Contemporary orthopaedics最新文献

Osteophyte formation in the vertebral column is a well documented phenomenon that is poorly understood. The most commonly identified etiologic factors are degeneration and altered mechanics of the spine, either of which in turn have been considered to be a result of the natural aging process or the pathogenesis of spinal disease. In Part I [Contemporary Orthopaedics, 29(1): 31-37, 1994], the process of osteophyte formation was reviewed. In Part II, the sequential and consequential changes from the finely interwoven events of aging, degeneration, mechanical instability, and disease are described.

Four cases of locked finger metacarpophalangeal joints are reported. Two of these cases were caused by entrapment of the sesamoid behind an exostosis off the second metacarpal head. The third was from subluxation of the dorsal interosseous tendon over a dorsal osteophyte on the metacarpal. The fourth was from an exostosis tethering the accessory collateral ligament. Surgical exploration using a palmar approach was the treatment of choice. All patients regained full range of motion within two months. A review of the various causes and treatment options for this unusual condition is presented.

Previous reports have noted a relationship between pelvic obliquity and hip dysplasia in spastic cerebral palsy but did not confirm its existence by scientific study. A study is reported that confirms the association of pelvic obliquity with hip dysplasia in spastic cerebral palsy. At presentation of subluxation or dislocation prior to surgery, 80 patients were indexed into five body alignment types. Reclassifications were performed with passage of time in order to study the natural history and effects of surgery. In all cases, hip dysplasia was found to be consistent with the forces related to pelvic obliquity.

As part of the UCLA limb salvage program, 151 patients received 151 endoprostheses for primary tumors involving bone. Follow-up of all patients was to death (56), revision (21), or a minimum two years for the 74 additional survivors (range: 24-114 months; mean: 52 months). Endoprosthetic replacements were of the distal femur (81), proximal femur (19), proximal humerus (13), proximal tibia (11), scapula (11), total femur (8), total humerus (4), intercalary prostheses (2), and one each of the distal humerus and the pelvis. There were three soft tissue sarcomas, five benign bone lesions, and 143 primary malignant tumors of bone. MSTS function was good-excellent in 78%. There were 64 local complications in 55 patients (36%). Mechanical failure occurred in 24 patients (15.9%), local recurrence occurred in ten (6.6%), minor wound healing problems in nine (5.9%), and infection in eight (5.3%). Few systemic complications were reported. Function appeared to be location dependent. All of the 29 patients with benign or low grade malignant tumors (parosteal, IA, IB) have survived. Of the 116 patients with stage IIA and IIB disease, 59% survived three years, and a Kaplan-Meier analysis projects that 56% are expected to survive at five years. Only 17 (11%) of these 151 endoprostheses have been revised; an additional four (3%) eventually came to amputation. The Kaplan-Meier analysis revealed that 91% of the prostheses survived three years and 83% survived five years. The Cox Proportional Hazards model revealed that for patients with stage IIA and IIB disease, the risk of death is four times the risk of the need for revision at five years. Although endoprosthetic reconstructions have their own unique complications, they have proven durable in this series of patients. Local problems usually can be managed without amputation, and patient satisfaction is high.

A study was conducted to evaluate the outcome of massive proximal femoral shortening in the cerebral palsy patient with severe spastic quadriplegia and hip instability. A retrospective review of 13 children (age range: three to 19 years of age) representing 18 hips treated with massive shortening of the proximal femur was conducted. Bilateral procedures were performed in five patients. All procedures were performed between February 1986 and March 1990. Radiographs were evaluated for preoperative and postoperative migration percentage (MP) and femoral neck-shaft angle (NSA). Charts were reviewed for complications and clinical results. All femoral osteotomies healed without difficulty. Clinical follow-up averaged 27.6 months. Satisfactory results occurred in all but one hip. Radiographs taken an average of 19.5 months postoperatively showed improved MP in all but one hip. The average preoperative MP was 70% and postoperative MP was 18%. Femoral NSA also was improved. Heterotopic bone formed in 13 hips but caused no significant problems. Other complications included postoperative seizure, urinary tract infection, cast sores, transient arm weakness, weight loss, pin protrusion through skin, and femur fracture after cast removal. Based on the good results and minimal complications in this series, massive femoral shortening appears to be a superior alternative to proximal femoral resection in these difficult patients.

Fifty patients who had an arthroscopic anterior cruciate ligament reconstruction for chronic insufficiency were reviewed at an average of 13.6 months following surgery. Among these patients, 32% complained of anterior knee pain that interfered with daily activities. Radiographic patella infera was present in 12% of patients using the Insall-Salvati ratio and in 16% using the Blackburne-Peel ratio. Radiographic patella infera did not correlate with the clinical problem of postoperative anterior knee pain. However, loss of knee extension of greater than 5 degrees correlated highly with pain (p=0.002).

The recent development of an indexed tissue advancement system makes it possible to take advantage of the viscoelastic properties of skin to close large wound deficits in one procedure. A case is presented in which serial excision of a previous split-thickness skin graft and tissue expansion to achieve wound coverage were performed in one sitting to close an 8cm defect on the lateral side of the patient's leg without subsequent wound separation or dehiscence.