Jeffrey W. Mast

A New Periacetabular Osteotomy for the Treatment of Hip Dysplasias Technique and Preliminary Results

A new periacetabular osteotomy of the pelvis has been used for the treatment of residual hip dysplasias in adolescents and adults. The identification of the joint capsule is performed through a Smith-Petersen approach, which also permits all osteotomies to be performed about the acetabulum. This osteotomy does not change the diameter of the true pelvis, but allows an extensive acetabular reorientation including medial and lateral displacement. Preparations and injections of the vessels of the hip joint on cadavers have shown that the osteotomized fragment perfusion after correction is sufficient. Because the posterior pillar stays mechanically intact the acetabular fragment can be stabilized sufficiently using two screws. This stability allows patients to partially bear weight after osteotomy without immobilization. Since 1984, 75 periacetabular osteotomies of the hip have been performed. The corrections are 31 degrees for the vertical center-edge (VCE) angle of Wiberg and 26 degrees for the corresponding angle of Lequesne and de Seze in the sagittal plane. Complications have included two intraarticular osteotomies, a femoral nerve palsy that resolved, one nonunion, and ectopic bone formation in four patients prior to the prophylactic use of indomethacin. Thirteen patients required screw removal. There was no evidence of vascular impairment of the osteotomized fragment.

The Use of Endosteal Substitution in the Treatment of Recalcitrant Nonunions of the Femur: Report of Seven Cases

Seven patients, with an average age of 53 years, were treated for bone loss or recalcitrant nonunions of the femur. The average duration from initial injury to presentation was 37 months (range 4-92 months). The patients had undergone one to eight (mean, 3.9) previous surgical attempts at achieving union. The nonunion involved the diaphysis in three patients, the diaphyseal-supracondylar junction in three patients, and the pertrochanteric region in one patient. All patients were treated using a standard lateral plate in combination with an endosteal plate and primary iliac crest bone grafting. The mean surgical time was 6.3 h, and the average blood loss was 1.7 L. There were three complications, including one superficial wound infection, one nonfatal pulmonary embolism, and one wound hematoma. At a mean follow-up of 12.6 months (range 4-24 months), all fractures had healed with an average time to union of 19.2 weeks (range 15-36 weeks). Knee flexion averaged 118 degrees (range 100-135 degrees), and all patients were satisfied with the operative procedure. Endosteal plating, in combination with a standard lateral plate and iliac crest bone-grafting, can successfully treat difficult nonunions of the femur.

Planning and reduction technique in fracture surgery

1: Rationale.- 2: Anticipation (Preoperative Planning).- Fractures and Post-traumatic Residuals.- Osteotomies.- The Goals of Planning.- Preoperative Planning by Direct Overlay Technique: The Making of a Jigsaw Puzzle.- Preoperative Planning of an Acute Fracture Using the Sound Side: Solving the Jigsaw Puzzle.- 3: Reduction with Plates.- Using a Straight Plate as a Reduction Aid.- Reduction of a Distal Third Oblique Fracture of the Tibia by Means of an Antiglide Plate.- Fractures of the Fibula.- Forearm Fractures.- Acetabular Fractures.- Using the Angled Blade Plate as a Reduction Tool.- Proximal Femur.- Summary.- 4: Reduction with Distraction.- The Femoral Distractor.- The External Fixator in Reduction and Internal Fixation of Os Calcis Fractures.- The Minidistractor.- Summary.- 5: Substitution.- Combined Internal and External Fixation.- Composite Fixation.- Summary.- 6: Tricks.- Tricks with Instruments.- Tricks with Implants.- References.

Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures.

Summary Indirect reduction and percutaneous screw fixation were attempted in 20 displaced tibial plateau fractures in 20 patients. Closed, indirect reduction was successful in 18 fractures; two others, both Schatzker type II fractures, required open reduction. The 18 fractures were followed for an average of 16.2 months (range, 12–24 months). Of the fractures successfully reduced with indirect techniques, 13 were reduced anatomically (72.2%), and five were considered nonanatomic (27.8%). Four of the five fractures with a nonanatomic reduction were type II fractures. Clinically, there were six excellent (33%), 10 good (56%), and two fair (11%) results. No fracture lost reduction; no patient developed an infection. Indirect techniques could effectively reduce only split fragments. Depressed fragments could not be reduced reliably with either lig-amentotaxis or percutaneous elevation with a tamp. There was no correlation between radiographic reduction and clinical outcome. It did not matter whether two, three, or four screws were used to stabilize the fracture.

A comparison of different surgical approaches for the periacetabular osteotomy.

The periacetabular osteotomy is a well established surgical procedure for the preventative treatment of degenerative joint disease caused by symptomatic acetabular dysplasia. Surgeons on several continents use varying surgical approaches to achieve the same effective osteotomy. Individual surgical approaches must provide accurate and adequate exposure for the osteotomy and the reorientation of the acetabular fragment. The aim of the surgical approach for such complex and expansive surgery is to minimize morbidity related to the approach. This article compares experiences among three common approaches including the modified Smith-Petersen, ilioinguinal, and direct anterior approaches and describes the double approach.

Fractures of the tibial pilon.

Fractures of the tibial pilon are difficult to manage because of their severity. They are the product of high-energy compression forces and too frequently result in comminution and impaction of the weight-bearing surface of the distal tibia. Other fractures involving the roof of the ankle joint may be called “pilon fractures,” but have a better prognosis because the compressive force is coupled with torsional forces. Operative reduction with the application of stable fixation in a clinically proven sequence of steps may lead to a satisfactory outcome in approximately three fourths of the cases, but must be accomplished with a sound understanding of the anatomy of the ankle joint and the principles of stable internal fixation by a surgeon with good atraumatic technique.

Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation.

Displaced fractures of the glenoid fossa are an uncommon and anatomically diverse group of injuries. Failure to restore anatomy in these fractures results in poor outcome in most cases. The success of a treatment protocol that encompasses appropriate preoperative imaging, injury pattern assessment, prudent approach choice, and a comprehensive reduction and fixation tactic was evaluated. Twenty-seven patients were assessed clinically and radiographically at a mean followup interval of 43 months from surgery. Anatomic reconstruction was achieved in 24 (89%) patients. Three patients had residual joint incongruities measuring 2 mm or less. The only perioperative complication was a partial superficial wound dehiscence. Two additional patients had infraspinatus palsies of indeterminate origin. Functional rating revealed six (22%) excellent, 16 (60%) good, three (11%) fair, and two (7%) poor outcomes. The fair and poor outcomes largely were related to associated injuries. These findings show that anatomic surgical reconstruction with a low complication rate and good functional outcome can be obtained for most patients with glenoid fossa fractures.

Biomechanical Evaluation of the Schuhli Nut

The schuhli out is a device designed to lock an AO 4.5-mm cortical screw to a 4.5-mm dynamic compression plate independent of bony contact with the plate. The nut engages the screw below the plate, elevating the plate, and locking the screw at a 90 degrees angle, thus preventing toggling. Photoelastic modeling and biomechanical testing on sheep tibias were done to determine the mechanical properties of constructs using schuhli nuts. Use of schuhli nuts was shown to decrease stress in the bone below the plate. The initial axial stiffness of a construct fixed with schuhli nuts is less than a construct with standard screws, but the rate of loss of stiffness with cyclic loading is similar. When a cortical defect is present at the near cortex and the screw engages the far cortex only, the use of a schuhli nut significantly improves the stability of the construct compared with a standard screw alone, and behaves mechanically the same as a standard construct with intact cortices. This indicates that the schuhli nut acts as a substitute for a deficient cortex. The schuhli nut can be useful in osteoporotic bone because it prevents the screw from stripping the threads in the bone as the screw is advanced. It also serves to lock the screw to help prevent the screw from backing out. The schuhli nut may be a useful tool to improve stability in the treatment of complex fractures, reconstructions, or in pathologic bone.

The salvage of open grade IIIB ankle and talus fractures.

Summary Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5–12). The total in-patient hospital stay averaged 61.6 days (20–107 days) and in patient costs averaged 62,174.43/patient (range:

The evolution of indirect reduction techniques for the treatment of fractures

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