We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups.
To compare the findings on magnetic resonance (MR) images of the knee obtained with a three-dimensional gradient-echo (GRE) sequence with findings at arthroscopy, the menisci, cruciate ligaments, and hyaline cartilage were assessed in 100 patients. At MR imaging (performed by means of fast imaging with steady-state precession) and arthroscopy, the menisci (n = 200) and areas of hyaline cartilage (n = 500) were assigned grades of zero (normal) to three (greatest abnormality). The cruciate ligaments were considered intact, partially torn, or completely torn. The sensitivity of MR imaging in diagnosis of meniscal tears seen at arthroscopy was 97% and the specificity, 94%. For complete tears of the anterior cruciate ligament, the sensitivity was 92% and specificity, 96%. In the posterior cruciate ligament, both the sensitivity and specificity were 100%. Good correlation existed between findings at MR imaging and those at arthroscopy in assessment of focal thinning and full-thickness loss of hyaline cartilage, but arthroscopy enabled superior visualization of minor fissuring. Three-dimensional GRE MR imaging enables accurate assessment of the articular cartilage of the knee. The evaluation of meniscal tears and the cruciate ligaments has a high negative predictive value.
We reviewed 47 patients with neurofibromatosis and dystrophic spinal deformities; 32 of these patients had been untreated for an average of 3.6 years and in them the natural history was studied. The commonest pattern of deformity at the time of presentation was a short angular thoracic scoliosis, but with progression the angle of kyphosis also increased. Deterioration during childhood was usual but its rate was variable. Severe dystrophic changes in the apical vertebrae and in particular anterior scalloping have a poor prognosis for deterioration. The dystrophic spinal deformity of neurofibromatosis requires early surgical stabilisation which should be by combined anterior and posterior fusion if there is an abnormal angle of kyphosis or severely dystrophic apical vertebrae. Some carefully selected patients can be treated by posterior fusion and instrumentation alone.
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