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We have treated 350 displaced Colles fractures by percutaneous fixation with K wires arranged in a 'basket' formation, as described by Kapandji. This technique enables satisfactory stabilisation of the fragments and early mobilisation and rehabilitation, usually without the use of a plaster cast or brace. We describe our indications for use of the method, the technique followed and analyse our results.
The authors have reviewed 26 cases of tuberculosis of the foot and 32 of the ankle, which they have treated personally. All the patients were adults and most presented with advanced destruction of bone and joints. Bacterial and histological confirmation of the diagnosis was obtained in 56 patients. All were treated by chemotherapy; the drugs and regime varied over the years. All responded well to this treatment, but one relapsed after 24 months. Orthopaedic problems were usually managed by immobilisation in plaster casts, but 6 patients required arthrodesis, 5 of the ankle and one triple fusion. The functional results of the standard treatment were generally good. Arthrodesis is seldom needed and should be performed only for permanent pain or crippling deformity.
The management of 51 comminuted fractures of the shaft of the femur, treated in Africa with limited facilities, is described. The majority were immobilised on traction followed by a period in a plaster cast. Two thirds of the results were judged to be good or very good. In fifteen cases traction did not produce satisfactory alignment. Intramedullary nailing was then employed between the 16th and 47th days, when the fractures were beginning to unite. The fracture site was opened but intramedullary reaming was not used. These relatively unsophisticated methods produced satisfactory results.
We have carried out a retrospective study of 49 cases of tuberculosis of the hip in adults, all treated by one of the authors. All patients presented with destructive lesions in the hip. Abscess formation and sinuses were infrequent. A scientific diagnosis was obtained in 46 cases. All the patients were treated with chemotherapy for 6 to 12 months. The hip was immobilised for 3 months, either by skeletal traction followed by a plaster cast, or by a cast alone, depending on the need for correction of deformity. If deformity was fixed or absent, immobilisation was not undertaken. A favourable response to chemotherapy was observed in all 40 patients who were available for follow up. One relapsed after 12 months. Some hips progressed to total bony fusion, with the remainder showing either complete or moderate stiffness. The functional result depended on the presence of pain and the degree of deformity, and the need for surgery was determined by these two factors. Corrective osteotomy or arthrodesis have been performed. The indications for operation are discussed considering the sex, occupation and needs of the patient. The place of excision arthroplasty and of total replacement is examined.
Ruptures of Achilles tendon are quite common. We here report a case of fracture in an ossified mass of Achilles tendon in an 84-year-old male patient. The mass occurred 78 years following surgery for bilateral equinus deformities of his ankle. Clinically, he had a palpably definite gap in the ossified area of the Achilles tendon, which was confirmed by a roentgenogram and a magnetic resonance scan of his left ankle. He was treated conservatively in a plaster cast for 12 weeks. The overall functional result a year after his treatment was quite satisfactory.
A retrospective of 216 tibial fractures treated orthopedically was carried out. The aim was to analyze a set of clinicobiological parameters that owing to their assumed action on the physiological model of consolidation can be considered as risk factors to be taken into account in all kinds of orthopedic treatment, because they may lead to a lengthening of the normal consolidation time of the fracture. The variables analyzed were the following: type of immobilization, causative agent of the fracture, location of the focus of the fibular fracture, initial displacement, degree of conminution, type of wound, type of fracture, appearance of radiologically observable callus, commencement of weight-bearing, post-fracture hematoma, secondary displacement, and infection of soft tissues. In the particular case of immobilization by an ischiopedic plaster cast, the following parameters showed a greater degree of prognostic significance: initial displacement, secondary displacement, and age.
Twelve patients with juvenile kyphosis and eight patients with idiopathic kyphosis were reviewed at an average follow-up of 19 years. The average age of the patients at follow-up was 33 years (range 26-45 years). All the patients but one, who had a posterior fusion of the dorsal spine, had been treated with a plaster cast jacket followed by a plastic brace. At the end of treatment there had been an improvement of about 30% on the original curves in both juvenile and idiopathic kyphosis. At follow-up, however, all the patients had lost the correction obtained and the curves had become worse than originally, those in idiopathic kyphosis more so than those in juvenile kyphosis. Despite the increase in their angular deformity, all the patients managed fairly well and only two complained of distressing back pain.
The authors discuss the frequency, etiology, clinical symptomatology, classification, and treatment of congenital dislocations of the knee joint. They present 8 cases of their own material. The congenital knee joint dislocation can be treated conservatively with good results. Treatment with plaster casts does not interfere with treatment of simultaneous hip dysplasias in Pavlik bandages. Even foot deformities can be treated at the same time. They emphasise the need for earliest treatment which seems equally important for all three deformities: knee joint dislocations, hip dysplasias, and club feet.
Follow-up examinations of 35 patients with an arthroscopically confirmed isolated fresh tear of the anterior cruciate ligament were conducted after an average period of 5 years. After arthroscopy and immobilization of the knee in a plaster cast for 2 weeks, all 35 patients had been conservatively treated with neurophysiological physical therapy. Twenty-four of the tears were complete; the remaining 11 were partial. The results of the follow-up examination are based on subjective scores (O'Donoghue score, Lysholm score), an objective score (objective O'Donoghue score) and clinical examination. With the partial tears, good to satisfactory results were achieved, and surgery was needed less often. In these patients, it was largely possible to maintain the original level of athletic performance. Those patients with complete, isolated tears generally had satisfactory to poor results on the objective scores. There was a high rate of revision surgery, especially in the case of meniscus tears, and they were largely unable to regain their original level of athletic performance.
Six patients with displaced split-depression-type tibial condylar fractures were treated with absorbable, self-reinforced polyglycolide screws. One patient underwent reoperation because of an unacceptable primary fracture reduction unrelated to the implant material. The others healed well, with good functional and anatomical results despite one slight redisplacement in a medial condylar fracture treated without plaster cast immobilisation. Absorbable polyglycolide screws seem to be suitable for the fixation of selected tibial condylar fractures. The implant removal operation is thus avoided.
Differential counts and electron microscopical studies of osteocytes were performed on rats immobilized by spinal cord severing, plaster cast and ischiatic nerve dissection. In undecalcified ground sections of tibia and femur (100 micron) stained with basic fuchsin, osteocytes were differentiated into small (metabolically inactive) osteocy es enlarged (metabolically activated) osteocytes and empty lacunae. In rats (immobilizedfor' three weeks) with functioning parathyroid glands, but not after parathyroidectomy, the number of activated cells is markedly increased, whereas the number of small osteocytes is reduced. In animals with spinal cord severing the number of empty lacunae is also increased. Electron microscopical studies of undecalcified tibiae taken from rats immobilized for ten days showed a periosteocytic osteolysis with destruction of the lacunar wall, fragmentation of collagen fibres and loss of mineral crystals. The cytoplasmic seams of osteocytes were broadened, mitochondria were enlarged, and the cytoplasma showed vacuoles containing amorphous material which could be found in the pericellular space. Deep invaginations of the cytoplasma and an increase of the cell processes were typical findings. The results of the investigation point to an activation of osteocyte metabolism by immobilization. The osteocytes thus play an important part at the onset of immobilization osteoporosis. Periosteocytic osteolysis can be inhibited by parathyroidectomy. Therefore, the response of osteocytes to endogenous parathyroid hormone must be altered under conditions of immobilization.
Posterior dislocation of the shoulder is extremely rare in children. We encountered a posterior dislocation of the shoulder complicated by fracture of the acromion in a 14-year-old boy. He recovered uneventfully after immediate manual reduction performed under general anesthesia and truncal plaster cast fixation. Early diagnosis and treatment are considered to be especially important in managing this injury.
Rupture of the ACL may result in chronic anterior knee instability. However, in the majority of patients the secondary stabilizers of the joint such as collateral ligaments, menisci, and the capsule will compensate for this instability. We recommend surgical reconstruction of the acute rupture of the ACL only in the young, active athlete. Concomitant ruptures of capsuloligamentuous structures do not indicate surgical treatment: they may be treated by a plaster cast or a splint with good results. Chronic symptomatic anterior knee instability should first be treated by a vigorous muscle-training program. Surgery is performed only for those patients who cannot compensate for their instability after this rehabilitation program.
Two cases of genu recurvatum deformity and leg length discrepancy after partial growth arrest of the proximal tibial physis are described. The patients are both boys thirteen and fifteen years old respectively. The etiology of the deformity is considered to be local pressure on the tibial tuberosity, in the first case after treatment with plaster cast after correction of an angular deformity in a tibial fracture and in the second case after prolonged treatment with patellar tendon bearing brace. The boys were treated with physeal distraction which corrected both the leg length discrepancy and the angular deformity. The technique is recommended because the correction is done at the site of the deformity and knee motion is possible during the entire treatment period.
In a prospective series of 75 patients the results of early external fixation of comminuted intraarticular Colles' fractures were studied. Comparison was made to a control group of 32 patients treated with plaster cast fixation. The groups were equal with regard to age, sex and fracture type. The treatment consisted of reduction in general anaesthesia or arm block followed by the application of a small external fixation device. The fixation lasted for five weeks after which the patients were allowed free exercises. For evaluation at the one year follow up the following variables were used: Radiographic appearance. Healing in of the styloid process of the ulna. Subjective evaluation according to the Lidström score. Objective evaluation including range of motion and grip strength. In all follow up variables the treatment group was significantly better than the control group. The prognosis of conservatively treated comminuted intraarticular Colles' fractures is poor. The results of after external fixation are, however, very encouraging and the method can be recommended.
Thirty-eight patients with muscular torticollis were treated by a partial resection of the sternocleidomastoid muscle between 1970 and 1981. Clinical evaluations were performed on 35 of these patients who were followed up for 10 years (average of 11.3 years). Of 31 patients under 5 years of age at operation, good results according to Canale's criteria were obtained in 28 (90%). In four patients aged 6 years or more at operation, three showed good results. Postoperatively, massive cotton bandaging was applied with the neck in the neutral position for 3 weeks. A plaster cast, brace, or physiotherapy involving active motion training was not necessary.
A case of spontaneous dislocation of the tibialis posterior tendon in a 12-year-old boy is presented. Closed reduction under general anaesthesia was performed, and after immobilisation for 6 weeks in a plaster cast no recurrence was observed. This case illustrates an unusual case of habitual dislocation of the tibialis posterior tendon treated by conservative means.
Five fresh osteochondral fractures of the knee, which could not be fixed because of extensive fragmentation, were treated by excision of the fragments and reconstruction of the joint surface defect by an autogenous osteoperiosteal graft. The procedure was also used for joint surface reconstruction in sclerotic osteochondritis of the femoral condyle (nine knees) and grave patellofemoral chondromalacia (three knees). Plaster cast immobilization for 3 weeks was used in the two early cases. In all other cases, we employed a passive motion apparatus for 2 days postoperatively, followed by active mobilization in a knee brace with extension-flexion 30 to 90 degrees (femoral condyle reconstruction) or 0 to 45 degrees (patellar reconstruction). Gradual free movements were started 3 weeks postoperatively. The results after 1.5 to 6.5 years were satisfactory in all but one case. One arthroscopic removal of the loose graft was performed, as were two arthroscopic graft margin shavings. Three other reoperations were unrelated to the osteoperiosteal reconstruction. It appears that periosteal reconstruction should be considered in local osteochondral lesions, where excision of the injured cartilage is mandatory. The results were best in fresh trauma cases and younger people.