Andrew F. Brooker

Ectopic Ossification Following Total Hip Replacement: Incidence And A Method Of Classification

A method to classify the degree of ectopic-bone formation about the hip following total hip arthroplasty revealed that 21 per cent of 100 consecutive patients treated by total hip arthroplasty had ectopic-bone formation about the hip of various degrees when reviewed six months following the operation. Ectopic-bone formation, however, did not seem to affect the functional result as judged by the Harris hip evaluation unless apparent bone ankylosis resulted.

Nonunion of the humeral shaft

Retrospective review of records of 26 patients with nonunion of the humeral shaft revealed several factors frequently associated with the development of nonunion. The fractures were transverse and short oblique and treated per primant with hanging casts or open reduction. Surgical fixation was unstable. The types of nonunion were atrophie in 19 patients, hypertrophie in five patients, and synovial pseud-arthrosis in two patients. Twenty-four of 26 nonunions (92%) treated with bone grafts and rigid internal fixation healed in an average of 5.6 months. Overall, 47 surgical procedures, including prior procedures, were performed on these 26 nonunions. The average number of operations per patient was 1.8. Successful platings produced immobilization, consisting of an average of 6.8 points of cortical fixation above the nonunion and 7.1 cortices below. Rigid fixation was not obtained in the unsuccessful procedures. Unsuccessful platings were noted to have unstable fixation, with an average of 2.7 points of cortical fixation above the nonunion and 3.0 cortices below. Bone grafting was performed in only 55% of the unsuccessful platings. Optimal treatment of nonunions of the humeral shaft consists of resecting atropic nonunions, shortening the bones, drilling sclerotic areas, and apposing bleeding di-aphyseal surfaces; open reduction with internal fixation with a broad compression plate, including at least six points of cortical fixation above and below the nonunion; compression of the nonunion by means of interfragmentary lag screws, prestressing of the plate, dynamic compression by the plate, or direct compression by the external compression device; and autogeneic cancellous iliac bone grafts.

Total replacement of the hip for avascular necrosis in sickle cell disease

Total hip replacement was performed in 27 hips of patients who had sickle cell anaemia with avascular necrosis of the femoral head. The disease was bilateral in 11 patients. Considerable medical problems were encountered although most of the patients had exchange transfusion before surgery (86%), which prevented postoperative sickle cell crises in all but two cases. At the primary operation hard sclerotic bone was seen in nine femora with complete obliteration of the femoral canal. There were four femoral fractures, three following perforation of the shaft due to this hard bone. There was a very high morbidity due to loosening in both cemented and uncemented prostheses. With a rate of 59% over a cumulative 5.5 year period, revision was being performed at an average of only 43 months. Surgeons should be aware of these problems.

Excision of heterotopic bone followed by irradiation after total hip arthroplasty.

Twelve patients who had had a total hip arthroplasty had extensive excision of heterotopic bone, followed by prompt, low-dose irradiation, between 1983 and 1990. Volumes of as much as 900 milliliters of heterotopic bone tissue were resected. Of these patients, eleven had excellent relief of pain, and all twelve gained an average of 45 degrees of flexion and 25 degrees of abduction. Two patients had a recurrence of heterotopic bone (Brooker et al. class II); however, only one of these patients was symptomatic and had a result that was considered a failure.

Distal Femoral Fractures: Comparison of Open and Closed Methods of Treatment

Ninety-eight distal femoral fractures were analyzed to compare open and closed treatment methods. Four radiographic groups were identified. Patients treated by open methods spent less time in the hospital, returned to prefracture activity sooner, had better functional results, and had a lower incidence of nonunions and complications. Thirty-eight of 47 fractures treated by open methods had good functional results. Only 18 of 51 fractures treated by closed methods had good functional results. Simple nondisplaced fractures were noted to have good results when treated by closed methods. Fractures of the distal femur, except the most simple cases, are best managed by open treatment methods.

Tissue pressure to evaluate compartmental syndrome.

This article presents a simplified, direct way of measuring tissue pressure and shows that in a series of 45 patients with serious extremity injuries, it is possible to predict the need for fasciotomy, eliminating much of the risk to the patient.

The treatment of fractures of the femoral shaft with the Brooker-wills distal locking intramedullary nail.

Ninety-two fractures of the femoral shaft in eighty-five patients were followed after treatment with the Brooker-Wills distal locking intramedullary nail. Twenty-one (22.8 per cent) of the fractures were open and seventy-one (77.2 per cent) were closed; 84.8 per cent of the fractures were comminuted. All but one fracture united, in a mean time of 4.4 months. Four fractures healed with mild angulation, and three had shortening of more than one but less than two centimeters. Significant rotatory deformities did not occur. No patient required postoperative traction or external stabilization, and all but five patients regained a normal range of motion of the ipsilateral hip and knee. There were intraoperative technical problems in eleven patients (12.0 per cent) and postoperative complications in eighteen patients (19.6 per cent), including fourteen patients (15.2 per cent) with pulmonary emboli, infection, or heterotopic bone at the site of the insertion of the nail. Five patients (5.4 per cent) had postoperative complications that were directly related to the proximal and distal fixation of the nail. There was one non-union (1.1 per cent). No problems were encountered with removal of the nail. The Brooker-Wills distal locking intramedullary nail proved to be an effective device for the stabilization of fractures of the femoral shaft. The use of this modified Küntscher nail with both proximal and distal fixation has been successful in preventing clinically significant femoral angulation, malrotation, and shortening and has allowed early mobilization of the patient.

External fixation shoulder arthrodesis.

Shoulder arthrodesis, while providing a useful and predictable solution to many problems associated with glenohumeral degeneration, has been less than desirable for many patients due to the frequent need for postoperative spica cast or airplane splint immobilization. A new technique of external fixation of shoulder fusions has been developed that provides many advantages, including strong, reliable fixation, obviating the need for bulky casts or splints, and immediate postoperative use of the involved arm. This technique of shoulder arthrodesis using the Hoffman external fixation device has been used on four patients, with a follow-up period of 30–36 months. The series includes patients with infected arthroplasty, osteoarthritis, tumor, and previous failed arthrodesis. Bony union was obtained in six to 10 weeks, and the external fixation frame was left in place seven to 14 weeks. In each case, the external fixation frame enabled the patient to use the involved arm immediately after operation.

Advanced three-dimensional evaluation of acetabular trauma: volumetric image processing

Volumetric image processing is a new approach to generating simulated three-dimensional images from transaxial CT data. The major advantages compared to conventional surface-rendering 3D technique include: preservation of every pixel of CT data for increased accuracy of rendered image; tissue layer translucency allowing appreciation of multiple tissue layers on each image; simulation of real-time rotation in varying axes for optimal appreciation of abnormalities; and a high-speed, high-capacity computer setup which generates high-quality images rapidly, giving the system sufficient flexibility for these complicated functions while remaining user friendly and fast.

Multiplanar Computed Tomography of Acetabular Fractures

Following plain radiographic examination CT with multiplanar reformatting (CT/MPR) was used to assess 34 patients with pelvic trauma and definite (24 patients) or clinically suspected (10 patients) fractures. Computed tomography/MPR detected four fractures missed on conventional radiography. The findings on CT/MPR led to major alterations of patient management in seven cases. In four patients in whom the initial decision had been to use closed management with traction, information derived from CT/MPR led to open surgical reduction. In three patients in whom the initial impression had been that open management was dictated, CT/MPR contributed anatomical information that reserved that decision, leading to more conservative management. In all patients going to surgery the surgeons believed that surgical planning and execution had been significantly affected by the information provided by CT/MPR. Computed tomography/MPR was used postoperatively in 10 patients to confirm the status of reduction and fixation and to evaluate patients with unusual problems in the recovery period.