There is no threshold for good results. In general there is an inverse relationship between volume and outcome. High volume, though, is not a substitute for good results. It is not possible to infer good quality from high volume alone. Small-volume departments should document quality of care and results thoroughly.
The success of precisely indicated surgical treatment of posttraumatic deformities of the femur shaft depends on painstaking preoperative planning with exact assessment of the locus of correction, careful determination of the correction angle, and choice of an adequate operation method. In correction operations plate osteosynthesis is necessary, in contrast to the various possibilities for care of primary fractures of the femur. Therefore we concentrate in this paper mainly on the use of plate osteosynthesis, without forgetting that there are also indications for intramedullary nailing, especially of not yet consolidated fractures or aseptic wound healing impairments. Long X-rays of the leg are an essential part of the preoperative preparation. The success of all operative treatments does not depend only on the degree of disablement, the age of the patient, and realistic target. Particularly in view of the difficulty of plate osteosynthesis and the variety of methods of primary osteosynthesis, the surgeon has to consider the rules of biomechanics as they apply to the incorrectly set femur and to simulate the surgical treatment with preoperative planning in order to attain physiological axial conditions with the best operative method. This applies particularly to the knee joint. Axial deformities are very often combined with shortening, and surgical correction is therefore sometimes difficult.
Two cases of posttraumatic "psychogenic clubfoot" deformity are reported. Case I. A woman, aged 44, with foot deformity after infantile paralysis on the right side sustained an inversion injury to the left ankle in April 1979. Two weeks later she was admitted to our hospital. She was unable to walk and examination showed a drop foot with supination contracture of the left foot. Neurological examination was normal inclusive electromyogram. Ligaments of the ankle and peroneal tendons were reviewed by operative procedure under suspicion of rupture. There were no pathological findings, no hematomas or other traumatic signs. The neurological control examination was normal and psychogenic contracture was diagnosed. The personal history showed a corresponding problematical psychic background. Case II. A man, aged 24, was admitted to our hospital 3 months after an inversion injury to the right ankle. Examination showed a drop foot with supination contracture (Fig. 1 a, b). He walked with two crutches. Roentgenograms were normal, the ankle had normal stability, and neurological examination showed no pathological findings. There were no signs of an organic lesion. Psychogenic club-foot was diagnosed. Both patients were treated functionally with active exercises and psychological care. The follow-up control 1 resp. 1/2 year after injury showed normal muscles and free active mobility in both cases (Fig. 1 c, d).
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