Evidence Of Avascular Necrosis Research Articles

Distal oblique osteotomy of the first metatarsal for the correction of hallux limitus and rigidus deformity

The purpose of this study was to evaluate the effectiveness of the distal oblique osteotomy of the first metatarsal (a triplanar shortening decompression osteotomy) to correct stage I and II hallux rigidus. The osteotomy cut is performed from dorsal-distal to plantar-proximal with an angle ranging from 35 degrees to 45 degrees in the sagittal plane. The capital fragment is then displaced plantarly and proximally and fixed with two screws and the metatarsal head is remodeled. From January 1993 through December 1995, a total of 26 patients (21 females and 5 males) underwent 30 distal oblique osteotomies of the first metatarsal (22 unilateral and 4 bilateral). The mean age of the patients was 54 years and the mean follow-up was 21 months. Patient satisfaction and objective clinical and radiographic measurements were evaluated. Patients' satisfaction was measured postoperatively with a modification of the University of Maryland 100-Point Painful Foot Center Scoring System. The results were: 84% good to excellent; 7% fair; and 9% poor. Radiographic measurements included: intermetatarsal angle mean: preop = 12.2 degrees, postop = 8.6 degrees; proximal articular set angle mean: preop = 11.8 degrees; postop = 10.3 degrees. There was no evidence of avascular necrosis in any of the cases. Clinical findings were: dorsiflexion of the first metatarsophalangeal joint: preop = 22 degrees, postop = 45 degrees; plantarflexion of the first metatarsophalangeal joint: preop = 15 degrees, postop = 18 degrees; hallux purchase power: preop = 2.5, postop = 2.3; pain on the second and third metatarsophalangeal joints, associated with excessive pressure on the central metatarsal heads: preop--present in 10 patients, postop--present in 12 patients; forefoot supination angle: preop = 13 degrees, postop = 7 degrees.

Management of displaced femoral neck fractures in young adults (a group at risk)

25 young adults (age 15–50 years) with femoral neck fractures were operated on an ordinary operating table, using a Watson-Jones approach. Open reduction of the fracture site through an anterior capsular incision was performed and fixation with three cancellous screws was done. Patients were regularly assessed for clinical and radiological evidence of non-union and avascular necrosis. Average follow-up was 32 months. Non-union was seen in one case (4 per cent) and evidence of avascular necrosis was seen in three cases (12 per cent). The results were compared with available published series of similar fractures, treated by closed and open reduction technique. The comparison showed that in young adults, primary open reduction and internal fixation of femoral neck fractures can be recommended as the treatment of choice.

Incidental detection of calcified dialysis graft on Tc-99m MDP bone scan.

A 48-year-old woman with a renal transplant and a history of immunosuppressive steroid use presented with a history of persistent hip pain. She was referred for radionuclide bone scan to evaluate the presence of avascular necrosis. No evidence of avascular necrosis was seen; however, incidental uptake of Tc-99m MDP was seen in a heavily calcified, nonfunctioning, synthetic dialysis access graft in the left groin.

LUDLOFF’S MEDIAL APPROACH FOR OPEN REDUCTION OF CONGENITAL DISLOCATION OF THE HIP

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff’s medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff’s medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

Ludloff's medial approach for open reduction of congenital dislocation of the hip. A 20-year follow-up.

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff's medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff's medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

Percutaneous pin fixation of chronic slipped capital femoral epiphysis.

Eighteen consecutive patients with 24 chronic-slipped capital femoral epiphyses were treated with percutaneous Knowles pin fixation. The average followup was 41 months (range, 21 to 64 months). All patients experienced complete closure of the growth plate within 12 months. There was no evidence of avascular necrosis, chondrolysis, slip progression, pin penetration, hardware failure, or intertrochanteric femoral fracture. Treatment of chronic slipped percutaneous pin is a safe and effective procedure.

Effect of mandibular distraction on the temporomandibular joint: Part 1, Canine study.

The effect of osteodistraction on the temporomandibular joint was evaluated in a canine model. Eleven mongrel dogs were used in the study. An intraoral expansion device was placed after an osteotomy was made at the angle of the mandible via an intraoral approach. The mandibles were expanded either fully to 20 mm or partially to 10 mm. After expansion, nine animals were immediately killed; the remaining two were maintained in fixation for an additional 10 weeks. Cephalometric radiographs and computed tomographic scans obtained preoperatively and before killing were evaluated. No gross temporomandibular joint deformation or bodily movement was noted in the expanded or contralateral, unexpanded side. The temporomandibular joints were harvested en bloc for gross and microscopic evaluation. Flattening of the posterior aspect of the expanded condylar head was noted, with thinning of the condylar cartilage. New bone deposition was noted, which was evident as anterior lipping. Condyles maintained in 10 weeks fixation showed reparative changes. No evidence of avascular necrosis, microfracture, or cystic degeneration was noted. This study indicates that the force of distraction can induce bony changes in the temporomandibular joint and that these effects are minimal and reversible.

Modified Chevron Osteotomy for Hallux Valgus

The chevron osteotomy for hallux valgus was modified by addition of screw fixation and change of the osteotomy angle. Thirty-six patients underwent this modified osteotomy. All had mild to moderate symptomatic hallux valgus deformities. No other forefoot procedures were performed. Standing radiographs were taken before surgery, at 1 month after surgery, and, for the 15 patients who returned for long-term follow-up, at 1 year or more after surgery. Overall, 35/42 procedures were rated as satisfactory without reservations and 7 were rated as satisfactory with mild reservations. All patients stated that they had some improvement in their preoperative symptoms, which included pain, cosmetic concerns, and shoe wear difficulties. Radiographically, none of the capital fragments displaced and there were no malunions, nonunions, nor evidence of avascular necrosis. The average metatarsophalangeal-1 angle improved 8 degrees and the average intermetatarsal 1-2 angle improved 4 degrees. This modification is relatively simple, increases stability, and allows early weightbearing. In our experience, the modified chevron osteotomy has been a very reliable procedure for mild to moderate symptomatic hallux valgus deformity.

A Review of Ankle Arthrodesis: Predisposing Factors to Nonunion

The purpose of this study was to review 15 years of experience with ankle fusions, specifically addressing the underlying etiology of ankle pathology, incidence of nonunion, and associated predisposing conditions that can lead to nonunion. Seventy-eight ankle fusions, performed between 1975 and 1990, were reviewed for this study. The average follow-up was 4 years. Patients with nonunion were evaluated separately to look at the predisposing factors that may have lead to nonunion. Factors associated with nonunion included fracture type, evidence of avascular necrosis, infection, major medical problems, and open injuries. Factors that were not associated with nonunion included age, past history of subtalar or triple arthrodesis, and technique.

Femoral neck fracture following leg lengthening by callotasis

A 27-year-old man had 4.5 cm of true shortening of his left leg following a fracture of his femur 10 years previously. Leg lengthening was performed using the technique of callotasis (De Bastiani et al., 1987) at a diaphyseal osteotomy. Lengthening began 3 weeks postoperatively at 1 mm per day in four increments. After the desired lengthening had been achieved the patient was encouraged to walk bearing partial weight with crutches. Sixteen weeks after lengthening had been discontinued the regenerate appeared to be consolidating satisfactorily. However the patient complained of recent, gradually worsening pain in the left hip. No significant injury had been sustained. Radiographs revealed a displaced subcapital fracture of the left hip (Figure I). This was treated by removal of the fixator and, when the pin tracks had healed, by open reduction and internal fixation of the fracture with cannulated hip screws. After 18 months follow-up the femoral neck fractures united satisfactorily and there was no evidence of avascular necrosis.

Radiographic changes in the first metatarsal head after distal chevron osteotomy combined with lateral release through a plantar approach.

The purpose of this study was to evaluate the development of clinically significant avascular necrosis of the head of the first metatarsal after: (1) distal metatarsal osteotomy of the chevron configuration beginning apically at the center of the metatarsal head and extending into the head metatarsal neck junction and (2) release of the adductor hallucis muscle, the lateral capsulosesamoid ligament, and the lateral head of the flexor hallucis brevis via fibular sesamoidectomy in the majority of procedures (71/77). Although there were initial radiographic findings suspicious of avascular necrosis, subchondral lucencies (28 feet), mottling (40 feet), and focal lucencies (29 feet) in 76% of the feet, at final follow-up (12-43 months, average 25 months) this figure had fallen to 25%. The range of motion of the first metatarsophalangeal joint and articular symptoms were important in this study because of the assumption that these two parameters of evaluation would correspond to the severity of radiographic evidence of avascular necrosis. Only those patients (8 feet) with persistent mottling at final follow-up had a statistically significant decrease in the average range of motion (P = .013), with 51 degrees total arc of motion compared with 64 degrees total arc of motion for the remainder. There were no patients with persistent radiographic changes suggesting avascular necrosis who complained of pain.(ABSTRACT TRUNCATED AT 250 WORDS)

The natural history of the silent hip in bilateral atraumatic osteonecrosis

The natural history of presymptomatic ischemic necrosis of the femoral head was studied in the contralateral hip of 15 patients undergoing total hip arthroplasty for avascular necrosis between 1979 and 1984. These 15 hips were retrieved from among 416 patients undergoing total arthroplasty during this time period. Presymptomatic avascular necrosis was defined according to three strict criteria that allowed the hips to be studied from an index entry point (no evidence of avascular necrosis). Follow-up examinations of each of these 15 hips from, this entry point revealed that all hips eventually collapsed at a mean of 23 months after index entry point (range, 3–66 months). These data indicate that the “silent hip” is at significant risk of developing avascular necrosis and, if it becomes involved, it progresses to collapse in a high percentage of patients in a relatively short time. There was no correlation between underlying etiology and the time to collapse.

Avascular necrosis following closed reduction of congenital dislocation of the hip. Review of influencing factors and long-term follow-up

We studied the pathogenesis, incidence and consequences of avascular necrosis in 184 children treated for congenital dislocation of the hip. Of 210 hips, 99 (47%) had some evidence of avascular necrosis (total 81, partial 18). The incidence was not influenced by the age at reduction, the duration of traction or the use of adductor tenotomy. Patients treated by closed reduction without preliminary traction did not have a higher incidence of avascular necrosis. At long-term clinical and radiological review of 81 hips, early avascular necrosis significantly increased the chance of a poor outcome but did not predispose to acetabular dysplasia. If review includes minor forms of avascular necrosis, then this condition is common after closed reduction. Its presence is an important determinant of long-term radiological and clinical outcome.

Internal Fixation of a Capitellar Fracture Using Herbert Screws

Fractures of the capitellum can involve a significant portion of the articular surface, rendering the elbow joint unstable. In this situation it is desirable to reduce and internally fix the capitellar fragment, because this restores the articular surface and augments joint stability. A 35-year-old woman sustained a posterolateral dislocation of the left elbow associated with a capitellar fracture. Fixation of the capitellar fragment with Herbert screws stabilized the joint, allowed anatomic reduction, and gave good fixation. Active motion was possible at three weeks. When the patient was evaluated at one year, the fracture had united and there was no evidence of avascular necrosis.

Surgical Treatment of Nonunions of the Surgical Neck of the Humerus

End-to-end alignment of the fragments usually does not provide good bone contact or stability for fractures of the surgical neck of the humerus because cavitation of the head fragment and comminution constitute bone stock deficiency. Painful and disabling nonunion of the surgical neck of the humerus in five patients was repaired by impaling one fragment into the other, usually the shaft into the head. A corticocancellous iliac graft bridged the nonunion by extending from the interior of the head to the shaft, where it was fixed by screws. Rush rods were used for internal fixation. All five patients obtained union without evidence of avascular necrosis during the period of observation (12 to 39 months), had good pain relief, and regained satisfactory function.

Pipkin Type-II fractures of the femoral head.

Ten patients with a Pipkin Type-II fracture of the femoral head associated with dislocation of the same hip were treated and followed for two to five years. Five of these ten fractures, which were reduced anatomically after closed reduction of the dislocation, were treated by traction. All five healed and no evidence of avascular necrosis was identified radiographically or clinically at follow-up. Of the remaining five patients who had an unsatisfactory closed reduction, four were treated by open reduction and internal fixation with two screws and one, by excision of the comminuted fragment. Four of these five patients had no complications and one had avascular necrosis requiring total hip replacement after one year.

Vascular pedicle graft of the ipsilateral fibula for non-union of the tibia with a large defect. An experimental and clinical study.

Failure of union of the tibia with a large defect is difficult to treat, especially in the presence of sepsis and adherent scars. Conventional methods of fixation and bone grafting are not easily applicable. Experiments on Macaca monkeys showed that a vascularised pedicle graft of the shaft of the ipsilateral fibula could be fixed across a defect in the tibia and remain viable, even if it was isolated from surrounding soft tissues. Transfer of part of the shaft of the ipsilateral fibula on a vascular and muscle pedicle was carried out in 11 patients with large tibial defects and sepsis. There was one failure because of severe infection, but the other 10 patients gained sound union in about four months. The tibia was then protected by a caliper for the 18 months of full reconstitution. The bone infection healed and there was no evidence of avascular necrosis. Although the salvaged limbs were scarred, stiff and ugly, none of the patients suffered from pain, recurrent oedema or persistent infection.

Reduction of neglected traumatic dislocation of the hip by heavy traction

Heavy traction treatment was applied to seven patients with old isolated posterior dislocation of the hip. Traction of seven to eighteen kilograms applied under sedation for five to seventeen days allowed over-reduction of the dislocation. Then gradual reduction of the femoral head into the acetabulum was accomplished by reducing the traction and abducting the limb. The results were good to excellent. In six patients there was no evidence of avascular necrosis or osteoarthritis during a follow-up period of from six months to three years. The femoral heads became fully concentric. The method failed in one patient in whom the dislocation was of nine months' duration and in whome a comminuted fracture of the acetabulum and other fractures of the pelvis were also present.

The use of methylmethacrylate as an adjunct in the internal fixation of unstable comminuted intertrochanteric fractures in osteoporotic patients

Forty-two unstable, four-part intertrochanteric fractures in forty-one patients (seventy-one to 104 years old) with severe osteoporosis were treated by open reduction and internal fixation (Jewett nail or compression screw-plate) supplemented with methylmethacrylate packed into the curetted medullary space. One patient was lost to follow-up, one died of a myocardial infarction at six weeks, and one was excluded because of an unsuspected myeloma found at the fracture site. All patients were sitting up in a chair the day after operation. Full weight-bearing on the limb was started within three weeks by thirty patients and at an average of 118 days by six who had very comminuted fractures. Three patients, non-ambulatory preoperatively, did not walk after operation. Of the thirty-eight fractures followed for from nine to thirty-seven months, thirty-seven healed with no loss of position. One fracture which had been fixed with the nail and cement not extending far enough into the head and neck displaced, and the operation had to be repeated, this time with a successful result. The fractures healed by periosteal new-bone formation. There was no evidence of avascular necrosis or wound complications.

Compression Fixation after Biplane Intertrochanteric Osteotomy for Slipped Capital Femoral Epiphysis

A modification in the technique of biplane intertrochanteric osteotomy for slipped capital femoral epiphysis, used in twenty-four patients, allows supplementation of the corrective osteotomy by compression fixation. Healing is faster, and no losses in position have occurred with the new fixation apparatus. Eight of the twenty-four hips showed some degree of joint-space narrowing; no evidence of avascular necrosis has been observed.