Indications and technique of open reduction and internal fixation of radial head fractures.
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Biomechanical Phenomena↗
Biomedical subjects
C R Perry
Publications and source records attributed to C R Perry.
Treatment of acutely infected arthroplasties with incision, drainage, and local antibiotics delivered via an implantable pump.
Twelve patients with acutely (symptomatic less than ten weeks) infected arthroplasties were treated with minimal debridement and intraarticular antibiotic, amikacin, delivered via an implantable pump. The infection was suppressed in ten cases. Intraarticular levels of amikacin were obtained in eight cases. These levels ranged from greater than 150 micrograms/ml to 1688 micrograms/ml. The systemic level of amikacin remained below 10 micrograms/ml in all but one case. Duration of hospitalization averaged 19 days. There were no significant toxic side effects to amikacin.
Acute Disease↗
Basic principles and clinical uses of screws and bolts.
The orthopaedic surgeon uses screws for interfragmentary fixation, fastening soft tissue to bone, or holding plates or nails to bone. The most common function of screws is to fix bone to bone. This article reviews the design parameters and types of screws used in orthopaedic surgery.
Bone Screws↗
Local antibiotic delivery in the treatment of bone and joint infections.
Antibiotics can be delivered locally via an implantable pump to treat bone and joint infections. This is a completely closed system, and the pump is refilled percutaneously at intervals based on its flow rate. The use of this method is described in three specific clinical situations: (1) resistant osteomyelitis (patients with persistent infections despite previous therapy), (2) acutely infected arthroplasties (symptomatic for less than six weeks), and (3) chronically infected arthroplasties (patients infected more than six weeks). In all three clinical situations, hospitalization time was shortened, and high local and low systemic levels of antibiotic were obtained. There was only one incident of side effects to the antibiotic used. This method has been successful in obtaining long-term suppression of infection in 30 of 42 patients with resistant osteomyelitis, 30 of 37 patients with acutely infected arthroplasties, and seven of ten patients with chronically infected arthroplasties. The complication unique to this method of therapy is pump-site and catheter-site infections. This occurred in three patients with recalcitrant osteomyelitis and three patients with acutely infected arthroplasties.
Acute Disease↗
Accuracy of cultures of material from swabbing of the superficial aspect of the wound and needle biopsy in the preoperative assessment of osteomyelitis.
The pathogens that were identified on cultures of material obtained by swabbing of the superficial aspect of the wound and needle biopsy were compared with those that were isolated from material that was obtained at débridement from sixty patients who had post-traumatic or postoperative osteomyelitis. The cultures of material that was obtained by superficial swabbing of the wound and needle biopsy were inadequate for prediction of the presence of aerobic organisms. Moreover, the failure to isolate anaerobes from the material obtained by needle biopsy did not rule out the presence of anaerobic organisms. Therefore, tissue for culture of aerobic and anaerobic organisms must be obtained during operative débridement in order to identify all pathogenic organisms. Fungi were isolated from the material obtained by biopsy in two patients. In addition, histological examination of the tissue obtained at biopsy led to the diagnosis of epidermoid carcinoma in two patients in whom this diagnosis had not been suspected before biopsy. Cultures were negative for mycobacteria in all patients. An additional ten patients who had a tibial non-union and latent osteomyelitis were studied. In nine of them, cultures of material obtained by needle biopsy showed no growth. Six of these nine patients had an exacerbation of the osteomyelitis after intramedullary nailing for the non-union. Therefore, the absence of growth of organisms from tissue obtained at needle biopsy does not rule out the possibility that osteomyelitis may be reactivated after intramedullary nailing with reaming.
Bacteria↗
Transcondylar fractures of the distal humerus.
We classify transcondylar fractures of the distal humerus into four groups: undisplaced; simple displaced; T-type; and fracture dislocations (Posada's fracture). Our treatment of these fractures is based upon this classification. Undisplaced fractures are treated with immobilization. Displaced fractures are reduced and stabilized with internal fixation. Stabilization of these fractures is difficult because the distal fragments are small and a large portion of their surface is covered with articular cartilage. Transposition of the ulnar nerve allows us to use the cubital tunnel as a point for fixation. We found in our series of 11 patients that undisplaced fractures have the best prognosis. However, all of our patients lost elbow motion, particularly extension. Radiographic signs of post-traumatic arthritis were more pronounced in displaced fractures.
Aged↗
The Ilizarov technique in the treatment of infected tibial nonunions.
Five patients with infected tibial nonunions and segmental defects were treated with the method of Ilizarov: application of circular small-wire fixator, corticotomy and bone transport to fill the segmental defect. Four of the five patients developed regenerate bone at the corticotomy distraction site. The one failure was related to a previous surgery--reamed locked nailing of the tibia. Three of the four patients with regenerate bone required open reduction and internal fixation at the nonunion site following bone transport. Superficial pin tract infections, broken wires and psychological intolerance of the frame were frequent but minor problems.
Bone Transplantation↗
Works in progress #4. Current status of local antibiotic delivery via an implantable pump.
We present our technique and results in using an implantable drug pump to deliver antibiotics locally in the treatment of two specific orthopaedic infections: chronic recalcitrant osteomyelitis and acutely infected total joints. This method of antibiotic delivery in conjunction with appropriate surgical management results in prolonged suppression of infection in 71% of patients with chronic recalcitrant osteomyelitis. In acutely infected arthroplasties we were able to salvage the prosthesis and suppress the infection in 18 of 20 cases.
Adult↗
Imaging rounds #101. Bosworth fracture.
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Adult↗
Patellar fixation protected with a load-sharing cable: a mechanical and clinical study.
The stability of patellar fracture fixation protected with a load-sharing cable was studied in cadavers. A transverse patellar osteotomy was produced and stabilized with standard patellar fixation with or without a figure-of-eight cable that extends from the proximal pole of the patella to the tibial tubercle. Standard fixation techniques (interfragmentary cancellous screws or modified tension-band wiring) alone failed after significantly fewer cycles of flexion and extension than did the same fixation when supplemented with a load-sharing cable. In the clinical evaluation of the load-sharing cable, 14 consecutive patients with displaced patellar fractures were treated. No immobilization was used and the patients were started on passive and active range of motion and weight-bearing ambulation in the early postoperative period. Thirteen fractures healed uneventfully. The increased stability of patellar fracture fixation protected with a load-sharing cable offers three advantages: (a) adjunctive casting is unnecessary, (b) comminuted fractures can be "pieced" together anatomically with less concern for loss of fixation, and (c) early postoperative passive and active range of motion can be achieved.
Adolescent↗
Local delivery of antibiotics via an implantable pump in the treatment of osteomyelitis.
Twenty-one patients with osteomyelitis were treated with surgical debridement and local antibiotic therapy. Amikacin (19 patients) or netilmicin (2 patients) was delivered locally via a pump implanted subcutaneously. The outflow catheters were led from the pump subcutaneously to the infected area and placed in the defect created by the surgical debridement. The pump was refilled at intervals, on an outpatient basis. The pump was surgically removed at the conclusion of therapy. Follow-up evaluation was for 12-27 months. The duration of hospitalization was five to 52 days (mean, 23 days). The infusions were sustained for 32-140 days (mean, 63 days). Systemic levels of antibiotics were always below acceptable trough levels. Levels in the wound drainage of the 11 patients who drained after operation were always greater than the upper limit of the assay. Nephrotoxicity and ototoxicity were determined using pre- and posttherapy creatinine clearances and audiograms. Two patients exhibited minimal nephrotoxicity (creatinine clearance of 66 ml/minute and 55 ml/minute; normal, 70 ml/minute). There were no other adverse effects of the antibiotics. Sixteen patients have not drained since removal of the pumps.
Adult↗
Open reduction and internal fixation of radial head fractures associated with olecranon fracture or dislocation.
Six fracture dislocations or dislocations of the olecranon associated with radial head fractures were treated with open reduction and internal fixation of the radial head. The olecranon was reduced and if fractured (three cases) was internally fixed. Postoperatively, early active range of motion was achieved in all cases. Twelve to 48 months after surgery, there was an average loss of 18 degrees of elbow extension and 56 degrees of forearm rotation. An average of 132 degrees of flexion was maintained. There was no elbow instability or wrist pain.
Adolescent↗
Locked flexible intramedullary nails in treatment of unstable femoral fractures.
Twenty patients with unstable femoral fractures were treated with distally locked flexible intramedullary nails. We present our surgical technique and our results. The method has the following advantages: it prevents rotational malalignment and shortening, it is a closed procedure, no reaming is necessary, there is no increase in c-arm time, and there is minimal increase in operative time. Locked flexible intramedullary nails should be used in patients with unstable femoral fractures who have dense metaphyseal bone. Osteopoenia is a contraindication to this method as it increases the risk of nail penetration into the hip.
Adolescent↗
Antibiotics delivered by an implantable drug pump. A new application for treating osteomyelitis.
Osteomyelitis is usually treated with wide surgical debridement and prolonged intravenous antibiotics. The advent of the implantable drug pump has led us to evaluate this therapeutic modality for the treatment of osteomyelitis. We have previously shown that amikacin retains microbiologic activity in an implantable drug pump over a six-week period when incubated at 37 degrees C. We have also demonstrated in rabbits that high local levels and low systemic levels of antibiotic can be achieved using an implantable drug pump as a delivery system and that this method can be used to sterilize infected wounds. This method was applied in the treatment of osteomyelitis in 14 patients whose duration of symptoms ranged from one month to 22 years. In 13 patients, active drainage had been present for more than six months, and all patients had undergone one or more attempts at eradication of their infection. Prior therapy included surgical debridement alone (one patient), one or more attempts at debridement and extended intravenous antibiotic therapy (13 patients), debridement and local flap procedures (four patients), and extended oral antibiotic therapy (two patients). The bones involved were the tibia (six patients), femur (four patients), and elbow, shoulder, hip, and radius (one patient each). Intra-operative cultures indicated that the infecting organism was Staphylococcus aureus alone (seven patients), S. aureus in combination with gram-negative bacteria (five patients), or gram-negative organisms alone (two patients). Debridement and pump implantation were performed in one stage. On an outpatient basis, the pumps were filled with amikacin in a concentration determined by each patient's serum level. Duration of therapy was based upon cessation of drainage and erythrocyte sedimentation rate. During therapy, serum amikacin levels ranged from less than 2.5 micrograms/ml to 8.2 micrograms/ml. The amikacin concentration in the wound drainage was always greater than the upper limits of what could be measured (greater than 55 micrograms/ml to greater than 5,000 micrograms/ml). There were no cases of ototoxicity and one case of minimal renal toxicity (posttreatment creatinine clearance of 66 ml per minute; normal equal to 70 ml per minute). Length of therapy ranged from 32 to 140 days (mean equal to 63 days). Length of hospitalization ranged from five to 52 days (mean equal to 24 days). Drainage in all patients stopped during therapy, but resumed in three patients after pump removal--in two patients, for brief periods of time, and in one patient, it continues. Twelve patients have posttreatment erythrocyte sedimentation rates less than or equal to 20 mm per hour.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Antibiotic stability in an implantable pump.
We measured the stability of vancomycin, amikacin, netilmicin, tobramycin, gentamicin, clindamycin, and aztreonam in an implantable drug pump. Two pumps were filled with the antibiotic being tested and were incubated at 37 degrees for 3 weeks. Samples were taken daily. At 3 weeks the pumps were disassembled and examined microscopically for signs of deterioration. If the pumps were intact, bioassays were used to quantitate the biologic activity of each daily antibiotic sample. Vancomycin degraded the pump. Amikacin, netilmicin, tobramycin, gentamicin, clindamycin, and aztreonam had no effect on the pump and maintained their biologic activity over the 3-week period.
Amikacin↗
Isolated avulsion of the tibial origin of the anterior tibiofibular ligament.
A case report of a patient with an isolated avulsion of the anterior tubercle of the tibia is presented. This is the origin of anterior tibiofibular ligament, and this injury is the first stage of a supination external rotation injury of the ankle. It can be easily missed and, if not treated properly, can result in an unstable ankle. The patient was not treated initially and the result was an unstable ankle.
Adult↗
Cefamandole levels in serum and necrotic bone.
Seven patients with chronic osteomyelitis were treated by surgical debridement. Cefamandole was administered intravenously before surgery. During the debridement, cefamandole concentrations were measured in serum and necrotic bone. Although adequate levels of antibiotic were achieved in the serum, minimal or no concentration of antibiotic was found in the necrotic bone. There was only minimal penetration of cefamandole into necrotic bone.
Bone and Bones↗
A new surgical approach to fractures of the lateral tibial plateau.
We are reporting on a previously undescribed surgical approach and postoperative protocol for the treatment of fractures of the lateral tibial plateau in which there is a split pattern and depression of the articular surface. In this approach the anterior horn of the lateral meniscus is incised and detached so that the split fragment can be opened like a book. Detachment and incision of the anterior horn minimizes the need to free the lateral meniscus from its tibial attachment. The postoperative protocol includes continuous passive motion followed by non-weight-bearing in a toe-to-groin plaster cast for three months. Our preliminary results have been encouraging, and arthroscopic examination in the seven knees so studied indicated a healed fracture, restoration of the tibial articular surface, and a healed lateral meniscus.
Adult↗