Background:

In recent times there has been an increasing trend towards surgical intervention in paediatric femoral shaft fractures with widening indications. Titanium elastic nails and external fixation are two widely practiced procedures for such fractures.

Introduction

Recurrent dislocation after hip arthroplasty is a difficult problem. The purpose of the present study was to evaluate the results with the use of a constrained cup for treatment for instability after hip arthroplasty.

Aim

The aim of the study was to characterise gait in patients with achondroplasia post lengthening.

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures.

This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20⁰, using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years.

All patients in both operatively treated groups were corrected to under 10⁰ of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture.

The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%.

Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%.

MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible.

There was no loss of correction in either operatively treated groups.

The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction.

MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity.

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

Clear-cell sarcoma is a very rare tumor, and is almost always associated with tendons or aponeuroses or is metastatic from other organs. Sporadic cases only have been reported involving primarily the bone or extending from soft tissues to surrounding bones. To our knowledge, the ilium has not been previously reported as the primary site for clear cell sarcoma.

We report a rare case of Primary clear cell sarcoma involving right ilium region in a 18-year-old boy presented with a painful swelling over right ilium and limp on right lower limb of ten month duration. He was initially suspected having tuberculosis based on clinicoradiological evaluation and diagnosis of primry clear cell sarcoma could be established on histopathology. Patient was treated with partial excision of the ilium, the remaining ilium was fused with sacrum. Stabilization was achieved with a cortical autograft harvested from the right fibula and fixation with a titanium plate.

The patient had no local recurrences but the plate holding ilium to sacrum broke and was removed in the subsequent surgery after which he developed Trendelenberg’s gait.

Introduction: Inaccuracies in kinematic data recording due to skin movement artefact are inherent with motion analysis. Image registration techniques have been used extensively to measure joint kinematics more accurately. The aim of this study was to assess the feasibility of using MRI for creating 3D models and to quantify errors in data collection methods by comparing kinematics computed from motion analysis and image registration.

Methodology : 5 healthy and 5 TKR knees were examined for a step up/down task using dynamic fluoroscopy and motion capture. MRI scans of the knee, femur and tibia were performed on the healthy subjects and were subsequently segmented using ScanIP(Simpleware) to produce 3D bone models. Registration of the models produced from fine and coarse scan data was used to produce bony axes for the femoral and tibial models. Tibial and femoral component CAD models were obtained for the TKR patients. The 3D knee solid models and the TKR CAD models were then registered to a series of frames from the 2D fluoroscopic image data (Figure 1) obtained for the 10 subjects, using KneeTrack(S. Banks, Florida) to produce kinematic waveforms. The same subjects were also recorded whilst performing the same action, using a Qualisys (Sweden) motion capture system with a pointer and marker cluster-based technique developed to quantify the knee kinematics.

Results: The motion analysis method measured significantly larger frontal and transverse knee rotations and significantly larger translations than the image registration method.

Conclusion: The study demonstrated that MRI, rather than CT scan, can be used as a non-invasive tool for developing segmented 3D bone models, thus avoiding highly invasive CT scanning on healthy volunteers. It describes an application of combining fine and coarse scan models to establish anatomical or mechanical axes within the bones for use with kinematic modeling software. It also demonstrates a method to investigate errors associated with measuring knee kinematics.

Aim: The carpal bone arrangement can be described as a matrix of two rows and three columns. There a various theories as to how the bones within the matrix move during ulna to radial deviation. One theory suggests that there are two types of wrist movement, namely Row & Column¹.

The aim of this study was to investigation how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Materials and Methods: Ulna to radial deviation was assessed in 50 normal wrists in 25 normal subjects aged 19 to 57. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metcarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation.

Results: The mean range of movement was 45 degrees (SD 7). In full ulna deviation the wrist rotational axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).

Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement. i.e. Column movers and row movers¹.

Introduction: After adopting a new low suspensory bio-absorbable femoral fixation technique for single bundle, four strand, hamstring Anterior Crutiate Ligament (ACL) in conjunction with a rapid rehabilitation program, we observed at routine follow up that there was no evidence of femoral tunnel widening, as often observed with conventional high suspensory fixation systems.

Method: We conducted a retrospective observational cohort study to test the hypothesis that the Rigid-Fix (Mitek) system of femoral fixation, a low suspensory technique, is less prone to tunnel widening than traditional suspensory techniques.

14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs.

All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling.

Results: All subjects had regained knee stability, and all but one had returned to their pre-injury level of sport. Clinically all knees were ligamentaly stable, exhibiting negative Luchman and pivot shift tests.

Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature.

Conclusions: We conclude that the Rigid-Fix femoral ACL fixation system does not exhibit any evidence of clinically significant tunnel widening, even when used in conjunction with a rapid rehabilitation program.

Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation.

Background: Back pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc.

Objective: To form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’.

Methods: This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with lysis block and discography. On this basis, of a total of ten patients, seven were offered lysis repair and bone grafting using ‘Morscher’s clamp’; three were offered spinal fusion. Outcome was assessed using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) done pre-operatively and six months post-op.

Results: Out of ten patients (28 to 45 years; 4males and 6 females), seven patients underwent primary lysis repair using ‘AO Morscher clamp’. Union of pars achieved in all the patients by 4 months (Follow-up 4 months to 2 years). Three underwent fusion. Mean VAS improved from 7.2 to 1.2 in lysis repair group. Mean ODI improved from 68 % to 24%. All patients had full range of spinal movement postop.

Conclusion: A thorough pre-operative workup of patients with pars defect and adjacent level disc degeneration showed that pain is due to the pars defect in 70% of our cohort. This subgroup of patients could successfully be treated with ‘lysis repair’ rather than a more morbid procedure of ‘spinal fusion’.

The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively.

The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).

The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995).

Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus arthritic knees using lateral capsular approach and realignment of vastus lateralis.

Material and Method: We reviewed results of 50 mobile bearing total knee arthroplasties performed consecutively between 2001 and 2006 for Valgus arthritic knees, using lateral capsular approach and realignment of vastus lateralis. Patients were evaluated using oxford and International knee society Score. Radiographs were examined for alignment of the component, evidence of loosening and scanograms assessed to evaluate the restoration of mechanical axis.

Results: The study group consisted of 47 patients, 20 men and 27 women who received fifty knees. The mean age at the primary operation was 71.57 years (range 47–82 years; SD, 9.5). The mean follow up was 4.2 years (range 1–6 years; SD, 1.35). The mean Valgus deformity was 15.92° (rang from 15–20 SD 1.89). Fixed flexion deformity was seen in 15 knees.

The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points at final follow up.

There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear.

Radiological evaluation: None of these knees had radiographic evidence of loosening or osteolysis. Mechanical axis was restored in all the patients.

Conclusion: This study demonstrates satisfactory results of Mobile bearing knee arthroplasty using lateral parapatellar with proximal realignment of vastus lateralis for Valgus arthritic knees.

Aim: The aim of this investigation was to determine how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Materials & Methods: Ulna to radial deviation was assessed in 30 normal wrists in 15 normal subjects aged 19 to 32. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metacarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation.

Results: The mean range of movement was 47 degrees (SD 8). In full ulna deviation the wrist rotational axis was in the region of the lunate/capitate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 22 mm (SD 14). In 17 wrists the distal displacement was accompanied by mean displacement towards the ulna of 13 mm (SD 8). In 13 wrists the distal displacement was accompanied by a mean displacement towards the radius of 7 mm (SD 5).

Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 type of carpal movement. i.e. Column movers and row movers [Craigen & Stanley].

Purpose of the Study: To ascertain the role of Dynesys system (Zimmer Spine, Minneapolis) in the surgical management of chronic low back pain

Methods: 55 patients with persistent low back pain despite conservative measures were treated with Dynesys over a period of two and a half years. Participants either underwent Dynesys procedure alone or in combination with fusion or decompression surgery. Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and SF-36 questionnaires were completed pre-operatively and at one and two years post-operatively. Pre-operative testing using the Distress and Risk Assessment Method (DRAM) identified psychological distress prior to surgery. Patient Oriented Outcome questionnaires were circulated retrospectively following surgery to obtain data regarding patient’s perceptions and expectations of their outcome.

Results: Overall, the mean ODI reduced by 10.23% after one year and 16.15% after two years following surgery. VAS improved by 12mm one year and by 17mm two years after operation. Patients with psychological distress pre-operatively showed less improvement in their ODI and VAS at two-year follow up. The results of fusion were similar to Dynesys alone, and patients who also had decompression had best results. 72.2% patients reported an improvement following their surgery and the same percentage would have the operation again in retrospect.

Conclusion: This is the first study exploring clinical outcomes following surgery using Dynesys dynamic stabilization system in patients with disabling low back pain. Previous studies have reported good outcome in the treatment of spinal stenosis. Over 70% patients in our study reported improvement following the procedure but more evidence is needed to determine if it is a viable alternative to spinal fusion.

We describe results of a new ‘two needle technique’ of selective nerve root blocks done through posterior triangle of neck in the management of cervical radiculopathy with 2 year results.

Methods: Patients presenting with cervical radiculopathy were evaluated clinically and radiologically and were initially managed with supervised physiotherapy, analgesics and rest. Selective cervical nerve root block was offered to the patients, who did not respond to conservative management. The procedure was performed as a day case, under local anesthesia, with image intensifier guidance, using ‘two needle technique’. A thinner needle is rail-roaded through the lumen of large diameter guide needle to reach the target nerve root foramen and a mixture of Bupivacaine and Triamcinolone acetonide is injected. The outcome was measured using visual analogue score (VAS) and neck disability index (NDI) done on the day of the procedure and compared to the scores at 3 months and 1 year after the procedure.

Results: Outcome in 30 patients who underwent this procedure over three years’ period is presented. Average Visual Analogue Score was 7.36 (range 6 – 10) before the intervention, which improved to 2.27 (range 0 – 7) at 3 months and 1.9 (range 0 – 4) at 1 year. The average Neck Disability Index score prior to intervention was 66.87 (range 44 to 82), which improved to 31.67 (range 18 – 66) at 3 months and 30.44 (range 20 – 48) at 1 year. There were no major complications noted. We conclude that selective cervical nerve root block using ‘two-needle technique’ is safe and reproducible. The therapeutic effect achieved is long lasting, making this procedure a good alternative to surgical management in patients with cervical radiculopathy who do not respond to conservative management.

Purpose of the Study: To assess the use of synthetic hydroxyapatite for postero-lateral spinal fusion using a new classification system

Methods: This is a prospective study on 30 patients who underwent bilateral postero-lateral spinal fusion between October 2002 and January 2004. The sides were randomised to synthetic phase pure Hydroxyapatite (Apapore® 70) mixed with bone marrow and autologus bone on one side and Apapore® 70 with bone marrow on the other. Plain Antero-posterior and Lateral x-rays were done in the immediate post-operative period and at 3, 6, 12 and 24 months. Two independent observers assessed the Antero-posterior films using a new classification system. Spine was considered fused when either or both sides showed good evidence of bone formation between the graft particles and graft and transverse process.

Results: In 6 patients x-rays were lost and 2 did not have two year follow-up. Twenty of the remaining 22 patients (90.9%) showed evidence of fusion as documented by both the observers. Good evidence of bone formation was noted as early as 6 months on the side where Apapore was used with bone marrow with 90.9 % achieving fusion at 2 years as against 57.1 % on the opposite side. The inter-observer agreement was good (mean 81.6%) with kappa score of 0.736.

Conclusion: The Hydroxyapatite based bone graft substitutes behave differently than autologus bone graft and poses difficulty in assessing fusion according to the radiographic classification systems described. The classification described above is useful in such situations and has shown to have good inter-observer reliability. With the increasing use of bone substitutes this classification system may be valuable in assessment of fusion and inter-study correlation.

Delays in the surgical treatment of acetabular fractures often results in extensile or combined approaches being required. This study reports the outcome from a regional centre aiming to treat these fractures via a single surgical approach where possible.

Seventy-two patients (73 displaced acetabular fractures) with an average age of 39.5 years (range 15–76 years) were studied with an average follow up period of 45.5 months (range 24–96). All radiographs were reviewed together with a full clinical assessment of each patient including the Harris Hip Score.

Thirty-four fractures were simple and 39 were complex including 27 both column fractures. Eight were noted to have an associated injury to the femoral head. The average time from injury to surgery was 11.7 days (range 1–35 days) with 80 percent of cases being operated on within two weeks after injury.

In 67 fractures (92%), including 24 both column fractures, a single approach alone was used (Anterior Ilioin-guinal 26 cases; Posterior Kocher-Langenbeck 41 cases). Five fractures needed an extensile triradiate approach and only one case required a combined anterior and posterior approach. A congruent reduction (gap or step of 2mm or less) was achieved in 65 cases (89%). Functional outcome was good with an average Harris Hip Score of 85 (range 20–100). There were 2 cases of deep infection (2.7%) and 4 patients (5.5%) required later hip replacement. There were no cases of venous thrombosis. Twenty cases exhibited heterotopic ossification of varying degree but none of these were grade IV.

Conclusion: In most cases, internal fixation of a displaced acetabular fractures is possible via a single surgical approach. Morbidity and complications are much reduced but single approach surgery requires that patients are assessed and treated early and prompt referral to a specialist unit is recommended.

Midline skin incision and medial arthrotomy for knee arthroplasty may be preformed in flexion or extension. Anatomical studies have revealed a risk to the infra patellar branch of the saphenous nerve. This study addresses

whether sensory loss is greater following skin incision in flexion or extension.

Null hypothesis- there is no detectable difference in sensation before and after knee arthroplasty. Pilot study- light touch, sharp touch and two point discrimination were evaluated pre-operatively, at one week, six weeks and six months postoperatively in twelve patients recruited prospectively. Randomization was achieved using an envelope system. Six patients underwent approach and closure in flexion and six in extension. Prospective cohort study – 50 patients underwent sensory mapping for light touch and sharp touch pre-operatively. These control results were compared with the post-operative findings at six months. All measurements were standardised to anatomical landmarks with the knee in 90 degrees flexion.

There is a constant area of sensory loss lateral to the midline scar, which shows some recovery with time. The sensory loss affects both light and sharp touch. Initially, this is in a similar distribution anteriorly and laterally extending from the superior pole of the patella to the tibial tubercle, approximately 2cm lateral to the midline. The loss is most marked immediately after surgery. There is a noticeable recovery in sharp touch by six weeks. The recovery in light touch is slower and less complete at the six month review. There is no demonstratable difference in sensory loss regardless of whether the incision is made in flexion or extension, (p=0.1)

Lateral sensory loss is a constant feature in this series six months following knee arthroplasty. Patients may benefit from pre-operative counselling regarding the likelihood of lateral cutaneous sensory deficit following knee arthroplasty.

A series of 14 patients suffering from tuberculosis of the sternum with a mean follow-up of 2.8 years (2 to 3.6) is presented. All were treated with antitubercular therapy: ten with primary therapy, two needed second-line therapy, and two required surgery (debridement). All showed complete healing and no evidence of recurrence at the last follow-up. MRI was useful in making the diagnosis at an early stage because atypical presentations resulting from HIV have become more common. Early adequate treatment with multidrug antitubercular therapy avoided the need for surgery in 12 of our 14 patients.

Vertebral disease constitutes approximately 50% of all skeletal tuberculosis. We describe a patient who developed a discharging sinus at the tip of the coccyx. Extensive examination revealed isolated tuberculosis of the coccyx. Although rare, the condition should be suspected in patients presenting with a chronic sinus in the sacrococcygeal area and a lytic lesion in the coccyx on CT or MRI, particularly in the developing world.