doug garland | University of Southern California (original) (raw)

Papers by doug garland

The Journal of Trauma: Injury, Infection, and Critical Care, 1987

Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of s... more Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of surgical implants are available. In carefully chosen patients treated with appropriate surgical technique, early motion and good knee function can be obtained with open reduction and internal fixation. However, the morbidity (and mortality) are substantial following complications of open reduction and internal fixation of supracondylar fractures of the femur. We present a series of 30 consecutive patients referred to Rancho Los Amigos Medical Center for complications following open reduction and internal fixation of supracondylar femur fractures. Three patients with septic pseudarthrosis underwent above-knee amputations. Two of these three patients died of systemic sepsis. Fourteen additional patients were treated for nonunions, with 13 patients achieving union at an average time of 36.5 months from the date of injury. Six patients underwent quadricepsplasties for residual knee stiffness. Only 16 patients were returned to their preinjury ambulatory status.

Journal of Orthopaedic Research, 1992

The Journal of Hand Surgery, 1989

Surgical management of spastic thumb-in-palm deformity in adults with brain injury Spastic thumb-... more Surgical management of spastic thumb-in-palm deformity in adults with brain injury Spastic thumb-in-palm deformity was surgically treated in 27 adults with brain injury. Procedures included muscle lengthening, recession, or release, arthrodesis of the thumb interphalangeal joint, or Z-plasty of the thumb web space. At mean follow-up of 39 months, 23 of 27 had a satisfactory correction. Unsatisfactory results included two with inadequate correction and two with over-correction. Surgical treatment of this entity requires careful preoperative planning, addressing predominantly those spastic muscles responsible for the deformity. (J HAND SURG 1989;14A: 174-82.

Clinical Orthopaedics and Related Research, 1980

The charts and roentgenograms of 41 adult patients with severe head injuries who sustained 47 tib... more The charts and roentgenograms of 41 adult patients with severe head injuries who sustained 47 tibial shaft fractures were reviewed. Twenty-seven (57%) of the fractures were open and the incidence of peroneal nerve injury was 17%. The average time to weight-bearing was 3.1 months. Closed fractures united at 5.4 months and open fractures at 5.8 months. Three nonunions (6.5%) occurred in 2 patients. This review failed to demonstrate either an early rate of union or an abnormally high union rate. Furthermore, exuberant callus was not observed roentgenographically. Tibia fractures in adults with head injuries, whether on the normal or paralyzed extremity, appeared to heal in a fashion similar to fractures in normal patients. Conventional methods of treatment render satisfactory results.

The Journal of Bone and Joint Surgery ( …, 1997

We reviewed the results, in eight patients, of excision of heterotopic ossification about the elb... more We reviewed the results, in eight patients, of excision of heterotopic ossification about the elbow performed three to ten months (average, seven months) after the initial injury and followed by radiation therapy to prevent recurrence. The etiology of the heterotopic ossification included a neurological (head or spinal cord) injury in five patients and a local injury (fracture or fracture-dislocation) of the elbow in three patients. The average preoperative arc of motion of the three joints that were capable of motion was 12 degrees (5, 10, and 20 degrees); the remaining five joints were fixed in an average of 56 degrees (range, 10 to 90 degrees) of flexion. All of the patients received a total dose of radiation of 1000 centigray, divided into five fractions. The radiation therapy was instituted on the first postoperative day, and at least three of the remaining four treatments were administered on consecutive days. Radiation therapy was not performed on the weekend, so the five fractions were administered over the course of seven days. At an average of forty-six months (range, twenty-five to seventy-two months), the arc of motion averaged 103 degrees, which compared favorably with the 121-degree arc of motion that had been attained intraoperatively. Two patients who had residual motor deficits in the involved extremity had an arc of motion of 50 and 70 degrees at the latest follow-up evaluation; those who had normal motor function fared considerably better, averaging 118 degrees of motion. There was no substantial recurrence of ossification either radiographically or that limited motion, and no complications attributable to the radiation therapy were noted. On the basis of this experience, it seems that the generally recommended twelve to eighteen-month delay between injury and excision, to allow for maturation of heterotopic bone and thus to lessen the likelihood of recurrence, may be eliminated. Additional studies are needed to define the relative risk of recurrence in the various clinical settings in which heterotopic ossification is seen and to determine whether radiation therapy is necessary to prevent recurrence after early excision in each of these instances.

The Journal of Bone and Joint Surgery-American Volume

Topics in Spinal Cord Injury Rehabilitation, 2005

... Charles A. Stewart, MD, is Chief, Department of Medical Imaging, Rancho Los Amigos National R... more ... Charles A. Stewart, MD, is Chief, Department of Medical Imaging, Rancho Los Amigos National Reha-bilitation Center, Downey, California. Page 2. History of Bone Loss in LE 49 ... Contemp Orthop. 1993;26:375–379. 10. Vico L, Collet P, Guignandon A, et al. ...

Pathologic fractures alerted the clinician of bone loss secondary to spinal cord injury (SCI) in ... more Pathologic fractures alerted the clinician of bone loss secondary to spinal cord injury (SCI) in the early twentieth century. At mid century bone biopsies from the pelvis and chemical markers, mostly from the urine, began to define this phenomenon. By century's end newer technologies such as densiphotometry, computed tomography and absorptiometries allowed identification of locations as well as specific amounts of bone loss. Characterization of bone loss or loss of bone mineral density (BMD) in persons with SCI remains problematic at the beginning of this century due in large part to the relatively small population of individuals with SCI from which research samples can be drawn. Duration of injury (DOI), sex, neurologic classification, age and acute versus chronic loss have been confounding variables in defining this bone loss. This entity is not systemic. A consensus has not established the most appropriate study site. Studying data in men with neurologically complete SCI reduces the influence of some of the confounding variables, such as estrogen, variable sensory feedback and voluntary muscle influence. BMD at the knee may be selected as an effective site to study treatment since fractures herein are common. Knowledge of the natural history of bone loss, sites of loss, risk factors and fracture sites will assist in research design and outcome interpretation of treatments. Natural History of Bone Loss Changes in BMD have been divided into three phases: acute (or response to injury); subacute (or adaptation and adjustment); and chronic (Garland et al. 1992, Garland et al. 2005a) (Figure 1).

Orthopedic Clinics of North America

Archives of Physical Medicine and Rehabilitation

ABSTRACT

Orthopaedic review

Cerebrovascular accidents remain one of the most serious medical problems in the United States. T... more Cerebrovascular accidents remain one of the most serious medical problems in the United States. They are responsible for 200,000 deaths per year and are the leading cause of hemiplegia in the adult. The purpose of these reports is to review the orthopaedic aspects of stroke rehabilitation, with emphasis on functional defects, evaluation of the patient, and methods of treatment. Part I will discuss the pathophysiologic changes and patient evaluation. Part II will discuss the surgical and nonsurgical management of extremity deformities.

Orthopaedic review

Cerebrovascular accidents are among the most serious medical problems in the United States. In Pa... more Cerebrovascular accidents are among the most serious medical problems in the United States. In Part I of this report, the pathophysiology, types of impairment, and evaluation of the stroke patient were discussed. In this report, Part II, the management of extremity deformities will be reviewed.

The Journal of trauma

Knee motion following femoral fractures is often less than satisfactory. Surgical procedures to i... more Knee motion following femoral fractures is often less than satisfactory. Surgical procedures to increase knee motion are rarely done. This paper presents a series of nine patients who had severe femoral fractures, primarily in the distal third. Once union was obtained, all patients had knee flexion incompatible with normal gait (average 30.2 degrees). All patients underwent a quadricepsplasty at Rancho Los Amigos Medical Center. Eight of the nine achieved knee flexion allowing normal gait (average 78 degrees). This paper presents our indications, methods, results, and complications in performing quadricepsplasty to achieve knee flexion following femoral fractures.

The Journal Of Hand Surgery

Twenty-five brain-injured adults who were treated for tardy ulnar neuropathy during a 5-year peri... more Twenty-five brain-injured adults who were treated for tardy ulnar neuropathy during a 5-year period were studied. Two patients had bilateral involvement. The incidence of late ulnar neuropathy in this population was determined to be 2.5%. The ulnar neuropathy was always on the neurologically impaired side and associated with significant spasticity. Diagnosis was made when intrinsic atrophy was noted in the hand. No patient initiated a subjective complaint. Nerve conduction velocity measurements confirmed impingement of the ulnar nerve in the cubital canal in 16 cases. Twenty-one of the 27 (78%) elbows had moderate to severe heterotopic ossification causing impingement of the ulnar nerve. All patients were treated by anterior transposition of the ulnar nerve. Follow-up averaged 22.7 months. Twenty-three (85%) extremities had complete recovery of ulnar nerve function. Four patients had improved but incomplete recovery of function. Prolonged compression of the nerve led to incomplete recovery.

Contemporary orthopaedics

Contemporary orthopaedics

One hundred thirty-nine established fracture nonunions were treated using a pulsed electromagneti... more One hundred thirty-nine established fracture nonunions were treated using a pulsed electromagnetic field (PEMF) device that also recorded patient usage. Patients who used the device less than an average of three hours a day had a success rate of 35.7% (5/14), while those who used the device in excess of three hours daily had an 80% success rate (108/135). The difference in the success rate was statistically significant at p less than .05. Treatment success was unaffected by long versus short bone, open versus closed fractures, nonunion of nine to 12 months duration compared to one to ten years, age of patient (whether less than or greater than age 60), gender, recalcitrant versus first time treatment, infected versus noninfected nonunions, fracture gaps up to 1cm, or weightbearing versus nonweightbearing. Ninety-seven fractures in 90 patients (90% follow-up) who averaged more than three hours of PEMF treatment daily and were originally classified as healed were reevaluated clinically and radiographically at four years following treatment (range: 3.6-5.4 years; mean: 4.1 years). Eighty-nine (92%) maintained a solid union. The success rate of PEMF treatment for nonunion repair demonstrated no statistically significant change over long-term follow-up.

The Journal of Trauma: Injury, Infection, and Critical Care, 1987

Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of s... more Surgical treatment of supracondylar fractures of the femur has become commonplace. A variety of surgical implants are available. In carefully chosen patients treated with appropriate surgical technique, early motion and good knee function can be obtained with open reduction and internal fixation. However, the morbidity (and mortality) are substantial following complications of open reduction and internal fixation of supracondylar fractures of the femur. We present a series of 30 consecutive patients referred to Rancho Los Amigos Medical Center for complications following open reduction and internal fixation of supracondylar femur fractures. Three patients with septic pseudarthrosis underwent above-knee amputations. Two of these three patients died of systemic sepsis. Fourteen additional patients were treated for nonunions, with 13 patients achieving union at an average time of 36.5 months from the date of injury. Six patients underwent quadricepsplasties for residual knee stiffness. Only 16 patients were returned to their preinjury ambulatory status.

Journal of Orthopaedic Research, 1992

The Journal of Hand Surgery, 1989

Surgical management of spastic thumb-in-palm deformity in adults with brain injury Spastic thumb-... more Surgical management of spastic thumb-in-palm deformity in adults with brain injury Spastic thumb-in-palm deformity was surgically treated in 27 adults with brain injury. Procedures included muscle lengthening, recession, or release, arthrodesis of the thumb interphalangeal joint, or Z-plasty of the thumb web space. At mean follow-up of 39 months, 23 of 27 had a satisfactory correction. Unsatisfactory results included two with inadequate correction and two with over-correction. Surgical treatment of this entity requires careful preoperative planning, addressing predominantly those spastic muscles responsible for the deformity. (J HAND SURG 1989;14A: 174-82.

Clinical Orthopaedics and Related Research, 1980

The charts and roentgenograms of 41 adult patients with severe head injuries who sustained 47 tib... more The charts and roentgenograms of 41 adult patients with severe head injuries who sustained 47 tibial shaft fractures were reviewed. Twenty-seven (57%) of the fractures were open and the incidence of peroneal nerve injury was 17%. The average time to weight-bearing was 3.1 months. Closed fractures united at 5.4 months and open fractures at 5.8 months. Three nonunions (6.5%) occurred in 2 patients. This review failed to demonstrate either an early rate of union or an abnormally high union rate. Furthermore, exuberant callus was not observed roentgenographically. Tibia fractures in adults with head injuries, whether on the normal or paralyzed extremity, appeared to heal in a fashion similar to fractures in normal patients. Conventional methods of treatment render satisfactory results.

The Journal of Bone and Joint Surgery ( …, 1997

We reviewed the results, in eight patients, of excision of heterotopic ossification about the elb... more We reviewed the results, in eight patients, of excision of heterotopic ossification about the elbow performed three to ten months (average, seven months) after the initial injury and followed by radiation therapy to prevent recurrence. The etiology of the heterotopic ossification included a neurological (head or spinal cord) injury in five patients and a local injury (fracture or fracture-dislocation) of the elbow in three patients. The average preoperative arc of motion of the three joints that were capable of motion was 12 degrees (5, 10, and 20 degrees); the remaining five joints were fixed in an average of 56 degrees (range, 10 to 90 degrees) of flexion. All of the patients received a total dose of radiation of 1000 centigray, divided into five fractions. The radiation therapy was instituted on the first postoperative day, and at least three of the remaining four treatments were administered on consecutive days. Radiation therapy was not performed on the weekend, so the five fractions were administered over the course of seven days. At an average of forty-six months (range, twenty-five to seventy-two months), the arc of motion averaged 103 degrees, which compared favorably with the 121-degree arc of motion that had been attained intraoperatively. Two patients who had residual motor deficits in the involved extremity had an arc of motion of 50 and 70 degrees at the latest follow-up evaluation; those who had normal motor function fared considerably better, averaging 118 degrees of motion. There was no substantial recurrence of ossification either radiographically or that limited motion, and no complications attributable to the radiation therapy were noted. On the basis of this experience, it seems that the generally recommended twelve to eighteen-month delay between injury and excision, to allow for maturation of heterotopic bone and thus to lessen the likelihood of recurrence, may be eliminated. Additional studies are needed to define the relative risk of recurrence in the various clinical settings in which heterotopic ossification is seen and to determine whether radiation therapy is necessary to prevent recurrence after early excision in each of these instances.

The Journal of Bone and Joint Surgery-American Volume

Topics in Spinal Cord Injury Rehabilitation, 2005

... Charles A. Stewart, MD, is Chief, Department of Medical Imaging, Rancho Los Amigos National R... more ... Charles A. Stewart, MD, is Chief, Department of Medical Imaging, Rancho Los Amigos National Reha-bilitation Center, Downey, California. Page 2. History of Bone Loss in LE 49 ... Contemp Orthop. 1993;26:375–379. 10. Vico L, Collet P, Guignandon A, et al. ...

Pathologic fractures alerted the clinician of bone loss secondary to spinal cord injury (SCI) in ... more Pathologic fractures alerted the clinician of bone loss secondary to spinal cord injury (SCI) in the early twentieth century. At mid century bone biopsies from the pelvis and chemical markers, mostly from the urine, began to define this phenomenon. By century's end newer technologies such as densiphotometry, computed tomography and absorptiometries allowed identification of locations as well as specific amounts of bone loss. Characterization of bone loss or loss of bone mineral density (BMD) in persons with SCI remains problematic at the beginning of this century due in large part to the relatively small population of individuals with SCI from which research samples can be drawn. Duration of injury (DOI), sex, neurologic classification, age and acute versus chronic loss have been confounding variables in defining this bone loss. This entity is not systemic. A consensus has not established the most appropriate study site. Studying data in men with neurologically complete SCI reduces the influence of some of the confounding variables, such as estrogen, variable sensory feedback and voluntary muscle influence. BMD at the knee may be selected as an effective site to study treatment since fractures herein are common. Knowledge of the natural history of bone loss, sites of loss, risk factors and fracture sites will assist in research design and outcome interpretation of treatments. Natural History of Bone Loss Changes in BMD have been divided into three phases: acute (or response to injury); subacute (or adaptation and adjustment); and chronic (Garland et al. 1992, Garland et al. 2005a) (Figure 1).

Orthopedic Clinics of North America

Archives of Physical Medicine and Rehabilitation

ABSTRACT

Orthopaedic review

Cerebrovascular accidents remain one of the most serious medical problems in the United States. T... more Cerebrovascular accidents remain one of the most serious medical problems in the United States. They are responsible for 200,000 deaths per year and are the leading cause of hemiplegia in the adult. The purpose of these reports is to review the orthopaedic aspects of stroke rehabilitation, with emphasis on functional defects, evaluation of the patient, and methods of treatment. Part I will discuss the pathophysiologic changes and patient evaluation. Part II will discuss the surgical and nonsurgical management of extremity deformities.

Orthopaedic review

Cerebrovascular accidents are among the most serious medical problems in the United States. In Pa... more Cerebrovascular accidents are among the most serious medical problems in the United States. In Part I of this report, the pathophysiology, types of impairment, and evaluation of the stroke patient were discussed. In this report, Part II, the management of extremity deformities will be reviewed.

The Journal of trauma

Knee motion following femoral fractures is often less than satisfactory. Surgical procedures to i... more Knee motion following femoral fractures is often less than satisfactory. Surgical procedures to increase knee motion are rarely done. This paper presents a series of nine patients who had severe femoral fractures, primarily in the distal third. Once union was obtained, all patients had knee flexion incompatible with normal gait (average 30.2 degrees). All patients underwent a quadricepsplasty at Rancho Los Amigos Medical Center. Eight of the nine achieved knee flexion allowing normal gait (average 78 degrees). This paper presents our indications, methods, results, and complications in performing quadricepsplasty to achieve knee flexion following femoral fractures.

The Journal Of Hand Surgery

Twenty-five brain-injured adults who were treated for tardy ulnar neuropathy during a 5-year peri... more Twenty-five brain-injured adults who were treated for tardy ulnar neuropathy during a 5-year period were studied. Two patients had bilateral involvement. The incidence of late ulnar neuropathy in this population was determined to be 2.5%. The ulnar neuropathy was always on the neurologically impaired side and associated with significant spasticity. Diagnosis was made when intrinsic atrophy was noted in the hand. No patient initiated a subjective complaint. Nerve conduction velocity measurements confirmed impingement of the ulnar nerve in the cubital canal in 16 cases. Twenty-one of the 27 (78%) elbows had moderate to severe heterotopic ossification causing impingement of the ulnar nerve. All patients were treated by anterior transposition of the ulnar nerve. Follow-up averaged 22.7 months. Twenty-three (85%) extremities had complete recovery of ulnar nerve function. Four patients had improved but incomplete recovery of function. Prolonged compression of the nerve led to incomplete recovery.

Contemporary orthopaedics

Contemporary orthopaedics

One hundred thirty-nine established fracture nonunions were treated using a pulsed electromagneti... more One hundred thirty-nine established fracture nonunions were treated using a pulsed electromagnetic field (PEMF) device that also recorded patient usage. Patients who used the device less than an average of three hours a day had a success rate of 35.7% (5/14), while those who used the device in excess of three hours daily had an 80% success rate (108/135). The difference in the success rate was statistically significant at p less than .05. Treatment success was unaffected by long versus short bone, open versus closed fractures, nonunion of nine to 12 months duration compared to one to ten years, age of patient (whether less than or greater than age 60), gender, recalcitrant versus first time treatment, infected versus noninfected nonunions, fracture gaps up to 1cm, or weightbearing versus nonweightbearing. Ninety-seven fractures in 90 patients (90% follow-up) who averaged more than three hours of PEMF treatment daily and were originally classified as healed were reevaluated clinically and radiographically at four years following treatment (range: 3.6-5.4 years; mean: 4.1 years). Eighty-nine (92%) maintained a solid union. The success rate of PEMF treatment for nonunion repair demonstrated no statistically significant change over long-term follow-up.