Knee dislocations and their management. A report of 16 cases.

We retrospectively studied the outcome of 16 knee dislocations. 11 patients had surgical treatment, 4 were managed nonoperatively and 1 patient died. In the elderly the outcome was poor, regardless of the type of treatment. Only 3 adolescents obtained excellent results and 2 young adults had good results after surgical repair of the knee. Concurrent arterial and nerve damage increased the morbidity.

Complete versus incomplete nonviable amputations of the thumb. Comparison of the survival rate and functional results.

81 patients with 84 complete (55) or incomplete (29) nonviable amputations of the thumb were studied to compare the survival rate and functional results between the two groups. 3 of these patients had bilateral thumb amputations. Of the 55 completely amputated thumbs, 43 survived (78 percent), while of the 29 incomplete nonviable amputations, 25 were salvaged (86 percent). Excluding patients with an amputation at the level of or distal to the interphalangeal (IP) joint, motion at the IP joint which did not exceed 40 degrees flexion even when a secondary procedure was done, did not show a statistical difference between the 2 groups. Average two-point discrimination was 14 mm for patients with complete amputations and 11 mm for patients with incomplete nonviable amputations. We conclude that incomplete nonviable amputations of the thumb are associated with a higher survival rate and better sensibility than complete thumb amputations, while motion at the IP joint does not differ between the two groups of patients.

Distal phalanx microsurgical replantation.

Replantation of a completely amputated part of the distal phalanx, which has a very small vessel size, has been reported by several authors with a varying rate of success. Drainage through venous anastomosis is not always possible. In 12 completely amputated fingers, at the level of, or more distal to, the distal interphalangeal joint, we attempted microsurgical replantation with a successful outcome in ten cases. Seven digits had one or two veins anastomosed. In five digits, an adequate size vein was not found, and the drainage was accomplished with provoked bleeding which was maintained for the 3 postoperative days at the expense of blood transfusion. In all successful cases the patients returned to their occupation in a mean of 9 weeks with very good or excellent functional results.

Osteonecrosis of the femoral head in immunosuppressed patients: hip salvaging with implantation of a vascularised fibular graft.

Osteonecrosis frequently occurs in patients being treated with steroids for conditions such as systemic lupus erythematosus and other collagen diseases and in renal transplant recipients. It remains an unsolved problem and can cause more disability than the underlying disease, particularly in young patients. In a series of eight young patients who received continuous corticosteroids and immunosuppressive agents, we attempted hip salvage in ten joints by implantation of a vascularised fibular graft into the necrotic femoral head. Follow-up ranged from 18 to 36 months. Joints which were operated on prior to articular surface collapse had complete restoration of normal function. In patients with more advanced lesions, surgery resulted in a painless hip, improved range of motion, and cessation of further progress of the disease. The preliminary data are considered encouraging enough to suggest that the vascularised fibular graft is an appropriate method for hip salvage in immunosuppressed patients with osteonecrosis of the femoral head.

Free vascularized fibular graft: a versatile graft for reconstruction of large skeletal defects and revascularization of necrotic bone.

The microvascular transfer of a fibular graft that was initially introduced for the treatment of massive bone loss in the appendicular skeleton has more recently found another useful application in the management of the osteonecrosis of the femoral head. Since 1989, we have successfully used the free vascularized fibula in two patients with segmental bone loss, one in the forearm and the other in the distal femur. We have also attempted revascularization of the femoral head in fifteen patients (eighteen hips) with osteonecrosis. Although our follow-up is short, the results have been encouraging and this method is now the treatment of choice in the early stages of the disease.