Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator.

We treated 24 patients with high-energy fractures of the tibial plateau by the Ilizarov fixator and transfixion wires. Eleven fractures were open, and 20 patients had complex injuries. Twelve were treated by ligamentotaxis and percutaneous fixation, seven by limited open reduction and five by extensive open reduction. All were followed for at least 24 months. All the fractures united, with an average time to healing of 14.4 weeks. Thirteen patients achieved full extension and 13 more than 110 degrees of flexion. Twenty-two knees were stable. Fifteen patients walked normally and the rest with only a slight limp. All but two knees had an articular step-off of less than 4 mm and all had normal axial alignment except two. There were no cases of postoperative skin infection, osteomyelitis or septic arthritis. Ilizarov circular fixation is an ideal method of treatment for these fractures when extensive dissection and internal fixation are contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution.

The Rotaglide total knee arthroplasty. Prosthesis design and early results.

The Rotaglide knee (Cozim Medical, UK) is a three-part knee containing a mobile polyethylene meniscal platform, imparting reduced loosening forces to the tibia. The femoral component design provides a high degree of congruency throughout the range of motion from 0 degree to 110 degrees, and both femoral and tibial components ensure minimal bone removal. The system is versatile, including a large number of component options, and it may be used in both primary and revision arthroplasties. The first results in 170 cemented knees (161 patients) with 2- to 5-year follow-up periods (average, 3.1 years) were very encouraging (excellent or good in 95% of knees, based on the British Orthopaedic Association knee assessment system). Poor results were seen only in revision cases. There have been no mechanical implant failures and no platform bearing dislocations, and the platforms continue to move as documented by postoperative roentgenograms, which show the metal markers of the platforms moving anteriorly in flexion and posteriorly in extension.

Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection.

Non-union of the tibia associated with infection was treated with radical resection of the necrotic bone and distraction osteogenesis in twenty-eight patients who were eighteen to seventy-four years old. Non-union, infection, shortening, deformity, and osteoporosis were all addressed simultaneously. All patients had either one-segment or two-segment lengthening of bone with a technique of bone transport in which a bone fragment is moved toward the site of non-union, leaving a defect that is bridged by distraction osteogenesis. The size of the bone defect that was bridged averaged six centimeters (range, two to thirteen centimeters). The infection was eradicated in all patients before the fixator was removed. The mean duration of treatment was ten months. The mean time to union, calculated from the day that the intercalary segment came into contact with the target segment, was six months. The mean duration of follow-up was thirty-nine months. The deformity and the inequality of the lengths of the legs were corrected successfully--to less than 7 degrees and to less than 2.5 centimeters, respectively--in fourteen of the twenty-eight patients. In these fourteen patients, the bone result--determined according to the criteria of union, healing of the infection, status of the deformity, and amount of residual shortening--was considered excellent. Of the fourteen remaining patients, eight had a good bone result; one, a fair result; and five, a poor result. The functional result was excellent in seven patients, good in eleven, fair in four, and poor in five. One patient had an amputation. Three patients (11 per cent) had a problem with union that was treated with augmentation with a bone graft. One patient, who had sustained a refracture, had an amputation. Twenty-five patients (89 per cent) had a total of seventy-one minor or major complications, a rate of 2.5 complications per patient.

Factors influencing neurological recovery in burst thoracolumbar fractures.

The association between the thoracolumbar vertebrae fracture pattern, treatment and neurological recovery was estimated. Sixty-three patients with burst fractures at the T11 to L2 vertebral level and associated neurological deficit were evaluated by plain roentgenograms, CT scan and a quantitative neurological examination. The parameters used were percent canal compromise, location of the retropulsed middle column fragment, kyphosis, type of treatment, and neurological recovery. The follow-up varied from 24 to 84 months (mean 44 months). Treatment was conservative in 15 patients and surgical in 48 patients. Posterolateral decompression was carried out in 26 patients. The severity of the initial paralysis did not correlate with the initial fracture pattern except perhaps for Frankel A cases. Neurological recovery did correlate with the initial kyphosis but not with the amount of canal compromise or the location of the middle column fragment. Neurological recovery did not correlate with decompression. Improvement of paralysis was associated with restoration of the sagittal spine alignment. From the patients with greater than 5 degrees correction of kyphosis the majority improved neurologically. If the correction of the kyphosis was less than 5 degrees the recovery was poor regardless of the method used. We assume that the initial paralysis in burst fractures with severe kyphosis is partially caused by permanent cord or root damage and partially by neuroapraxia from angulation of the neural structures and their vessels. With reduction of the fracture and correction of the kyphotic deformity, spinal cord, roots and their vessels become lax, and the chances for neurological recovery increase significantly.

[Treatment of femoral and tibial septic pseudarthrosis by internal lengthening. Apropos of 24 cases]. / Le traitement des pseudarthroses fémorales et tibiales septiques par allongement interne. A propos de 24 cas.

Twenty two patients aged 18 to 47 years were treated for 24 infected bone defects and nonunions (6 femora and 16 tibiae) by radical resection of the necrotic bone and distraction osteogenesis techniques to regenerate the excised bone. Nonunion, infection, limb shortening, deformity, and osteoporosis were all addressed simultaneously. All patients underwent either bifocal or trifocal internal lengthening by bone transport technique of sliding a bone fragment, producing distraction osteogenesis behind it until the defect was bridged. The mean bone defect was 8.2 cm, with a range up to 16 cm. Eradication of the infection was achieved in all cases prior to the removal of the fixator. Problems with union requiring bone graft augmentation were encountered in three patients. One patient, who sustained a refracture, underwent an amputation. The mean time to union was 4.4 months, if the time was taken from the day the intercalary segment came in contact with the targed segment. Deformity and length inequality were corrected successfully in the majority of the patients. The bone result was excellent in 15 cases, good in 7, fair in one, and poor in one. The functional result was excellent in 11 cases, good in 8, fair in 3, and poor in 2. Distraction osteogenesis treatment seems to be superior to any other method used for treatment of infected bone defects and nonunions, especially in terms of eradication of osteomyelitis and quality of bone union. However, the ability to achieve excellent bone result in even the worst infected bone defects and nonunions does not guarantee a favourable functional result, unless the patient has an acceptable neurovascular status.

Tumor induced osteomalacia.

We describe a case of mesenchymal tumor induced osteomalacia. Our patient presented a typical clinical and radiological picture of osteomalacia, with low serum phosphate. With the excision of the tumor, which was located in the right forearm, the serum phosphate concentrations increased to normal values within a week postoperatively and the symptoms improved dramatically.

Management of adult spinal deformity with combined anterior-posterior arthrodesis and Luque-Galveston instrumentation.

Twenty-five consecutive adult women with nonparalytic spinal deformity were treated with fusion to the sacrum. Two patients were lost to follow-up and one patient died, leaving 22 patients for review. All patients underwent a first-stage anterior spinal fusion without instrumentation followed by a second-stage posterior spinal fusion with Luque-Galveston instrumentation. The average age of the patients was 47 years (range, 25-64 years). The average follow-up was 39 months (range, 24-60 months). Ten patients had had previous surgery in the area of the instrumentation. The main indications were pain (22 patients), loss of sagittal plane balance (17 patients), and progression of the deformity (13 patients). Additional procedures included anterior corpectomies (five patients), anterior and posterior osteotomies (two patients), posterior osteotomies (eight patients), and posterior decompression (five patients). The average curve correction was 27% for thoracic scoliosis and 44% for lumbar scoliosis. Physiologic sagittal plane realignment was obtained in four patients who presented preoperatively with sagittal plane deformities. Pain improvement was reported in 14 of 22 (63%) patients. Nineteen (82%) patients had 34 complications. Pseudarthrosis occurred in nine patients (41%) and was successfully repaired in four; hence the fusion rate was 77% at follow-up. Of the 23 patients, one died from pulmonary embolism, 15 (66%) were in good condition, one (4%) was in fair condition, and seven (30%) were in poor condition. Previous surgery and additional procedures such as vertebrectomies or osteotomies did not adversely affect the outcome. There were no permanent neurologic deficits related to the instrumentation or the passage of sublaminar wires. The Luque-Galveston method provided correction of sagittal plane deformities and flatback syndrome.

Late failure and revisions of old-type total knee replacements.

This paper reports the failure rate and survival of old-generation total knee replacements (TKR). Revision operations are also discussed. During a 5-year period from 1974 to 1979, 117 patients, 165 knees, were operated. The prostheses used were Geomedic in 75 knees and Attenborough in 90 knees. Revision was performed in 46 knees (28%). Six knees (4%) were infected. The survival time from implantation averaged 4.3 years, and the followup was 7 to 13 years for the Geomedic (mean 9.7) and 6 to 9 years for the Attenborough (mean 6.7). Mechanical problems were related to loosening of the tibial and femoral components, and revision was required for this reason. The success rate of the revision was 50% at 5.4 years; the less invasive the primary operation, the simpler the revision. Constrained prostheses must be used when ligaments are not intact. In case of infection, removal of the implants is not always necessary.