[Recent fractures of the distal end of the femur. Apropos of 87 cases (after the end of treatment)]

Anatomopathologic study of fractures of lower end of femur in 87 patients demonstrated the frequency of compound lesions in adults, epiphyseal detachment being the most common finding in children. Therapy used resulted in consolidation within a mean period of 4 months. Anatomic results were satisfactory in 87% of cases, 2 of 3 patients recuperating a knee compatible with a normal active life. Complications were rare. The current therapeutic attitude in adults is resolutely surgical, particularly in case of an intra-articular fracture line. In children, treatment remains orthopedic, except for epiphyseal detachments when minimal fixation allows perfect anatomic reduction and avoids secondary growth disorders.

Pseudarthrosis following proximal humeral fractures: a possible mechanism

A small series of four patients with pseudarthrosis of the proximal humeral shaft is reported. These patients all had restricted movement of the shoulder joint prior to the trauma, three as a result of rheumatoid arthritis and one due a surgical fusion of the glenohumeral joint. It is suggested that pseudarthrosis is more likely under these circumstances and that pursuit of union of the fracture in such patients may not always be necessary.

Fractures of the shaft of the tibia treated with Hoffmann external fixation

Ninety-six compound or unstable fractures of the tibial shaft were treated with external fixation of different mountings. The median healing time was 10 months without a statistically significant difference between the healing time after treatment with unilateral frames and quadrilateral frames. The rate of pin-track infection was 36%, which is comparable to those of other published series. Seven cases of chronic osteitis and four pseudarthroses required further surgical management. We had no primary or secondary amputations in this series.

[Recent isolated fractures of the tibia in the adult]

A series of 80 cases of recent isolated fracture of tibia in adults demonstrated the specific problems raised by this type of fracture, related for the most part to the integrity of the fibular splint. A resulting therapeutic attitude is based on a biomechanical study, the place of osteotomy of the fibula being discussed: orthopaedic treatment is suggested for fractures without displacement, under strict radiologic surveillance, and surgical treatment for fractures with primary or secondary displacement. The indications for fibular osteotomy are reviewed.

Non-union of a fractured coracoid process after dislocation of the shoulder. A case report

A patient with a fractured coracoid process in association with a dislocation of the shoulder is reported. The fracture was not recognised initially, and early mobilisation was encouraged; the widely separated fracture did not heal and a painful pseudarthrosis developed. We believe that this association may not be as rare as generally supposed, and emphasise the importance of careful clinical examination in patients with shoulder dislocation. If a coracoid fracture is suspected, lateral or oblique radiographs should be taken to confirm the diagnosis. A further radiograph after reduction is a useful precaution.

St. Georg hinged-knee prosthesis. A 2.5- to 8-year follow-up

Thirty-eight St. Georgs hinged-knee arthroplasties were studied with a follow-up of 2.5-8 years; 86.8% of the patients obtained an excellent or a good result, and 7.9% of the arthroplasties were failures. There was an infection rate of 3.8% and 3.8% loose prostheses. Among the failures there were two infected arthroplasties. One was arthrodesed, resulting in a pseudoarthrosis and one was successfully revised. One traumatic loosening lead to arthrodesis. It is concluded that hinged-knee arthroplasty under special circumstances may be a useful procedure.

Pseudarthrosis after spinal fusion for scoliosis. A comparison of autogeneic and allogeneic bone grafts

This study was undertaken to compare the incidence of pseudarthrosis in fusions supplemented with autogeneic and frozen allogeneic grafts. The records of 208 patients with adolescent idiopathic scoliosis who were treated by posterior fusion and Harrington instrumentation were studied. The fusion was supplemented by an autogeneic iliac bone graft in 114 patients and by an allogeneic bank bone graft in 94 patients. The fusion mass was explored in all patients with suspected pseudarthrosis; therefore, all pseudarthroses reported in this series were proved by surgical exploration. Pseudarthrosis developed in five patients (4.4%) receiving an autogeneic graft and in five patients (5.3%) receiving an allogeneic graft. The incidence of pseudarthrosis was not significantly different at the 95% level of certainty. Average blood loss and operative time were determined for all patients. The decreases in average blood loss and operative time in those patients receiving allogeneic grafts were significant (p less than .01). Thus, based on the incidence of pseudarthrosis, allogeneic frozen bank-stored bone is an attractive alternative to autogeneic iliac bone for fusion supplementation in the treatment of scoliosis. Total operative time and blood loss can be decreased, and possible complications associated with a donor site can be avoided.

A comparison of different methods used to diagnose pseudarthrosis following posterior spinal fusion for scoliosis

Pseudarthrosis is a recognized complication of posterior spinal fusion for scoliosis, and its early recognition and repair may prevent loss of correction, failure of the instrumentation, or pain. In this study of 200 fusions for scoliosis, we compared the reliability of different methods that are currently used to determine the presence or absence of a pseudarthrosis. Anteroposterior tomography was found to have the highest rate of correlation (96 per cent), as there was only one false-negative study. Other methods of diagnosis--including anteroposterior, lateral, and oblique radiographs and clinical findings such as loss of correction and back pain--were less accurate.

[Ventral intercorporeal traction spondylodesis of the lumbar spine]

At 35.7% the average rate of pseudarthrosis following ventral spondylodesis of a segment of the lumbar spine is very high. The inadequate degree of primary stability in the segment to be ankylosed is seen as the fundamental reason for this. In the present paper an implant made of a nickel-titanium alloy ("Memory Alloy") is described, which is inserted intercorporeally and immobilizes the moving segment by traction. Experiments in sheep have confirmed that the anchorages of the implant are stable; it was also established that bony fusion occurred both around the implant as well as through it. Observations thus far in 10 patients treated by this method have shown that the implant remains stably anchored, and in some cases clear signs of bone bridge formation were demonstrable on radiographs after only a short time. If the primary stability provided by the Memory implant continues to be thus confirmed, postoperative hospitalization will in future be limited to a few days.

[Injuries of the medial epicondyle of the humerus in children. Conservative or surgical therapy?]

18 patients with avulsions of the medial epicondyle 1 10/12 to 16 2/12 years after trauma are presented. Non-union occurs very often after conservative treatment involving avulsion with or without displacement. Although non-union of the medial epicondyle gives no or only little disability, the fixation with one or two Kirschner wires is recommended to avoid non-union. Open reposition is necessary in cases with injury of the n. ulnaris and in cases with incarceration of the epicondyle in the elbow joint.

Surgical fusion in childhood spondylolisthesis

Twenty cases of surgical fusion for spondylolisthesis were reviewed at the Scottish Rite Hospital (Atlanta, GA, U.S.A.) to determine whether a procedure other than a simple posterolateral fusion is necessary for most patients. The patients were treated postoperatively with pantaloon spica cast immobilization. The fusion rate was high (90%), and patient satisfaction was high. One patient developed neurologic loss postoperatively. Two patients' slips progressed greater than 10% before solid fusion occurred. Thus, bilateral posterolateral fusion, followed by pantaloon spica cast immobilization, is effective for patients with symptomatic spondylolisthesis or asymptomatic children with grade 3 or greater slips. Reduction was not performed in this series.

Nonunion of the radial head

A case of posterior fracture-dislocation of the elbow with a comminuted radial head fracture which subsequently went on to nonunion is reported. Radiographs at followup revealed a pseudoarthrosis of the radial neck, with at least part of the normal pronation and supination occurring through the pseudoarthrosis site.

The surgical treatment of congenital kyphosis. A review of 94 patients age 5 years or older, with 2 years or more follow-up in 77 patients

Ninety-four patients with surgical treatment of congenital kyphosis have been reviewed. Of these, 77 had a follow-up of 2 years or more, with an average follow-up of 7 years. The average age at surgery was 15, and the average kyphosis was 75 degrees. Twenty-seven had posterior fusion only, and 48 had combined anterior and posterior fusion. (Two others had anterior fusion only). The average kyphosis in the two groups was the same, but the anterior and posterior group had a better correction and a better maintenance of correction than the posterior group alone. Kyphosis of less than 55 degrees in growing children often was stabilized successfully by posterior surgery only, but adults and patients with kyphosis greater than 55 degrees required both anterior and posterior fusion. Halo-femoral traction was responsible for two of the three paralyses in this review.

Long-term results of tibiotalar arthrodesis

One hundred and one tibiotalar arthrodeses were performed using a single surgical technique that has not been previously reported. The average follow-up was ten years (range, two to twenty-five years). The rate of pseudarthrosis was 5 per cent, four to five times less than in other recent large reports. Pseudarthrosis occurred only in patients with a sensory deficit. Secure fusion was radiographically documented in 95 per cent and the functional clinical result was good to excellent in 90 per cent. The ideal fusion position was found to be neutral or slight equinus angulation, and varus-valgus angulation equal to that of the contralateral side. More than 7 degrees of varus angulation of the heel was associated with symptomatic lateral metatarsalgia in all feet in which it occurred. Radiographic measurement documented an average 85 per cent (11-degree) increase in postoperative tarsal motion. Neither symptoms nor function correlated with the degree of tarsal hypermobility.

The management of nonunions following high tibial osteotomies

Nonunion is an uncommon complication of high tibial osteotomy. Reported techniques of treating such a complication include resection of the pseudarthrosis and cast immobilization with risk of joint stiffness and loss of alignment. The special AO/ASIF threaded external fixator with double clamps was used to treat three patients with nonunions following high tibial osteotomy for medial compartment osteoarthritis. The pseudarthrosis was not resected in any instance. All were allowed full unrestricted joint motion postoperation. Rapid healing of the osteotomy ensued. The external fixator achieved excellent stability and rapid union while maintaining joint motion.

Ankle arthrodesis. Clinical and conceptual applications

Ankle fusion provides an excellent salvage for an otherwise intolerable deformity or painful joint derangement. It is the only available alternative for a failed ankle prosthesis. It produces a serviceable foot when done in proper perspective for the appropriate indication. It produces a good result when consolidation occurs and the remaining tarsal joints have preserved integrity. Improvement in occupational and daily activities can be anticipated when arthrodesis and correct alignment are obtained.

Ulnar impingement syndrome

We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.

[Current methods of treating pseudarthrosis]

Treatment of 706 patients with 708 false joints is described. 756 operations were fulfilled. Consolidation was achieved in 632 patients (89,9%). Principles of the treatment are described.

The role of tomography in the evaluation of the postoperative spinal fusion

Despite the fact that pseudarthrosis is the most common complication after posterior spinal fusion, no reproducible diagnostic method has been established. This study analyzes the accuracy of the anteroposterior trispiral tomography in evaluating the posterior spinal fusion mass. Tomography was shown to be both sensitive and specific in its ability to detect the presence or absence of a pseudarthrosis. Radiation exposure is not increased when tomography is performed in lieu of less accurate diagnostic studies. Anteroposterior trispiral tomography is a useful adjunct in the routine postoperative evaluation of the patient who has undergone a posterior spinal arthrodesis.