Central slip tenotomy for chronic mallet finger

We performed a retrospective audit of a consecutive series of twenty-three patients to evaluate the results of central slip tenotomy performed for chronic mallet finger. The surgery was performed at a mean of 42 (range four to 480) months after surgery and the pre-operative extensor lag at the distal interphalangeal joint was a mean of 44 (range 20–80) degrees. At the time of evaluation, at a mean of 33 (range six to 95) months after surgery, the extensor lag had improved to a mean of seven (range zero to 40) degrees. Using a simple clinical grading system, there were 12 excellent, six good, three fair and two poor results. Three patients had complications; one infection requiring antibiotics, and two who had post-operative extensor lags at the proximal interphalangeal joint which responded to a period of splinting and hand therapy.     

Complex acetabular fractures

Displaced acetabular fractures belonging to the associated fracture group described by Judet and Letournel present a formidable diagnostic and therapeutic challenge. Of 116 acetabular fractures, 31 had associated fracture types with follow-up evaluation of one year or longer. The patients' mean age was 30.7 years, their mean injury severity score was 15, and the average follow-up period was 21 months. Four patients had failed previous acetabular surgery. Operating time averaged 4.5 hours. Mean blood loss was 1150 cc. Clinical results were satisfactory in 77% of cases, with 11 excellent, 13 good, four fair, and three poor results. Complex acetabular fractures can be reduced by a combined anterior and posterior approach designed by the authors. This approach offers significant advantages for visualization and stabilization of these fractures. The combined approach is recommended for the surgeon who has mastered the single-approach techniques for standard, simple fracture patterns.     

Der Flexor-hallucis-longus-Transfer zum Ersatz der Achillessehne

BACKGROUND: Transfer of the flexor hallucis longus (FHL) tendon is a therapeutic option to replace a dysfunctional Achilles tendon in cases of rerupture with large defects, loss of the Achilles tendon after postoperative infection or severe tendinosis. MATERIALS AND METHODS: Between January 1994 and December 2005, 35 patients (5 female and 30 male, average age 47 years) were treated with 36 FHL transfers and 25 patients with 26 FHL transfers could be re-evaluated at a mean follow-up time of 79 months (range 20-133 months) after surgery. RESULTS: Of the 25 patients, 18 (72%) subjectively rated the result as excellent, 5 (20%) as good, and 1 patient (4%) each as fair and poor. According to the criteria of Trillat and Mournier-Kuhn, 18 patients (72%) were rated excellent, 4 (16%) good and 3 (12%) fair. The AOFAS ankle/hindfoot score at follow-up averaged 91 (range 13-100), the AOFAS forefoot score averaged 95 (range 24-100). CONCLUSIONS: FHL transfer to the Achilles tendon provides favorable results in cases of complicated cases with defects, infections or severe tendinosis after Achilles tendon rupture.     

Total hip replacement after failed hemiarthroplasty

A retrospective follow-up study comprising 37 patients operated upon using total hip replacement (THR) following failed hemiarthroplasty (HA) is reported. The mean duration time after HA was 83 months. Twenty-four patients showed satisfactory results at a mean follow-up of 4.8 years, while 13 patients found the results unsatisfying from the very beginning. The mean (SD) observation time after THR was 50 (38) months. The mean (SD) age of 28 women and 9 men examined at the follow-up was 69 (10) years. The mean Mayo/Harris hip scores were 76/76 (range 41-98) points. The final results were excellent in nine, good in ten, fair in five and poor in thirteen cases. After complicated subcapital femoral fractures treated by HA, the final result after THR was excellent or good in four, fair in three and poor in seven cases. However, revision arthroplasty was performed in two cases, in the one because of loosening, in the other due to recurrent dislocation. Radiologically, at follow-up in 13 patients, 11 femoral and 6 acetabular components showed signs of loosening. In conclusion, THR can be recommended as primary operation for the treatment of acute subcapital femoral fractures in elderly and active patients.     

Outcome of compartment syndrome following intramedullary nailing of tibial diaphyseal fractures

Seventeen cases of compartment syndrome were treated in a group of 626 consecutive patients with tibial diaphyseal fractures. Clinical and radiological follow-up was performed at an average of 24 months (range 8-54 months). Functional outcome was assessed using Edward's classification. All patients who developed compartment syndrome had fracture stabilisation with a reamed intramedullary nail using skeletal traction. The average interval between the nailing procedure and fasciotomy was 11 h. Results were good in 10 cases, fair in four cases and poor in the remaining three cases. Patients who had decompression within 12 h had a good functional outcome. Patients with poor results were all treated at an interval greater than 24 h.     

Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment

During a period of forty-two years, twenty patients who had a post-traumatic proximal radio-ulnar synostosis were treated by excision of the area of synostosis and various concurrent procedures in an attempt to restore rotation of the forearm. The time from injury to operation averaged eighteen months, and the postoperative follow-up averaged forty months. Results were graded on the basis of improvement in the arc of rotation of the forearm. After excision of the area of synostosis in the fifteen patients for whom data were available, the intraoperative arc of passive rotation averaged 121 degrees. At the most recent follow-up, the range of active rotation averaged 55 degrees for all twenty patients. Four patients had an excellent result; three, good; four, fair; and nine, poor. The outcome of this type of surgical treatment varies, but roughly half of the patients can be benefited.     

Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures

The authors reviewed 31 distal tibial fractures (16 involving the tibial plafond) treated with Ilizarov external fixation. The study population was composed of 19 males and 12 females, with an average age of 54. The fractures were classified according to the AO classification: A1 (3), A2 (6), A3 (6), C1 (2), C2 (8), C3 (6). There were six open injuries. In 14 pilon cases, open reduction of the intra-articular fragments and bone grafting via a limited incision was performed. Clinical follow-up averaged 28 months (range 18-42). All but one fracture united with an average healing time of 13.9 weeks. Nearly all patients with AO type A fracture had excellent or good functional scores. The 14 cases of AO C2 and C3 group had five (38%) good results, five (38%) fair results and three (24%) poor results. This method yielded results comparable with previous studies using open reduction and internal fixation. Twenty-nine percent of the patients had pin track infection, which remained the most important complication of this method.     

Bone-block iliotibial band reconstruction for anterior cruciate insufficiency. Follow-up note and minimum five-year follow-up period

Sixty-two of 71 patients (87%) who received a bone-block iliotibial band transfer were followed with a minimum follow-up period of five years (range, 5-10 years). Sixteen of the originally studied knees were examined with an average follow-up period of 104 months (range, 90-120 months). A second group of 46 knees was studied at an average follow-up period of 75 months (range, 60-92 months). Preoperatively, all patients had giving way (buckling). The average postoperative score of the original group was 83 (range, 52-99 points). There were nine excellent, three good, and four poor results. The average postoperative score of the second group was 89 (range, 73-99 points). There were 24 excellent, 18 good, and four fair results. Giving way was absent in 93% of the patients postoperatively; 88% had a negative pivot-shift test. Sixty-eight percent of the patients no longer used a brace for sports, 24% wore a brace for protection only, and 8% used it for instability. Improvement of at least one grade in the Lachman and anterior drawer tests was found in 61% and 85% of the patients, respectively. Pain was the major reason for fair and poor results. All but one had previous meniscectomy. There were no fair or poor results with menisci intact. So far, there has been no deterioration with time. The procedure remains ideal for recreational athletes who cannot afford a long absence from work and for those patients whose daily activities are compromised by recurrent knee instability.     

The judet quadricepsplasty: Long-term outcome of 21 cases

BACKGROUND: The lack of knee flexion represents a possible complication in severe femur fractures. In 1956, Judet proposed a quadricepsplasty technique that allowed for a graded release without the disruption of the vastus medialis obliqus, vastus lateralis, or rectus femoris. METHODS: This article reports the clinical outcome of 21 cases of Judet quadricepsplasty after an average follow-up of 101.0 months (range, 21-204 months). The definitive flexion gain was classified as excellent, good, fair, or poor. Excellent when >100 degrees, good when >80 <99 degrees, fair when >50 degrees <79 degrees, poor when <50 degrees. The flexion and extension strength were graded from 0 to 5, according to the Daniel's scale. RESULTS: The average strength score was 4.71 in flexion, 4.81 in extension. The average definitive flexion was 95.67 degrees (range, 54-128 degrees) and the average definitive flexion gain was 72.43 degrees (range, 40-122 degrees). When the patients were grouped on the basis of the definitive flexion, excellent results were observed in eight cases (38.10%), were good in nine (42.86%), and fair in four (19.05) with zero poor results. CONCLUSIONS: Our experience has shown that, even if first proposed in 1956, the Judet procedure still gives a reproducible amount of good results.     

The modified Blanchet ligamentoplasty for chronic ankle instability

We have treated 12 patients with chronic ankle instability using a modified Blanchet ligamentoplasty. The lateral ligaments were shortened and reinforced with an inferior extensor retinaculum flap. All 12 patients had functional instability and were assessed with preoperative stress X-rays. Follow-up averaged 19 months. A subjective grading scale was used to classify the results. Postoperative stress radiographs were also taken. There were 9 excellent results, 2 good results, 1 fair result and no poor result. Overall, 11 had an excellent or good result. There were no complications.     

Double-plating of comminuted, unstable fractures of the distal part of the femur

The cases of nine patients who had a complex fracture of the distal part of the femur and a deficient medial-cortical buttress were reviewed. Stable fixation was not achieved with the lateral condylar buttress plate alone. Collapse of the distal fragment into varus angulation was noted intraoperatively, with the axis of rotation being the junction of the distal screws and the plate. Additional stabilization with a medial plate and a bone graft from the iliac crest was applied in all nine patients: in six, at the time of the index operation and in the remaining three, after the open wound and open fracture were considered clean. At an average duration of follow-up of twenty-six months (range, twenty-one to thirty-four months), all of the fractures had healed. Evaluation of the functional outcome revealed five good and four fair results. In three patients, less than 90 degrees of flexion of the knee was present and in six, the arc of flexion was limited to between 90 and 100 degrees. Additionally, four patients had an extensor lag of 5 degrees.     

联合手术入路治疗复杂型髋臼骨折

目的总结复杂型髋臼骨折联合手术入路的治疗经验。方法对19例复杂型髋臼骨折行联合手术入路治疗。结果术后以M atta复位标准:优4例,良13例,中2例。经6个月~3年随访,患者均下地行走,按照M atta功能评分:优5例,良11例,中2例,差1例。结论联合手术入路治疗复杂型髋臼骨折可以取得满意疗效。医师的临床经验对于提高复位质量、改善疗效十分重要。     

Total knee arthroplasty in patellectomized patients

Thirty-two total knee arthroplasties (TKAs) in patellectomized patients were evaluated with recent clinical and radiographic examinations. Eighteen patients had primary TKA with a mean follow-up period of 49 months, and 14 patients had a revision TKA with a mean follow-up period of 36 months. A control group of 13 TKA patients with intact patellae were randomly generated but matched for age, sex, follow-up data, diagnosis, and prosthesis. Posterior cruciate ligament-retaining types of prostheses were used in the primary knees, while the revision knees underwent arthroplasties with the more constrained, posterior cruciate ligament-substituting prostheses. All knees were evaluated based on the Knee Society's clinical and radiographic scoring system. In addition, 18 patients (9 primary, 9 revision) underwent isokinetic dynamometer testing for quantitation of peak quadriceps and hamstring torque. The knee score, indicative of pain relief, averaged 82.5 in the primary group (16 good/excellent, 1 fair, 1 poor), 86.5 in the revision group (12 good/excellent, 1 fair, 1 poor), and 93,9 in the control group (13/13 excellent). The function score averaged 59.7 in the primary group (6 good/excellent, 6 fair, 6 poor), 60.0 in the revision group (5 good/excellent, 2 fair, 7 poor), and 80.9 in the control group (12 good/excellent, 1 fair). The lower function scores predominantly reflected the patients' difficulty in independently climbing or descending stairs. This was also reflected in their higher flexion to extension peak torque ratios. There was one failure in the primary group requiring a revision and one failure in the revision group requiring a knee fusion. There was no radiographic evidence of impending failure in any of the remaining knees. No clinical or radiographic differences were found between the patients with osteoarthritis or rheumatoid arthritis. Although the knee and function scores were lower in the patellectomized patients, the overall results were generally satisfactory without a high incidence of failures. Satisfactory results were obtained in the primary TKAs using the minimally constrained prostheses when the posterior cruciate ligament was intact. Revision TKAs, in which the posterior cruciate ligament was absent, also demonstrated satisfactory results with the more constrianed, posterior cruciate ligament-substituting prostheses.     

Management of complex tibial and femoral nonunion using the Ilizarov technique, and its cost implications

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully. Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately pound 30,000 per patient. We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.     

Long-term results of dorsally displaced distal radius fractures treated with the pi-plate: is hardware removal necessary?

The purpose of this study was to evaluate the outcome of patients treated with open reduction and internal fixation (ORIF) using dorsal plates and screws (AO/ASIF pi-plate) for dorsally displaced fractures of the distal radius. Although extensor tendon rupture is a recognized complication of all distal radial fractures, there appears to be an increased risk of this using dorsal plating. In addition, there is the added complication of extensor tendon irritation and dorsal wrist pain, which may necessitate plate removal. The low-profile pi-plates intended to overcome this problem have not done so, with quoted rates ranged from 19% to 55%.We treated 32 completely evaluated patients (13 men and 19 women) in our department between 2000 and 2004, with an average age of 46 years. They underwent ORIF of dorsally displaced fractures of the distal radius using the specially designed pi-plate. Bone graft was used in 18 patients who had significant metaphyseal defect. Clinical examination, plain radiographs, and functional assessments using the modified Mayo Wrist Score were performed at an average follow-up of 86 months (range, 56-115 months). Satisfactory reduction was achieved in all 32 fractures at the time of operative fixation with no instances of loss of fracture reduction during the study period. According to the Mayo Wrist Score, 23 patients (72%) had excellent or very good results, 7 (22%) had fair results, and 2 (6%) had poor results. Two cases (6.25%) of extensor tendon rupture were noted during the first postoperative month, and 2 other patients showed progressive weakness of index finger extension 6 months postoperatively. The remaining 28 patients had no soft tissue problems.     

经腹直肌外侧入路钢板结合后柱拉力螺钉内固定治疗髋臼前后柱骨折

目的探讨经腹直肌外侧切口入路钢板结合后柱拉力螺钉内固定治疗髋臼前后柱骨折的临床疗效。方法回顾性分析自2011-03—2015-10采用经腹直肌外侧切口入路前柱钢板加后柱顺行拉力螺钉内固定治疗髋臼前后柱骨折48例的临床资料,术后根据改良的Merle D'Aubigne和Postel评价标准评价患侧髋关节功能。结果本组48例均为单一经腹直肌外侧切口入路完成手术,手术时间45~150 min,平均85 min;术中出血180~1 200 ml,平均330 ml;所有患者均获得随访10~24个月,骨折均愈合,髋臼前后柱骨折均复位良好,髋臼后柱拉力螺钉位置理想。复位标准按照Matta标准进行评估:优34例,良8例,可6例,优良率87.5%。2例出现腹壁伤口皮下脂肪液化,经换药后愈合。末次随访疗效根据改良的Merle D'Aubigne和Postel评分系统评定:优30例,良10例,可8例,优良率83.3%。结论经腹直肌外侧切口入路能从骨盆内侧面充分显露髋臼前柱、四方体及后柱,并直视下复位髋臼前后柱骨折,前柱钢板+后柱顺行拉力螺钉固定能达到稳定的固定效果。     

Anatomic Repair of the Central Slip with Anchor Suture Augmentation for Treatment of Established Boutonniere Deformity

BackgroudThe rupture of the central slip of an extensor tendon of a finger causes a boutonniere (or buttonhole) deformity, characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Currently, there are no standard treatment guidelines for this deformity. This study aimed to report clinical results of surgery to correct chronic boutonniere deformity.MethodsThis retrospective case series was conducted between January 2010 and December 2018 and only 13 patients with trauma-induced chronic deformity were included. After excision of elongated scar tissue, a direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation was conducted. Total active motion was assessed before and after surgery and self-satisfaction scores were collected from phone surveys.ResultsAll patients presented with Burton stage I deformities defined as supple and passively correctable joints. The initial mean extension lag of the PIP joint (43.5°) was improved by an average of 21.9° at the final follow-up (p < 0.001). The mean hyperextension of the DIP joint averaged 19.2° and improved by 0.8° flexion contracture (p < 0.001). The average total active motion was 220.4° (range, 160°–260°). Based on the Souter''s criteria, 69.2% (9/13) of the patients had good results. Only 1 patient reported fair outcome and 23.1% (3/13) reported poor outcome. The average Strickland formula score was 70 (range, 28.6–97.1). In total, 10 patients (77%) had excellent or good results. Of 10 patients contacted by phone, self-reported satisfaction score was very satisfied in 2, satisfied in 3, average in 3, poor in 1, and very poor in 1. Three patients reported a relapse of the deformity during range of motion exercises, 1 of whom underwent revision surgery. One patient complained of PIP joint flexion limitation, and 2 complained of DIP joint flexion limitation at final follow-up.ConclusionsIn chronic boutonniere deformity, central slip reconstruction with anchor suture augmentation can be an easily applicable surgical option, which offers fair to excellent outcome in 77% of the cases. The risk of residual extension lag and recurrence of deformity should be discussed prior to surgery.     

Simple decompression with small skin incision for cubital tunnel syndrome

Eighteen elbows in 17 patients with cubital tunnel syndrome were treated by simple decompression using only a 1.5-2.5 cm skin incision with no endoscopic assistance. According to McGowan's criteria, three elbows were classified preoperatively as grade I, six as grade II and nine as grade III. The mean follow-up period was 14 months (range 3-25). Clinical results were evaluated as excellent for four elbows, good for ten and fair for four. Improvement of symptoms occurred in all patients and dislocation of the ulnar nerve was not observed. Simple decompression through a small skin incision can be recommended for the treatment of cubital tunnel syndrome, if the indication is appropriate.     

A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III

Although several treatment options for radial head fractures are available, no clear solutions exist. In this study we therefore compare open reduction and internal fixation (ORIF) with bipolar radial head prosthesis replacement in treatment of radial head fractures of Mason type III. Cement stem and bipolar radial prosthesis were used to treat 12 fresh cases and two old cases of Mason type III radial head fracture. As a control group, another eight cases of radial head type III fracture were treated with ORIF with cannulated screws and Kirschner (K) wires. The 14 patients who received radial head prosthesis replacement were followed-up for 15.9 months (range 10-27 months). According to elbow functional evaluation criteria by Broberg and Morrey, we found excellent results in nine cases, good in four, and fair in one. Mean follow-up of the eight cases in the ORIF group was 14 months (range 10-21 months), with good results in one case, fair in four, and poor in three. The result was good or excellent in 92.9% of prosthesis replacement patients and in 12.5% of ORIF patients. This difference is statistically significant (P = 0.0004; Fisher's exact test). We concluded that bipolar radial head prosthesis replacement is better than ORIF in treatment of Mason type III radial head fracture.     

强脉冲光治疗激素依赖性皮炎

目的 探讨应用强脉冲光技术治疗面部激素依赖性皮炎的毛细血管扩张和皮肤萎缩症的疗效及安全性.方法 对13例皮肤类型为Ⅲ～Ⅴ型、连续使用激素15个月至13年的患有面部激素依赖性皮炎所致的明显毛细血管扩张和皮肤萎缩症者应用强脉冲光进行治疗,治疗3～8次,每次间隔3～4周.结果 面部毛细血管扩张临床显效3例,有效7例,进步1例,无效2例,有效率为76.92%;13例中有10例萎缩皮肤的厚度得到一定程度的改善.结论 强脉冲光技术能明显改善激素依赖性皮炎所致的面部毛细血管扩张和皮肤萎缩症,治疗后恢复时间短,不良反应少,是治疗素激依赖性皮炎所致的毛细血管扩张和皮肤萎缩症的有效手段之一.