Z-bunionectomy with internal screw fixation.

A new procedure for the correction of hallux valgus was performed on 39 patients (66 feet). The follow-up period averaged 29 months, with a range of 24 to 32 months. The new procedure is a horizontally directed displacement Z-osteotomy in the head and shaft region of the first metatarsal. Rigid internal fixation is obtained with 3.5 or 2.7-mm bone screws. The surgeons' satisfaction rate of 79% compares favorably with the patients' complete satisfaction rate of 85%.

Identification of IgG in the canine intervertebral disc.

Nucleus pulposus was taken at necropsy from five mongrel dogs and tested in an enzyme linked immunoabsorbent assay (ELISA) system designed to indicate the presence of IgG and IgM. This assay positively identified IgG. Agarose-bound Protein A was used to treat the nucleus pulposus material to extract the IgG. Repeating the ELISA using Protein A-treated nucleus pulposus showed that the ELISA was greatly diminished in activity, confirming the presence of whole molecules of IgG in nucleus pulposus. Investigators have postulated an immunologic basis for spinal pain syndromes. None to date has demonstrated IgG in the nucleus pulposus. This IgG may be a mediator by which an inflammatory response is activated which contributes to the clinical picture of chronic back and radicular pain.

The inflammatory effect of nucleus pulposus. A possible element in the pathogenesis of low-back pain.

Homogenized autogenous nucleus pulposus was injected into the lumbar epidural space of four dogs through an indwelling catheter. After daily injections of the material over 5 to 7 days, the dogs were killed at 5, 7, 14, or 21 days after the first injection. In four dogs that served as controls, normal saline was injected on an identical schedule and the dogs were killed at times identical to the experimental group. Evaluation of the dural sac, the spinal cord and its roots was performed by gross inspection and microscopic analysis. There was evidence of an inflammatory response to the nuclear material injected, but no inflammatory response occurred in the control group.

The effect of adjunctive methylmethacrylate on failures of fixation and function in patients with intertrochanteric fractures and osteoporosis.

In a retrospective review of eighty-two intertrochanteric fractures (twenty-nine stable and fifty-three unstable) in seventy-nine elderly, debilitated patients with associated advanced osteoporosis (Grade III or less by the system of Singh et al.), fifty-six were available for follow-up: twenty-eight that had been treated at the University of Illinois with an approximately anatomical reduction and compression-screw fixation and twenty-eight (in twenty-seven patients) that had been treated at the University of Chicago with an approximately anatomical reduction, compression-screw fixation, and adjunctive methylmethacrylate bone cement in the head-neck fragment. Follow-up analysis after an average of thirty-four months for the group that had augmentation with cement and an average of twenty-six months for the uncemented group showed that for the eighteen stable fractures that could be followed the rates of complications of fixation were the same in the two groups, while for the thirty-eight unstable comminuted fractures that were followed the rate of complications of fixation was lower when adjunctive methylmethacrylate cement was used. Among the unstable fractures, one failure (in twenty-one fractures) in the cement-augmented group and ten failures (in seventeen fractures) in the uncemented group were due to failure of fixation (p less than 0.01). For reasons that are not clear, when the thirty-two patients with a healed fracture who could be evaluated for function were rated using the Iowa hip score, the nineteen who were treated with adjunctive cement had significantly lower scores than did the thirteen who were treated without cement (76 +/- 16.5 compared with 92 +/- 12.1, p less than 0.01).

A prospective, randomized study of the management of severe ankle fractures.

One hundred and thirty-eight patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture (Lauge-Hansen classification) who were seen in the emergency room of the University of Chicago Hospitals were entered into a randomized study of the results of various methods of treatment. Ninety-six patients with satisfactory initial closed reduction were randomized between continued closed treatment in a plaster cast and open reduction with rigid internal fixation according to the techniques of the Association for the Study of Internal Fixation (ASIF). Forty-two patients with unsatisfactory closed reduction were randomized between open reduction with internal fixation of only the medial malleolus and open reduction with rigid internal fixation according to the ASIF techniques. Of the 138 patients who were admitted to the study, only seventy-one (51 per cent) could be followed for an average of 3.5 years (a typical return rate of urban trauma centers). The outcomes were evaluated by a scoring system that included clinical, anatomical, and arthritis scores. Statistical analysis of the data showed that, of the patients with initial satisfactory closed reduction, the ones treated by open reduction and rigid internal fixation had significantly higher total scores, particularly the patients who were more than fifty years old and those with a medial malleolar fracture. The small number of patients with unsatisfactory closed reduction who were treated by one of the two types of open reduction and internal fixation and were available for follow-up precluded drawing any conclusions about the superiority of one method of internal fixation over the other in that group. The difference in the talocrural angle between the injured and normal sides was the only statistically significant radiographic indicator of a good prognosis.

Triplane fractures of the distal tibial epiphysis.

Triplane distal tibial fractures can occur as two-, three-, or four-part fractures with or without a fibular fracture. Diagnosis of the particular anatomy of each fracture is ascertained by plain radiographs; if the fracture is displaced 2 mm or more on any view, anteroposterior and lateral tomograms and, if possible, a limited computerized tomography (CT) scan should be done. A plaster cast in situ for non-displaced fractures or closed reduction for displaced fractures should be attempted first by internal rotation and anterior movement of the fibular metaphyseal piece. Failure to obtain and/or maintain an adequate closed reduction (less than 2 mm displacement), determined by plain radiographs, is an indication for operative treatment. Operative treatment consists of screw fixation for the metaphyseal fragment alone in two-part fractures and both metaphyseal and epiphyseal screw fixation in three-part fractures. Associated fibular fractures may also require internal fixation. The prognosis is generally good if adequate reduction has been achieved by closed or open means.

Indications for open reduction of femoral neck fractures.

The Garden alignment index is useful for femoral neck fractures in the aged and defines an acceptable reduction as 155 degrees-180 degrees in both views. The quality of films available in the operating room may not permit accurate measurements of the index. As a substitute, anterior and medial cortical displacement of more than 2 mm may be used as a measure of unsatisfactory reduction. Because malreduction is associated with a high incidence of nonunion and avascular necrosis, inability to achieve acceptable reduction of an adult femoral neck fracture is an indication for open reduction. Since posterior communication is also associated with a high rate of healing complications, it is another indication for open reduction. Bone grafting and careful reshaping of the distal fracture fragment at open reduction can provide stability to promote healing. The incidence of complication of femoral neck fracture is especially high in young adults and children. Anatomic reduction is essential in these age groups to minimize nonunion and avascular necrosis. Primary open reduction is advisable for displaced femoral neck fractures in patients less than 40 years of age if a single gentle closed manipulation fails to provide anatomic reduction.

The role of osteoporosis in intertrochanteric fractures.

Osteoporosis is not the only factor that determines success in treating intertrochanteric fractures. Singh's index provides a simple and useful method for measuring this factor, however, and it should not be ignored. The index helps to predict the fractures that involve increased risk of fixation failure. It can serve as one of the guides for deciding about appropriate treatment. And if we fail to include some estimate of proximal femur strength in our evaluations of fracture results, we cannot learn how to improve those results.

Dislocation of the hip with traumatic separation of the capital femoral epiphysis: report of a case with successful outcome.

Experience with a successfully treated transepiphyseal fracture-dislocation of the femoral head in a 4-year-old boy, a review of 6 similar injuries from the literature, and consideration of the anatomy of the immature femoral head and neck, suggest that the treatment of choice for this injury is immediate open reduction and internal fixation with a smooth pin followed by cast protection. Contrary to recommendations in the literature, closed manipulation does not seem justified at any time, since it could eliminate residual blood supply to the femoral head by disruption of the soft tissue hinge between the head and neck. In a child, preservation of the blood supply through intra-articular soft parts is even more imperative than in adults.

Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture.

Triplane fractures of the distal end of the tibia in fifteen children (average age, thirteen years) represented 6 per cent of 237 consecutive epiphyseal fractures of the ankle. Thirteen children were treated by closed methods (including manipulation) and two had open reduction of the fractures. At an average of twenty-six months after injury, three of fourteen patients showed roentgenographic evidence of premature symmetrical epiphyseal closure with less than 0.5 centimeter of shortening and no angular deformity. Of twelve children examined clinically, three had a 5 to 10-degree external rotation deformity and one patient also had an articular incongruity due to inadequate reduction. In the five cases in which tomograms were used to the medial malleolus, and the anteromedial part of the epiphysis. The lateral fragment included the remainder of the epiphysis together with a piece of posterior metaphysis with attached fibula.

Intertrochanteric fractures. The role of complications of fixation.

A review was made of 244 intertrochanteric fractures of the hip. The complications of fixation were examined; nail penetration, plate separation, or bending or breaking of the device. Factors associated with fewer such complications were (1) stable (noncomminuted) fractures, (2) nails that can accomodate to varus, (3) placement of the nail tip more than 10 mm from the subchondral cortex of the femoral head, (4) valgus reduction of the fracture, and (5) high osteoporosis grade (denoting less osteoporosis). Neither medial displacement osteotomy nor exact anatomic reduction of unstable fractures improved resuts. In most patients, complications of fixation did not adversely influence the clinical course measured in terms of altered walking capacity, need for secondary surgery, or residual hip pain.