Factors determining outcome in fractures of the extremities associated with arterial injuries.

Fifteen patients with fractures of the extremities and associated arterial injuries treated from 1976 to 1987 were retrospectively analyzed. Complete ischemia was present in only two cases; in four cases with partial ischemia, the vascular injury presented late after 12 h-14 days. All limbs could be preserved, but complications were frequent and necessitated 28 operations. Complications were less frequent in primary external fixation of lower-extremity lesions compared with internal fixation. Normal function was regained only in closed fractures or in the absence of discontinuous nerve lesions. It is concluded that short-term salvage of these severe combined injuries depends on the degree and duration of deficient perfusion, but the mid- to long-term functional result depends on the severity of skin, muscle, bone, and nerve injury. The high salvage rate is attributed to the short delay to arterial reconstruction in complete ischemia and the restoration of circulation in isolated tibial artery injuries in partial ischemia cases.

Alignment of supracondylar/intercondylar fractures of the femur after internal fixation by AO/ASIF technique.

Fifty-nine supracondylar-intercondylar fractures of the femur in 57 patients were evaluated after a mean follow-up of 5 years 7 months (range 2 years to 11 years 3 months) after internal fixation using AO/ASIF technique. Axial alignment was compared with that of the uninjured side by orthoroentgenography in the upright position and by bilateral anteroposterior (AP) and lateral views of the femur. Identical values for varus/valgus were noted in 24%, for ante/recurvation in 72%, and for rotation in 61%; differences were within 5 degrees of varus/valgus in 74%, of ante/recurvation in 78%, and of rotation in 83%. Alignment differences were more frequent in complicated and intercondylar fractures according to the AO classification of fractures. We conclude that restoration of the distal femoral angle is far more difficult than restoration of the sagittal plane and rotation, but a satisfactory functional result appears to be compatible with angulation differences of less than or equal to 5 degrees in any plane and that this difference appears to be within the reasonably achievable limits. 93% of the patients were satisfied; 64% of patients were pain-free, and 27% had slight intermittent pain (not interfering with daily activity); 67% of the patients had unlimited walking distance, and 78% of the patients were able to walk without aid. Excellent and good results according to the rating systems of Neer et al., Pritchett, and Schatzker and Lambert were noted in 82, 39, and 26%, respectively. This discrepancy between alignment, pain, function, and results according to different rating systems underlines the need for future standardized, clearly defined reporting and classification of rating.

Midterm results (5.5-10 years) of acetabular allograft reconstruction with the acetabular reinforcement ring during total hip revision.

Acetabular reconstructions using frozen femoral head allografts and the acetabular reinforcement ring of M. E. Müeller (Protek AG, Bern) have been analyzed after an average follow-up period of 7.2 years (range, 5.5-10 years) in 27 patients/hips. The deficiencies, according to the American Academy of Orthopaedic Surgeons classification, were 1 segmental, 14 cavitary, and 12 combined cavity and segmental. Twenty-two (82%) of the reconstructions were classified as adequate and five (18%) as inadequate based on the operative report and radiographic assessment, including anteroposterior, oblique, and lateral views. Reconstructions were considered adequate if an appropriate sized ring had been used in accordance with the recommendations of the authors (contact on host pelvic bone cranially, posteriorly, and inferomedially). Radiographic evaluation revealed acetabular component migration of more than 2 mm in 12 reconstructions (44%). Of these, cranial migration averaged 4 mm (range, 2-9 mm) in inadequate reconstructions, whereas it averaged only 2 mm (range, 1-4 mm) in adequate reconstructions. The incidence of migration in adequate reconstructions for segmental only and combined cavitary and segmental defects was 6 of 12 (50%), whereas it was 1 of 10 in reconstructions of cavitary deficiencies. Kaplan-Meier survivorship analysis revealed a 79.6% probability of survival at 10 years with revision as the endpoint for failure. It is concluded that durability of the reconstruction can be expected if support of the metallic reinforcement device is provided by host-bone. Segmental and combined deficiencies may require additional internal fixation by plates and screws.

The unstable intertrochanteric fracture in the elderly. A technical note on valgus resection osteotomy and fixation with 150 degrees dynamic hip screw.

Valgus resection osteotomy has proven its effectiveness for the treatment of unstable intertrochanteric fractures in the elderly. A modified technique is presented, which consists in (a) resection of triangular fragments proximally and distally, (b) reduction and impaction in valgus, (c) fixation through the osteotomy site by a 150 degrees dynamic hip screw, and (d) reattachment of the greater trochanter by an 8-shaped wire cerclage. The postulated advantage is that the implant acts as an intramedullary splinting in crossing the "osteotomy" site, with minimization of implant cutting out compared with a 130 degrees angled blade plate or an I-Beam Nail Plate.

[Total hip prosthesis in bone loss of the femur]. / Hüfttotalprothese bei Knochenverlust im Femurbereich.

Severe bone deficiency in total hip arthroplasty (THA) represents a serious problem, and there is an increasing demand for reconstructive measurements even on the femoral side to salvage these hips. The different therapeutical concepts are reviewed. Mechanical stability has proved to be of the utmost importance for successful results; fixation of the prosthesis by acrylic cement both in the graft and in the host femur seems to be superior to cementless fixation in most cases. The Wagner cementless self-locking revision stem has the advantage of facilitating regeneration in the deficient proximal femur without allografts and their disadvantages.

Internal fixation of supracondylar fractures after condylar total knee arthroplasty.

Condylar buttress plates were applied in six patients with total knee arthroplasties and supracondylar fractures. According to the criteria of Cain, 50% of the patients had a satisfactory result with an average follow-up period of 17 months. Time to union (full weight bearing) averaged 14 weeks. The final coronal femorotibial alignment averaged 5 degrees of valgus, whereas preoperative valgus had averaged 8 degrees. Four patients were pain free and the two others had minimal pain that did not interfere with daily activity. Knee motion averaged 97 degrees. All patients were ambulating; five of six patients needed two crutches outdoors for reasons unrelated to the index fracture. Four patients had rheumatoid arthritis (RA) with multiple joint involvement, and the fifth was debilitated secondary to old age. No nonunion, loss of fixation, or infection occurred. Open reduction and internal fixation (ORIF) using the condylar buttress plate provides stable fixation, allowing early knee motion and ambulation. If extreme osteoporosis is present, the addition of bone cement enhances screw fixation.

Growth disturbance of the distal radial epiphysis after trauma: operative treatment by corrective radial osteotomy.

Growth disturbance owing to partial posttraumatic closure of the distal radial physis is rare. The resulting painful, stiff wrist often requires operative treatment. Problems with the operative technique are presented in this case report; different operative techniques described in the literature are discussed. Our technique, described in the literature are discussed. Our technique, osteotomy of the distal radius with interposition of a tricortical bone graft, allows the surgeon to restore the normal longitudinal relationship between the radius and ulna and to reorient the distal radial articular surface to achieve a normal radiocarpal and radioulnar relationship. The patient experiences improved painless wrist motion as a result of this technique.

[Arthritis following osteosynthesis of supra-/intercondylar femoral fractures]. / Arthrose nach Osteosynthese von supra-/interkondylären Femurfrakturen.

Of 104 supra-/intercondylar femur fractures in adults (AO/ASIF Classification types A 1-3 and C 1-3), who were treated by open reduction and internal fixation from 1975 to 1985 59 fractures in 57 patients could be traced and reviewed clinically and radiographically after a mean follow-up period of 5 years and 7 months (range: 2-11 years). Among these, 47 knees/patients without preexisting knee-joint pathology were analyzed for the development of degenerative arthritis. The incidence for grade 2 and 3 changes in the femoropatellar compartment were 23% for supracondylar fractures (A type) and 62% for intercondylar lesions (C type). In the femorotibial compartment the incidence for supracondylar fractures was 38% and 23% for intercondylar fractures. In 93% of the patients the arthritic changes were radiographical findings, which did not cause relevant symptoms. The development of radiographical degenerative changes depends mainly on the type of the fracture; it is favoured by axial malalignment of more than 5 degrees of varus or valgus and local complications.