Since HLA B27 and ankylosing spondylitis are more common in American Indians than other Americans, the association between radiological sacroiliitis (SI) and HLA B27 was examined among the Pima Indians. SI (grade II to IV) was found in 20 per cent of randomly selected Pima adults. B27 was present in 50 per cent of males, but in only nine per cent of females with SI, vs a population frequency of 18 per cent. Among first degree relatives of probands with SI, radiologic changes were found no more frequently than in a randomly selected age matched control series. Uveitis occurred in 18 per cent of the B27 positive subjects, but in only five per cent of the B27 negative subjects (p less than 0.05). B27 was associated with SI and uveitis in Pima males, but no association was demonstrated between B27 and SI in Pima females.
Eighteen patients with nonunions of the proximal tibial metaphysis were treated at one institution. Nine patients had a history of osteomyelitis. There was an average of 4 prior surgical procedures to achieve fracture union, obtain soft-tissue coverage, or eradicate infection. Stable internal fixation with bone grafting was performed in 13 patients, with a fixed angle blade plate in 10 and standard compression plate in 3. Three patients were treated with hybrid circular external fixators, and one patient was placed in a cast. An additional patient underwent long-stem total knee arthroplasty with structural allografting. Follow-up averaged 45 months. Osseous union was achieved in 100% of patients. Alignment was within 5 degrees of neutral in 94% of patients. Forty-four percent of patients continue to require the assistance of a cane for ambulation. Twelve patients have some pain with activity, primarily related to ipsilateral knee arthrosis. No infections have recurred. Knee motion improved an average of 28 degrees. Healing of nonunions of the proximal tibial metaphysis may be achieved with meticulous soft-tissue care and appropriate stabilization of small, osteoporotic, periarticular fragments.
Reply: We appreciate the insightful and instructive comments from Drs. Judet, Marmorat, and Mullins. Hopefully our dialogue will be instructive for other surgeons. When reading our paper keep in mind that these patients were cared for by a large number of surgeons at two hospitals over many years. This explains the variation in operative techniques. There is no doubt that the term olecranon is to a large extent misleading, and even inaccurate. We used the term olecranon to emphasize that these are primarily elbow (ulnohumeral) rather than forearm (radioulnar) injuries (in particular the anterior or trans-olecranon1 fracture-dislocation that often is misidentified as a Monteggia lesion). We also wanted to emphasize that although some fractures may look like olecranon fractures, it is important to realize that they are a very complex type of olecranon fracture. Standard techniques such as tension band wiring would be inadequate. Whatever term is applied (dislocation, disruption, or subluxation), ulnohumeral articular surfaces rarely are dislocated in olecranon fracture-dislocations. It is rare to rupture the medial collateral ligament in an anterior or a posterior injury. It also is rare to injure the lateral collateral ligament in an anterior injury. The identification of radial head dislocation is not very meaningful without knowing if the proximal radioulnar joint is also dislocated (a Monteggia injury); if the ulnohumeral joint is dislocated (an elbow dislocation or fracture-dislocation); or if the ulnohumeral joint is disrupted with displacement of the forearm, but not true dislocation of the ulnohuneral joint (the majority of olecranon fracture-dislocations). These are all distinct injury patterns with different structures that are injured, different treatment considerations, and different complications. As for the appropriate treatment of the radial head fracture in posterior olecranon fracture-dislocations, we routinely restore radiocapitellar contact. However, many well respected elbow surgeons are not convinced that this is necessary.2 Regarding the technique of repairing or replacing the radial head, we usually can do this using the traumatic posterior interval including the olecranon fracture. When the olecranon is mobilized proximally there usually is sufficient exposure of the radial head without the need for additional dissection between the radius and ulna (which may increase the risk of synostosis). It is unusual to need a separate lateral muscle interval. The comments by Drs. Judet, Marmoat, and Mullins reflect an excellent understanding of these injuries and we appreciate their useful response. Job Doornberg, MS David Ring, MD Jesse B. Jupiter, MD Massachusetts General Hospital,, Boston, MA
The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment.Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey.The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees.Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.
1. Clemente: Surgical anatomy of the Paranasal Sinus 2. Passali, D/Passali, GC/Passali, FM/Belussi: Physiology of Paranasal Sinuses 3. Stultz/Modic: Imaging of the Paranasal Sinuses 4. Levine: Diagnosis and Management of Rhiosinusitis 5. Schatz/Slavin: The Relationships of Allergy and Asthma to Rhinosinusitis: Epidemiologic, Mechanstic and Clinical Considerations 6. Passali, D/Lauriello/Passali, GC/Passali, FM/Bellussi: Rhinosinusitis in Immunnocompromised Host 7. Kazahaya, Tom: Pediatric Rhinosinusitis 8. Levine: Headache and Rhinosinusitis 9. Ferguson: Medical and Surgical Management of Allergic Fungal rhinosinusitis 10. Levine: Surgical Approaches: Endonasal Endoscopic 11. Clemente: Combined Microscopic and Endoscopic Technique. Comet Surgery 12. Doble: Minimally Invasive Endoscopic Sinus Surgery with Powered Instrumentation 13: Anon/Klimek: Stereotactic Surgery 14. Schaitkin: The Frontal Sinus: The Endoscopic Approach 15a. Levine: Lasers and Rhinosinusology 15b. Jakobowicz: Nd YAG Laser and the Treatment of Nasal and Sinus Pathology 16. Levine: Outcomes and Results in the Surgical Management of Rhinosinusitis 17. Stankiewicz/Na/Chow: Revision endoscopic Sinus Surgery 18. Rudert: Complications, Management, and Avoidance 19. Mark Levine: Ophthalmologic Complications of Endoscopic Sinus Surgery 20. Ferguson: The diagnosis of Allergic Fungal Sinusitis 21. Levine: Meningoencephaloceles and Cerebrospinal Fluid Leak 22. Metson/Cosenza: Endoscopic Orbital Decompression 23. Metson: Dacryocystorhinostomy 24. Mayers/Hildebrandt: Anesthesia for Sinus Surgery 25. Levine/Clemente: Postoperative Care for the Patient Undergoing Sinus Surgery 26. Bilski/Davis/Levine: Nursing Care for Outpatient Endoscopic Sinus Surgery
Twenty-three patients who had a clavicular non-union were treated operatively at the Massachusetts General Hospital from 1974 to 1985. Twenty-one non-unions were the result of fracture and two, secondary to osteotomy. Twenty non-unions were located in the middle third of the clavicle, while three were in the lateral third. Radiographically, eighteen non-unions were atrophic and three, hypertrophic. Two non-unions resembled pseudarthrosis. Of the etiological factors that were reviewed the extent of displacement of the original fracture was the most significant. Associated complications of the non-union included limited mobility of the shoulder in fourteen, neurological symptoms in eight, thoracic outlet syndrome in four, and arterial ischemia in one. Of the nineteen patients who were treated to obtain union, seventeen had a successful result at an average length of follow-up of 23.8 months. In sixteen (93.7 per cent) of the seventeen patients union was achieved by fixation with a plate; one patient required two procedures. Ancillary bone graft was used in eighteen patients, with three requiring a sculptured bicortical graft from the iliac crest to span a defect. Of the four other patients three were treated with a partial clavicular resection and one, with complete clavicectomy.
