David B. Levine

Minimally invasive plate osteosynthesis of distal fractures of the tibia

Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.

Salvage and reinfusion of postoperative sanguineous wound drainage. A preliminary report.

Thirty-five patients who were to have posterior spinal arthrodesis, total hip arthroplasty, or total knee arthroplasty were entered into one of two groups: Group A, to receive unwashed, filtered sanguineous drainage from the wound, or Group B, to receive washed, filtered drainage. The purpose of this prospective study was to evaluate the safety, efficacy, and difficulty of reinfusion of washed compared with unwashed drainage that had been salvaged from the wound after an orthopaedic operation. The sixteen patients in Group A received a mean of 475 milliliters of unwashed drainage for each total knee arthroplasty, 427 milliliters for each total hip arthroplasty, and ten milliliters for the one posterior spinal arthrodesis. The complications included immediate hypotension (two patients), hyperthermia (one patient), and hypotension five hours after reinfusion (one patient). The latter patient died, four days after the operation, of a massive myocardial infarction. The nineteen patients in Group B received a mean of 193 milliliters of washed, filtered drainage for each total knee arthroplasty, 203 milliliters for each total hip arthroplasty, and 179 milliliters for each posterior spinal arthrodesis. Salvage and reinfusion of washed drainage from the wound caused no problems in these patients.

Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly.

This paper presents the short term results of an ongoing prospective randomized trial comparing a cemented unipolar with a cemented bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures in the elderly. Forty-seven patients with an average age of 77 years completed 6-month followup. Outcomes at 6 weeks, 3 months and 6 months were assessed by completion of a patient oriented hip outcome instrument and by functional tests of walking speed and endurance. No differences in the postoperative complication rates or lengths of hospitalization were seen between the two groups. Patients treated with a bipolar hemiarthroplasty had greater range of hip motion in rotation and abduction and had faster walking speeds. However, no differences in hip rating outcomes were found. These early results suggest that use of the less expensive unipolar prosthesis for hemiarthroplasty after femoral neck fracture may be justified in the elderly.

Long-term psychological sequelae of surgically versus nonsurgically treated scoliosis.

Forty-six female scoliosis patients (21-34 years of age) were tested psychologically 4 or more years following treatment. Twenty-three had been treated by bracing (Group A) and 23 by posterior spinal fusion (Group B). Variables evaluated were: self-esteem, capacity for intimacy, sexual satisfaction, and mental representation of the patients own body (body image). The prediction that normal controls would show better psychological adjustment than scoliotic women—surgically treated or not—was only partially borne out. Contrary to expectations, both groups of scoliotics showed higher levels of sexual satisfaction than controls. Group B showed a greater need for intimacy and better sexual adjustment, self-esteem, and body image than Group A.

Fragmentation of the distal pole of the patella in spastic cerebral palsy

Of eighty-five consecutive patients, thirteen to twenty years old, with spastic cerebral palsy involving one or both extremities (thirty-five patients seen at one institution and fifty, at another), four had roentgenographic evidence of fragmentation of the distal pole of the patella. In addition, three other patients with six spastic lower extremities, four of them with patellar fragmentation, were also included. In these seven patients, there were nine knees with patellar fragmentation, twelve knees with patella alta, nine with a flexion contracture, five that were painful, and four with changes in the tibial tubercle resembling those found in Osgood-Schlatter disease. Excessive tension in the quadriceps mechanism, usually in the presence of a flexion contracture, appeared to cause the lesions. Four of the fragmented patellae healed after hamstring release and correction of the flexion deformity.

The Effects of Internal Fixation on the Articular Cartilage of Unfused Canine Facet Joint Cartilage

Custom-made distraction instrumentation was placed in the lumbar spine of eight large dogs with care taken to preserve the integrity of two intervening apophyseal joints. Histologic staining of immobilized joint cartilage showed varying degrees of chondrolysis, cloning, invasion of the tide mark, and loss of proteoglycans as early as 2 months postoperatively. Every specimen had significant degenerative changes characteristic of osteoarthritis. The joints one segment caudal to the lower hooks also were examined and were found to have similar histologic evidence of degeneration. Three dogs had the instrumentation removed and were then sacrificed 1.5-3 months later. The degenerative changes were not reversible following instrumentation removal.

Routine preoperative MRI and SEP studies in adolescent idiopathic scoliosis.

In this prospective study, 72 patients with the clinical diagnosis of adolescent idiopathic scoliosis underwent routine preoperative magnetic resonance imaging (MRI) scans and neurologic consultations. Forty-eight patients also had preoperative somatosensory evoked potentials (SEPs). All patients had normal neurologic examinations. Abnormal findings included two patients with Chiari type I malformation and one with a finding of a fatty collection in a vertebral body. In four cases, interpretation of the MRI was suspicious or equivocal, necessitating a computed tomography myelogram or other additional studies for clarification. Abnormal preoperative SEP results were obtained in three patients, none of which proved significant. All surgical patients underwent instrumentation and fusion without incident. The results indicate that routine preoperative SEP is not necessary. Routine preoperative MRI is probably not indicated in adolescent idiopathic scoliosis if the patient has a normal neurologic examination.

Evoked potentials recorded from scalp and spinous processes during spinal column surgery

Peroneal nerve evoked potentials were simultaneously recorded from scalp and from wire electrodes inserted into lumbar and thoracic spinous processes at multiple levels during surgery for correction of spinal column curvature in 43 patients. Spinal potentials progressively increased in latency rostrally. Over cauda equina and rostral spinal cord initially positive triphasic potentials were recorded. Over caudal spinal cord the response consisted of initial positive-negative diphasic potentials that merged with broad large negative and positive potentials. At rapid rates of stimulation, the initial diphasic component was stable but the subsequent potentials significantly diminished in amplitude. This suggests that the diphasic component reflects presynaptic activity arising in the intramedullary continuations of dorsal root fibers and that the subsequent components reflect largely postsynaptic activity. Scalp recordings at restricted bandpass (30-3000 c/sec) revealed well defined positive and negative potentials with mean peak latencies of 25.9 and 29.9 msec (PV-N1). The amplitudes and latencies of PV-N1 remained relatively stable throughout general anesthesia with halogenated agents which suggests that this component may be a reliable monitor of conduction within spinal cord afferent pathways during spinal surgery. Data are presented which suggest that selective filtering may help to distinguish faster frequency, synchronous axonal events from slower frequency, asynchronous axonal or synaptic events.

Treatment of Lisfranc Fracture-Dislocations with Primary Partial Arthrodesis

Background: The optimal method of treatment for Lisfranc fracture-dislocations remains controversial, and the role of primary partial arthrodesis for combined osseous-ligamentous Lisfranc injuries is unclear. This study reviewed the outcomes of Lisfranc injuries treated by primary partial arthrodesis. Methods: Patients who underwent primary partial arthrodesis for a primarily ligamentous or combined osseous and ligamentous Lisfranc fracture-dislocation were reviewed retrospectively and assessed at followup according to radiographic, clinical and standardized patient-based outcomes. Twenty-five patients (12 ligamentous, 13 combined), median age of 46 (range, 20 to 73) years, were followed for an average of 42 (range, 24 to 96) months. Results: The average American Orthopedic Foot and Ankle Society (AOFAS) score was 81 points (scale 0 to 100), with patients in general losing points for mild pain, limitations of recreational activities, and fashionable footwear requirements. There was no statistical difference between ligamentous and combined injuries with regard to the physical or mental component scores on the SF-36. At latest followup, patients reported an average return to 85% of their preinjury activity level (range, 50% to 100%). Twenty-one patients (84%) expressed satisfaction with their outcome and at latest followup, the mean visual analog pain scale (VAS) score was 1.8 out of 10 (range, 0 to 8). Three patients showed radiographic signs of posttraumatic arthritis of adjacent joints. Conclusion: Treatment of both primarily ligamentous and combined osseous and ligamentous lisfranc injuries with primary partial arthrodesis produced good clinical and patient-based outcomes. Level of Evidence: III, Retrospective Comparative Study

Osteoporosis in Scheuermann's disease.

A prospective study was undertaken to evaluate osteoporosis in Scheuermanns disease. Ten consecutive untreated patients with thoracic Scheuermanns were studied. The mean age was 16 years, 1 month, and the mean kyphosis was 64°. Osteoporosis was quantitated by single and dual photon absorptiometry. Seven age-, sex-, height-, and weight-matched subjects were used as controls. The mean bone mineral density (BMD) of the lumbar spine was 0.975, compared with 1.130 for the control group, significant at P < 0.025. For patients with a kyphosis > 45°, the BMD was 0.913, significant at P < 0.005. The mean BMD of the femoral neck was 1.00, compared with 1.22, significant at P < 0.005. For patients with a kyphosis > 45°, the femoral neck BMD is 0.983, significant at P < 0.005. The BMD of the radius by single photon absorptiometry was 0.689, compared with 0.748 in the controls, which was not significant. In patients with a kyphosis > 45°, the BMD was 0.655, which is significant at P < 0.01. A highly significant association exists between osteoporosis and Scheuermanns disease. Further investigation is indicated to determine the role of medical management in the treatment of these patients.