Average Angulation Research Articles

The anatomy of the proximal ulna

The posterior border of the ulna is the most important bony landmark for all dorsal surgical approaches and the guideline for open reduction, internal fixation of displaced comminuted fractures of the proximal ulna. We examined 74 cadaveric specimens to evaluate the anatomy of the proximal ulna, especially the course of the posterior border, the point of varus angulation, the width of the shaft, and the relationship of the posterior border to the interosseous and anterior ones. In 63 specimens, the mean point of varus angulation was 85.4 mm, and the average angulation angle was 17.7 degrees. In 11 specimens, the posterior border was either radially bowed or the bow was poorly defined and not localized to a specific area along the length of the bone. In conclusion, the variations of the proximal ulna have to be considered if dorsal plates and intramedullary screws are used.

Outcome Results of Ilizarov Osteosynthesis for Congenital Pseudarthrosis of the Tibia: An Interim Report

Purpose : This study evaluated the efficacy of the Ilizarov technique for the treatment of patients with congenital pseudoarthrosis of the tibia (CPT). Material and Methods : Twenty-two patients with CPT, who underwent osteosynthesis using the Ilizarov technique and were followed-up for more than 3 years, were enrolled in this study. The clinical and radiological data were reviewed to evaluate the outcomes of the Ilizarov technique. Results : The initial osteosynthesis was carried out successfully with the Ilizarov method at average age of 4.6 years. Twenty refractures occurred in 12 patients, who were also treated successfully using the Ilizarov method. Tibial lengthening (27 cases), medial tibial hemiepiphysiodesis (23 cases), distal tibiofibular synostosis (17 cases) were combined with a total of 42 Ilizarov osteosyntheses. After an average 8.1 years follow-up, the mean limb length discrepancy was 1.6 cm, and average anterior apex and valgus angulation of the tibial shaft were 6.3˚ and 7.3˚, respectively. The mean ankle alignment was valgus 1.9, and the mean range of motion of the ankle joint was 21˚ dorsiflexion and 33˚ plantar flexion. Conclusion : The Ilizarov technique combined with tibial lengthening, distal tibiofibular synostosis and/or medial tibial hemiepiphysiodesis is an effective procedure that can achieve bony union as well as a functional limb.

Distal Metaphyseal Fractures of Tibia: A Prospective Randomized Trial of Closed Reduction and Intramedullary Nail Versus Open Reduction and Plate and Screws Fixation

To compare closed intramedullary nailing with open plate and screw fixation and set the indications for each treatment modality in distal metaphyseal fractures of tibia, 64 consecutive cases of fractures that had been randomly treated with either method were prospectively followed up. Thirty-four patients were in the group treated with closed intramedullary nailing (Group I) and 30 patients were treated with open reduction and internal fixation with anatomic plates and screws (Group II). They were observed for 2 years, and the end results were compared between the two groups. The duration of operation was 72 minutes in Group I and 89 minutes in Group II (p = 0.02). The period of time before radiologic union was 18 weeks in Group I and 20 weeks in Group II (p = 0.89). There was one superficial infection in Group I and six superficial infections and one deep infection in Group II (p = 0.03). The average angulation was 2.8 degrees in Group I and 0.9 degrees in Group II (p = 0.01). The ankle dorsiflexion at the final follow-up was 14 degrees in Group I and 7 degrees in Group II (p = 0.001). The Olerud and Molander functional ankle score was 88.5% of normal side in Group I and 88.2% in Group II (p = 0.71). Our results have shown that locked intramedullary nails have an advantage in the duration of operation, restoration of motion, and reduced wound problems, and anatomic plate and screws can restore alignment better than intramedullary nails. It can be concluded from this study that intramedullary nails are recommended for fractures associated with soft-tissue damage of Tscherne C2 or higher. In other cases, the authors think that either treatment modality can yield expected results.

Residual Neck Pain After Traumatic Spondylolisthesis of the Axis

Most patients with traumatic spondylolisthesis of the axis are treated nonsurgically. Some patients do not develop symptoms, but others experience strong and persistent neck pain. To clarify the factor that plays a major role in residual neck pain after this fracture, we reviewed nine patients who underwent conservative treatment. Patients were assessed via telephone interviews an average of 62 months after injury and were divided into two groups: those with and those without neck pain. Angulation and anterior translation between the second and third cervical vertebrae were measured on lateral radiograms at the time of injury, removal of brace, and final follow-up. Fracture lines were also investigated by computed tomography. At the time of final follow-up, the average angulation was 6.3 degrees and the average translation was 5.3 mm in the neck-pain group and 0.6 degrees and 0.2 mm, respectively, in the no-symptom group. In patients with fracture lines present on the articular surface of the inferior face joints, angulation persisted or increased, even though the fractures were hemilateral. This was compatible with severe neck pain. In contrast, angulation and translation were improved in patients with an intact inferior articular surface of the axis, and pain was not reported. Injury on the inferior articular surface of the axis may disturb spontaneous healing of C2-C3 subluxation and cause residual neck pain. It is necessary to assess the presence of injury to the inferior facet bilaterally with plain or computed tomograms.

Radial Neck Fracture Nonunion in Children

Radial neck nonunion in children is a rare complication of a displaced radial neck fracture. The authors conducted a retrospective review of nine cases of radial neck nonunion in an effort to identify risk factors for nonunion and to evaluate treatment options. Nine patients, average age 8.2 years, sustained displaced Salter-Harris type II fractures of the radial neck, with average angulation of 83 degrees and average displacement of 83%, and elbow dislocation or additional fracture in eight of nine patients. Initial treatment with open reduction achieved anatomical alignment of the fracture fragments in seven of the nine patients. Initial reduction was lost and radial neck nonunion developed in all patients. The nonunion was treated with observation, radial head and neck excision, or open reduction and internal fixation with bone graft, depending on the level of pain, deformity, and functional deficit. Healing of the nonunion did not necessarily lead to improvement of clinical symptoms. Severity of initial fracture displacement and inadequate fixation technique contributed to radial neck nonunion. Treatment of the nonunion should depend on the patient's pain, deformity, and functional restriction.

Evaluation of the effect of the residual bone angulation on implant-supported fixed prostheses in mandibular posterior edentulism. Part I: Spiral computed tomography study.

Dental implants are usually angulated buccolingually because of the anatomy of the residual bone in mandibular posterior edentulous cases. Although angulated dental implants compromise the construction of implant-supported prostheses, the effect of buccolingual angulation of the residual bone has not been clearly stated. This study is performed to determine the biomechanical effect of buccolingual angulation. The goal was to reveal the actual buccolingual angulation values of the residual bone in which implants were to be placed. Thirty mandibular Kennedy I and II cases comprised of forty edentulous posterior regions with missing second premolars and first, second, and third molars were included. Buccolingual angulation values along the 28 mm of residual bone were measured on 1-mm spacing cross-sectional images of spiral computed tomography. Paired sample t test was used for the statistical analysis. The minimum angulation values at the second premolar, first molar, and second molar region were 0 degrees, 3 degrees, and 9 degrees, respectively. The average angulation values were 4 degrees, 10 degrees, and 15 degrees, respectively, and the maximum angulation values were 11 degrees, 18 degrees, and 22 degrees, respectively. The ability to measure the buccolingual angulation of mandibular posterior residual bone before dental implantation may help the clinician at the implant treatment-planning phase.

Static and dynamic MRI of a urinary control intra-vaginal device.

The aim of this study was to describe by MRI, in dynamic conditions at rest and straining, the anatomical modifications induced by a commercially available intravaginal device (IVD) aimed at relieving female stress urinary incontinence. Ten female patients complaining of stress urinary incontinence (SUI) had pelvic MRI with static and dynamic sequences, without and with a self-inserted IVD. We studied positions and angulations of the IVD in the pelvis. Paired t-test allowed comparisons of: position of the bladder neck; urethral angulation with the pubis axis; position of the urethra; and posterior urethro-vesical angle (PUVA) without and with IVD. At rest, in ten of ten cases IVD laid cranial to the pubo-rectal muscle; with an average angulation of 95 +/- 10 degrees with the pubis axis, laterally tilted in three of ten cases. In maximum straining with IVD bladder neck descent was lower by an average of 5.2 +/- 3.1 mm (p = 0.001), pubo-urethral angle opening was smaller by an average of 22 +/- 20 degrees (p = 0.015), and bladder neck to pubis distance was shorter by an average of 5.7 +/- 4 mm. Posterior urethro-vesical angle was not significantly modified. Dynamic MRI allowed a non-invasive assessment of the mode of action of an IVD. The main modifications were a support of the bladder base and bladder neck, with a superior displacement of the urethra toward the pubis.

Sagittal computerized tomography reconstruction of the lateral nasal wall for functional endoscopic sinus surgery.

Coronal computerized tomography (CT) scanning is imperative in the preoperative work-up for functional endoscopic sinus surgery (FESS). This study describes additional information provided by lateral CT reconstruction with special attention to the (naso-) frontal recess. Thin axial scans were taken from 10 patients suffering from chronic rhinosinusitis. This procedure avoided artefacts from dental fillings on the computerized reconstructions. The common landmarks of the lateral nasal wall as described in the surgical anatomy of FESS were easily identified on sagittal views. The average angulation of the sagittal plane from the midline required to obtain optimal images of the frontal recess was antero-posteriorly 8.7 degrees (SD, 2.4), cranio-caudally 7.7 degrees (SD, 2.6). Size and condition of the frontal recess could be demonstrated. Variations of the angle between frontal sinus and ethmoid infundibulum appeared to depend on the anterior projection of the frontal sinus and may give an indication as to the optimal endoscopic angle for visualization of the frontal ostium. Sagittal reconstructions provide information for better spatial orientation particularly in the plane of the surgical approach and may help to diagnose underlying functional changes of chronic frontal sinusitis.

Femoral Fracture Malalignment following Interlocking Intramedullary Nailing

Interlocking intramedullary nailing has become a common method of treatment for femoral shaft fractures in adults. But sometimes the malalignment of the femoral fracture results in pain, limb length discrepancy, and traumatic osteoarthritis of the knee, etc. Therefore, it is very important to know what makes the malalignment after the femoral shaft fractures. We performed CT scan in 46 patients who had femoral shaft fractures, treated by interlocking intramedullary nailing at the orthopaedic department of the Kwangju Verterans Hospital. There were thirty-five men and eleven women, and their mean age was 36 years at the time of the operation. We measured the rotational deformity of both femurs by the CT scanning and the angulation deformity by plain radiographs in forty-six patients. We also compared the amount of the angulation and rotational deformity according to the type or the site of fracture, the degree of comminution, the time from injury to operation and the associated injury. Average angulation deformity was 2.7°in sagittal plane and 2.5°in coronal plane. Average 대한골절학회지 제12권, 제1호, 1 9 9 9년 1월 The Journal of the Korean Society of Fractures Vol.12, No.1, January, 1999

Feasibility of stent placement above the sphincter of Oddi ("inside-stent") for patients with malignant biliary obstruction.

Animal studies suggest that placement of endobiliary stents wholly above the papilla (the "inside-stent") prolongs the duration of stent patency. We reviewed the cholangiographic characteristics of patients with malignant obstructive jaundice in order to evaluate the feasibility of this approach and to assist in the design of a new stent. A review was conducted of 270 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for malignant obstructive jaundice at our hospital, to determine the relative frequencies of the types of cancers. The ERCP films of 59 relevant consecutive patients with malignant obstructive jaundice were studied to determine the length of the stricture, the distance between the stricture and the papilla, and the angulation of the common duct. The most frequent primary cancers causing malignant obstructive jaundice were pancreatic cancer (57%), biliary cancer involving the hilum (19%, including metastatic disease), nonhilar biliary cancer (14%), and papillary cancer (10%). The length between the lower end of the stricture and the sphincter was more than 2 cm for all hilar biliary cancer, representing two-thirds of nonhilar biliary cancer cases, while it was less than 1 cm for most pancreatic cancers. There was an average angulation of 30-40 degrees in the axis of the distal common bile duct. For most biliary cancers, the stricture is high enough to allow the placement of a stent fully above the papilla, but this is not possible for most pancreatic cancers (or any papillary cancers). An "inside-stent" approach would be possible in about one-third of patients with malignant obstructive jaundice if a clearance length of over 2 cm between the stricture and the sphincter is required, and in about 45% of patients if a minimum clearance of 1 cm is required. A 30-40 degrees flexion in the distal part of the stent would approximate the average angulation in the axis of the common bile duct and help to prevent dislocation.

Factors affecting the emergency room treatment of boxer's fractures

There is considerable controversy over the point at which boxer's fractures need to be reduced. This study characterizes the features of fractures that prompted reduction. A retrospective review of 57 consecutive patients with 57 boxer's fractures presenting to the emergency room was carried out. Forty percent of the fractures were reduced. With reduction, the average angulation on lateral radiographs improved from 40.5° to 31.6°. The improvement of angulation, after reduction, was statistically significant (P<0.005). After an average of 17 days follow-up period the angulation was 35.2°. There was no significant loss of reduction shown between the post reduction and follow-up radiographs (P>0.1).

Anatomic considerations of plate-screw fixation of the anterior column of the acetabulum.

Fifteen cadaveric adult bony hemipelvis specimens and 30 adult dry bone specimens were obtained to evaluate the configuration of the anterior column of the acetabulum and to develop a safe path for screw placement into it. Each cadaveric specimen was sectioned at 1-cm intervals, beginning at the level of the inferior border of the acetabulum (junction between the anteroinferior edge of the acetabulum and the most anterolateral edge of the superior ramus of the pubic bone). The plane of the cross-section was perpendicular to the anterior column. The projection of the medial acetabular boundary on the anterior column was determined by analysis of each cross-section. Results showed that the average width of the anterior column at 1.0, 2.0, and 3.0 cm superior to the inferior acetabular boundary is 31.0 +/- 4.7, 34.2 +/- 5.1, and 39.4 +/- 6.2 mm, respectively. At 1.0 cm superior to the inferior margin of the acetabulum, the average medial angulation for 0.5-, 1.0-, and 1.5-cm entry points lateral to the pelvic brim were 24.9 +/- 4.4 degrees, 35.5 +/- 5.2 degrees, and 44.4 +/- 6.6 degrees, respectively. At 2.0 cm superior to the inferior acetabular margin, the corresponding average medial angulation for 0.5-, 1.0-, 1.5-cm entry points were determined to be 29.2 +/- 5.5 degrees, 38.6 +/- 5.9 degrees, and 48.1 +/- 5.7 degrees, respectively. At 3.0 cm superior to the inferior acetabular margin, these angles were found to be 20.7 +/- 4.3 degrees, 29.4 +/- 6.0 degrees, and 39.3 +/- 5.9 degrees, respectively. All of the above mentioned angles are with respect to the perpendicular of the longitudinal axis of the anterior column without violation of the hip joint. Screws placed 1.0 cm lateral to the pelvic brim at the levels of 1.0, 2.0, 3.0, and 4.0 cm superior to the inferior acetabular margin and directed perpendicular to the anterior column penetrated the hip joint.

Modern Management of Spinal Tuberculosis Clinical Study

The resurgence of pulmonary tuberculosis in the United States has been paralleled by a concomitant rise in tuberculosis of the spine (Pott's disease). The appearance of drug-resistant strains of tuberculosis, infection in large numbers of immunocompromised hosts, newer imaging modalities, and the development of more effective spinal reconstruction techniques have raised important issues regarding the management of Pott's disease. In spite of this, there has been little published recently on the modern management of Pott's disease in developed countries. We report our experience with the management of 20 patients with Pott's disease in the past 5 years, 16 of whom were admitted during the last 18 months of this retrospective study. The mean patient age was 49 years. Sixteen (80%) were men. Nineteen (95%) had a positive tuberculin skin test, and 13 (65%) had pulmonary tuberculosis. Symptoms consisted of spinal pain, weakness, sensory complaints, and flank mass in order of decreasing frequency. Ten patients were neurologically intact; the remainder had motor deficits of variable severity. The thoracic spine was involved in 13 patients, the lumbar spine was involved in 4, the cervical spine was involved in 2, and the thoracolumbar spine was involved in 1. Spinal deformity was present in 11 patients, spinal epidural compression was present in 13, and a paraspinal mass was present in 18. Operative indications included motor deficits, spinal deformity, nondiagnostic computer tomographic-guided needle biopsy, and noncompliance with, or lack of, response to medical therapy. Eleven patients underwent operations. Six patients had vertebrectomy and bone grafting with posterior instrumentation when indicated; three had laminectomy, debridement, and abscess drainage; one had laminectomy and posterior instrumentation; and one had paraspinal abscess drainage. Two patients have died; the remainder have been monitored for at least 1 year and are neurologically improved or normal without residual infection. The average angulation decreased from 31 to 24 degrees by the follow-up examination. In selected patients, early operative treatment with instrumentation, when indicated, minimizes neurological deterioration and spinal deformity, allows early ambulation, and results in excellent neurological outcome.

Short arm plaster cast for distal pediatric forearm fractures.

Ten years' clinical experience with below-elbow plaster cast treatment of distal one third pediatric forearm fractures was subjected to an independent retrospective radiographic review. In the study population of 761 fractures, no significant displacement occurred while the forearm remained in plaster. The average angulation change was 4.5 degrees (SD +/- 2.2 degrees). In each angulation change > 5 degrees, poor cast molding was evident, as reflected by a high "cast index" (p < 0.01). Although this technique is technically demanding, excellent results are obtained in all distal pediatric forearm fractures if proper cast molding is used.

Correction with growth following diaphyseal forearm fracture.

In 25 children with fracture of the shafts of the forearm an average angulation deformity of 20 degrees was recorded when the fracture had healed. At follow-up, which took place after the cessation of growth, and angulation deformity was reduced by half; there was, however, a large individual variation. Both severe and less severe deformities were found to be corrected. Correction was more likely in younger children than in older children, though again there were exceptions to this rule. The most common dysfunction recorded was a decreased pronation-supination. This was not very closely correlated with angular deformity.

Conservative Treatment of Nonarticular Fractures of distal third Tibia

Distal one third tibial fractures can be difficult to manage. Variety of treatment methods have been suggested for these injuries, including conservative treatment, external fixation, intramedullary nailing, and plate fixation. None of these techniques can be considered the "gold standard" for these injuries. The purpose of this prospective study is to evaluate the results of conservative treatment of these fractures. Total 39 fractures of distal third of tibia were treated with closed reduction and long leg cast for six to eight weeks followed by PTB cast for six to eight weeks from January 2004 to October 2008. One year follow up was done with 32 patients, eight months follow up with three patients and four patients were lost to follow up. All the fractures united within six months of duration. Immediate post-reduction average angulation was 3.72 degree in sagital plane and 3.32 degree in coronal plane. Average final angulation was 5.04 degree in sagital plane and 4.32 degree in coronal plane. Average limb length shortening was 6.8 mm. Full range of motion of ankle and knee joint was achieved compared to the normal side by six months of follow up. Though there was displacement of fracture during conservative treatment final outcome was within acceptable limit. Hence distal one third tibial fractures can be treated conservatively with closed reduction and cast immobilization with numerous advantages over operative methods.