Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Jun 1995
Radiographic analysis of tibial fracture malalignment following intramedullary nailing.
Intramedullary nailing of the tibia was performed on 145 tibiae (137 patients) for fracture or nonunion from 1985 to 1992. There were 133 cases available for radiographic analysis of postoperative tibial alignment. Of the 133 nailings, 16 (12%) were malaligned (12 acute fractures and 4 nonunion-malunions). ⋯ The average anterior bow deformity of 5 proximal third fractures was 7 degrees (range, 5 degrees-12 degrees). Careful attention to operative technique and entrance angle, particularly with proximal third or comminuted fractures, is recommended to prevent angular deformity and malunion after tibial nailing. Proximal third tibial fractures may require a neutral or slightly lateral entrance angle to ensure a more anatomic reduction and centromedullary nail orientation to offset the tendency for valgus angulation.
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Fifty open tibial fractures with circumferential cortical bone loss were reviewed. Prospective treatment protocols included fracture stabilization with repeated irrigation and debridement followed by wound coverage. Bony stabilization was accomplished using external fixators, small diameter unreamed interlocking nails, and, in rare instances, plate fixation. ⋯ Techniques of reconstruction had no correlation to the development of nonunion or infection. They were valuable in determining malunion and total treatment time. These data confirm that carefully staged reconstruction leads to successful outcomes.
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Clin. Orthop. Relat. Res. · Jun 1995
Open tibial diaphyseal fractures. Results of unreamed locked intramedullary nailing.
Forty-three high energy open tibial diaphyseal fractures were treated with unreamed locked intramedullary nails from 1989 to 1992, and were reviewed at a minimum of 1 year from injury. There were 6 Grade I, 2 Grade II, 16 Grade IIIA, 9 Grade IIIB, and 1 Grade IIIC open fractures. Ninety-eight percent of the fractures united in an average time of 6.1 months. ⋯ Complications included 49% of fractures with malunions, 12% deep infections, 41% locking screw breakages, and 20% compartment syndromes. These results are similar to those achieved with external fixation of open tibial fractures. The unreamed locked intramedullary nail has not improved the outcome of open tibial diaphyseal fractures because the biologic consequences of the injury are of greater significance than the methods or techniques of fracture stabilization.
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Wound coverage after a complete degloving injury of the hand and fingers is 1 of the most difficult problems in hand surgery. Important structures such as tendons, nerves, and bones are exposed and will necrose if not covered adequately. The goal of treatment should be coverage with a pliable, sensitive, and cosmetically similar tissue that will allow early mobilization. ⋯ In 6 patients with degloving injuries of the thumb in whom replantation was not possible, the thumb was reconstructed using a free wraparound flap from the big toe. In 3 patients with degloving injuries of the fingers, coverage was obtained as an emergency measure using an island radial forearm flap. In conclusion, replantation should be attempted when the degloved skin is available and the vessels are not damaged; secondary reconstruction should be done as early as possible to limit the time of tendon, bone, and joint exposure.
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Advances in microsurgical techniques have permitted replantation and reconstructive procedures to restore amputated or injured parts with a high degree of success in children. Despite this progress, some technical concerns remain. During a 15-year period, replantations were done in 53 children with major limb (18), hand (10), or digit (25) amputations. ⋯ The microsurgical success rate was 86.8% for replantation procedures and 96% for reconstructive procedures. Although the technical aspects and outcome of replantation attempts still differ between adults and children, there appears to be little difference in free tissue transfer. Thus, most replantation and reconstructive procedures can be attempted with a high possibility of success in children.