Answer please. Osteofibrous dysplasia.
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Child↗
Biomedical subjects
H S Tullos
Publications and source records attributed to H S Tullos.
Radial head fracture. A potentially complex injury.
A prospective study was undertaken on 50 acute, consecutive fractures of the radial head. Clinical examination and stress testing were performed on each patient. A valgus stress radiograph, in conjunction with clinical stress testing, was used to assess competence of the medial elbow ligaments. Axial stability of the radius was determined by the axial stress test. Eleven patients (22%) sustained a comminuted radial head fracture; all had instability either to valgus or axial stress. Seventeen patients (34%) had a displaced vertical shear type fracture or an impacted fracture of the radial neck. All sustained some injury to the medial collateral ligament, with variable degrees of valgus elbow instability. Twenty-two (44%) of the fractures were minimally or nondisplaced. All 22 were stable. Radial head fracture morphology can be used to assess the likelihood of associated soft-tissue injury.
Adolescent↗
The effect of femoral component position on the kinematics of total knee arthroplasty.
In a laboratory study using seven fresh-frozen anatomic specimen knees, the effect of total knee arthroplasty on the three-dimensional kinematics of the patella, femur, and tibia were measured. Experiments were performed in the intact knee, after division of the anterior cruciate ligament (ACL), after total knee arthroplasty, and after 10 degrees internal rotation, 10 degrees external rotation, 5-mm medial shift, and 5-mm lateral shift of the femoral component on the femur. The presence of a high lateral ridge on the anterior surface of the femoral component effectively prevented patellar subluxation or dislocation, but displaced and tilted the patella medially. Internal rotation or medial displacement of the femoral component exaggerated this medial patellar displacement and shift. External rotation of the femoral component corrected it, except at flexion angles greater than 100 degrees, where the femur was shifted medially on the tibia and externally rotated 15 degrees. This combination produced a net 10-mm medial displacement of the patella relative to the tibia at 120 degrees knee flexion. Lateral placement of the femoral component compensated for the effect of the high lateral ridge and allowed more normal patellar tracking while allowing tibiofemoral motions similar to those seen after sectioning of the ACL. The kinematics of the patellofemoral and tibiofemoral joints were not reproduced with a total knee prosthesis that sacrifices the ACL. When using a prosthesis with a high lateral ridge, lateral placement of a femoral component prevented patellar dislocation and allowed patellar tracking patterns similar to those seen in the intact knee without further altering tibiofemoral motions.
Adult↗
Management of acquired adult dropfoot.
Dropfoot is a catchall term for ankle equinus, equinovarus, and equinovalgus. The deformity can be flexible or rigid and may be associated with other pathology. In the adult, dropfoot may be congenital or acquired. Acquired dropfoot results from weakness of the ankle dorsiflexors, overpull of the plantarflexors, contracture of the soft tissues, bony deformity, or any combination of these factors. Appropriate treatment includes observation, orthotic devices, bracing, tendon transfers, arthrodesis, and neurolysis. The purpose of this paper is to review the pathophysiology and treatment of acquired dropfoot.
Adult↗
Long-term results of total arthroplasty in adolescents with debilitating polyarthropathy.
The authors retrospectively reviewed 29 hip and 13 knee arthroplasties performed in 17 adolescents and young adults from 1973 through 1979. Most patients had severe multiple joint involvement; 16 had juvenile rheumatoid arthritis. Clinical and roentgenographic evaluations were performed before operation and at routine intervals for up to 11 years after operation. The average final follow-up evaluation was at ten years seven months. The modified Harris rating improved from 17 before operation to 68 at final evaluation. A dramatic improvement was noted in the ambulatory ability of 13 patients in whom increased joint motion and reduced deformity was observed at follow-up evaluation. At the 11-year roentgenographic review, 32% of hips had gross loosening, and an additional 39% had radiolucent lines greater than 2 mm in thickness in more than two radiographic zones. No lucency greater than 2 mm was noted in any of the knee replacements. Complications included one immediate collapse of the medial tibial plateau, four femoral fractures, one hip dislocation, and one case of arthrofibrosis. Despite untoward roentgenographic results and the high incidence of complications, total arthroplasty has dramatically improved the quality of life for these patients with multiple joint pathology. For this reason, the authors continue to recommend joint replacement in these individuals and the use of new prosthetic designs and surgical techniques.
Adolescent↗
Intramedullary fixation for congenital pseudarthrosis of the tibia.
Eighteen consecutively seen patients who had a congenital pseudarthrosis of the tibia were treated operatively. The mean age when the patients were first seen was four years. Seventeen previous procedures had failed: six patients had had one previous procedure; three, two previous procedures; and one, five previous procedures. At an average follow-up interval of ten years (range, three to nineteen years), healing with re-formation of the medullary canal was seen in thirteen of the eighteen tibiae, including one tibia that had united after a Boyd amputation. Five patients did not have healing of the tibia: four of them had a below-the-knee amputation, and one declined additional treatment. The average residual angulation was 12 degrees in the sagittal plane and 5 degrees in the coronal plane. Union occurred in ten of the thirteen patients who had been managed with intramedullary fixation. Of these thirteen, eight had been managed with intramedullary fixation, bone-grafting, and implantation of an electrical stimulator, and seven of them had union. Five of the thirteen patients had been managed with intramedullary fixation and bone-grafting, and three of them had union. Union occurred in one of two patients who had been managed with vascularized free fibular transfer, one who had been managed with delayed bone-grafting, and one who had been managed with a Boyd amputation. Four of the five patients who did not have union were subsequently managed with a below-the-knee amputation, and one patient refused additional treatment.
Adolescent↗
Surgical management of chronic medial elbow instability.
Chronic medial elbow instability in the active adult working population is a rarely diagnosed entity. Although it is recognized in the professional athlete as a cause of disability, reports in the general population do not exist. Fourteen adult patients with symptomatic chronic medial instability were evaluated from 1982 to 1986. Surgical reconstruction of the medial collateral ligaments was performed with follow-up evaluation averaging two years. Symptomatic complaints, physical examination, and roentgenographic evaluation were recorded preoperatively. Range of motion, postoperative stability, ulnar nerve symptomatology, and activity level were recorded postoperatively. All but one patient reported improved stability of the elbow.
Adolescent↗
Anterior and posterior internal fixation of vertical shear fractures of the pelvis.
A laboratory study was undertaken to evaluate the effectiveness of alternative methods of fixation of unilateral vertical shear fractures of the pelvis. Prior to experimental testing, a biomechanical analysis was performed to estimate the forces that displace the hemipelvis in the presence of two different patterns of injury: an interforaminal sacral fracture and a disruption of the sacroiliac joint. These lesions were then experimentally created in five unembalmed human pelvises and sequentially fixed with an external Hoffmann frame alone, a Hoffmann frame with sacral bars, or sacral bars with either one or two bone plates placed across the symphysis pubis. Each pelvis/fixator system was mechanically tested by loading along the direction of the resultant muscle force predicted by the biomechanical analysis. During loading the proximal migration of the ilium was continuously recorded with a transducer. At intervals during loading, the three-dimensional displacement of the detached hemipelvis at the pubic symphysis was also measured using a stereophotographic technique. With both the sacral fracture and the sacroiliac disruption, the addition of posterior sacral rods substantially increased the strength and rigidity of fixation provided by the Hoffmann fixation frame alone (p less than 0.01). In specimens with a sacral fracture, the use of anterior plates with posterior rods restored 65-71% of the strength of the intact pelvis, in comparison with 46% observed with the combination of sacral rods with an anterior Hoffmann frame (p less than 0.01). All of the methods of fixation evaluated in this study were less successful in stabilizing the sacroiliac disruption.(ABSTRACT TRUNCATED AT 250 WORDS)
Biomechanical Phenomena↗
Rigid internal fixation for shoulder arthrodesis.
Fifteen patients underwent a shoulder arthrodesis utilizing standard dynamic compression plate fixation, but with limited postoperative immobilization with only an abduction pillow. In each case, the position of the extremity relative to the scapula and trunk was recorded immediately postoperatively, at regular intervals until fusion, and at follow-up evaluations. Thirteen of 15 shoulders fused without change of intraoperative position after an average postoperative period of 4 months. One patient lost position in the early postoperative period secondary to inadequate fixation, but subsequently fused. Another who demonstrated a persistent non-union at 2 1/2 years was subsequently explored and underwent a bone graft. Four patients complained of residual symptomatic hardware, with two requiring surgical removal of the plate and screws. All but one patient were satisfied with the clinical result at follow up. Only two patients were within 5 degrees of the preoperatively determined position of 30 degrees abduction, 30 degrees forward flexion, and 30 degrees internal rotation. However, almost all were able to function satisfactorily. The authors concluded that shoulder arthrodesis utilizing rigid internal fixation without postoperative cast or brace immobilization maximizes patient comfort without compromising the success of arthrodesis. However, control of arm position remains inexact and additional modifications are needed to ensure fusion position and to minimize disability.
Adolescent↗
Use of a hinged silicone prosthesis for replacement arthroplasty of the first metatarsophalangeal joint.
A series of ninety consecutive total joint replacements of the first metatarsophalangeal joint with a flexible hinged prosthesis was reviewed after an average duration of follow-up of three years (range, twenty-four to sixty-one months). Although subjectively the results were satisfactory in most of the patients, and pain, the most common preoperative symptom, was reduced, mechanical failure of the implant was common, as determined radiographically. The frequency of failure of the implant and the extent to which it failed were related to the length of time that the implant had been in place. The range of motion of the metatarsophalangeal joint was decreased from normal. Dorsiflexion averaged 26 degrees and plantar flexion, 18 degrees. Callosities under at least one metatarsophalangeal joint were noted in fifty (69 per cent) of the feet that had a physical examination. Pedobarographic analysis of the distribution of plantar pressure revealed that none of the patients exerted weight-bearing pressures on the affected great toe. However, the subjective results were not significantly associated with radiographic evidence of failure of the implant. Despite its success in relieving the symptoms in our patients, we have abandoned this procedure because of the high and increasing rate of failure of the implant, as demonstrated radiographically.
Adult↗
Total hip arthroplasty following failed internal fixation of hip fractures.
A retrospective review was performed on 27 consecutive patients with total hip arthroplasty (THA) following failure of internal fixation of fractures of the proximal femur. The results were comparable to primary THA in femoral neck fractures. Considerably less satisfactory results were obtained in THA in intertrochanteric fractures. Bone loss and medial displacement of the femoral shaft led to high incidence of intraoperative complications and postoperative dislocations. Extreme care must be taken to avoid fracture and penetration of the femoral shaft. Autograft, allograft, or head and neck replacement components should be available for reconstruction of the difficult cases.
Adult↗
Arthrodesis with dual plates after failed total knee arthroplasty.
Eleven patients were treated by arthrodesis with dual compression plates after failed total knee arthroplasty. All patients had a solid fusion, at an average of 5.6 months after the operation. The complications included one femoral stress fracture and one persistent infection, both of which were treated successfully. Fixation with dual compression plates is a useful technique for the salvage of a failed total knee arthroplasty, even when the patient has an infection. Staggering of the plates may help to prevent late stress fractures.
Adult↗
Arthroscopic treatment of symptomatic total knee arthroplasty.
This paper reports experience with arthroscopic treatment of 53 patients with symptomatic total knee replacements since October 1983. There were no postoperative complications. Eighteen patients were diagnosed with the tethered patella syndrome--a patellofemoral dysfunction manifested by painful popping, catching, grinding, and jumping of the patellar component. Three distinct types of bands were identified that prevented the patella from seating into the femoral sulcus and/or tethered the patellar laterally. Complete resolution of preoperative symptoms followed arthroscopic removal of the fibrous bands. Of the seven patients with arthrofibrosis, two patients had knee fusions, two are awaiting that procedure, and three patients maintained increased motion, although one remains symptomatic with pain. Two patients demonstrated patellar malalignment treated by arthroscopic lateral retinacular release. Of the 24 patients who had arthroscopic evaluation as a diagnostic procedure, five patients had retained foreign matter or soft tissue, two patients had traumatic hemarthroses, nine patients had undefined pain syndromes, one patient demonstrated posterior instability, four patients were infected, two patients demonstrated loose tibial components, and two experienced dissociation of the metal tibial component from its polyethylene-articulating surface. In the authors' experience, operative arthroscopy of the prosthetic knee was reliable, safe, and effective.
Adult↗
Dissociation of the tibial component in total knee replacements.
Dissociation of the polyethylene component from its metal backing in total knee arthroplasty is a recognized problem regarding the patella. Two cases of dissociation of the metal-backed tibial component from its polyethylene articulating surface presented symptoms of prosthesis failure: persistent pain, swelling, sensations of instability, and gait difficulty. Investigations ruled out prosthesis malalignment, loosening, and sepsis. Precise diagnosis of dissociation of the tibial component was made by diagnostic arthroscopy.
Adult↗
Advances in total hip reconstruction.
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Biocompatible Materials↗
An anatomic study of subtalar instability.
Subtalar instability has been recognized as a cause of ankle symptoms. The purpose of this anatomic study is to determine the ligament damage required to produce subtalar instability, and to define a radiographic technique to demonstrate it. Ten fresh adult cadaver ankles were dissected. Selective sectioning of the calcaneofibular ligament, capsule, and interosseous ligaments of the subtalar joint were done. Radiographic documentation of subtalar opening was recorded, using a lateral and Brodan's view. Sectioning of the calcaneofibular ligament alone produced a 5-mm opening of the subtalar joint. When combined with sectioning of the interosseous ligament, a 7-mm opening was produced. This was reproduced with a plantar flexion-supination load to the foot. Instability of the ankle joint (talar tilting) was produced only when loading caused additional tearing of the anterior talofibular ligament. This study suggests that surgical repairs to correct lateral ankle instability should include repair or substitution of the calcaneofibular ligament if subtalar instability is a consideration.
Humans↗
Acute lateral ankle ligament injuries: a literature review.
The average general orthopaedic surgeon examines and treats a considerable number of acute lateral ankle ligament sprains in a busy office practice. A cursory review of recent articles published on this subject will present a confusing picture regarding diagnosis and treatment of Grade III injuries. An air of controversy surrounds the interpretation of diagnostic x-rays, and the management of these common ankle problems. This review article is presented to summarize current thoughts on the anatomy, biomechanics, diagnosis, and treatment of acute lateral ankle ligament sprains.
Adolescent↗
The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty.
Efficacies of three alternate methods of postoperative analgesia were studied in 156 patients who had total knee arthroplasty (TKA). Forty-two of these patients received parenteral meperidine hydrochloride or morphine (Group 1), 58 patients received periodic epidural injections of morphine (Group 2), and 56 patients received continuous epidural infusions of bupivacaine hydrochloride and Duramorph (Group 3). The postoperative course of all patients was documented in terms of the incidence and severity of pain, range of joint motion, duration of hospitalization, and occurrence of complications. Although epidural analgesia increased the cost and duration of the operation, good-to-excellent pain relief was attained in 86% (Group 2) and 88% (Group 3) of cases with epidural analgesia compared with 61% of patients (Group 1) receiving conventional analgesia. Moreover, 67% of patients in Group 1 experienced frequent episodes of moderate-to-severe postoperative pain in contrast to 40% of patients in Group 2 and only 10% of patients in Group 3. As a result of diminished pain, greater joint motion was obtained within the first 72 hours in Groups 2 and 3. They also had shorter hospitalization (9.6 days versus 11.2 days for Group 1 and 10.8 days for Group 2). However, the use of epidural analgesia did not reduce the incidence of complications, including nausea. Continuous infusion of epidural bupivacaine and Duramorph provided good-to-excellent control of postoperative pain after TKA. However, better analgesics are needed to reduce the high incidence of side effects associated with various treatment methods.
Aged↗