate, and delayed fixation. A total of 121 low-velocity gunshot fractures were evaluated in 107 patients. Cases were separated into three groups according to the actual timing of the internal fixation procedure. The results revealed a total deep infection rate of 2.6% (3/121) and a nonunion rate of 3.3% (4/121), with no significant differences among the three groups. Early internal fixation reduced comparative hospital stay length and overall costs for operative patients.

A study of 38 patients, ages birth through 17 years, is reported that was performed to identify patterns of thoracic and lumbar spine injuries and healing in children in order to make appropriate treatment recommendations and avoid unnecessary surgery. This retrospective/prospective study, which is the largest review of children's thoracic and lumbar spine injuries in the orthopaedic literature, supports several accepted concepts regarding children's spine fractures. In addition, the periosteal sleeve fracture mimicking lumbar dislocations in small children, which has not been reported previously in the clinical setting, is described. Thoracic and lumbar spine injuries in children have distinct differences from these injuries in adults, and the treatment should take these differences into consideration.

Sixty-one active-duty military personnel with operatively treated ankle fractures were randomized into two postoperative immobilization regimens: Group I--six weeks short-leg cast, nonweight-bearing; Group II--six weeks removable orthosis, nonweightbearing. Group I began physical therapy at six weeks postoperatively, and Group II began physical therapy within the first postoperative week. Objective measurements of swelling, strength, range of motion, and functional tests were examined. Subjective scores of pain, function, cosmesis, and motion were recorded. Patients in Group II (early mobilization) had significantly better subjective scores at three and six months postoperatively; however, time to return to duty was not significantly different. Objective tests of swelling, strength, range of motion, and functional tests were not significantly different at three months postoperatively for either group. Early mobilization in a removable orthosis, while not objectively altering the postoperative course, provides a safe, preferable method of treatment in the reliable and cooperative patient.

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.

Twenty-nine patients who eventually had a diagnosis of reflex sympathetic dystrophy (RSD) following total knee replacement were treated with lumbar sympathetic blocks with local anesthetic. The diagnosis was made based on the complaint of constant pain unrelated to physical activity in the absence of overt sepsis or implant loosening. In six of these cases, other factors may have clouded the diagnosis. Thirteen (44.8%) patients obtained complete relief following an average of 1.8 blocks. Three of these patients had symptoms for more than two years. Twelve patients had complete or partial relief for varying periods of time, but the relief was not sustained. Three obtained no relief at all, and in one the block could not be successfully carried out. This success rate, while shedding no light on the etiology or diagnostic accuracy, has encouraged the authors to continue with this method of treatment in such cases.

The charts of 234 patients who underwent 260 spinal fusions for degenerative spinal disease were reviewed to determine prognostic factors for predicting successful surgical outcome. All patients were evaluated for fusion success and symptomatic relief. Pseudarthrosis occurred in 26 patients (10%) and 14 others failed to have symptomatic improvement despite successful fusion. Outcome was found to be significantly related to smoking status, diagnosis, use of hardware, insurance status, preoperative SGPT level, prior operations or decompressions, and age. The relative risk associated with smoking was 2.9. The association with smoking was present for both subjective and objective poor outcomes. A predictive function based on smoking status and diagnosis was developed. Ninety-two percent of nonsmokers with favorable diagnoses had a good outcome, compared to 77% of those with unfavorable diagnoses. The percentages for the comparable groups of smokers were 77% and 54%.

Injuries of the distal radioulnar (DRU) joint are common. If the joint is unstable or discongruous, attempts should be made to restore anatomic alignment and stability. Although most acute injuries of the DRU joint are easily treated, they are often overlooked or misdiagnosed because they usually occur in association with other major injuries of the upper limb. Acute and chronic abnormalities are described briefly and the treatment for each is discussed. Appropriate diagnosis and management of the acute injury will yield a much higher success rate than reconstructive procedures to correct a chronic disorder. A differentiation should be made between DRU joint dysfunction and ulnar impingement against the carpus; ulnar shortening is the most commonly used technique to treat the latter condition. In an elderly patient, a Darrach procedure is the preferred treatment for a DRU joint dysfunction; in younger patients, the treatment of choice appears to be resection arthroplasty of the DRU joint with preservation of the ulnar length, the ulnar styloid, and the triangular fibrocartilage complex (TFCC). In cases of malunion of the distal radius with involvement of the DRU joint, the recommended treatment is corrective osteotomy and soft tissue reconstruction of the ligamentous support of the joint.

Seven cases of Ewing's sarcoma presenting with primary lesions of the foot bones are described. Difficulty and delay in making the initial diagnosis are the hallmarks of the problems encountered at this site. Although radiation therapy plays an important role for control of disease in Ewing's sarcoma, surgery along with chemotherapy appears to give better results. Lesions of the forefoot are amenable to surgery; however, no guidelines are available in the literature for hindfoot lesions. Chemotherapy has revolutionized the outcome, and its use along with surgical intervention is recommended in all cases of Ewing's sarcoma of foot bones.