The Journal of bone and joint surgery. American volume
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J Bone Joint Surg Am · Feb 1985
Optimizing tourniquet application and release times in extremity surgery. A biochemical and ultrastructural study.
Despite numerous studies investigating the pathophysiology of tourniquet ischemia, definitive data at the cellular level have been lacking and no consensus regarding safe tourniquet-application times in extremity surgery has emerged. In light of the particular vulnerability of skeletal muscle to ischemic injury, we determined the degree of muscular metabolic derangement and cell damage produced by seven different protocols of tourniquet application and release, each providing three hours of total tourniquet time. We performed thirty-six experiments on canine hind limbs, comparing the following time-patterns of tourniquet application: I--three sequential one-hour periods, II--two sequential one and one-half-hour periods, III--two hours followed by one hour, and IV--a single continuous three-hour application. ⋯ No additional benefit was derived by extending the reperfusion periods to fifteen minutes. The longest period of continuous ischemia in each tourniquet-application protocol bore the closest relationship with the amount of cell damage produced. Within the spectrum of observed pathological changes, time-patterns I and II produced comparatively little muscle damage.
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J Bone Joint Surg Am · Jan 1985
Randomized Controlled Trial Clinical TrialThe use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.
Seventy-three patients with lumbar radicular pain syndromes were treated in a prospective, randomized, double-blind fashion with either seven milliliters of methylprednisolone acetate and procaine or seven milliliters of physiological saline solution and procaine. All patients had radiographic confirmation of lumbar nerve-root compression, consistent with the clinical diagnosis of either an acute herniated nucleus pulposus or spinal stenosis. ⋯ Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine. Therefore, a decision to use epidural steroids must be made with the realization that we failed to demonstrate its clinical efficacy in this study and that reports of serious complications of this procedure have been published.
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J Bone Joint Surg Am · Oct 1984
Case ReportsHyperalimentation for superior mesenteric-artery (cast) syndrome following correction of spinal deformity.
The cast syndrome, recently called the superior mesenteric-artery syndrome, is a well recognized complication that can occur after a body cast has been applied. We are reporting the cases of three patients who had this syndrome following surgical correction of spinal deformity. The complication failed to resolve with the usual non-operative measures but did resolve with treatment by total parenteral nutrition.
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J Bone Joint Surg Am · Oct 1984
Comparative StudyComminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail.
In a retrospective study, we attempted to assess progress in the treatment of comminuted fractures of the femoral shaft at Parkland Memorial Hospital from 1978 to 1983. Seventy-nine comminuted femoral-shaft fractures were available for follow-up: thirty-two treated by roller traction, twenty-three treated by cerclage wires and an intramedullary nail, and twenty-four treated by an interlocking intramedullary nail. Using the classification of Winquist and Hansen, Grade-III and IV comminuted fractures accounted for 69 per cent of those treated by roller traction, 68 per cent of those treated by nailing and cerclage wires, and 96 per cent of those treated by an interlocking nail. ⋯ For the purposes of this study, treatment was assumed to have failed if a change in treatment was necessary, an unplanned reoperation was performed, femoral shortening exceeded 2.5 centimeters, angulation was more than 15 degrees, non-union or a deep infection developed, motion of the knee was less than 70 degrees of flexion, or a refracture occurred. By these criteria, the frequency of failure after roller traction was 66 per cent (secondary to malalignment and shortening); after insertion of an intramedullary nail with cerclage wires, 39 per cent (secondary to unplanned surgery, non-union, shortening, and infection); and after use of an interlocking nail, 4 per cent (secondary to shortening). Currently, at our institution, an interlocking intramedullary nail is the treatment of choice for comminuted femoral-shaft fractures because it encourages early union with maintenance of length and alignment and the results are predictable.
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J Bone Joint Surg Am · Oct 1984
Case ReportsChanges in tibiofibular relationships due to growth disturbances after ankle fractures in children.
We analyzed the longitudinal growth of the distal tibial and fibular physes and the longitudinal displacement of the distal metaphysis and epiphysis of the fibula relative to the distal metaphysis and epiphysis of the tibia during growth using a roentgenstereophotogrammetric technique in eight children: six with a traumatic growth disturbance in one or both of the distal tibial and distal fibular physes and two with a normal ankle. In the normal ankles the distal fibular metaphysis moved distally in relation to the distal tibial metaphysis and the growth in the distal fibular physis was slower than that in the distal tibial physis. Growth arrest in the distal fibular physis and continued growth in the distal tibial physis resulted in distal displacement of the fibular metaphysis relative to the tibial metaphysis, probably due to traction on the distal ligaments of the fibula or more rapid growth in the proximal fibular physis than in the proximal tibial physis, or both. ⋯ Simultaneous growth arrest in both the distal tibial and the distal fibular physis was associated with movement of the distal end of the fibula in a distal direction relative to the tibia, probably due to the more rapid growth in the proximal fibular physis than in the proximal tibial growth plate. Therefore, growth arrest of the distal tibial or fibular physis may result in either proximal or distal sliding of the fibular metaphysis in relation to the tibial metaphysis. Probably growth arrest in the distal fibular physis has a less favorable prognosis than arrest in the distal tibial physis, because after tibial arrest proximal sliding of the fibula may compensate for overgrowth of the fibula better than distal sliding of the fibula can compensate for fibular arrest and overgrowth of the tibia.