Plating of femoral shaft fractures. A review of 15 cases

The objective of this study was to define the role, indications and outcome of plating in femur shaft fractures. All femoral shaft fractures admitted and treated by the authors during a 2-year period were analysed. The authors personally treated a total of 135 femur fractures. Of these 135 fractures, 15 (11%) were treated with primary plating. The femoral fractures were classified as grade I (n = 4), grade III (n = 3), grade IV (n = 4), grade V (n = 3), and grade VII (n = 1) (OTA classification). Three patients sustained open fractures (one grade I and two grade II, Gustilo and Anderson classification). Pelvic (6) or ipsilateral lower extremity injuries (4) occurred in 10 of the 15 patients. A total of 23 body areas were injured, most commonly the chest (n = 10), abdomen (n = 5), head (n = 6) and blood vessels (n = 3). There were no infections reported. Two implant failures were noted. Femur plating is a useful technique in polytrauma patients for specific indications where intramedullary nailing (IMN) may be contra-indicated or technically not feasible. Although the postoperative morbidity (ARDS, death) in our study seems to be lower after plating than after intramedullary nailing, the rate of complications of fracture healing (30%) is significantly greater with femur plating than with intramedullary nailing (12%).

Forefoot reconstruction in rheumatoid arthritis patients: Keller-Lelièvre-Hoffmann versus arthrodesis MTP1-Hoffmann

The aim of this study was to compare the subjective, clinical and pedodynographic results of two large groups of patients operated on in our department. From January 1987 to December 1992, 38 rheumatoid patients (59 feet) underwent a Keller-Lelièvre arthroplasty of the first metatarsophalangeal (MTP1) joint and a Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 35 months. From June 1992 to August 1997 48 patients (62 feet) with rheumatoid arthritis underwent an arthrodesis of the MTP1 joint and Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 25 months. In 10 feet the arthrodesis was performed as a revision procedure of a failed Keller-Lelièvre arthroplasty. The patients of both series were assessed in the same way: personal interview, clinical examination, radiographs, bilateral footprints, and pedodynographic measurements. Static and dynamic pedodynographic measurements were taken with a 64-sensor matrix insole in a standard shoe. Six of our patients had an arthrodesis-Hoffmann procedure performed on one foot and a Keller-Lelièvre-Hoffmann procedure on the contralateral side. Although there is better loadbearing of the first ray with relative unloading of the central metatarsal heads in the arthrodesis MTP1-Hoffmann group, subjective evaluation of the procedure was slightly better in the Keller-Lelièvre-Hoffmann group. Ninety-three percent of the patients in the Keller group were satisfied or satisfied with minor reservations versus 87 percent in the arthrodesis group. This difference is not statistically significant. Recurrent deformity was not more prominent in the Keller-Lelièvre-Hoffmann group; however, it may be that with a longer follow-up, the feet in the arthrodesis-Hoffmann group hold up better over time. The arthrodesis MTP1-Hoffmann procedure can be used as a revision procedure for a failed Keller- Hoffmann operation, although these procedures were more difficult and needed a longer recovery time than the primary MTP1 arthrodesis.

Results after cheilectomy in athletes with hallux rigidus

From 1987 to 1993, 20 athletes (22 feet) underwent cheilectomy for Regnauld grade I, grade II hallux rigidus. Average age was 31 years (10 men and 12 women); mean follow-up was at 5.1 years. All patients performed high-level sports (judo, track & field, soccer, and skating). Indications for surgery included failure of nonsurgical treatment with persistent pain during sports activities, shoefitting problems, and recurrent bursitis. The aim of our study was to evaluate the results clinically, radiographically, and objectively, using dynamic and static pedodynographic measurements. After a mean follow-up of 5 years, cheilectomy was demonstrated to be a reliable treatment method in athletes with Regnauld grades 1 and 2 hallux rigidus. Functionally, 14 excellent, seven good, and one fair result were noted. Radiological progression was noted in 7 of 13 patients, with a follow-up of >4 years. Postoperative dynamic pedodynographic findings demonstrated moderate but significant changes in peak pressures under the first metatarsal head, the hallux, and in the center of pressure distribution under the forefoot.

Operative treatment of humeral shaft fractures

The results of the operative treatment of 27 humeral shaft fractures treated at the University of Louisville during a 2-year period were reviewed. The aim of this study was to analyze 1) the indications and results of surgical treatment, 2) the indications for nailing versus plating, and 3) the failures and their treatment (especially surgical nonunions). Indications for surgery were polytrauma patients (including open fractures, associated neurovascular injuries, associated ipsilateral forearm injuries) and isolated unstable fractures in which closed reduction failed. Plate and screw osteosynthesis was used in patients with proximal and distal fractures, in the presence of neurovascular injuries, progressive radial nerve palsy and failure of closed reduction due to interposition of soft tissue. Intramedullary antegrade nailing was preferentially used in polytrauma patients. Seven patients (25%) needed further surgery because of nonunion. The frequency was higher after plating (30%) than after nailing (20%), it was more common in comminuted fractures, middle third fractures and after insufficient distal locking. Exchange nailing resulted in union in 5 of the 7 cases. Although excellent results with low complication rates are reported in the recent literature following plate and screw osteosynthesis or locked intramedullary nailing, we found that operative treatment of difficult humeral shaft fractures is still fraught with a high complication rate.

The treatment of Lisfranc injuries

Thirty-one patients with fracture-dislocations of the tarsometatarsal joint were examined to assess the functional end results after a mean follow-up of 2.9 years (range 20 to 56 months). Sixty-one percent were polytrauma patients; 39% suffered isolated fractures. Forty-five percent had associated lesions of the tarsal joint complex (Chopart and subtalar joint). According to the Baltimore Painful Foot Scoring System (PFS), 52% achieved an excellent or good result and 48% a fair or poor result. Of the four different treatment modalities, open reduction and temporary screw or K-wire fixation yielded the best results. The major determinants of acceptable results were the type of treatment, type of lesions, the quality of initial reduction and associated involvement of the tarsal joint complex. The extent of the initial injury was the determining factor in the development of late degenerative arthritis. Degenerative changes of the tarsal joint were seen in almost all cases (94%). Such changes were more frequent after temporary screw fixation but did not seem to influence the final results. An initial anatomical reduction did not guarantee excellent results but minimized the chance of late degenerative arthritis. Primary arthrodesis demonstrated no advantage in our series. Although partial arthrodesis may be necessary in severely comminuted joints, it cannot be routinely advocated and should be used as a salvage procedure.

Pedodynographic measurements after forefoot reconstruction in rheumatoid arthritis patients

From January 1987 to December 1992, 38 patients (59 feet) with rheumatoid arthritis underwent reconstruction of the forefoot using Keller-Lelièvre arthroplasty of the first metatarsophalangeal joint and Hoffman resection of the lesser metatarsal heads. The average age of the patients was 61.3 years, with both feet involved in 21 patients and 17 with single foot involvement. The aim of our study was to evaluate the results both on a functional and an objective basis using dynamic and static pedodynographic measurements. Attention was given to dynamic pressure measurements under the metatarsal heads, the center of pressure distribution, gait analysis, and peak loads taken on different areas of the forefoot during normal walking. Correlations were made between these measurements and symptoms. After a mean follow-up time of 35 months, the clinical results were satisfactory in 54%, satisfactory with some reservations in 39%, satisfactory with major reservations in 3%, and unsatisfactory in 3% of patients.

Split posterior tibial tendon transfer through the interosseus membrane in spastic equinovarus deformity

The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years. This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak. The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.

A false aneurysm complicating a subcutaneous Achilles tendon lengthening

Subcutaneous lengthening of the Achilles tendon is a routinely used technique in our department. We report a case with a severe complication after this minor procedure in a 13-year-old patient with cerebral palsy. Six weeks after the operation the patient had a false aneurysm caused by a lesion of the posterior tibial artery at the time of surgery. After ligating the artery and draining the false aneurysm, recovery was uneventful. Although subcutaneous lengthening is an easy and reliable operation, one has to keep in mind its possible complications.

Jones transfer to the lesser rays in metatarsalgia: technique and long-term follow-up

Thirty-three feet in 29 patients with metatarsalgia were reviewed after Jones transfer to the lesser rays to evaluate the long-term results and the indications for these procedures. Transfer of the long extensor tendons to their respective metatarsal necks and fusion of the interphalangeal joints with shortening of the toe were performed. The procedures were performed in patients with symptoms of metatarsalgia, secondary to anterior pes cavus deformity (clawfeet, 16 patients), and in patients with mild or severe spreadfoot deformity with fall of the central metatarsals (12 patients). In all of our patients, the striking clinical sign was the long toes. Rating of the results was based on (1) the presence of pain or calluses and (2) residual deformity of the forefoot and toes. Symptoms of metatarsalgia were relieved in 25 feet, occasionally present in 6 feet, and unchanged in 2 patients. Complete correction of the deformity was achieved in 26 patients, 6 patients had slight residual deformities, and in the 1 poor result, overcorrection was present after the procedure. This operation is believed to be an excellent choice for patients with metatarsalgia due to (simple) pes cavus deformity and in patients with clawing and metatarsalgia secondary to excessively long toes.

Syndactyly of the ring and small finger

Five new cases of isolated syndactyly of the small and ring finger are described. Autosomal dominant inheritance is obvious. Brachymesophalangia of the fifth finger is a frequent association. Surgery is required at a young age.