Introduction

Short-stem hip arthroplasty is gaining popularity as a method of treating hip arthritis in biologically younger patients. The potential benefit of using a short-stem is preservation of bone in the proximal femur for a future revision. We have compared the early clinical and radiological results of a short-stem hip arthroplasty versus a conventional total hip arthroplasty (THA) using a standard length femoral prosthesis with particular focus on functional outcome.

Ultrasound treatment can be used as an alternative to surgical methods for treating non-union or to enhance healing in a delayed union. This study presents our short-term results of using low intensity pulse ultrasound stimulation in long bone non-union. 18 patients with surgically treated long bone non-union were treated using the Exogen® ultrasound stimulator (Smith & Nephew Inc., UK). The average age of patients was 48 years (20–73 yrs). There were 8 femur fractures, 9 tibial fractures and 1 knee arthrodesis. 5 of these patients had infected non-union. The average follow up after initiation of treatment was 4 months (range 2–8 months). They received 20 minutes stimulation daily at the fracture site with regular follow up in clinic. We reviewed their serial radiographs and clinical progress. The mean interval to initiation of the ultrasound treatment was 7.9 months (2–27 months). Complete bony union was obtained in 6 of the 18 cases (33%) within 4 months of initiation of treatment. In 7 of 18 cases (38%) there was good evidence of progress towards bony union, while in 4/18(22%) patients there was no progress towards union at average of 4 months (range 2–8 months). There were no complications noted with this treatment. Most non-unions are treated by surgical revision, with consolidation rates ranging from 85 to 100% according to previous studies. Our study suggested 72% patients showing progress towards union with 33% achieving bony consolidation at 4 months. Patients with infected non-union also benefitted from this treatment. In summary ultrasound treatment can be a viable option to treat long bone non-unions, which may avoid the morbidity and complications associated with surgery.

Background

Chronic osteomyelitis with intramedullary sequestrum resulting in persistent infection is a challenging orthopaedic problem that often involves multiple surgical operations and unfortunately has a significant recurrence rate. Reasons for this may include difficulty in eradicating all intramedullary microsequestra making subsequent prolonged antibiotic therapy less effective. Use of the Reamer-Irrigator-Aspirator (RIA) has many advantages for management of intramedullary infections in chronic osteomyelitis. The RIA technique allows irrigation of sterile large quantities of saline with simultaneous bony debridement with very sharp reamers that are specially designed to allow simultaneous fluid aspiration.

Previous reports have shown the efficacy of muscle interposition grafts in treating recalcitrant infection in the presence of hip arthroplasty. We report our experience with a two stage debridement and rectus femoris pedicled interposition graft technique in chronic severe native hip infection with a persistent draining sinus.

During the last 16 months, three paraplegic patients presented with persistently draining sinuses and chronic osteomyelitis of the pelvis, acetabulum and proximal femur, in a total of four hips. The mean patient age was 49 years (range, 40 to 59 years). In all patients there had been previous attempts to control the infection with wound debridement and long-term antibiotics.

A two-stage operative treatment was used in all patients. The first stage comprised wound debridement, washout, gentamycin-bead application and temporary vacuum assisted wound coverage.

At the second stage, approximately ten days later, through a standard anterior midline incision, the rectus femoris muscle was elevated on its pedicle, rolled, transposed into the acetabulum and sutured to the transverse acetabular ligament. At the second stage, all patients had local administration of antibiotics with genetamycin impregnated absorbable collagen fleece and all wounds were closed by delayed primary closure with a negative pressure dressing placed over the closed wound. All patients were commenced on a 6 week course of intravenous antibiotics, according to sensitivities.

No loss of flap occurred in any of the patients. One wound had partial dehiscence and required a split skin graft. At the final follow-up examination all the wounds were healed and there was no recurrence of draining sinuses, pressure sores or systemic sepsis.

The two stage technique with a pedicled rectus femoris interposition graft may be a useful technique for the treatment of complex chronic persistent osteomyelitis of the pelvis, acetabulum and proximal femur, with the primary aim of stopping the discharging sinus.

Background: To analyse the effects of surgery on sagittal alignment¹ in patients with severe Scheuermann’s kyphosis. To assess the ability of two surgical techniques to prevent loss of correction in the thoracic kyphosis. To assess factors of patient’s Body Mass Index (BMI) and instrumentation level on the risk of adjacent level kyphosis or pullout.

Methods: A retrospective study of 13 consecutive cases of rigid Scheuermann’s kyphosis. Group A: 6 patients with anterior interbody cages. GroupB: 7 patients with interbody autogenous rib graft. All patients were instrumented posteriorly from T2 to L2. Radiographs from initial presentation, pre-operatively, post-operatively and at final follow –up were assessed. The thoracic kyphosis, lumbar lordosis, sagittal balance² and sacral inclination were measured.

Results: There were 7 males and 6 females with a mean age of 22 years (range 15 to 38yrs). The mean follow-up was 26 months (range 7 to 53 mths). In Group A: the mean preoperative kyphosis was 87° (range 82° to 92° ) and postoperative kyphosis was 45° (range 38° to 60°). The mean loss of correction was 0.3° (range 0° to2°). In Group B: the mean preoperative kyphosis was 83° (range 70° to 100°) while the postoperative kyphosis was 43° (range 30° to 60°). The mean loss of correction was 1.1° (range 0°to 2°) at final follow-up. The mean lumbar lordosis pre-operatively for all patients was 66° (range 62° to 84°) reducing to 48° (range 34° to 82°) following surgery. The mean sacral inclination pre-operatively was 41° (range 18° to 80°) reducing to 32 °(range 14°to 40°) following surgery. The mean sagittal balance preoperatively was −1.1 cm (range +0.1 to −3.5). It reduced postoperatively to −2.2 cm (range +1.5 to −4 cm) and was −1.6cm (range +0.2 to – 3.5cm) at final follow- up. Three patients with BMI greater than 25 had an increased lumbar lordosis at final follow up, with one case of implant failure and 2 cases with lower junctional kyphosis. No patient had an upper thoracic junctional kyphosis. There was no evidence of neurological compromise.

Conclusion: Patients had a mean thoracic kyphosis correction of 41° (49%). This was maintained during follow-up with no significant difference between autograft and cages. Cranially, all patients had instrumentation to T2 and there was no junctional kyphosis. Caudally, three obese patients (BMI > 25) suffered screw pullout (1 patient) or junctional kyphosis (2 patients). Instrumentation to L3 may avoid this complication in this patient group. The lumbar lordosis and sacral inclination reduced immediately postoperatively, with further correction at final follow –up.

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach.

Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out.

Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up.

Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition.