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Biomedical subjects

J B Jupiter

Publications and source records attributed to J B Jupiter.

At least 37 records · Page 2Linked to original sources
PubMed1999

Radiocarpal fracture-dislocation.

Radiocarpal fracture-dislocation is an uncommon but complex injury that is often the result of high energy trauma. The combination of ligamentous and osseous injuries demands meticulous attention to restoration of anatomy, especially of the radial styloid. Open reduction and internal fixation is often necessary to restore the relationship of the end of the radius to the carpus and distal ulna. We present a retrospective review of 12 patients treated over a 10-year period and review the literature.

Adult↗
PubMed1999

Septic arthritis and osteomyelitis of the wrist: reconstruction with a vascularized fibular graft.

A case of spontaneous staphylococcus arthritis of the wrist with associated carpal and distal radius osteomyelitis is reported. Following sequential debridements and a 6-week course of parenteral antibiotics, an extensive defect was bridged with a vascularized fibular autograft to achieve a successful fusion. There was no donor site morbidity or recurrent infection. Follow-up radiographs 41 months later demonstrated complete incorporation and hypertrophy of the graft.

Arthritis, Infectious↗
PubMed1999

Wire-loop fixation of volar displaced osteochondral fractures of the distal radius.

We describe the technique of wire-loop fixation to treat 4 young men with a unique variant of Melone's type 4 articular fracture of the volar lunate facet, characterized by a displaced rotated articular fragment supported by a limited amount of subchondral bone. This is an unusual injury that threatens the integrity of both the radiocarpal and distal radioulnar joints. It is the result of a compressive force to the wrist and may require trispiral computed tomography for delineation. Open reduction and internal fixation is recommended to maintain stability and articular congruity. The displaced volar-articular fragment, however, may be relatively small; therefore, direct manipulation could lead to soft tissue stripping and osteonecrosis. We have found the technique of wire-loop fixation to be a simple, reproducible, and effective alternative method of internal fixation for these difficult fractures. Malunion, nonunion, loss of fixation, tendon rupture, infection, arthrosis, or pain caused by hardware has not occurred. Use of this technique is not recommended in patients with osteoporotic bone.

Accidental Falls↗
PubMed1999

Treatment of triplane fractures of the head of the proximal phalanx.

We report the morphology and treatment of 2 cases of a triplane intra-articular bicondylar fracture of the head of the proximal phalanx. Fracture lines in the coronal, sagittal, and transverse planes characterize this fracture, making it highly unstable. Open reduction and internal fixation using two 1.5-mm interfragmentary screws oriented in a dorsal to volar direction resulted in anatomic restoration of the articular surfaces and satisfactory functional results. In 1 case, autogenous cancellous bone graft was harvested from the ipsilateral radial styloid to support the articular fragments.

Accidents, Occupational↗
PubMed1999

The surgeon as a hand patient: the clinical and psychological impact of hand and wrist fractures.

To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons' personality, motivation, and ability to accept and adapt to the injury; the nature of the injury; and the importance of the hand to the surgeons' careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.

Adult↗
PubMed1999

Salvage of contaminated fractures of the distal humerus with thin wire external fixation.

Fractures and osteotomies of the distal humerus that are contaminated or infected represent a difficult management problem. Stable anatomic fixation with plates and screws, the acknowledged key to a good result in the treatment of bicondylar fractures, may be unwise. A thin wire circular (Ilizarov) external fixator was used as salvage treatment in such complex situations in five patients. The fixator allowed functional mobilization of the elbow while allowing achievement of the primary goal of eradicating the infection or colonization. Two patients required a second operation for fixation of a fibrous union of the lateral condyle. One patient with a vascularized fibular graft later required triple plate fixation for malalignment at the distal host and graft junction. Four of five patients ultimately achieved complete union. The fracture remained ununited in one patient who has declined additional intervention. All five patients achieved at least 85 degrees ulnohumeral motion, two after a secondary elbow capsulectomy performed after healing was achieved. This experience suggested that the Ilizarov construct, although not a panacea, represents a reliable method of skeletal stabilization that allows functional mobilization while elimination of infection or colonization is ensured. If necessary, stiffness and incomplete healing can be addressed with an increased margin of safety at subsequent operations.

Adolescent↗
PubMed1999

Infected nonunion of the tibia.

The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.

Adult↗
PubMed1999

Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer.

Ten male patients with previously infected bony defects involving both sides of an articulation underwent arthrodesis using a vascularized fibular transfer. The average age of these patients was 38 years (range, 20 to 60 years). The size of the bony defect averaged 9 cm (range, 3 to 21 cm). The ankle was involved in five patients, the knee in two patients, the wrist in two patients, and the elbow in one patient. Nine cases represented septic pseudarthroses (eight after trauma and one after attempted ankle arthrodesis). One patient had a defect across the wrist after debridement of a chronic infection. The patients were followed for an average of 71 months (range, 26 to 144 months). Nine patients healed after the index vascularized fibular transfer, and one patient (ankle arthrodesis) required a second cancellous bone-grafting procedure for delayed union at the junction of the fibula with the talus. Four of seven patients with lower limb involvement had residual leg length discrepancies averaging 5 cm (range, 3 to 8 cm), and one had a persistent 20-degree internal rotation deformity. Two of the patients with upper limb involvement had stiff digits. Five of the nine previously employed patients returned to their former occupation (including heavy labor in four cases). Complications included two wound separations, one case of instability of the donor ankle after removal of a large fibular graft (related in part to a prior injury), and one fracture at the junction of the fibular graft with the local bone 10 months after the index procedure, which united after plate fixation and application of autogenous cancellous bone graft. Arthrodesis using a transfer of vascularized fibular bone represents a viable option for limb salvage in the face of an infected transarticular bony defect.

Adult↗
PubMed1999

The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients.

Twenty-two elderly patients (average age, seventy-two years) who had an atrophic, unstable, ununited fracture of the humeral diaphysis were managed with plate-and-screw fixation and application of an autogenous bone graft from the iliac crest. Fifteen of the patients had had at least one previous operation in an attempt to obtain union of the fracture. One patient had an active infection and two had a quiescent infection, all with Staphylococcus epidermidis. The average duration of nonunion before the patients were first seen by us was two years and four months (range, five months to sixteen years). Fifteen of the nonunions were synovial. In each patient, at least one modification of the standard technique of plate-and-screw fixation was needed as a result of osteopenia. In order to enhance fixation, the standard protocol incorporated the use of a long plate (with an average of eleven holes and an average length that was 76 percent of that of the bone), a plate with a blade (used in thirteen patients), and replacement of loose, 4.5-millimeter cortical-bone screws with 6.5-millimeter cancellous-bone screws (twelve patients). Spiked nuts (Schuhli nut; Synthes, Paoli, Pennsylvania) that lock the screws to the plate, creating a solid point of fixation analogous to a blade, were incorporated into the protocol when they became available (used in six patients). In five limbs, the nonunion was associated with an osseous defect that could not be addressed by shortening of the bone alone. Three of these limbs were stabilized with a bridge plate that had been contoured to stand away from the bone at the site of nonunion (so-called wave-plate osteosynthesis), and the remaining two limbs were stabilized with a combination of intramedullary and extramedullary plates. In one of these two limbs, the extramedullary plate was contoured (that is, a wave plate). The fracture united in twenty (91 percent) of the patients. There was no progressive loosening or breakage of a fixation device, even in two patients who had radiographs that were suggestive of an incomplete union. Five of the patients were followed for a limited duration (average, one year and six months) as a result of death or illness. They had two excellent results, two good results, and one poor result according to a modification of the rating system of Constant and Murley. The remaining seventeen patients, including the two who had a persistent nonunion, were followed for an average of three years and one month (range, two years to five years and ten months). They had significant improvements in all of the functional scores at the most recent follow-up evaluation: the average score according to the modified system of Constant and Murley increased from 9 to 72 points (p < 0.001), the average score according to the Enforced Social Dependency Scale decreased from 39 to 9 points (p < 0.001), and the average score based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire decreased from 77 to 24 points (p < 0.001). According to the scores based on the Disabilities of the Arm, Shoulder, and Hand Questionnaire, nine of the seventeen patients who had been followed for more than two years had an excellent result, four had a good result, two had a fair result, and the two who had a persistent nonunion had a poor result. Complications included postoperative delirium, a stitch abscess, transient radial nerve palsy, a fracture distal to the plate, and the need for a blood transfusion, in one patient each. Two patients had a fibrous union. There were no major medical complications. An unstable, united fracture of the humeral diaphysis can be extremely disabling and may threaten the ability of an elderly patient to function independently. Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves function and the degree of independence

Activities of Daily Living↗
PubMed1999

Posttraumatic nonunion of the proximal tibial metaphysis.

Eighteen patients with nonunions of the proximal tibial metaphysis were treated at one institution. Nine patients had a history of osteomyelitis. There was an average of 4 prior surgical procedures to achieve fracture union, obtain soft-tissue coverage, or eradicate infection. Stable internal fixation with bone grafting was performed in 13 patients, with a fixed angle blade plate in 10 and standard compression plate in 3. Three patients were treated with hybrid circular external fixators, and one patient was placed in a cast. An additional patient underwent long-stem total knee arthroplasty with structural allografting. Follow-up averaged 45 months. Osseous union was achieved in 100% of patients. Alignment was within 5 degrees of neutral in 94% of patients. Forty-four percent of patients continue to require the assistance of a cane for ambulation. Twelve patients have some pain with activity, primarily related to ipsilateral knee arthrosis. No infections have recurred. Knee motion improved an average of 28 degrees. Healing of nonunions of the proximal tibial metaphysis may be achieved with meticulous soft-tissue care and appropriate stabilization of small, osteoporotic, periarticular fragments.

Adult↗
PubMed1998

Outcome of ulnar neurolysis during post-traumatic reconstruction of the elbow.

We performed ulnar nerve neurolysis and transposition during reconstructive operations on 20 consecutive patients (21 elbows) with neuropathy after the failure of primary treatment of elbow fractures. There were 11 men and nine women with a mean age of 48.3 years. Preoperatively, four elbows were in McGowan stage I, seven in stage II and ten in stage III and the mean Gabel and Amadio ulnar nerve score was 3.2. At a mean follow-up of 32.1 months (24 to 67) we performed comprehensive neurological, functional, electrophysiological and outcome assessments. Patient satisfaction was high with good pain relief and restoration of hand strength and dexterity. The mean Gabel and Amadio score had improved to 6.5, an improvement of 3.3. There were one excellent, 16 good, 2 fair and 2 poor results; both of the last were due to failure of the underlying elbow reconstruction. Even for advanced stage-II and stage-III lesions we achieved good function, return of intrinsic power, and a high rate of patient satisfaction.

Adult↗
PubMed1998

Management of recurrent, complex instability of the elbow with a hinged external fixator.

We have treated 16 patients with recurrent complex elbow instability using a hinged external fixator. All patients had instability, dislocation or subluxation of the ulnohumeral joint. The injuries were open in eight patients and were associated with 20 other fractures and five peripheral nerve injuries. Two patients had received initial treatment from us; 14 had previously had a mean of 2.1 unsuccessful surgical procedures (1 to 6). The fixator was applied at a mean of 4.8 weeks (0 to 9) after the injury and remained on the elbow for a mean of 8.5 weeks (6 to 11). After treatment we found the mean range of flexion-extension to be 105 degrees (65 to 140). At a final follow-up of 23 months (14 to 40), the mean Morrey score was 84 (49 to 96): this translated into one poor, three fair, ten good and two excellent results. Complications included one fractured humeral pin, one temporary palsy of the radial nerve, one recurrent instability, one wound infection, one severe pin-track infection and one patient with reflex sympathetic dystrophy. Although technically demanding, the use of the fixator is an important advance in the management of recurrent complex elbow instability after failure of conventional treatment.

Adult↗
PubMed1998

Operative treatment of post-traumatic proximal radioulnar synostosis.

The results of operative resection of a post-traumatic proximal radioulnar synostosis performed by one surgeon in eighteen limbs of seventeen consecutive patients during an eight-year period were reviewed retrospectively. The resection was performed an average of nineteen months after the injury; eight limbs had the resection less than twelve months after the injury. A free fat graft was used in the first eight patients. No adjuvant non-steroidal anti-inflammatory medication or low-dose radiation was used postoperatively as prophylaxis against heterotopic ossification. We classified the proximal radioulnar synostoses into three subgroups: A indicated a synostosis at or distal to the bicipital tuberosity (four limbs), B indicated a synostosis involving the radial head and the proximal radioulnar joint (seven limbs), and C indicated a synostosis that was contiguous with bone extending across the elbow to the distal aspect of the humerus (seven limbs). The patients were followed for an average of thirty-four months (range, twenty-four to sixty months). The synostosis recurred in one patient, the only patient in the series who had sustained a closed head injury at the time of the initial injury. Additional complications included a fracture of the ulna, a broken pin on a hinged elbow distractor, and dislodgment of a free nonvascularized fat graft in one patient each. The seventeen limbs that did not have a recurrence regained an average of 139 degrees of rotation of the forearm. With the number of patients available, we could not detect a significant relationship between subsequent rotation of the forearm and the size of the synostosis, the use of interpositional fat, or the concomitant use of a hinged elbow distractor. The eight limbs that had resection of the synostosis less than twelve months after the injury regained an average of 144 degrees of rotation compared with 134 degrees in the nine limbs that had resection at least twelve months after the injury. This difference could not be shown to be significant. In this series, operative resection of a post-traumatic proximal radioulnar synostosis led to good results despite the lack of adjuvant radiation therapy or anti-inflammatory medication.

Adult↗
PubMed1998

Monteggia fractures in adults.

The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.

Female↗