Modified treatment concept in fractures of the humeral head in elderly patients

Between 1990 and 1994, 94 patients over 65 years with subcapital humerus fractures were treated by plate osteosynthesis. All patients were operated on within 48 h after trauma. Intensive physical exercising was begun in the early postoperative period. Three months after the operation all osteosynthesis materials were removed with differentiated treatment of the subacromial area. If deemed necessary on the basis of the intraoperative findings (i.e. symptoms of impingement) treatment included a Neer acromioplasty. Sixty-nine of the 94 patients were followed up, including clinical, radiological and ultrasonographic examinations. Twenty-two patients showed an excellent, 26 a good, 9 a satisfactory and 12 an unsatisfactory result, i.e. in more than 82% of patients functional result was excellent to satisfactory. Therefore, we recommended plate osteosynthesis of subcapital humerus fractures in the elderly, in combination with our standard postoperative regimen.     

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

The proposed two-factor structure of the Psychopathy Checklist (Revised) was assessed by confirmatory factor analyses on a sample of 376 community and prison based methadones maintenance patients. Confirmatory factor analyses indicated that the two-factor model proposed by previous researchers did not fit well with the data from this population. Exploratory analyses extracted five interpretable factors, three psychological factors (glibness/manipulative, callousness, irresponsibility), and two behavioral factors (criminal behaviors, promiscuity), which accounted for 61% of the variance. The data provided support for the psychometric reliability of the PCL-R, as indicated by a Chronbach's alpha of 0.83, weighted kappas for concordance between raters ranging from 0.51 to 1.00, and 100% agreement on diagnoses of psychopathy between raters. The data indicate that a two-factor structure does not adequately capture the dimensions of psychopathy in this population. While the factors do fall into distinct psychological and behavioral dimensions, more than two general factors are required to describe the dimensions of psychopathy.     

Total knee arthroplasty in morbidly obese patients

We reviewed the clinical outcomes of fifty primary total knee arthroplasties that had been performed with cement in forty patients who were considered morbidly obese (a Quetelet index of more than forty). These results were compared with those of 1768 similar procedures, performed during the same time-period by the same surgeon, in 1539 patients who were not morbidly obese (controls). At a mean of approximately five years postoperatively, there was a significant difference between the morbidly obese patients and the control group with regard to the knee and functional scores (84 and 53 points compared with 92 and 67 points; p < 0.00005 for both scores). No significant difference was detected, with the numbers available, with regard to the range of motion or the radiographic score (p = 0.77). The rate of perioperative complications was significantly higher in the morbidly obese patients (p < 0.00005). Of the fifty knees in these patients, eleven (22 percent) had a wound complication, five (10 percent) had an infection, and four (8 percent) had an avulsion of the medial collateral ligament. The five infections developed within twenty weeks after the operation, and three were associated with a wound complication. In comparison, thirty-five (2 percent) of the 1768 knees in the control group had a wound complication, eleven (0.6 percent) had an infection, and none had an avulsion of the medial collateral ligament. We concluded that total knee arthroplasty in morbidly obese patients can be successful but is associated with an increased rate of perioperative complications, including problems with wound-healing, infection, and avulsion of the medial collateral ligament. Alterations in the operative technique for soft-tissue closure and protection of the medial collateral ligament have decreased the rates of complications related to wound-healing and the medial collateral ligament.     

Total knee arthroplasty in patients receiving Workers' Compensation

The poor outcomes in patients who have a low-back injury that was sustained while they were on the job have been well described in many studies. The purpose of the current study was to determine the influence of Workers' Compensation on the outcome of total knee arthroplasty in forty-two patients who had been managed between January 1980 and December 1993. There were thirty-two men and ten women, and the mean age at the time of the operation was forty-eight years (range, twenty-nine to sixty-eight years). These patients were directly matched with a group of forty-two patients who were not receiving compensation. The two groups were matched with regard to nine parameters: age, gender, obesity index, preoperative deformity in the coronal plane, preoperative level of symptoms, preoperative radiographic severity according to the criteria of Ahlb?ck, method of fixation, number of previous procedures, and duration of follow-up. After a mean duration of follow-up of eighty months (range, forty-eight to 178 months), the patients who were receiving compensation had a mean Knee Society score of 64 points (range, 25 to 100 points). Twelve (29 per cent) of the patients in this group had an excellent or good clinical result, and thirty (71 per cent) had a fair or poor result or had had a revision. The patients who were not receiving compensation had a mean Knee Society score of 93 points (range, 57 to 100 points) after a similar duration of follow-up. Thirty-seven patients (88 per cent) in this group had an excellent or good clinical result, and five (12 per cent) had a fair or poor result or had had a revision; the difference between the two groups with regard to fair or poor results and revisions was significant (p < 0.01). With the numbers available, no significant differences could be detected between the two groups with regard to objective measurements of range of motion and stability or with regard to radiographic alignment, the presence of radiolucent lines, or the shedding of beads. On the basis of our findings, we believe that surgeons should be aware that Workers' Compensation is one of several variables that may have an untoward influence on the perceived outcome of total knee arthroplasty.     

Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients

The aim of this paper is to review the incidence and characteristics found in traumatic spinal cord injury (SCI) occurring in patients with long-standing ankylosing spondylitis (AS). The incidence of patients with traumatic SCI admitted to our unit from January 1984 to February 1996 was 2% (15 out of 893). They were all men with a mean age of 56 years. Most frequently the etiology of the lesion was a motor vehicle accident and the injury was mainly due to a hyperextension mechanism. Acute spinal fracture occurred in 13 patients, all involving the cervical region. No fracture was observed in two patients with thoracic neurological level. Three patients presented with an interval free period of neurological symptoms in whom a spinal epidural hematoma was visualized with magnetic resonance imaging. On admission eight patients were diagnosed as having complete SCI and the other seven an incomplete SCI. In the acute phase, respiratory complications were most frequent, causing six patients to die. Treatment was conservative in 14 patients. Multidisciplinary management of these patients should be implemented in an institution equipped with both a Spinal Injury Unit and an Intensive Care Unit.     

Problem elbow fractures in children

In this article guidelines are given for the treatment of pediatric elbow fractures, including supracondylar, medial epicondylar, lateral condylar, proximal radial, and olecranon fractures. Treatment techniques are described in detail and suggestions are provided to minimize complications.     

Periprosthetic humeral fractures: mechanisms of fracture and treatment options

The mink (Mustela vision) is a top trophic level species that readily bioaccumulates environmental pollutants and is considered to be a sensitive indicator of ecosystem health. Spatial trends in levels of organochlorine and heavy metal contaminant burdens were determined from 1991 to 1995 for wild mink from western Northwest Territories (NWT), Canada. Tissue samples from 207 mink from seven communities were analyzed for residues of 63 organochlorines and 10 heavy metals. All groups of organochlorines were detected in mink livers at relatively low levels; maximum community means were 9.52 ng/g sigma DDT and 73.07 ng/g sigma PCB (sum of 43 congeners). There was a general trend of decreasing organochlorine burdens along a northerly or westerly gradient for some groups of compounds, primarily sigma DDT, sigma PCB, sigma chlordane and dieldrin. Toxic equivalents (TEQs) of mink liver tissue were low, with the maximum community mean of 0.28 pg/g wet weight (5.5 pg/g lipid weight). Levels of heavy metal burdens in liver and kidney tissues were found to be relatively low, with the exception of Hg, which was found at moderate levels. There was no obvious geographic trend to the pattern of heavy metal burdens. The available evidence suggests that long-range atmospheric transport is the main source of the organochlorine contaminants observed. Local conditions (geology, water and soil chemistry, diet, etc.) may determine heavy metal burdens. Levels of contaminants in NWT mink appear to be one to two orders of magnitude lower than levels observed to cause reproductive impairment, reduced survival of kits, or lethality in adult mink. In the western NWT mink may be the best indicator to assess trends in environmental contaminants and ecosystem health; periodic monitoring is recommended.     

Fixation for distal radius fractures

Distal radius fractures are common fractures that can cause significant disability. As techniques and implants have improved, better results can be expected from internal and external fixation of complex wrist fractures. With meticulous technique, articular alignment can be secured and small articular fragments can be replaced in anatomic locations through limited open or arthroscopic techniques. Bone graft should be used liberally in comminuted articular fractures. Such procedures are demanding, however. Familiarity with the techniques described in this article will enhance the surgeon's ability to restore function in this group of patients.     

The retrograde intramedullary supracondylar nail: an alternative in the treatment of distal femoral fractures in the elderly?

To find out whether retrograde nailing of distal femoral fractures is beneficial for the aged patient, we performed a prospective study of consecutive patients 65 years or older with distal femoral fracture treated with a retrograde femoral nail between 1 March 1993 and 30 April 1996 in our department. In total, 26 patients with unilateral distal femoral fractures had been treated in our department, and 24 patients had been followed up for more than 12 months. All fractures had healed. Six patients did not walk before the injury. According to the Neerscore we counted 10/18 excellent results (> or = 85 points), 6/18 good results (> or = 70 points), 2/18 fair results (> or = 55 points) and no failures (< 55 points). Retrograde intramedullary nailing makes a biological osteosynthesis of distal femoral fractures possible. Even in our aged patients good functional results could be obtained. Poor hold of the distal interlocking screws and difficult proximal locking are the two major technical problems encountered with this implant. Early weight-bearing is not advisable.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.     

The primary treatment of frontobasal and midfacial fractures in patients with head injuries

The timing of operation can be especially difficult when frontobasal fractures are combined with other head injuries and midfacial injuries. In these cases, the head injury represents a considerable hazard to the patient and therefore it is mandatory to avoid any additional strain that might be caused by treating the midfacial injury first. On the other hand, because of poorer results with the secondary treatment, the surgical therapy for midfacial injuries should be achieved as early as possible. This report describes the results obtained in 68 patients managed over a period of 5 years and discusses their definite primary treatment. It emphasizes the need for close cooperation between the various surgical specialties involved.     

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.     

Radiohumeral arthrodesis for salvage of failed total elbow arthroplasty

Ulnohumeral arthrodesis is the standard technique for elbow fusion. The geometry and surface area of the distal humerus and proximal ulna enhance the chances of fusion while maintaining some wrist motion. A case of a patient with multiple failed elbow procedures in which the standard ulnohumeral fusion was not possible is presented. A radiohumeral arthrodesis was performed in an attempt to obtain a stable, nonpainful elbow. After complete healing of the fusion, the patient was able to use the arm for most functions. This technique is presented as an option for salvage failed elbow arthroplasty in the face of significant bone loss.     

Total hip arthroplasty in patients who have chronic lymphocytic leukemia

Twenty patients who had chronic lymphocytic leukemia underwent 25 elective primary total hip arthroplasties at the Mayo Clinic. No patient had a postoperative prosthetic infection. No patient had an intraoperative or postoperative hemorrhagic complication. One patient had a revision for aseptic loosening. After an average follow-up period of 4.6 years, there were 84% good and excellent results. It is concluded that patients who have early-stage chronic lymphocytic leukemia may not be at increased risk for major perioperative or postoperative complications in total hip arthroplasty. The surgeon must remain vigilant for postoperative complications, but satisfactory clinical results can be obtained in this patient population.