Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynthesis.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol.

A retrospective review of 46 consecutive patients with complex (Schatzker V and VI) tibial plateau fractures treated at Harborview Medical Center between 1984 and 1989, disclosed a subset of 14 grade II or III (Gustilo) open injuries. We wished to determine the incidence of infection, union rate, and the number of operations required to achieve a satisfactory result, based on a treatment protocol: alignment and splinting of fracture at the scene of injury if possible, antibiotics administered in the emergency room (ER) and continued for 48 h, and admission of patient to the operating room as quickly as possible for irrigation and thorough debridement of the wound, immediate rigid internal fixation, and delayed primary closure at 5 days. No acute deep infection or radiographic evidence of implant loosening was noted. The final outcome was graded by Hospital for Special Surgery (HSS) Knee Rating Score at an average follow-up of 2 years 7 months. Radiographs were reviewed for reduction and evidence of postoperative change in reduction. The average HSS Functional Score was 81.5, and Knee Score was 84.6. Of 14 limbs, 10 had an excellent radiographic grade that did not change at follow-up, 2 had a satisfactory grade, and 2 had a poor grade.

Augmented repair of acute Achilles tendon ruptures.

Twenty-five patients who had an acute Achilles tendon rupture were managed with an augmented repair using the gastrocnemius-soleus fascia. All patients healed their repair and there were no re-ruptures. There was one infection. Augmented repair allowed early functional recovery as evidenced by full ankle motion by four to eight weeks, full unassisted weight bearing by three weeks, cessation of braces by four weeks, and return to work by one to six weeks post-operatively. Augmentation adds a sufficient amount of collagen to allow early range of motion and weight bearing without re-rupture. Disadvantages included a long incision, soft tissue prominence, one infection, and sural nerve injury.

The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation.

The proximal radioulnar joint was dissected in 24 cadaveric elbows to localize the area of the radial head that did not articulate with the lesser sigmoid notch of the ulna. The nonarticulating portion of the radial head was posterolateral in the anatomic position of full supination. Gross observations of the nonarticulating portion of the radial head revealed a thinner band of yellowish cartilage relative to a wider, white, glistening cartilage of the articular portion of the radial head. The nonarticular portion of the radial head did not contain the angled peak, which is most prominent in the middle of the articular portion. The average arc of the nonarticulating radial head was 113 degrees (range, 106 degrees to 120 degrees; standard deviation, 4 degrees). This nonarticulating portion of the radial head (or safe zone for prominent fixation) consistently encompassed a 90 degrees angle localized by palpation of the radial styloid and Lister's tubercle. Using these palpable distal landmarks to localize the safe zone of the radial head, 24 different cadaveric elbows were internally fixed with a plate and screws through 3 different approaches (anterior, lateral, and posterolateral). Regardless of approach, the internal fixation allowed full forearm rotation in all the specimens. Utilization of this method and anatomic landmarks to localize the nonarticular portion of the radial head may assist the surgeon in open reduction and internal fixation of fractures of the radial head and neck.

Alcalose metabolica causada por antibioticos. / Metabolic alkalosis caused by antibiotics

Os autores apresentam quatro pacientes que desenvolveram alcalose metabolica e hipopotassemia durante o uso de antibioticos.O antibiotico mais associado com essas alteracoes foi a carbenicilina. Discutem-se os provaveis mecanismos implicados nessas alteracoes metabolicas