Failure of cast immobilization for thumb ulnar collateral ligament avulsion fractures

PURPOSE: This report describes the early clinical experience with use of a transluminally placed endovascular graft (TPEG) covered with pre-expanded polytetrafluoroethylene (PTFE) to treat iliac artery aneurysms and fistulas. MATERIALS AND METHODS: Eight patients with iliac artery aneurysms (n = 7) and common iliac artery to common iliac vein fistula (n = 1) were treated with TPEGs. The iliac artery aneurysms were either common iliac (n = 6) or hypogastric (n = 1). All of the patients had significant comorbid diseases. The TPEG devices were made with pre-expanded PTFE sutured to Palmaz stents and delivered through 10- or 12-F sheaths. RESULTS: The aneurysms were successfully excluded in six of seven patients and the one iliac artery-to-vein fistula was successfully occluded. There were no immediate procedural complications related to the TPEG devices. Follow-up was limited (mean, 12 months), but no stenoses or occlusions of the TPEG devices were detected. The one failure was probably due to the marked tortuousity of the iliac artery, which prevented an adequate seal. CONCLUSION: In the authors' early clinical experience, the use of TPEG devices with pre-expanded PTFE successfully treated iliac artery aneurysms and an iliac artery-to-vein fistula. Although the results are encouraging, longer follow-up is necessary to better evaluate this type of treatment.     

Treatment of closed humeral shaft fractures with intramedullary elastic nails

PURPOSE: Our purpose is a retrospective study of the results of diaphyseal humeral fracture treatment by elastic intramedullary nailing in comparison with plate osteosynthesis. METHODS: Thirty cases were reviewed, with an average follow-up of 2 years. In 14 cases, flexible nails were used, and in the remaining 16 cases, A-O plates were used. We considered patients' sex and age, fracture type according to the A-O classification, type of treatment, consolidation defects, additional therapeutic procedures, healing time, and functional recovery. The surgical technique of elastic nailing appeared very simple, safe, and rather atraumatic because the nail is introduced in a retrograde manner and does not need proximal interlocking. RESULTS: The results of elastic nailing, in terms of fracture healing time and functional recovery, appeared comparable with the results of plating, and complications appeared milder. CONCLUSION: We conclude that intramedullary elastic nailing is valid for routine use in appropriately selected humeral shaft fractures.     

Rotational instability and integrity of the interosseous membrane in cadaveric ulnar shaft fractures

We demonstrate that the novel immunosuppressive agent mycophenolate mofetil (MMF), that has been approved for use in kidney transplant recipients, strongly potentiates the antiviral activity of acyclovir in murine models for herpesvirus infections. Hairless mice that were infected intracutaneously with herpes simplex virus type 1 were treated systemically with ACV (20 mg/kg per day) and topically with 5% MMF. Combined use of both drugs resulted in an almost complete protection, whereas single use of either compound had virtually no effect. When athymic-nude mice were infected with an ACV-resistant (ACVr)-thymidine kinase-deficient (TK-) HSV-2 strain, combined use of systemically administered ACV (100 mg/kg per day) and topically applied MMF (5%) protected 60% of the animals against the infection, whereas all mice treated with either drug alone succumbed. Since transplant recipients under MMF therapy may develop opportunistic herpesvirus infections, requiring treatment with acyclovir (or valaciclovir), our findings have important implications for the treatment of these herpesvirus infections.     

Imaging modalities for study of the distal ulnar region

Judicious use of diagnostic imaging maximizes the diagnostic capabilities of the surgeon treating the distal radio-ulnar joint (DRUJ). A good clinical history and clinical examination are necessary to direct the selection of appropriate imaging studies. Plain radiographs are almost always the first imaging examination. More advanced imaging techniques are costly and may provide only limited information. This article discusses imaging modalities useful for assessment of the DRUJ and the area around it.     

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.     

Treatment of humeral shaft fractures by retrograde locked nailing

From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.     

Operative treatment of fractures of the tibial plafond. A randomized, prospective study

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allg?wer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.     

Treatment of distal femoral fractures in the elderly. Results with the retrograde intramedullary supracondylar nail

The incidence of neural tube defects including myelomeningocele, which is one of the most common causes of infant and childhood disability, can be substantially reduced by folic acid supplementation to the diet of women before and during the early stages of pregnancy. All females of childbearing age should be taking folic acid supplements of 0.4 mg/day (400 micrograms/day) and consuming a diet rich in folate. Because many pregnancies are unplanned, supplementation should not await plans for pregnancy. Because pediatric nurse practitioners are in frequent contact with both adolescent patients and patients whose mothers are of childbearing age, and because pediatric nurse practitioners have an interest in preventing neural tube defects in future pediatric patients, they are in a good position to provide the necessary anticipatory guidance regarding the critical need for adequate folic acid intake by females of childbearing age. This article discusses and includes guidelines for providing this anticipatory guidance.     

Retrograde nailing of humerus shaft fractures with the unreamed humerus nail. An international multicenter study

Combined with the new unreamed humeral nail (UHN) (Synthes), the retrograde approach to the endomedullary canal of the humeral shaft promises careful reduction and fixation of humeral shaft fractures. This prospective multicenter study reports and analyses 102 retrograde nailings with the UHN and their operative procedures. Seven patients with pathological fractures have died meanwhile, but 75 patients could be followed up until bone healing. Seventy-three fresh humeral shaft fractures, 12 pseudarthrosis, 3 refractures and 14 pathological fractures have been treated with the UHN. In 98 cases (96.1%) the surgeon estimated fracture stability well enough to initiate immediate postoperative elbow and shoulder mobilization. The difficulties involved with free-hand interlocking proximally at the nail tip in 5.9%, fissure or avulsion at the insertion point in 3.9% and radial nerve palsy also in 3.9% of the cases were the most important intraoperative complications. In all 75 patients followed up, bone healing occurred, but five fractures (6.7%) needed more than 8 months connected with a second operative procedure. In one case spongious bone transplantation and new locking bolts had been performed. In three cases a special compression device has been used, whereas in one case also a new nail and in the second spongious bone transplantation had been added. In the fifth case plate osteosynthesis had been performed. At the end of treatment 89.4% of the patients had excellent shoulder function and 88.0% excellent elbow function. Once the indication for surgery is established, the UHN can be considered a reliable and safe implant for stabilizing humeral shaft fractures.     

A prospective study of trephined bone grafts of the tibial shaft and iliac crest

BACKGROUND: Our purpose was to analyze the expression of Fas antigen on CD4+ lymphocytes in the aqueous humor (AH) and cerebrospinal fluid (CSF) of patients with Vogt-Koyanagi-Harada disease (VKH). METHODS: Using three-color flow cytometry, we assessed T-lymphocyte subsets stained with fluorescence-conjugated anti-CD3, CD4, CD8, CD29, CD45RA, CD45RO, HLA-DR, and Fas monoclonal antibodies in AH, CSF and peripheral blood (PB) from 8 patients with active VKH. RESULTS: CD3+ T cells constituted the majority of lymphocytes in AH and CSF, in contrast to with PB. The percentages of CD4+ lymphocytes in uveitic AH and CSF were significantly higher than that in PB (P < 0.01). Activated CD4+ and CD8+ cells were significantly more frequent in AH than in CSF and PB (P < 0.01). Although the percentages of CD45RA+ cells within CD4+ cells in AH and CSF were extremely low compared with those in PB, the proportions of CD29+ and CD45RO+ (memory) cells within CD4+ were much higher than those in PB (P < 0.01). Fas antigen was also highly expressed on such CD4+ cells in AH, as in other uveitis patients and on such cells in CSF. Moreover, the percentages of Fas+ and memory cells in AH were significantly higher than those in CSF. CONCLUSIONS: The majority of CD4+ lymphocytes in AH and CSF from patients with active VKH were activated memory cells, on which Fas antigen was also highly expressed. Although this Fas expression may not be an apoptosis-related phenomenon, accumulation of Fas+ memory T lymphocytes in AH and CSF probably reflects the immunopathologic mechanism of VKH.     

Risk factors for stress fractures in track and field athletes. A twelve-month prospective study

The aim of this 12-month prospective study was to investigate risk factors for stress fractures in a cohort of 53 female and 58 male track and field athletes, aged 17 to 26 years. Total bone mineral content, regional bone density, and soft tissue composition were measured using dual-energy x-ray absorptiometry and anthropometric techniques. Menstrual characteristics, current dietary intake, and training were assessed using questionnaires. A clinical biomechanical assessment was performed by a physical therapist. The incidence of stress fractures during the study was 21.1% with most injuries located in the tibia. Of the risk factors evaluated, none was able to predict the occurrence of stress fractures in men. However, in female athletes, significant risk factors included lower bone density, a history of menstrual disturbance, less lean mass in the lower limb, a discrepancy in leg length, and a lower fat diet. Multiple logistic regression revealed that age of menarche and calf girth were the best independent predictors of stress fractures in women. This bivariate model correctly assigned 80% of the female athletes into their respective stress fracture or nonstress fracture groups. These results suggest that it may be possible to identify female athletes most at risk for this overuse bone injury.     

Chrysotherapy. A prospective study

A 4-year prospective clinical study of chrysotherapy was designed to reexamine old beliefs and traditions, and to test potentially new approaches to chrysotherapy. The standard weekly dosage of 50 mg was compared to that based on 1 mg/kg body weight; no significant differences were found. The rapidly absorbed aqueous thiomalate was compared to the slowly absorbed oil repository thioglucose; the latter produced significantly less side effects and an appreciably higher percentage of improvement. Almost half (43%) of nonresponders on standard regimen had a satisfactory clinical response at higher dosage levels without increase in toxicity. Some of these findings vary so much with traditional beliefs and practices that the authors urge caution in their interpretation. But generally speaking these problems are technical and do not detract from the conviction that chrysotherapy is valuable and comparatively safe in the management of rheumatoid arthritis and that it deserves more widespread application in clinical practice.     

Treatment of non-resectable pelvic malignancies by isolated pelvic perfusion. A preliminary study

Management of non-resectable pelvic tumours by intra-arterial local chemotherapy was shown to be beneficial but systemic toxicity limits its use. To overcome this problem isolated pelvic perfusion (IPP) was introduced as an alternative. This study summarizes our preliminary experience with IPP in the treatment of 18 non-resectable pelvic tumours [recurrent rectal adenocarcinoma (six), soft tissue sarcoma (STS) (five), bone tumour (three), epidermoid carcinoma (two), prostatic adenocarcinoma (one), malignant melanoma (one)]. Results of IPP were regarded as complete remission (CR), partial remission (PR), stable disease (SD) and disease progression (DP) according to the changes in three parameters including; scoring in pain, tumour marker and tumour size measurements. Complete and partial remission were established in five (27%) and seven (39%) patients respectively indicating a benefit ratio of 66%. Objective pain relief was encountered in 53% of the cases. All patients with STS had undergone further surgical treatment after IPP with successful curative resections in four. No residual tumour was found at the laparotomy of the fifth patient. Presenting symptom of the prostatic adenocarcinoma patient was symptomatic hypoglycaemia which resolved completely after IPP. To our knowledge, this represents the first case reported in the English literature in whom tumour related hypoglycaemia was successfully managed by IPP. In conclusion; management of non-resectable pelvic tumours by IPP seems to offer serious palliation and increase in the quality of life without any systemic toxicity. Our preliminary experience suggests even resectability may be achieved in a number of patients especially in those with STS.     

Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients

We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.