Biomedical subjects
Publications and source records attributed to A Lortat-Jacob.
Osteosynthesis of the fractures of the lower extremity of the humerus by a lateral plate does not allow always a sufficient stabilization, when the medial column is comminuted. In this case the use of a medial premoulded plate is proposed.
Thirty-two cases of post-traumatic infection of the femur are reported. Apart from antibiotic treatment, surgical treatment comprised two components: excision and stabilization followed by a second stage of reconstruction by bone grafting. The excision was as extensive as was necessary, including thirteen resections of the shaft and twelve sequestrectomies. Stabilization was preferably achieved by an ALJ external fixator applied in a single posterolateral plane leaving the quadriceps free. Two types of reconstruction were used: 24 open cancellous grafts by the Burri-Papineau method and 7 closed corticocancellous grafts. One patient was not grafted. In 5 cases of bone infection with fragility, 4 open cancellous grafts gave sound bone and a healed wound in a mean of 6 months. In 16 out of 20 septic nonunions treated by open cancellous grafts, union and wound healing was obtained in a relatively short time, a mean of 8.2 months. But in four other cases, it was a matter of saving limbs with arterial damage, major lesions of the soft tissues and involvement of the knee joint. In these the healing time was much longer. The seven closed corticocancellous grafts had less satisfactory results; three of them required multiple procedures and healing was delayed for a mean of 27 months. Amputation was needed in one case. The authors consider that closed corticocancellous grafts are only suitable for the simplest cases in which, after excision and stabilization, good bone contact remains. But when the excision requires a considerable removal of bone involving its whole circumference, open cancellous grafts are preferable and lend themselves better to secondary bony procedures. In addition, they seem to be less subject to refracture because of the histological process of bone reformation.
This series comprises 74 post-operative infections of fractures of the upper end of the femur, 47 associated with internal fixation and 27 with prostheses. The organisms were different in the 13 men, with a predominance of gram-positive cocci, from those in the 61 women in which the significantly high proportion of gram-negative organisms seemed to be due frequent to soiling of urinary origin. In the 47 internal fixations, local wound toilet gave 29 successful results with union in the normal time. Two patients were not able to be operated on again and died before they could be treated. Sixteen failures, including seven deaths, were due to septic arthritis of the hip. The diagnosis of septic arthritis was difficult, which explains why resection of the head and neck of femur was only made in six cases, five of them successfully. In the 27 prostheses, the best results were obtained by deep wound toilet retaining the prosthesis, with nine successes in ten cases. An acceptable functional result was compatible with a persistent grumbling infection.
Explore the source record for details and available documents.
The authors have treated 51 cases of infection arising after intramedullary nailing of the femur or tibia. In 3 cases amputation was required, 48 united, but 10 were still draining. The final result was obtained after an average of 15 months. An average of four procedures per patient were needed. All the cases were septic non-unions at the onset of treatment, except 18 cases which had already united. In these cases, simple removal of the femoral nail led to rapid healing. In contrast, healing was less easy to obtain in the tibia. In 33 septic non-unions, 12 femoral and 21 tibial, the best results at the femoral level were obtained by retaining the nail in situ. At the tibial level, retention of the nail was rarely followed by bony union. Removal of the nail and the use of external fixation gave good results for the infection, but rarely resulted in bony union (1 case out of 14). The failures were treated by further operation of bone resection and grafting. The authors recommend, in cases of tibial septic non-union after nailing that primary removal of the nail should be associated with bony resection and external fixation, followed by reconstructive grafting, either by open cancellous grafting extending to the fibula or conventional tibio fibular grafting. In 8 cases, 7 in the femur and 1 in the tibia, the infection extended throughout the entire diaphysis and in 3 of these cases, a large diaphyseal resection was required.
The authors have treated 63 septic fractures of the tibia, 29 of whom were seen less than four months after the injury; the remainder were more long-standing. In both series the surgeon faced three problems--curing of the septic drainage, skin cover and bone union. In 46 cases bone excision was considered necessary: in 18 diaphyseal resection was performed. Immobilisation of the fracture was obtained by plaster cast in 14 cases, an external fixator in 48 cases, and medullary nailing in one. Reconstruction was needed in 11 cases after closed grafting, 9 of them being tibio-fibular, and in 46 after cancellous graft without skin closure. The results in 63 cases were 61 unions: 43 primary unions, 19 additional procedures to reinforce callus and 1 amputation. In two patients union remained particularly tenuous. Two patients are still showing discharge and 9 have poor skin cover. The average time to bone union was nine months and was twelve months in cases of resections greater than 3 cms. The authors are in favour of a technique of massive cancellous bone grafting of the tibia, aligned towards the fibula with partial skin closure. This procedure leads to a firmer and more rapid bone union than the Papineau technique. Secondary bone or skin procedures were needed less often. Tibio-fibular grafting was indicated in cases of limited infection and when the main tibial fragments were still uniting postero laterally.
Fifty one fractures of an epiphysis were treated by fixation using a new external fixator. The stability of the fixation was compared with that obtained by other types of fixator. The basis of the technique was the insertion of five pins into the epiphysis and of a series of pins in the diaphysis. Fixation between the epiphyseal and diaphyseal pins was achieved by three bars. The results obtained in 38 cases, half of them being at the proximal end of the tibia were analysed and were found to be encouraging. Only three had to be grafted secondarily. There was a low number of mal-unions. The main advantage of this method was to allow early mobilisation of the joint. The risk of sepsis did not give rise to concern provided that the rods do not cross the joint.
Eight instances of septic arthritis of the hip were treated in 6 paraplegics. On each occasion the hip had been infected through a nearby ulcer. In 2 cases the diagnosis was only made at operation because signs of a severe infection are not obvious in paraplegics. The radiographs were often misleading, the joint space being either normal or narrowed even before the onset of sepsis. The treatment combined antibiotic therapy with resection of the head and neck stabilized by external fixation for 45 days. The procedure was only successful in 5 cases out of 8 as far as infection was concerned. The resection did not impair ability to sit in this type of patient.
The authors have performed 28 ankle fusions for septic causes. There were 23 cases of septic arthritis and 5 severely comminuted compound fractures treated by primary fusion. Arthrodesis was made after wide excision and stabilization by external fixator. In 23 cases secondary bone grafting was done. Only in 13 cases was a satisfactory contact between the bony surfaces obtained. There was no contact at all in 9 cases. The authors have had good experience with the A.L.J. model of external fixator. On 7 occasions, secondary grafting was made using a cortico-cancellous graft with 3 failures. On 6 occasions, the Papineau technique was used with success but healing was slow. Out of 24 patients, the final result was good in 18 with 4 failures of fusion and 3 persistent sinuses. The importance of a wide excision is emphasised leading to the need for the use of external fixation. In cases of skin loss in recent comminuted fractures, the Papineau method is indicated as a primary procedure.
Explore the source record for details and available documents.
Thirty-four cases of severe trauma to the proximal ends of both bones of the forearm have been seen. All were treated surgically. A classification is proposed related to the site of the ulnar fracture. Type I is metaphyseal and the displacement is posterior, the reverse of that of a Monteggia fracture, with a posterior dislocation of the superior radio-ulnar joint. Type II is epiphyseal with anterior displacement. The superior radio-ulnar joint is intact. Type III is metaphysio-epiphyseal with anterior displacement. Type IV is the same with posterior displacement. Fractures of the radial head are present in all cases with posterior displacement and in these types, secondary displacements and non-unions are frequent (six cases). These were related to inadequate fixation of the ulna and to resection of the radial head which led to an increased strain on the ulnar fracture. Severe limitation of movements was infrequent (five cases) and was usually seen in fractures with posterior displacement. It was related to the time of cast immobilization and to the fracture of the radial head. Fractures with anterior displacement and an associated fracture of the radial head were rare but had a better prognosis in spite of the intra-articular site of the fracture. The relevance of repair of the radial column is stressed as being as important as stable fixation of the ulnar fracture.
Explore the source record for details and available documents.
The authors have tested the stability of Hoffmann fixation in relation to the number and location of the fixating pins. A double frame configuration as described by Vidal is not superior since it allows some mobility in the plane of flexion and extension. The authors believe that a double perpendicular plane configuration is more satisfactory without the use of a transfixing pin. This method is more stable. To improve stability in valgus-varus plane, the authors have designed a device which is more rigid and which decreases by 300 per cent any residual mobility at the fracture site. A newly designed plate allows good fixation in the epiphysis. The first clinical cases in which this new fixator has been used have given promising results.
The radiological assessment of knee deformity in the frontal plane is often fallacious because of the difficulty in determining the correct position of rotation of the lower limb. Deformity is under-estimated when the direction of the X-ray is not perpendicular to the frontal plane. To determine the frontal plane with accuracy the authors first looked for a true lateral view which is obtained when the posterior margins of the femoral condyles are superimposed. When the position of the patient has been determined by demonstrating the true lateral position, a second radiograph is taken using a large film in a plane at right angles to the preceding film. In this way a true frontal plane is obtained which requires no reference to the position of the foot or the patella which tends to be variable. An association flexion deformity does not invalidate the result. When this technique is used it can be shown that conventional methods tend to under-estimate the degree of knee deformity.
The authors have measured the depth of the patellar groove in a 100 human cadavers. An angle of about 143 degrees have been found to be present in normal knees, confirming the work of Brattström. When the angle was more than 150 degrees, the groove was considered to be dysplastic and likely to lead to patellar instability. In contrast when the angle was less than 138 degrees, the groove was thought to be excessively deep. This was present in 19 cases, in 13 of which there were obvious lesions of the articular cartilage. This study in cadavers has been confirmed by a scan study of 148 patients complaining of femoro-patellar syndrome. Deep patellar grooves were frequent in this series, the mean angle being 129 degrees. 80 p. 100 of the patients had an angle less than 135 degrees. It is concluded that deep patellar grooves with a lower angle than normal favour the development of patellar chondromalacia.
The authors have treated 82 non-unions by the Papineau method of bone grafting without skin closure. In 30 cases, a complimentary bone procedure had to be performed to reinforce bone union. This consisted of a new Papineau procedure in 18 cases and an iliac graft with skin closure in 12 cases. Infection recurred in several instances. In addition to these 30 cases, 3 secondary fractures were seen. In cases with persistently depressed scars, a fresh Papineau procedure may be needed. In cases with persistent skin ulceration, resection and skin suture should be tried before a cross-leg skin graft. The authors emphasize the frequency of vascular changes which should be looked for by arteriography.
The authors have observed 11 cases of Volkmann's ischemia in the lower limb. The main deformity was of equinus. 10 patients were operated on. In 8 cases, arthrolysis was performed with good results in 7 cases. In 2 cases an ankle arthrodesis was done with one good result and one secondary amputation. The surgical technique of the arthrolysis is described. In most of the cases, tendon lengthenings, capsulotomy and fixation with an external fixator was required. This device was tolerated and it is concluded that it is worthwhile in severe ischaemic syndrome and that arthrolysis is preferred to arthrodesis.
The authors have treated 9 cases of streptococcal gangrene of the limbs. They describe the clinical features:local oedema, erythema, and cyanotic spots. In 7 of the cases the infected general condition was very severe. At operation, the subcutaneous soft tissues were grey-green without pus. The authors have reviewed the literature and consider that treatment should be based on early excision of the skin and subcutaneous tissues. Antibiotics are of great help but are not sufficient by themselves. Nine patients reached a stable state but sequelae have been severe with one disarticulation of the shoulder, one ankylosis of the wrist, one ankylosis of the knee and one generalised stiffness of the hand. Only five patients have been completely cured.