We report a surgical technique for arthroplasty of the deformed hip after poliomyelitis.

A fifty three year old man presented to our unit with a long-standing history of hip problems since contracting poliomyelitis at the age of two. Unusually, both of his hips were affected. He had been operated on twice for his right hip. This had left him with a deformed upper femur with significant shortening. The right hip was sub-luxed on presentation; this was due to a markedly dysplastic acetabulum.

The polio and subluxation meant his muscles were weak and stretched. Like other authors, we were keen to achieve a stable hip. The senior author felt that a fully constrained socket would carry the following disadvantages:

Reduced range of movement.

An alternative approach, using a large diameter unconstrained metal on metal articulation, was employed; stability was achieved with the large head and the relatively small socket still preserved bone stock. The components chosen were a 52mm MMT, Birmingham acetabular resurfacing prosthetic, articulating with a 46mm chromium cobalt head. A fluted stem CAD CAM (computer aided design, computer aided manufacture) femoral prosthesis was used, as he needed to fully weight-bear from the outset, because of the weakness in his left leg.

He has a good, pain-free range of movement. This represents a novel solution for arthroplasty in hips surrounded by weakened musculature. It avoids dramatic limitation of movement whilst minimising the bone stock loss and risk of dislocation. The patient is delighted with the medium term results.

Background

In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure.

Background

In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure.

A 51 years old female who experienced difficulty in gait ambulation due to secondary osteoarthritis of knee showed knee instability caused by paralysis associated with poliomyelitis and scoliosis. At the first medical examination, right knee range of motion was 0° to 90°, and spino malleolar distance (SMD) showed 72cm for the right leg, 78cm for the left leg, and the bilateral comparison of SMD indicated the leg length discrepancy of 6cm. The patient has a history of surgeries with an anterior – posterior instrument for the treatment of scoliosis, and with Langenskiöld method for the paralyzed right knee at the age of seventeen. The patient also experienced varus degeneration at the age of twenty seven, which was surgically treated with high tibial osteotomy. In this case, a reoperation of her right knee was performed due to the reoccurrence of the knee pain. Preoperative planning was performed using Patient-matched instrument (Signature; Biomet) which was created based on computed tomography data. Each part of osteotomy followed the resection guide by Signature, and a total knee arthroplasty was carried out using the Rotating Hinge Knee System (Zimmer, warsaw. Inc). Two week after the operation, the patient showed the ability to walk without any assistance, and has been in a good condition.

Introduction. Taylor Spatial Frame (TSF) has been designed to treat complex tibial, foot and ankle deformities using computer software. We have performed various osteotomies in combination with different soft tissue procedures, with the use of TSF. Material and Methods. A retrospective study of 20 consecutive patients operated by, senior author SSM, from 2004 onwards who underwent surgical correction of tibia, ankle, midfoot and hind foot including lateral column lengthening, calcaneal and midfoot osteotomies. Demographic details, diagnosis, procedures (including previous operations), length of follow-up, outcome and complications were recorded. Of the 20 patients, 13 were men and 7 women. The mean age was 39 years (range 18 to 70). 5 patients had TSF for malunion or non-union of ankle fractures, malunion of tibia (5), congenital talipes equino-varus(3), acute fracture of ankle (2), one patient each for spina bifida, Poliomyelitis, Charcot-Marie-Tooth disease, equino-varus due to periventricular leuco-encephalopathy and avascular necrosis of the talus. Bilateral TSF for torsional malalignment of tibia (1). Results. Follow up 6 to 54 months (mean 19.4). Patient based foot and ankle outcome criteria were used. Of the 20 patients, 16 had no pain and satisfactory range of movement and function at the last follow up. Post-operative complications included pin site infection(2) and frame hardware malfunction (2)patients, residual deformity requiring surgical correction at 22 months, (1) delayed union, neuropathic pain in (1), residual equinus deformity requiring Botox injections(1) and osteomyelitis requiring debridement(1). Conclusion. We present this series of complex congenital and acquired conditions of the foot and ankle treated with corrective osteotomies and Taylor Spatial Frame with good results

Juvenile hip instability is associated with many conditions. Most of them belong to the group of neuromuscular diseases. Generally following categories can be enumerated: 1. Cerebral palsy, 2. Myelomeningocele, 3. Spinal cord injury, 4. Paraplegia following spine surgery, 5. Poliomyelitis, 6. Inflammatory hip disease, 7. Idiopathic instability, 8. Recurrent post-traumatic hip instability. In the groups 1–5 a chronic muscle imbalance is the reason of the displacement of the femoral head. Inflammatory joint disease produces displacement through cartilage and bone destruction and increased intra-articular pressure. Very rare idiopathic instability is usually associated with generalised hypermobility. For the early diagnosis a careful clinical examination is necessary involving range of motion, testing of the hip stability by the Palmén’s test in the same way like in new-borns. Routine x-ray screening at least once per year is mandatory. For the groups 1–5 a muscle imbalance has to be corrected first. Elimination of muscles contractures or muscles transfers respectively, showed a high efficiency if these surgical corrections were performed early. Femoral osteotomy alone does not provide reliable results. Any form of pelvic osteotomy is necessary to correct acetabular insufficiency. For the inflammatory hip disease early active surgical treatment is best prevention of displacement. Idiopathic hip instability has to be differentiated from common snapping hip. No treatment is necesary. Recurrent hip dislocation can be cured by a posterior capsulorrhaphy

We describe seven cases of permanent neurological damage following interscalene block used in post-operative analgesia after operations at the shoulder. MRI, Nerve Conduction Studies and Quantitative assessments of function confirmed that in all there was infarction of the anterior spinal cord, resulting in a spinothalamic and corticospinal tract defect especially at segments C7, C8 and T1. We think that these lesions were caused by injury to radicular arteries. Domisse has demonstrated the anatomy of the radicular vessels joining the anterior spinal artery to supply the anterior two thirds of the cord. They are branches of the vertebral, ascending cervical and deep cervical arteries which pass through the inter-vertebral foramina with the C7, C8 and T1 roots predominantly. Chakravorty has shown that radicular vessels contribute to the blood supply of the lower cervical cord. Injury to them can cause ischaemia, leading to Anterior Spinal Artery Syndrome. We suggest tamponade of the radicular vessels by infusion of fluid under pressure deep to the prevertebral fascia as the main mechanism but neurotoxicity and vasospasm can be other possible explanations. In a second group there was an additional interference with the vertebral artery presenting with transient bulbar and cranial nerve symptoms. We had 2 patients with such combined lesions. Complications of interscalene blocks are well documented but most are reversible and transient. In our cases the damage has been permanent and disabling. The innervation of the gleno-humeral joint is largely through the 4th, 5th and 6th cervical nerves and we suggest more appropriate placing of the blockade should be adapted and use of this technique for post-operative analgesia should be abandoned