Contemporary orthopaedics最新文献

Fractures of the distal forearm--the eponymic Colles' or Smith's fractures--are among the most common injuries treated by the orthopaedist. Most of these fractures are amenable to closed reduction and immobilization. A new modification of the Charnley splint is presented for use in the acutely injured patient. The major advantages of this new splint are decreased weight and ease of application.

Proximal femoral fractures, especially in young adults, usually are high-energy injuries associated with severe comminution. Presently available fixation devices such as the blade plate and DHS are difficult to apply in comminuted cases, their application requires the use of an image intensifier, and their versatility is limited. This report describes the use of the AO plate molded according to the proximal femoral anatomy in 21 cases (seven subtrochanteric and 14 trochanteric fractures) in which high-energy injuries were sustained. Eleven cases were primarily bone grafted. Postoperative mobilization was started by an average of 5.4 weeks. All cases united by an average of 3.2 months. There were six excellent, ten good, three fair, and one poor result (one patient died). This method was found to be superior to conventional devices as it offers more versatility in placement of screws and plate contouring. The inventory of implants is also reduced, and there is no need for specialized instruments, a significant factor in Third World countries.

Eighteen nonrheumatoid patients were reviewed an average of 4.4 years following limited wrist fusion to evaluate whether patient satisfaction or objective wrist scoring more closely correlated with functional outcome. Range of motion, grip strength, pain relief, radiographs, and patient satisfaction were assessed by examination and interview, and each wrist was scored based on a clinical scoring system described by Cooney. Twelve patients (67%) were very satisfied with their results, and six (33%) were dissatisfied. Thirteen (72%) experienced good pain relief, 12 of whom denied functional restrictions. Six patients (33%) reported suboptimal wrist function, and four indicated they had inadequate pain relief. Despite high levels of satisfaction in 12 patients, the objective wrist scores were only fair and poor. These low wrist scores unreliably reflected functional outcome. Patient self-assessment of wrist performance, however, was uniformly predictive. Pain relief was more critical to patient satisfaction than residual range of motion. Therefore, compared to objective wrist scoring, consideration of patient satisfaction may allow more accurate prediction and assessment of functional outcome following limited wrist fusion. Satisfactory postoperative function appears to be more dependent on pain relief than residual motion.

The use of bone grafting in polytrauma patients is associated with significant problems. Additional surgical time is required for the use of cancellous autografts, and there may be a significant incidence of donor site morbidity. Various types of allografts used in western countries are expensive to obtain and store, and the technical know-how required for their use may not be available in Third World countries. A series is reported in which formalin-preserved allograft (FPA) was used for the management of comminuted fractures in 22 polytrauma cases. This type of allograft is inexpensive, easy to prepare and store, and has been shown in experimental and clinical studies to be nonantigenic and sterile. The complication rate and time to union were comparable with a control series of autografted cases and previously reported series in the literature. Based on the results in this series of patients, the use of FPA is recommended for the grafting of multiple fractures, especially when other forms of allograft are not available because of technical or financial limitations.

Sacral ulcers usually are caused by pressure leading to pathologic changes in the layers of tissue extending from the skin to the bone. This type of ulcer occurs most commonly in paraplegic or unconscious patients. In a series of 25 patients with sacral pressure sores studied during a one year period of time, the initial management consisted of conservative treatment with excision of the ulcer and daily dressing changes. The results with this method of treatment were satisfactory in ten cases and unsatisfactory in 15 cases. The 15 cases in which the results were unsatisfactory then underwent treatment with operative methods including excision of the ulcer and primary closure, myocutaneous flaps, skin grafting, and transcutaneous skin flaps. In six of ten cases in which a myocutaneous flap was used, the wounds healed satisfactorily. In four cases an infection occurred; in three of these cases the wound healed after infection control, while skin grafting was required for the fourth patient. Overall, the postoperative results with the use of a myocutaneous flap were satisfactory, and the results also were good at follow-up.

The management of intraarticular fractures such as tibial plateau fractures in weightbearing joints is inherently complex. Bicondylar tibial plateau fractures resulting from high energy trauma are particularly difficult to treat successfully. The objectives in managing these fractures are to obtain adequate reduction and appropriate stabilization while allowing early range of motion and limiting potential morbidity. The incidence of complications and long-term sequelae is relatively high in cases treated with traditional open reduction and internal fixation. From 1986 through 1993, 32 bicondylar tibial plateau fractures were treated at our institution. Of these, 26 were treated operatively using various methods of open reduction and internal fixation, and, more recently, indirect reduction techniques with percutaneous screw and/or external fixation. These newer techniques include arthroscopically-assisted reduction with percutaneous screw fixation or applications of a hybrid circular external fixator with or without limited internal fixation. These techniques provide adequate reduction and fixation while limiting the complications associated with traditional open methods. This retrospective study was conducted to compare these newer techniques with more traditional methods of open reduction and internal fixation (ORIF).

The surgical treatment of a young adult with a localized defect in the articular cartilage of the knee most commonly employs arthroscopic shaving and/or subchondral drilling. Fresh osteochondral allografting is an alternative that is being performed with increasing frequency. As of June 1993, fresh osteochondral allografts have been used in 90 knees in our institution. Thirty-eight of these knees have been evaluated two or more years postoperatively, and a successful result was obtained in 76%. If the lesion was confined to the medial condyle, the success rate was 86%, but when both reciprocal surfaces were replaced (bipolar) the success rate was 56%.

Among 105 tibial shaft aseptic nonunions followed for a mean of 32 months, 30 were treated with dynamic compression plating and 75 were treated with either Küntscher or Grosse-Kempf interlocking intramedullary nailing. With the plating technique, the union rate was 90.0% (27/30), the period of time to union was 5.2 +/- 1.7 months, the complication rate was 16.7% (5/30), the infection rate was 13.3% (4/30), and the surgical time was 110 +/- 30 minutes. With the intramedullary nailing technique, the union rate was 93.3% (70/75), the period of time to union was 5.0 +/- 1.6 months, the complication rate was 17.3% (13/75), the infection rate was 13.3% (10/75), and the surgical time was 70 +/- 30 minutes. Thus, while the union rate was high with both techniques, the complication rate also was high, especially deep infection. However, the technique for nailing was simpler and required less surgical time than plating (p less than 0.001). With open reamed intramedullary nailing, a higher infection rate was noted in the cases initially treated with an external fixator than for cases in which other forms of treatment initially were used (p less than 0.05).