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Incidental durotomy is a frequent complication of lumbar spinal surgery. The number and complexity of spinal procedures is increasing, leading to a greater prevalence of dural tears; therefore, it is imperative that spine surgeons be familiar with safe and effective closure techniques. Occasionally, a tear may not be recognized during the procedure, so that one must recognize the signs and symptoms of a cerebrospinal fluid leak postoperatively. Several newer treatment concepts show promise. The current study represents an extensive review of the recent literature on the prevalence, mechanism, diagnosis, treatment, and outcomes of dural tears. The authors provide an overview of the problem, an update on current treatment strategies, and describe the senior author's technique of repair, which is easy to do and is effective in stopping additional leakage of cerebrospinal fluid.

This article describes a technique of ankle arthrodesis using a triangular external fixation frame and presents the results of biomechanical analysis and clinical experience with the frame. Clinical evaluation of 23 ankle arthrodeses performed using a triangular external fixation frame yielded a 91 .3% fusion rate at an average of 11 weeks postfusion. The triangular frame was 79% suffer than a compression-only external frame in torsion and 39% stiffer in anteroposterior bending. This high rate of fusion is attributed to the elimination of micromotion at the fusion site because of the increased rigidity of the triangular external compression frame.

CAPITELLUM FRACTURES

This is a retrospective analysis of 118 patients who underwent 132 operations in a city compensation setting for the treatment of lumbar disk disease from January 1976 to December 1987. Each of these patients had a work-related injury. There was a minimum 2-year follow up with an average follow up of 6.9 years. No patients were lost to follow up. The purpose was to determine what percentage of patients treated in a work-related setting could be expected to return to a sustained, pre-injury employment state following a carefully executed lumbar spine surgical procedure. Satisfactory surgical results were considered achieved only by those patients who returned to full-duty work status. Only 31 of the 118 patients (26%) returned to full duty and were considered satisfactory. Regarding the number of surgical procedures, 31 of 132 operations (23%) were successful. Sixteen reoperations in 13 patients all resulted in failure. Only 16 of the 64 patients (25%) treated with laminectomy and diskectomy alone had a satisfactory result. When a two-level, posterior lateral spinal fusion was added the success rate was increased to 44%, with 12 of 27 patients returning to work. Six patients with spinal stenosis underwent decompression laminectomy and entry level foraminotomies, and all had unsatisfactory results. Five patients with isthmic spondylisthesis underwent a Gill procedure and fusion. Only one of these patients (25%) returned to work. For a 2-year period chymopapain injection was given to 14 patients. Only two returned to work, with a 14% success rate. Overall, the surgical treatment of lumbar disk disease in this group of city compensation patients resulted in a 74% rate of permanent disability.

The purpose of this study was to evaluate the surgical results of anterior cervical discectomy and fusion using a countersunk interlocking autogenous iliac bone graft. Two hundred thirty-two patients were followed for an average of 6.8 years. All patients suffered neck and arm pain. Two hundred twenty patients received conservative treatment for at least six months. Overall results were satisfactory in 202 patients (87%) and unsatisfactory in 30 patients (13%). The pseudoarthrosis rate was 6.5% which is significantly lower than previous reports. The premise of this technique is that the interlocking graft prevents migration, promotes fusion by providing immobilization, and restores the height of the interspace. Anterior cervical discectomy and fusion, using a countersunk interlocking autogenous iliac bone graft, is a satisfactory surgical procedure in which successful pain relief is to be expected.

A randomized prospective trial of a continuous vacuum system (VariDyne) and an intermittent spring type system (Hemovac) was conducted in 126 consecutive orthopedic surgical wounds between February 1988 and October 1988 in which postoperative suction drainage was required. Comparison between the two groups showed a statistically significant difference among total drainage removed by the vacuum units and wound drainage into the dressing following drain removal. Hip and knee arthroplasty patients receiving continuous vacuum suction experienced a greater average drainage volume and better wound healing than those receiving the spring-loaded device. Overall, all wounds which utilized continuous vacuum drained less serosanguinous or serous fluid than those wounds utilizing the intermittent system following drain removal. A clear advantage to using a continuous vacuum suction device over an intermittent spring-loaded device is seen with respect to hematoma evacuation, wound drainage, wound healing, and possible complications.

Thirty-four patients with adolescent idiopathic thoracolumbar, lumbar, or lumbar components of double major curves between 20 and 55 degrees were identified. This study group was compared with an age- and sex-matched control group with regard to back pain, radicular symptoms, and perception of handicap. The objectives of this study were to define the natural history of moderate-range adolescent idiopathic thoracolumbar, lumbar, and double major curves with a lumbar component in this range. Studies that exclusively examined the natural history of thoracolumbar and more caudad curves have not been undertaken. Data from other related studies is often clouded by various factors. We reviewed the charts and radiographs of 363 patients with idiopathic scoliosis seen between 1935 and 1975 with available original radiographs. Thirty-four of 65 patients (52%) answered a questionnaire pertaining to severity of pain, functional abilities, and perceived quality of life. The same questionnaire was answered by 31 age- and sex-matched controls for comparison. The average follow-up was 22 years, and average patient age at current follow-up was 36 years. Curves at skeletal maturity measured an average of 35 degrees. On a scale of 1-10 (severe), current low-back pain in the study group was rated a mean of 3.19 versus 1.94 in the control group. Twelve of 34 patients in the study group (35%) reported no back pain, versus 21 of 31 (68%) in the control group. Twenty-four percent of the study group had radicular symptoms compared with 16% of the control group. None of the 34 study patients and 1 control patient underwent surgery for back pain. With an average follow-up of 22 years, the study group reported handicap scores comparable to those of the control group. The average age of the study patients was only 36 years, but it is encouraging that these individuals have continued to do well for at least 20 years past skeletal maturity.

Recorded here is a comprehensive review of the current literature on high tibial osteotomy with emphasis on postponing an inevitable total knee arthroplasty (TKA). Accompanying this review is a confirmatory, retrospective study of 35 patients with 39 high tibial osteotomies with an average follow-up study of 8.5 years (range, 3.8-15.1 years). Twenty-two of the patients (57%) had good results, seven (18%) fair, and ten (25%) poor at final follow-up examination. Nine of the 35 patients required TKA at an average of 4.7 years post-osteotomy. The percentage of good results diminished with time of follow-up study, starting at two years with 87% good results and ending at 15 years with only 57% of the patients remaining in that category. Patients lost an average of 8 degrees of flexion post-osteotomy, regardless of good, fair, or poor result. Patients with favorable results were usually younger than 60 years of age, and had less than 12 degrees of angular deformity, pure unicompartmental disease, ligamentous stability, and a preoperative range of motion are of at least 90 degrees.

Although total knee arthroplasty (TKA) has been studied extensively, objective muscle testing has not been reported. Isokinetic testing of 68 patients with degenerative joint disease scheduled for unilateral TKA revealed that marked muscular deficits in flexion and extension were present preoperatively in the involved knee. Postoperatively, hamstring peak-torque values were able to attain strength levels of the uninvolved knee within the period of seven to 12 months after surgery, whereas the quadriceps mechanism still showed a residual deficit at two years follow-up evaluation. In addition, the ratio of flexion to extension peak torques in the operated knee returned to normal values as the quadriceps mechanism was rehabilitated. A comprehensive evaluation system consisting of Cybex II isokinetic testing, gait mat analysis, and the Hospital for Special Surgery knee rating scale is also presented. Isokinetic testing correlated well with gait analysis. Patients with a nearly balanced quadriceps-to-hamstring ratio walked with a more symmetrical gait pattern. The knee rating scale was less reliable in assessing functional outcome. Functional testing and evaluation at the authors' institution has provided an important source of objective information that allows better planning and evaluation of TKAs. These isokinetic studies enable more critical planning of the rehabilitation program. Hamstring or quadricep exercises may be emphasized as required. The authors conclude that a balanced hamstring to quadriceps mechanism is needed for resumption of normal gait.

Signes cliniques et radiologiques (myelographie, scanner, RMN) chez deux patients porteurs de hernies discales L 1 L 2 et L 2 L 3 . Le traitement par laminectomie decompressive et facetectomie partielle, et l'evolution sont detailles

In this preliminary report, the authors present a new application of an external tubular fixation system for compression arthrodesis of the ankle. A triangular ankle fusion frame was designed that provides rigid immobilization of the tibiotalar joint, with midfoot control provided by a metatarsal pin. Over the past 3 years, the authors have used this device to achieve solid tibiotalar arthrodesis in 12 of 14 patients. The surgical method, including step-bystep construction and application of the triangular ankle fusion frame, is presented. Early results suggest a nearly 90% union rate, including reoperative cases for failed primary fusion.

Computerized tomographic (CT) scanning of the fourth and fifth lumbar disc spaces with the GE CT/T8800 scanner followed by metrizamide myelography was obtained for 134 consecutive patients with suspected lumbar disc disease. There was an overall concordance rate of 85% between CT scanning and myelography. In those 52 patients treated by surgery, concordance between the CT and the myelogram was similar at 86.5%. Myelography and surgical findings were in agreement in 94.2% of cases, while CT findings and surgical finding agreed in 92.3% of cases. The authors' data indicate that the CT scan is as accurate as myelography in the diagnosis of lumbar disc disease. When the CT scan interpretation is supported by clinical findings, the myelogram may be eliminated in the preoperative patient. Myelography may be reserved for equivocal cases.

Although epidural cortisone injections are commonly used for treatment of lumbosciatic pain, insufficient critical analysis of the end result can be found in the literature. The present study is a retrospective critical analysis of 367 patients with leg pain who were engaged for a minimum of two weeks or an average of two months in multifaceted conservative management without relief of pain. Injections of 10 cm3 of 0.5% bupivacaine and 100 mg of methylprednisolone were given to inpatients treated by the same anesthesiologist. The average follow-up period was 21.4 months (range, 6-36 months). Results were analyzed according to duration of pain and history of prior lumbar spine surgery. The most favorable results (approaching 70% offd-excellent) were observed in patients with subacute radicular leg pain (of less than three months' duration) and chronic leg pain (of greater than three months' duration) with no prior surgery. Negative myelograms and electromyograms (EMGs), in the absence of reflex or motor deficits on physical examination, also pointed toward optimal results. Those patients with chronic pain who had had prior lumbar spine surgery had the least satisfactory results.

A substantial drop in blood volume occurs in patients being treated by total knee arthroplasty (TKA). Of 140 TKAs (108 patients) studied to analyze this blood loss, 70 required transfusion and 70 did not. The average transfusion was 2.6 units per arthroplasty. Blood loss in the nontransfused group was 1.8 units per arthroplasty. The overall mean blood loss was 2.2 units per TKA. Insertion of a constrained TKA resulted in a statistically significant increase in blood loss. Preoperative diagnosis, anesthetic technique, revision arthroplasty, patellofemoral arthroplasty, and tourniquet technique did not statistically affect the blood loss. The bulk of the blood loss is collected postoperatively in the suction drainage system.

Muscle biopsy is often incorrectly performed despite the fact that it is a relatively simple procedure. A consistently reproducible surgical technique in 93 open vastus lateralis muscle biopsies implemented in conjunction with neuromuscular and malignant hyperthermia research demonstrated 14 cases of malignant hyperthermia and a variety of forms of neuromuscular pathology. No wound complications or disabilities have resulted from this procedure. The procedure includes careful selection of biopsy site, regional anesthesia, atraumatic dissection, and immediate processing of the biopsy sample. A new muscle biopsy clamp is described. The authors recommend the vastus lateralis for the biopsy site unless another area of involvement is specifically indicated. Careful attention to technical details is required for optimal results.