RESUMEN
A retrospective review was performed on all patients who had an in situ subtalar arthrodesis for painful sequelae of calcaneus fractures between 1989 and 1994. Nineteen feet were available for evaluation, with a mean follow-up of 27 months (range, 12-62 months). Lateral calcaneal wall decompression was performed in seven feet. Although loss of ankle dorsiflexion was associated with anterior ankle tenderness, loss of ankle dorsiflexion was not correlated with either talar declination angles or talar height differences. There was no correlation between American Orthopaedic Foot and Ankle Society hindfoot score and talar declination, talar height, or calcaneal width. Peroneal tendon/subfibular impingement, ankle tenderness, sural nerve injury, and patient smoking were all statistically associated with lower scores. The calcaneocuboid joint was frequently involved in the fracture but was not painful at follow-up. Late pain after a calcaneal fracture is not caused by only subtalar arthrosis. Radiographic criteria alone cannot be relied upon for surgical decision making. Careful physical evaluation should be used to determine sources of pain. Distraction arthrodesis should be considered only if findings of anterior ankle impingement are present. If sural nerve symptoms are present, a sural neurectomy may be added to the procedure. Pain localized to the plantar fat pad should be managed nonoperatively. Radiographic changes in the calcaneocuboid joint rarely require surgical intervention. Based on these results, in situ subtalar arthrodesis with lateral wall decompression is the procedure of choice in most cases of subtalar traumatic arthritis with lateral wall impingement.
Asunto(s)
Artrodesis , Calcáneo/lesiones , Fracturas Óseas/complicaciones , Dolor/etiología , Dolor/cirugía , Articulación Talocalcánea/cirugía , Adulto , Calcáneo/diagnóstico por imagen , Femenino , Humanos , Artropatías/complicaciones , Artropatías/etiología , Artropatías/cirugía , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: The purpose of this study was to assess the interobserver reliability and intraobserver reproducibility of the AO/ASIF and Rüedi and Allgöwer classifications for fractures of the distal tibia, and to determine the benefit of a computed tomography (CT) scan and experience on observer agreement for several fracture characteristics, including classification. METHODS: The radiographs of forty-three fractures of the distal tibia, fourteen of which had CT scans, were assessed by groups of experienced and less-experienced observers. Each case was classified according to the AO/ASIF and Rüedi and Allgöwer systems. Several other fracture characteristics also were assessed. The kappa coefficient of agreement was calculated and used to compare the interobserver reliability and intraobserver reproducibility of the classification systems and to determine the benefit of experience and CT scans. The intraclass correlation coefficient was used to assess noncategoric data. RESULTS: Interobserver and intraobserver agreements were good when classifying fractures into AO/ASIF types and significantly better than that for the Rüedi and Allgöwer system. However, agreement was poor when classifying the fractures into AO/ASIF groups. For most assessments, the experienced group tended to have higher levels of interobserver agreement, but not intraobserver agreement. Viewing the CT scans improved agreement on the percentage of articular surface involved, but it did not improve interobserver reliability or intraobserver reproducibility for either of the classification systems. CONCLUSION: The AO/ASIF classification for fractures of the distal tibia has good observer agreement at the type level, but poor agreement at the group level. Experience tends to improve interobserver agreement, but not intraobserver agreement. Viewing CT scans does not improve agreement on classification, but it tends to improve agreement on articular surface involvement.
Asunto(s)
Fracturas de la Tibia/clasificación , Fracturas de la Tibia/diagnóstico por imagen , Traumatismos del Tobillo/clasificación , Traumatismos del Tobillo/diagnóstico por imagen , Intervalos de Confianza , Humanos , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos XRESUMEN
Two surgical approaches for distal soft tissue release in the correction of hallux valgus, one using a dorsal first web space incision and the other a longitudinal medial capsulotomy incision (used also for medial eminence resection), were studied to compare and delineate the structures actually incised. Anatomic dissections were performed on six fresh-frozen amputation specimens using each of the approaches. The adequacy of release of the adductor hallucis, transverse and oblique heads, first metatarsophalangeal lateral capsule, and suspensory ligament was reviewed. Any inadvertent damage to the first metatarsal head cartilage, second metatarsophalangeal capsule, and lateral head of the flexor hallucis brevis tendon was also noted. Distal soft tissue release is thought to be an important part of hallux valgus surgery. Based on our anatomic dissections, the actual extent of the release may be inconsistent and unpredictable, and may have implications for the predictability of results after hallux valgus surgery.
Asunto(s)
Cadáver , Hallux Valgus/cirugía , Ligamentos Articulares/cirugía , Ortopedia/métodos , Humanos , Valor Predictivo de las Pruebas , Articulación del Dedo del Pie/anatomía & histologíaRESUMEN
Andreas Vesalius was born in Brussels on December 31, 1514. After having spent some disappointing years at the Universities of Louvain and Paris, he graduated as Doctor of Medicine in Padua on December 5, 1537. The next day he was appointed as a teacher of both human anatomy and surgery. During the 6 years he held this chair, Vesalius engaged in impressive academic activities and published three masterly anatomic books: Tabulae Anatomicae Sex, De Humani Corporis Fabrica Libri Septem, and Epitome. The last two works contain anatomic woodcuts of incomparable artistic quality by Titian's pupils (by Stefan v. Calcar in particular). In 1544, at the age of 28, Vesalius gave up his chair and took up service as a court physician, first with Emperor Charles V and later with his son, Philip II of Spain. He died in 1564 on the small Greek island of Zante on return from a pilgrimage to the Holy Land. The gist of Vesalius' teaching was his conviction that valid anatomic knowledge could be gained only through dissection of the human corpse and not through the study of the traditional texts. Vesalius rid the study of human anatomy of mythic speculations, which had encrusted it for two millennia. Through Vesalius' work, human anatomy became an empirical science. Like Copernicus, Kepler, Bruno, and Galileo, Vesalius was one of the initiators of the new science. The tables of osteology and of the spine in Fabrica and Epitome are most impressive. Much of the nomenclature used for the spine today can be credited to him.
Asunto(s)
Anatomía/historia , Anatomía Artística/historia , Bélgica , Historia del Siglo XVI , Humanos , Medicina en las Artes , Columna Vertebral/anatomía & histologíaRESUMEN
Twenty-one patients with severe tibial plafond fractures were treated by unilateral large screw external fixation. In 15 patients, this was combined with limited internal fixation. The fractures were classified according to the methods of Ovadia and Beals. There were nine type III, four type IV, and eight type V fractures, and according to the methods of Rüedi and Allgöwer, nine type II and 12 type III fractures. Seven fractures were open. In five fractures, no attempt was made at articular reconstruction due to severe comminution. Four of these fractures required ankle arthrodeses and one type IIIB fracture received a late amputation. All other fractures healed. There were no cases of wound infection, skin slough, or osteomyelitis. Large screw external fixation in the talus and calcaneus was not associated with significant early or late complications. The less extensive tissue dissection in an area prone to wound complications may account for the low rates of infections, wound complications, and nonunion.
Asunto(s)
Fijación de Fractura , Fracturas Cerradas/cirugía , Fracturas de la Tibia/cirugía , Adulto , Anciano , Fijadores Externos , Femenino , Fijación de Fractura/instrumentación , Fijación de Fractura/métodos , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Characteristics associated with long-term placement among community-living patients admitted to a skilled nursing facility (SNF) after a hip fracture were identified. Subjects were 151 consecutive, elderly, community-living persons discharged from two acute hospitals to SNFs after surgery for a hip fracture. Medical, functional, psychological, social, and outcome data were collected from hospital and nursing home charts. Ninety-seven subjects (64%) were discharged home within 6 months; 50 (33%) became permanent SNF residents; and four died. Multiple logistic regression identified orientation, younger age, ability to bathe independently, family involvement, ability to ambulate or transfer independently, and greater number of available physical therapy hours as factors contributing independently to returning home. Likelihood of returning home increased from 7% among subjects with fewer than two of the patient characteristics to 82% among subjects with four or more characteristics (P less than .0005). These results suggest that hip fracture patients at high risk of permanent SNF placement can be identified at time of hospital discharge. Investigations are needed to determine whether more intensive rehabilitation and discharge planning may improve the chance of returning home for a large percent of hip fracture patients.