Early motion with cast-brace after modified Coventry high tibial osteotomy

The records of 31 patients who were treated by a modified Coventry high tibial osteotomy were reviewed, and the early results of postoperative management with a cylinder cast were compared with those with early motion in a cast-brace. Thirteen patients (15 knees) who had immobilization in a cylinder cast after surgery for an average of 44.3 days had lost a mean of 10 degrees of flexion at three months of follow-up study. Their average total hospitalization was 15.5 days. Eighteen patients (19 knees) treated by early motion in a cast-brace had not lost any preoperative flexion at three months of follow-up study. The two most recent of these patients received continuous passive motion in the immediate postoperative period. The average total hospitalization for this group was 10.7 days. One patient in the cast-brace group had a significant loss of correction at the osteotomy site during healing. Eleven of the patients treated by a cylinder cast (84.6%) and 17 of the patients managed with a cast-brace (94.4%) stated that they had been improved by the surgery at this early stage. There were no nonunions or loss of internal fixation in either of the two groups. Early motion in a cast-brace (with a continuous passive motion machine, if available) is safe and is comfortable for and well accepted by patients.     

The treatment of femoral fractures by cast-brace and early walking: a review of seventy-nine patients.

Seventy-nine cases of fracture of the femoral shaft treated by cast-brace and early walking have been reviewed. Discrepancy in femoral length was assessed by scanogram. The cases were analysed to relate the incidence of shortening greater than 2 centimetres to the type and site of the fracture, and the time which elapsed from injury until the cast-brace was applied. Such shortening was encountered most frequently when the cast-brace was applied within the first two weeks from injury or after six weeks and in those patients with comminuted fractures of the middle third of the femoral shaft.     

Early knee mobilization after osteotomy for gonarthrosis

In a prospective study, 32 knees in 32 patients were randomized to either a cylinder plaster cast (17 knees) or hinged cast-brace (15 knees) after high tibial osteotomy for medial gonarthrosis. At 6 weeks, 3 months, and still 1 year after surgery, the range of motion was better in the cast-brace group. There was no difference in the other clinical results at 3 months and at 1 year after surgery, nor in changes of osseous correction or in the final knee alignment. All the patients in the cast-brace group were satisfied with early motion.     

The hip cast-brace for hip prosthesis instability.

The use of a hip cast-brace in the treatment of unstable hips following prosthetic replacement is described. A retrospective study of 21 patients with 22 hip prostheses treated with the cast-brace is reported. Seventeen Charnley low friction arthroplasties (LFA) were treated--four cast-braces were used for prophylaxis, five for single dislocations and eight for recurrent dislocations. To date, only four hips have required an operation to achieve stability. Five patients with Thompson hemi-arthroplasties were treated following dislocation with only one requiring surgery to achieve stability. A hip cast-brace is recommended as a useful alternative to surgical management of prosthetic instability.     

Early knee mobilization after osteotomy for gonarthrosis

In a prospective study, 32 knees in 32 patients were randomized to either a cylinder plaster cast (17 knees) or hinged cast-brace (15 knees) after high tibial osteotomy for medial gonarthrosis. At 6 weeks, 3 months, and still 1 year after surgery, the range of motion was better in the cast-brace group. There was no difference in the other clinical results at 3 months and at 1 year after surgery, nor in changes of osseous correction or in the final knee alignment. All the patients in the cast-brace group were satisfied with early motion.     

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty

Over a period of 20 years, 34 patients with a total hip arthroplasty were treated conservatively for a femoral shaft fracture. Thirty-five fractures were treated by traction followed by cast-brace or by cast-brace alone. Sound healing was obtained in 33 fractures. Problems were angular malalignment jeopardizing revision surgery in cases of loosening, long hospitalization, and a considerable complication rate. As a consequence, the authors no longer recommend conservative treatment as the first choice for these difficult fractures.     

Pressure recordings in patients with femoral fractures in cast-braces and suggestions for treatment.

Five patients with femoral-shaft fractures were treated by cast-brace application and early ambulation. As fracture healing progressed, pressures between the thigh and the cast were recorded with the patients lying still, contracting the quadriceps while lying down, and in four weight-bearing postures. Control results were gained by application of a second cast-brace to three of the patients when they had recovered completely. Resting pressures averaging sixteen millimeters of mercury were recorded under the whole cast. Much higher values were recorded under the proximal two-thirds of the cast, and these increased as healing proceeded. Removal of the hip hinge, thereby eliminating fixed abduction, reduced pressure recordings significantly.     

Functional cast-bracing for Colles' fractures. A comparison between cast-bracing and conventional plaster casts

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures.     

Pressures generated in the thigh muscles and under the thigh cast of an uninjured subject wearing a cast-brace.

Intrinsic pressures within the thigh muscles of a normal subject were recorded with the subject in five different postures before and after application of a cast-brace. The extrinsic pressures between the plaster cast and the underlying skin also were recorded. The intrinsic muscle pressures were significantly increased when the cast-brace was applied.     

Treatment of distal femoral fractures with early weight-bearing. A preliminary report.

Ten patients with 11 supracondylar fractures of the femur were treated with early weight-bearing and early knee motion. All fractures united. A good functional range of painless knee motion was restored in each case. No deformity or shortening developed during treatment in the cast-brace.     

Preliminary results of treatment of fractures of the femur by cast-bracing using the Zaria metal hinge

This is a prospective study of 27 patients with fractures of the femur at different levels and treated by cast-bracing using the Zaria hinge. The shortest follow-up period is 6 months. The brace was applied after an average of 4.5 weeks in traction. No alignment jigs or other accessory appliances were used. The patients got up 1–3 days after application of the brace and left hospital 5.8 weeks after fracture. Healing of the fracture was judged clinically and radiologically. The patients were pleased with the method. The average time in the brace was 9 weeks and to clinical union was 13.5 weeks. Three patients had shortening of more than 2.5 cm and six fractures were bent by more than 10 degrees but most of these deformities were present before the brace was applied. When the brace was removed the average range of flexion at the knee was 0–80 degrees and 6 months after fracture it was virtually full. The only notable difficulty with the hinge was loosening of the proximal end-plate.It is concluded that the Zaria metal hinge is an effective device for the cast-bracing of fractures of the femur, that alignment jigs and other accessory appliances are not essential for its application and that the cast-brace method is particularly suitable for use in the developing countries because of its effectiveness, simplicity and cheapness.     

Treatment of supracondylar fractures following prosthetic arthroplasty of the knee

Fifteen supracondylar fractures of the femur in patients with ipsilateral total knee arthroplasties were treated between 1975 and 1982. Three groups were identified for analyzation of treatment and end result. The average follow-up period after fracture was 18 months, with a range of ten to 48 months. Group I had four patients treated by closed reduction, cast immobilization, and early weight-bearing. At follow-up evaluation, three had a decrease in knee rating score, and one required a corrective osteotomy. Group II had eight patients treated by traction followed by cast or cast-brace immobilization. Four patients had a decrease in the knee rating because of malunion or loss of motion, and there was one nonunion requiring surgical treatment. Group III had three patients treated by immediate open reduction and internal fixation of the fracture. All three groups had functional arthroplasties following union of the fracture. Closed reduction and skeletal traction are recommended for the initial treatment. Open reduction and internal fixation, when technically feasible, is recommended when closed reduction and skeletal traction cannot maintain satisfactory alignment.     

Diagnosis and Macintosh substitution for chronic anterior cruciate insufficiency

Of 45 consecutive knees undergoing MacIntosh fascia lata anterior cruciate substitution, only five had accompanying collateral ligament laxity. Over a third of cases (16) had more than ten episodes of major instability causing falls to the ground pre-operatively. The initial injury caused haemarthrosis, usually without external trauma (36), was often accompanied by a sensation of knee disruption (18), and was always associated with immediate disability. The results of 26 lateral substitution operations with minimum 12 month follow-up show abolition of pivot shift jerk in all patients. Incomplete control of objective and functional instability postoperatively in four patients may have been related to soft tissue stretching associated with early mobilization in a cast-brace or generalized ligamentous laxity.     

Ambulatory treatment of femoral shaft fractures with cast-brace.

Our early results support use of the cast-brace, early ambulation treatment of both open and closed fractures of the femoral shaft in all adult age groups. We believe initial traction should be used to reduce the fracture and maintain reduction until the fracture is clinically "sticky" to avoid subsequent malalignment in the cast-brace. The method facilitates early rehabilitation of the fractured extremity and the patient with minimal residual disability such as non-union, malunion, chronic infection and joint stiffness, so often associated with other forms of long bone fracture treatment.     

DIAGNOSIS AND MACINTOSH SUBSTITUTION FOR CHRONIC ANTERIOR CRUCIATE INSUFFICIENCY*

Of 45 consecutive knees undergoing Macintosh fascia lata anterior cruciate substitution, only five had accompanying collateral ligament laxity. Over a third of cases (16) had more than ten episodes of major instability causing falls to the ground pre-operatively. The initial injury caused haemarthrosis, usually without external trauma (36), was often accompanied by a sensation of knee disruption (18), and was always associated with immediate disability. The results of 26 lateral substitution operations with minimum 12 month follow-up show abolition of pivot shift jerk in all patients. Incomplete control of objective and functional instability postoperatively in four patients may have been related to soft tissue stretching associated with early mobilization in a cast-brace or generalized ligamentous laxity.     

Surgical and nonsurgical treatment of acute ankle sprains

In the treatment of eversion injuries or tears of the medial structures, exact anatomic restoration is mandatory, and this must be accomplished by either closed reduction or surgery. The treatment of lateral ankle ligament injuries is usually cast immobilization, taping, or a cast-brace. Surgical treatment of lateral ankle ligament sprains is performed only on those highly competitive young individuals who require an almost normally functioning ankle.     

Elbow subluxation and dislocation. A spectrum of instability.

After sequential releases of the ligaments and capsules of 13 fresh autopsy specimen elbows, external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 with the anterior medical collateral ligament (AMCL) intact. Kinematic displacements measured with a three-dimensional electromagnetic tracking device showed that dislocation involved posterolateral rotation of 34 degrees-50 degrees and 5 degrees-23 degrees valgus at about 80 degrees flexion. Dislocation is the final of three sequential stages of elbow instability resulting from posterolateral rotation, with soft-tissue disruption progressing from lateral to medial. In each stage, the pathoanatomy correlated with the pattern and degree of instability. Testing for valgus stability of the elbow during simulated active flexion revealed no significant increase (-0.3 degrees-2.4 degrees) in valgus laxity after reduction compared with the intact specimens (p greater than 0.05, beta = 0.1, delta = 2.5 degrees). In no case did the digitized AMCL origin-to-insertion distance increase beyond normal during the dislocation (p less than 0.01). The mechanism of dislocation during a fall on the outstretched hand would involve the body "rotating internally" on the elbow, which experiences an external rotation/valgus moment as it flexes. Posterior dislocations should therefore be reduced in supination. If valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact, and rehabilitation in a hinged cast-brace with the elbow in full pronation can be commenced immediately.     

Microvascular decompression in hemifacial spasm: intraoperative electrophysiological observations

Facial muscle responses in patients with hemifacial spasm undergoing microvascular decompression operations were recorded. Two peripheral branches of the facial nerve were stimulated and the electrical responses of muscles innervated by these branches were studied to see how the lateral spread of activity that is known to be present in these patients was affected by decompressing the facial nerve. In some of the patients the hemifacial spasm ceased when the dura mater was opened, in some it ceased when the arachnoid was opened, and in others the spasm persisted until the offending vessel was dissected away from the nerve. The lateral spread of activity elicited by antidromic stimulation of a branch of the facial nerve was less affected by opening of the dura mater or arachnoid: it usually persisted until the blood vessel that had been compressing the facial nerve was removed and reappeared when the vessel that had been compressing the facial nerve was allowed to slip back onto the nerve. This seems to indicate that microvascular decompression of the facial nerve is effective in alleviating hemifacial spasm because it removes the actual cause of the disorder rather than simply causing local injury to the nerve as a result of the procedure.     

Low-friction arthroplasty of the hip. A 10-12-year follow-up study

The data from a series of patients operated upon by Charnley and reviewed after ten to 12 years shows that low-frictional torque arthroplasty remains a sound concept of design. If done with precision, it is still the best operation for patients with discomfort and disability from coxarthrosis. The development of a sound interface is controlled not only by the initial strength of the interlock achieved by the surgeon, but also by the loads applied to it by the patients. The total hip arthroplasty may be a miracle of modern medicine, but it can never be superior to normal articulation; this should encourage the surgeon to steer the patient away from unreasonable expectations. In this review, 217 arthroplasties were performed in 184 patients; 58 died, leaving 153 arthroplasties in 126 patients. Eighty-eight percent were more than satisfactory; 6% required revision. This was due to aseptic loosening in only two percent.