Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant
Purpose. Fracture-related infection (FRI) is an important complication related to orthopaedic trauma. Although the scientific interest with respect to the diagnosis and treatment of FRI is increasing, data on the microbiological epidemiology remains limited. Therefore, the primary aim of this study was to evaluate the microbiological epidemiology related to FRI, including the association with clinical symptoms and antimicrobial susceptibility data. The secondary aim was to analyze whether there was a relationship between the time to onset of infection and the microbiological
Aims. Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize
Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite varying anecdotal opinions, its association with different treatments, especially the Ponseti method, remains uncertain. This systematic review aimed to establish the
Aims. The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the
Femoroacetabular impingement causes pain in the hip in young adults and may predispose to the development of osteoarthritis. Genetic factors are important in the
Objectives. A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Methods. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed. Results. A total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients. In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results. Conclusion. Two thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the
1. During a fifteen-year period a clinical, radiological and in some cases a surgical study has been made of 319 patients suffering from spondylolisthesis–that is, forward slipping of one lumbar vertebra on another or forward sagging of the whole lumbar spine in relation to the sacrum. 2. The five
1 . Current theories of the
Stiffness after TKR is a frustrating complication that has many possible causes. Though the definition of stiffness has changed over the years, most would agree that flexion > 75 degrees and a 15-degree lack of extension constitutes stiffness. This presentation will focus upon the potential causes of a stiff TKR, intra-operative tips, the post-operative evaluation and management, and the results of revision for a stiff TKR. The management of this potentially unsatisfying situation begins pre-operatively with guidance of the patient's expectations; it is well-known that pre-operative stiffness is strongly correlated with post-operative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sised and aligned and rotated. Soft-tissue balancing must be attained in both the flexion/extension and varus/valgus planes. One must avoid overstuffing the tibio-femoral and/or patello-femoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close followup of a patient's progress is crucial for the success in return of ROM. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. At our institution, most manipulations are performed within 3 months post-operative under an epidural anesthetic; patients will stay overnight for continuous epidural pain relief and immediate aggressive PT. The results of re-operations for a stiff TKR are variable due to the multiple
Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on. Outcome of hip-preserving head reduction osteotomy combined with periacetabular osteotomy was good in one and moderate in the other up to three years after surgery; based on the pronounced hip destruction, the third received initially a total hip arthroplasty.Aims
Methods
A nationwide study of Perthes’ disease in Norway was undertaken over a five-year period from January 1996. There were 425 patients registered, which represents a mean annual incidence of 9.2 per 100 000 in subjects under 15 years of age, and an occurrence rate of 1:714 for the country as a whole. There were marked regional variations. The lowest incidence was found in the northern region (5.4 per 100 000 per year) and the highest in the central and western regions (10.8 and 11.3 per 100 000 per year, respectively). There was a trend towards a higher incidence in urban (9.5 per 100 000 per year) compared with rural areas (8.9 per 100 000 per year). The mean age at onset was 5.8 years (1.3 to 15.2) and the male:female ratio was 3.3:1. We compared 402 patients with a matched control group of non-affected children (n = 1 025 952) from the Norwegian Medical Birth Registry and analysed maternal data (age at delivery, parity, duration of pregnancy), birth length and weight, birth presentation, head circumference, ponderal index and the presence of congenital anomalies. Children with Perthes’ disease were significantly shorter at birth and had an increased frequency of congenital anomalies. Applying Sartwell’s log-normal model of incubation periods to the distribution of age at onset of Perthes’ disease showed a good fit to the log-normal curve. Our findings point toward a single cause, either genetic or environmental, acting prenatally in the
The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and
The purpose of this study was to identify
Introduction: Femoroacetabular impingement (FAI) causes pain in young adults and osteoarthritis. Genetic factors are important in the
1. Chondromalacia of the patella starts most frequently on the medial facet. 2. The anatomy of the medial femoral condyle is described, including the rim at its superior border, and the different arrangement at the upper border of the lateral femoral condyle. 3. Rubbing of the medial patellar facet on the rim at the upper border of the medial femoral condyle can explain in part the
A five-year prospective trial involving 120 patients was undertaken to investigate the
Introduction: Femoroacetabular impingement (FAI) is an important cause of hip pain in young adults and a precursor to osteoarthritis. Genetic factors are important in the
Over the long term, the results of the insertion of a Grammont inverted shoulder prothesis are unknown. The present study reports survivorship curves and the role of the initial
The purpose of this study was to identify
Surfing is a popular UK water-sport. Recommendations for protective gear are based on studies abroad from trauma from large waves and reef breaks which may not be relevant in the UK. This study assesses the
Introduction: This is a prospective study of a series of consecutive cases of Os Odontoideum focussing on CT and MRI data. Both congenital and post-traumatic
At the apex of an idiopathic scoliotic curve there is a greater proportion of "slow twitch" muscle fibres in multifidus on the convex as compared to the concave side. To determine whether this represents a primary muscular imbalance relevant to the
A study of the natural history and
Despite numerous studies on periprosthetic joint infections (PJI), there are no robust data on the risk factors and timing of metachronous infections. This study was performed to answer the following questions: 1) Is there any difference of manifestation time of metachronous PJIs between different localizations of multiple artificial joints? 2) Can we identify any specific risk factor for metachronous PJIs for different localizations of multiple artificial joints? Between January 2010 and December 2018, 661 patients with more than one prosthetic joint at the time of PJI surgical treatment were recruited. Seventy-one developed metachronous PJI after a mean time interval of 101.4 months (range 37.5 to 161.5 months). The remaining patients were chosen as control group. The diagnosis of the PJI, including the metachronous PJI, was made according to the Muscoloskeletal Infection Society (MSIS) criteria. The metachronous infections were divided in group 1: metachronous infections in the same extremity (e.g. right hip and right knee); group 2: metachronous infections of the other extremity (e.g. right knee and left hip); group 3: metachronous infections of the lower extremity and upper extremity (e.g. right knee and left shoulder).Aims
Methods
Introduction Both congenital and acquired
1. Breech malposition and hormonal joint laxity produce atraumatic posterior dislocations in the hip joints of young rabbits. 2. Experimental studies were shown to cause the development of a limbus and other softtissue changes similar to those found in human congenital dislocations. 3. The development of femoral retroversion and anteversion in the presence of joint laxity is described. 4. The co-existence of breech malposition and hormonal joint laxity in utero, and their importance as prime factors in the
1. Peroneal spastic flat foot is a term loosely and often inaccurately used to describe rigid valgus feet developing from widely different causes. 2. The most common causes are two anomalies of the bones of the tarsusâthe calcaneonavicular bar, and the talocalcaneal bridge. The first was described in 1921 by Sloman and in 1927 by Badgley; the other is described for the first time in this paper as an
A sibling risk study that shows a statistically significant increase in risk for anteromedial osteoarthritis of the knee. Anteromedial osteoarthritis is a distinct phenotype of osteoarthritis. Previous studies have shown a genetic
A prospective study was made of 119 children with transient synovitis or any other cause for synovial effusion and elevated intra-articular pressure. During a follow-up of one year not one case of Perthes' disease was diagnosed and the late clinical and radiographic changes were minimal with moderate overgrowth of the femoral head in 33% and widening of the joint space in 14.2%. Our results do not support the widely accepted concept that Perthes' disease develops as a result of the period of elevated intra-articular pressure found in transient synovitis. Further research into this and Perthes' disease should follow the premise that they are two different diseases without any
1. The clinical features of hyperostosis cranii are briefly reviewed. In large series of cases the syndrome has been found to occur almost entirely in females. 2. In recent studies of dystrophia myotonica, it is apparent that hyperostosis cranii is one of the variable features of the disorder. This disease occurs equally among males and females and the hyperostosis cranii also is distributed equally among males and females. 3. Hyperostosis cranii also occurs in patients with Morgagni's syndrome, with acromegaly, and as "senile hyperostosis.". 4. The
Slipped upper femoral epiphysis (SUFE) is a condition, which affects the immature hip joint. Many theories have been postulated as to its underlying
Aims: The study aimed at analyzing the outcome of femoral components in patients with total hip replacement following osteonecrosis of the femoral head with regard to the associated factor of the osteonecrosis. Methods: We reviewed 41 patients with 55 cementless total hip replacements operated for advanced osteonecrosis. According to
We report four patients who showed hundreds of brilliant white loose bodies at arthroscopy of the knee after a short history of pain and crepitus. Histological, historical and clinical evidence is presented which indicates that the
We have shown that stress fractures can be induced in the tibial diaphysis of an animal model by the repeated application of non-traumatic impulsive loads. The right hind limbs of 31 rabbits were loaded for three to nine weeks and changes in the bone were monitored by radiography and bone scintigraphy. The presence of stress fractures was confirmed histologically in some cases. Most animals sustained a stress fracture within six weeks and there was a positive correspondence between scintigraphic change and radiological evidence. Microscopic damage was evident at the sites of positive bone scans. The progression, location, and time of onset of stress fractures in this animal model were similar to those in clinical reports, making the model a useful one for the study of the
Introduction: To determine the
Heritable thrombophilic disorders have been proposed as one of the causes for Legg-Calvé-Perthes disease. A total of 62 patients diagnosed with this disease between 1988 and 1997 and 50 controls were screened for thrombophilia. The incidence and relationship of thrombophilia to the severity of the disease were evaluated. One patient and none of the controls had protein S deficiency. One of the control group and one of the patients had protein C deficiency with the latter child also having a combined deficiency with a mutant factor V gene. The number of children with a mutant factor V gene, protein C deficiency, who were homozygous for the C 677T polymorphism of methylenetetra-hydrofolate reductase or were heterozygous for mutant G20210A prothrombin did not differ statistically in the study and the control groups. No patient had antithrombin deficiency or positive lupus anticoagulant. We found no correlation between thrombophilia and the extent of the disease. The most common risk factors for arteriovenous thromboembolism showed no statistical significance in our patients compared with the control group or with the general population. These data do not confirm an
Introduction:. Recent studies have concluded that gender influences hip morphology at the time of surgery as well as dysplastic development of the hip. This may lead to a particular choice of implant including stem design and/or neck modularity. In this study we hypothesized that not only gender but also morphotype and
Introduction Spondylolysis and isthmic spondylolisthesis (IS) have both a familial and mechanical
To retrospectively analyze the
We performed electrophysiological studies on both legs of 52 children, aged from 3 months to 15 years, with idiopathic club foot. In only nine (17%) was no abnormality found. Isolated peroneal nerve damage was seen in 14 (27%). Abnormality of both peroneal and posterior tibial nerves was found in five (10%). Four patients (8%) had evidence of isolated spinal-cord dysfunction, whereas combined spinal-cord and peripheral-nerve lesions were seen in 14 (27%). Six patients (11%) had variable neurogenic electrophysiological patterns. In 13 patients in whom the studies were repeated neither progression nor improvement of the electrophysiological parameters was observed. Pathological electrophysiological findings were found in 66% of conservatively-treated patients. In the 43 patients treated surgically, all 16 with fair and poor results had pathological electrophysiological findings and 12 required further operations. Multiplicity of the pathological findings was related to the severity of the deformity of the foot; normal studies represent a good prognostic sign. Electrophysiological studies are useful in idiopathic club foot with residual deformities after conservative or operative treatment. Our findings support the theory that muscle imbalance is an
To evaluate the proportion of microbial associations causing PJI, diversity of their strains and impact on treatment failure after the removal of the hip implant and insertion of a spacer. Spectrum of pathogens in 189 cases of PJI was studied retrospectively. Strains were isolated from the joint aspirates, tissue samples and removed orthopedic devices. The cohort comprised 144 cases of PJI after primary THA and 45 cases after the hip replacement revision surgery. All patients underwent first stage of two-stage revision procedure which involves the removal of a hip implant, debridement of infected periprosthetic tissues and subsequent insertion of a bone cement spacer. There were 92 males and 97 females (median age of 57 yrs). Statistical analysis of the results was performed with GraphPad Prism 6.0 (California, USA). Microbial associations were detected in 28.6% (n=54) of PJI cases. Gram-positive bacteria prevailed in both groups with mono- and polymicrobial
The purpose of this study was to investigate the role that genetics play in the
Femoral head necrosis in the context of high impact gymnastics of young adolescents is rare but seems a more serious complication compared to a Perthes like necrosis. Between 2017 and 2019, three young females aged from12 to 14 years were referred due incapacitating hip pain and severe collapsing femoral head necrosis. The indication of hip preserving surgery was based on the extent of the necrosis, presence of a vital lateral pillar and joint subluxation. In one of our 3 cases total head involvement made THR necessary, which was performed elsewhere. In the remaining 2 cases, head reduction osteotomy plus periacetabular osteotomy led to a good and a fair result. Repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension/ external rotation could be the cause of severe femoral head necrosis in three adolescent female gymnasts we are reporting on. Supra-selective angiography or sonography may be helpful to improve indication. Targeted adaptation of training methods should be discussed. Due to the severe vascular insult, results have to be considered moderate.
Purpose: Infection after resection and total knee arthoplasty for malignant bone tumours in children is a serious complication which may compromise limb salvage. The purpose of this work was to study the
Purpose: The objective of this study was to analyze the clinical results of arthroscopic release for the treatment of shoulder stiffness and to report the results according to
1. An anatomical study of the bony structure of the pars interarticularis of the fourth and fifth lumbar vertebrae has been made in specimens from seven cadavers aged seventeen to sixty-seven. 2. Layers of cortical bone have been described antero-laterally and postero-medially which are thickest in the narrowest region of the pars. 3. In one specimen from a seventeen-year-old male, a healing fracture was found in the antero-lateral layer of cortical bone in the right neural arch of the fourth lumbar vertebra. 4. The stresses to which the pars is subject consist primarily of shear forces applied to the articular processes. The significance of these stresses to the
Purpose: Congenital idiopathic clubfoot is the most common musculoskeletal birth defect developing during the fetal period, but with no known
Object: To study the incidence,
Object: To study the incidence,
Aim. Paediatric fractures are common but those occurring in non-ambulant children are associated with higher rates of Non Accidental Injury (NAI). There is little published on the mechanisms of injury associated with accidental fracture in young children. This study explores the
We report the presence of estrogen receptor (ER) in the ligamentum capitis femoris (LCF) and hip capsule. We took 15 LCF and hip capsule biopsies from 15 patients undergoing hip surgery for the Developmental Dysplasia of the hip (DDH) and 15 hip capsules and LCF’s from intrauterine ex fetuses. The mean age of the babies was 10.3 months (6–18 months) at the time of surgery. Total 60 specimens were grouped into two as the DDH group and the control group and each of these groups were further divided into two to generate the groups for the LCF and hip capsules. Full thickness 1 x 1 cm anterior capsule and LCF portions were taken as biopsy specimens. An immunohistochemical study using monoclonal antibody against to estrogen receptors was performed to identify estrogen target cells in the hip capsule and LCF. The positive rates of ER staining in the control group were % 1.6 ± 0.2 for the LCF and % 1.3 ± 0.2 for the hip capsule, in the DDH group positive rates of ER staining were %2.5 ± 0.3 for the LCF and % 2.0 ± 0.3 for the hip capsule. The positive rates of ER staining in LCF and hip capsule of the control group were significantly lower than that in the DDH group in both groups we found ER’s to be significantly lower in the hip capsule than in LCF. The presence of estrogen receptors in the LCF and hip capsule supports the effect of estrogen in
Purpose of the study: Among the causes of secondary congenital equinovarus club foot, neurological disorders predominate. The entity we examine here corresponds to irreversible pure motor paralysis with no sensorial disorder affecting the lateral compartment predominantly and sometimes associated with involvement of the anterior compartment. There is no literature on this entity. Beyond the question of the
The
Background: To our knowledge, there are no publications that have evaluated physical activities in relation to the
The number of revision total knee arthroplasties (TKA) that are
performed is expected to increase. However, previous reports of
the causes of failure after TKA are limited in that they report
the causes at specific institutions, which are often dependent on
referral patterns. Our aim was to report the most common indications
for re-operations and revisions in a large series of posterior-stabilised
TKAs undertaken at a single institution, excluding referrals from
elsewhere, which may bias the causes of failure. A total of 5098 TKAs which were undertaken between 2000 and 2012
were included in the study. Re-operations, revisions with modular
component exchange, and revisions with non-modular component replacement
or removal were identified from the medical records. The mean follow-up
was five years (two to 12).Aims
Patients and Methods
Historically, US arthroplasty revision rates are based on CMS data that cannot verify initial surgery date in patients under 65 years or laterality of revision. We calculated US one-year revision rates for primary total hip replacement (THR) using a representative cohort. Reasons for revision were documented. A multi-center cohort from US surgeons in 28 states collected sociodemographic data; medical, emotional, musculoskeletal comorbidities; BMI; and patient-reported pain and function (SF36, HOOS) for elective THR patients. Cases in 2011–2013 were matched with CMS data to ascertain 1 year revision through 2014. Predictors of revision were identified. Chart reviews to verify reasons for revision were performed.Introduction
Methods
This study sought to determine the genetic contribution of Perthes' disease, using the world's largest twin-registry. We extracted all twin pairs from the Danish Twin Registry (DTR) in which at least one individual had Perthes' Disease. The DTR captures every twin pair born alive in Denmark. Those with Perthes' disease were identified using health record linkage to the Danish Morbidity Record. Probandwise concordance was calculated to describe the likelihood that any given individual had LCPD if their co-twin was also diagnosed. There were 81 twin pairs; 10 monozygotic (MZ), 51 dizygotic (DZ), and 20 unclassified (UZ). There was no association between birth weight and being the affected co-twin. Four pairs (two dizygotic and two unclassified) were concordant for LCPD, which is greater than would be expected assuming no familial aggregation. There were no concordant MZ twin pairs. The overall probandwise concordance was 0.09 (95% CI 0.01–0.18): 0.00 for the MZ, 0.08 (95% CI 0.00–0.18) for the DZ, and 0.18 (95% 0.00–0.40) for the UZ twin pairs. This study found evidence of familial clustering in LCPD but did not demonstrate a genetic component. The absolute risk that a co-twin of an affected individual will develop LCPD is low, even in the case of MZ twin pairs.
We report a study of 112 patients with primary anteromedial osteoarthritis of the knee and their families. Sibling risk was determined using randomly selected single siblings. Spouses were used as controls. The presence of symptomatic osteoarthritis was determined using an Oxford knee score of ≥ 29 supported by a Kellgren and Lawrence radiological score of II or greater. Using Fisher’s exact test we found that there was a significant increased risk of anteromedial osteoarthritis (OA) relative to the control group (p = 0.031). The recurrence risk of anteromedial OA to siblings was 3.21 (95% confidence interval 1.12 to 9.27). These findings imply that genetic factors may play a major role in the development of anteromedial OA of the knee.
Dual mobility significantly reduces the risk of prosthetic instability. This mechanical complication occurs when the prosthetic head moves out from the retentive polyethylene liner, such phenomenon called intra-prosthetic dislocation reports a ten-year incidence of 2% in the literature. We prospectively analysed all intra-prosthetic dislocations having occurred since 1985 in our department in order to investigate patient- and implant-related risk factors. 91 intra-prosthetic dislocations occurred with NOVAE (SERF) cups in 85 patients of mean age 50.7 years. Intra-prosthetic dislocation occurred after a mean period of 8.8 years. A PRO (SERF) stem was implanted in 56 cases and a PF (SERF) stem in 35. The stems were different from one another in their neck diameter and material: 13 mm titanium neck and 16 mm stainless steel neck respectively. When taking both prosthetic features into account, no significant difference could be established regarding the time between implantation and dislocation. Comparison between these two prosthetic features was performed by means of two continuous homogeneous series which included 240 patients implanted with PF stems and 382 patients with PRO stems. At a mean 15-year follow-up, the two series reported a non-statistically different intra-prosthetic dislocation rate of 4%. In both series, young age and large diameter cups were considered predisposing factors for intra-prosthetic dislocation. Therefore, unlike suggested by several authors, prosthetic neck material and diameter do not appear as the main predictors for intra-prosthetic dislocation which is highly promoted by patient-related features.
1. The hypothesis is advanced that the fundamental lesion of epiphysiolysis is a slow posterior growth migration of the head on the neck. 2. It is suggested that this is unrelated to the erect posture or to any abnormality of the growth cartilage. 3. Sitting stresses are measured and are postulated as the likely cause of the growth deviation. 4. The result of the deviation is an increase in the shear stress component; in the erect posture clinical epiphysiolysis is regarded as a simple fracture occurring in a proportion of deviated cases when the increased shear component exceeds the critical level appropriate to the individual. 5. It is suggested that this hypothesis explains the age and sex incidence, the left predominance, the reduced epiphysial angle found on the uninvolved hip and the clinical and radiological evolution of the disorder.
1. Six cases of quadriceps contracture in children are described. All were either premature or suffered severe illnesses soon after birth. 2. Some additional information is given about cases of the same condition previously published by other authors. 3. It is suggested that injections and infusions given to newborn babies are sometimes the cause of the condition. 4. Some of the therapeutic substances and measures which may be responsible are discussed. These include antibiotics, vitamin K preparations and "subcutaneous" fluid therapy.
1. Twenty-eight cases of the infantile and three cases of the adolescent type of tibia vara occurring in West Indian Negroes are reported. 2. The condition is characterised by failure of growth of the postero-medial part of the upper tibial epiphysis. 3. The deformity produced is acute varus at the upper tibia with medial torsion and eventually flexion of the diaphysis on the epiphysis. 4. These deformities are considered to be due to a vicious circle set up by considerable alteration of the lines of force on the medial portion of the upper tibial epiphysial line.
In controlled clinical studies of adult diabetics a 42% incidence of signs of Dupuytren's disease was found. The incidence was highest in the older patients with a longer history of diabetes, but was not related to the severity of the diabetes. The features of Dupuytren's disease in the diabetics has a distinctive pattern, being more severe in men than women and, compared with controls, having a radial shift towards the middle finger. The disease was mild and of benign prognosis, rarely needing operation. In a further study, 13% of patients with Dupuytren's disease were found to have a raised blood glucose level. The question is posed as to whether the biochemical disturbance causes the Dupuytren's disease or whether the pattern of inheritance predisposes to both Dupuytren's disease and diabetes.
The internal pressure of simple bone cysts was found to be slightly higher than the normal pressure of the bone marrow in the contralateral limb. The pressure within the cyst was measured during drilling with a Kirschner wire; it gradually decreased as the number of drill-holes increased. The PO2 of the cyst fluid was markedly lower than that of either venous or arterial blood measured synchronously. It is suggested that venous obstruction in the bone is the likely cause of these cysts. Seven patients with simple bone cysts were treated by the multiple drill-hole method, and the clinical outcome was excellent. Multiple drilling may prove to be the treatment of choice for simple bone cysts in the younger patient, as it presents fewer hazards than other procedures.
1. It is suggested that early weight-bearing on physiologically bowed legs in infants leads to slowing of growth of the tibia and consequent increase of the differential length between fibula and tibia. 2. Such differential growth can produce both varus and medial rotation, leading to established tibia vara or Blount's disease. 3. Stimulation of tibial growth by simple metaphysial forage can correct this deformity if performed at an early age.
A careful study of children with transient synovitis of the hip has failed to establish any connection with infection by staphylococci or streptococci, with allergy, with viral infection and with trauma.
Five knees with congenital dislocation were explored. The cruciate ligaments were found to be absent or hypoplastic. The results obtained by reconstructing an anterior cruciate ligament appear to be good. On the basis of dissections of foetal knees we believe that the cruciate ligaments are the main structures preventing an anterior dislocation of the knee in early foetal life; this deviation from the adult pattern is due to the bony configuration of the foetal knee. We therefore postulate that the basic defect in congenital dislocation of the knee is an absence or hypoplasia of the cruciate ligaments.
1. Eighty-five patients have been studied soon after a ligamentous injury at the foot or ankle. These patients were treated in one of three ways, and in fifty-six patients the results were evaluated six to fifteen months after injury. 2. It is concluded: 3. The mechanism of production of the proprioceptive defect is discussed.
To determine if patients with coronal plane deformity in the lumbar spine have a higher grade of lumbar spine subtype compared to controls. This was a retrospective case/control study based on a review of radiological investigations in 250 patients aged over 40 years who had standing plain film lumbar radiographs with hips present. Measurements of lumbar coronal plane angle, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence were obtained. “Cases” with degenerative scoliosis (n=125) were defined as patients with a lumbar coronal plane angle of >10°. Lumbar spine subtype was categorised (1–4) using the Roussouly classification. Lumbar spine subtype was dichotomised into low (type 1,2) or high (type 3,4). Prevalence of lumbar spine subtype in cases versus controls was compared using the Chi squared test. Pelvic incidence was compared using an unpaired T-test. Predictors of lumbar coronal plane angle were identified using stepwise multiple regression. Significance was accepted at P<0.05.Aim:
Method:
From a retrospective, cohort study of 205 patients diagnosed with full-thickness tears of the rotator cuff, we determined, using ultrasound, the prevalence of such tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full-thickness tears in siblings The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full-thickness tears of the rotator cuff.
Nonunion of the distal radius is a rare complication (0.2%) which gradually can lead to deformity, pain and dysfunction of the hand. We examined 7 patients who developed nonunion of the distal radius after surgical intervention and we try to rationalize this complication. Our material consisted of 7 patients (2 male and 5 female) average 51 years old (31–75). Two patients with distal radial malunion, developed nonunion after corrective osteotomy. Four patients with comminuted metaphyseal radial fracture and concomitant distal ulna fracture, developed nonunion after application of an external fixator alone or in combination with internal fixation. Finally one patient with isolated fracture of the distal metaphysis developed nonunion after internal fixation. All patients after the confirmation of the nonunion and until radiological union underwent 1–3 operations. The index procedures for final union were wrist arthrodesis (1 patient) radioscapholunate fusion with excision of the distal scaphoid (2 patients) and internal fixation (4 patients). Additionally, in 6 patients a supplementary method for DRUJ asymmetry was needed. Results were estimated after a mean follow-up of 30,8 months (1–4 years) based on radiological and clinical criteria. There were 1 excellent, 5 good and 1 fair result. Despite the existence of predisposing factors (comminution, associated fracture of the distal ulna, metabolic disease, osteoporosis, distraction through external fixator), the contribution of the surgeon to the development of the nonunion is undeniable.
To study the contribution of the special morphological features of lumbo-sacral spine as causes of the slipping in the spondylolisthesis, the roentgenographic measurements were performed in 47 cases of spondylolysis, 77 of spondylolisthesis and 597 of several low back pain as a control. The transitional lumbo-sacral spine was more frequently seen in the spondylolisthesis group, but there was no d ifference between the spondylolysis and control. The angle between the superior surface and the posterior border of the sacral vertebral body (posterior superior sacral angle) was apparently low in the spondylolisthesis, whereas no difference was noted between another groups. In conclusion, special morphological features such as low prices of the posterior superior sacral angle is considered one of the risk factors for the cause of slipping.
We report nine cases of irreducible congenital dislocation of the knee which were treated by early operation with good results. All were resistant to conservative measures and operation was performed at an average age of nine months. The essential abnormality was a short quadriceps muscle together with subluxation of the hamstring muscles to lie anterior to the axis of knee flexion. The quadriceps tendon was lengthened by VY-plasty and in six cases additional length was gained by proximal mobilisation of the muscle. After operation all the patients were able to walk.
This is a prospective study of 105 knees in 91 patients with idiopathic osteonecrosis of the femoral condyles, with an average follow-up of five years in 101 knees. Forty-eight of the 75 patients in whom the body weight was studied were obese and four of the 33 patients in whom a densitometry study was done showed decreased bone density. Prognosis is unfavourable if the lesion is larger than five square centimetres and if its width is more than 40 per cent of that of the condyle. Of the 22 patients followed up after conservative treatment 80 per cent were satisfactory. Of the 11 knees treated by arthrotomy alone 55 per cent were satisfactory. Of the 31 knees treated by osteotomy (21 with associated arthrotomy) 87 per cent were satisfactory. Arthrotomy did not significantly improve the results of osteotomies. The ideal correction was to 10 degrees of valgus. Of the 37 knees treated with replacement 95 per cent were satisfactory, and the best results were obtained with the total-condylar prosthesis.
A review was conducted of the records of fifty-five children who were admitted to the Hospital for Sick Children in Toronto between 1955 and 1975 with a diagnosis of Volkmann's contracture in fifty-eight limbs. Ten patients had been transferred to this hospital with established ischaemia after Bryant's traction for a fractured femur; all had a very poor outcome. Thirteen other cases of Volkmann's contracture affecting the superficial posterior compartment had been treated with a fixed Thomas' splint and a Bradford frame after fractures of the femoral shaft. Supracondylar fractures of the elbow resulting in Volkmann's contracture frequently had both an arterial injury and a compartment syndrome. Most of the fifty-five children reviewed here had not had early appropriate treatment. For the past twenty-one years the frequency of Volkmann's contracture has not declined in spite of many published reports on the compartment syndrome, and the hazards of supracondylar fractures and of Bryant's traction.
One hundred normal fingers were dissected and arthrographs obtained by injection of a chromopaquegelatin mixture, allowing comparison between the radiographic and macroscopic configuration of the synovial capsule. Synovial recesses protruding from each side of every metacarpo-phalangeal joint were found in relation to the collateral ligaments and corresponding exactly with the site of radiological erosions. A group of bursae lying on the superficial aspect of collateral ligaments were also demonstrated. A rudimentary infra-articular meniscus was found. The results of examination of the insertions of the interossei showed differences from traditional descriptions. The cause of rheumatoid deformity was suggested to be the rheumatoid process arising in the lateral recesses and lateral bursae, weakening the collateral ligaments, which give way in the directions of the deforming forces. These are derived from the long flexor tendons, which were shown to exert an ulnar and volar strain on the metacarpo-phalangeal joint of every finger during grip.
The cause of pseudarthrosis of the clavicle is obscure. Right-sidedness is an almost constant feature. We have proposed that the lesion is sometimes due to pressure upon the developing clavicle by the subclavian artery which is normally at a higher level on the right side. This may be accentuated in the presence of cervical ribs or unduly elevated first ribs, both of which we have observed in association with pseudarthrosis. We have also noted pseudarthrosis on the left side in association with dextrocardia (when the relative positions of the subclavian arteries are reversed) and in the presence of a large left cervical rib. We have speculated upon the nature of the clavicular defect in cranio-cleido dysostosis, in which disorder the first ribs are habitually elevated. A similar mechanism may be involved.
Data was collected on 139 eligible patients a minimum of 18 months post surgery who had had 2 or more ligaments reconstructed. 63 patients were available for clinical follow up. It is the largest single surgeon series studied. 27% of injuries were high energy traffic accidents. 73% were low energy, mainly sports related. 63% of patients were delayed referrals to our unit. Of these nearly 48% had already undergone knee surgery, often more than 6 months post injury. 17% of all cases presented with failed ligament reconstructions. Of those patients followed up 19% were operated upon within 3 weeks of injury, 56% were delayed reconstructions with a mean time to surgery of 21 months and 25% were revision reconstructions. Time to follow up ranged from 18 months to 10 years. The median KOS ADL, KOS Sports Activity and Lysholm scores for uni-cruciate surgery were all better than those for bi-cruciate surgery. All results were better for acute rather than chronic cases, which in turn were better than those for revision cases. The Tegner score showed that only acute uni-cruciate reconstructions returned to their pre-injury level. TELOS stress radiographs demonstrated a mean post drawer of 5.9 mm side-to-side difference after reconstructions involving the PCL. IKDC grades showed 6% of knees were normal and 57% were nearly normal. 37% required further surgery, mainly to increase movement or for hardware removal. There was 1 deep infection and 2 cases of thrombosis. There were no vascular complications but 2 had transient nerve injuries. Multi-ligament surgery can produce good functional outcomes but the knee is never normal. There is an increased risk of PCL laxity post op. Early referral to a specialist unit is suggested as delayed referral to a specialist unit potentially subjects the patient to unnecessary surgery and may affect outcome.
Since 1991 to 2008 approximately 800,000 Exeter stems have been sold worldwide with 80 reported cases of fracture (neck or stem). This study aimed to determine factors predisposing to fracture. Clinical, surgical, radiological and retrieval data was collated from Stryker Benoist-Girard and Exeter research databases. Risk factors associated with fracture were categorised to patient related (weight and activity levels), surgical related (poor medial support, component size, placement) and implant related (+ head).Background
Method
Postural and motor activities are the results of interactions of smaller inhibitory and larger facilitating structures of the central nervous system (CNS). In the case of dysbalance of inhibitory and facilitating structures during CNS evolution, the asymmetry of postural activities can appear. This asymmetry remains hidden in the early periods of evolution and becomes apparent in the periods of quick growth and increased hormonal and metabolic activities. Genetic and neural factors have proven to be significant in the cause of idiopathic scoliosis (IS), so we propose a neural developmental hypothesis of this disease. We evaluated a cohort of 19 patients, all of whom were girls with a mean age of 14·7 years (range 13–18) with right idiopathic thoracic curve (mean Cobb angle 53·5°, range 37–72°; of the apical vertebra from T7 to T9). Heart and pulmonary functions were evaluated by heart ECHO and spiroergometry.Introduction
Methods
Metal-on-metal (MOM) hip resurfacings release chromium and cobalt wear debris into the surrounding joint. The hip tissue taken from failed MOM hips shows specific histological features including a subsurface band-like infiltrate of macrophages with particulate inclusions, perivascular lymphocytic infiltrate and fibrin exudation. This tissue response has been called Aseptic Lymphocytic Vasculitis Associated Lesion (ALVAL). There is a recognised carcinogenic potential associated with hexavalent chromium and epidemiological data from first generation MOM arthroplasties may suggest an increased incidence of haematological malignancy. The ALVAL type reaction includes a marked proliferation of lymphocytes in the perivascular space and thorough investigation of this lymphocytic response is warranted. This study aims to further characterise the lymphocytic infiltrate using immunohistochemistry and to test clonality using polymerase chain reaction (PCR). Tissues from revised all cause failed MOM hip arthroplasties (n=77) were collected and analysed initially using routine H&E staining. Those that met the diagnostic criteria of ALVAL described above (n=34) were further stained with a panel of immunohistochemical markers (CD3, CD4, CD8 (T-cell markers) and CD20 (B-cell marker)). 10 representative ALVAL cases were selected and sent for gene rearrangement studies using PCR to determine whether the lymphocytes were polyclonal or monoclonal in nature. The analysis of the lymphocytic aggregates in ALVAL, showed a mixed population of B and T cells. Within the aggregates, there was a predominance of B cells (CD20) over T cells (CD3). Of the 10 cases which were analysed by PCR, 7 were suitable for interpretation. None of these cases showed evidence of monoclonal lymphocyte proliferation. The carcinogenic potential of wear debris from MOM hips, particularly affecting the haematopoietic system should be investigated. This study has shown a predominantly B-lymphocyte response in tissues surrounding MOM hips which is polyclonal. Although the numbers are small, the study suggests an immune mediated response in MOM hip tissue and excludes a neoplastic proliferation. However, long term follow up of patients with MOM hips may be prudent.
The fine structure of palmar fascia from patients with Dupuytren's contracture (DC) was compared with that from patients with carpal tunnel syndrome (CTS). In contrast to previous assumptions, the ultrastructure of fibroblasts both in vivo and in vitro from DC and CTS appeared identical, indicating that myofibroblasts are not specific to DC. The major differences between DC and CTS were: 1) a sixfold and fortyfold increase in fibroblast density in cord and nodular areas of DC compared with CTS; 2) a more disorganised pattern of collagen fibrils in DC; and 3) markedly narrowed microvessels surrounded by thickened, laminated basal laminae and proliferating fibroblasts in DC compared with CTS. To account for these morphological changes a hypothesis is presented which proposes that oxygen-free radicals cause pericytic necrosis and fibroblastic proliferation. This hypothesis provides a potential avenue for therapy of DC and other fibrotic conditions.
In a family study in which thirty-four patients with osteochondritis dissecans and eighty-six of their first-degree relatives were examined clinically and radiologically, only one relative was found to have osteochondritis dissecans. No association with other forms of osteochondritis, endocrinological abnormalities or dwarfism was found.
Neck injury of the whiplash type may lead to the cranial symptoms of the Barre-Lieou syndrome. Forty patients with this syndrome and 40 without it were investigated by a variety of imaging techniques. There was a clear correlation between root sleeve defects at C3/4 shown by special oblique myelographic views and cranial symptoms. Good results were obtained by anterior cervical discectomy and fusion at C3/4 in 21 cases. It is suggested that the syndrome may result from irritation of the sympathetic nervous supply at this level.
The results of operation for traumatic anterior dislocation of the head of the radius in eight children have been reviewed. We are satisfied on the basis of the results obtained and the outcome in one untreated patient that operative reduction is fully justified, provided that the annular ligament is reconstructed and internal fixation employed. We have not seen unilateral congenital dislocation and doubt its existence. Secondary subluxation of the distal radio-ulnar joint has been noted in an untreated patient.
1. That viruses may be involved in the causation of human tumours has long been suspected but not yet proved. The discovery that osteogenic sarcoma can be induced by viral agents in mice and hamsters makes the proposition that human sarcomas may also have a viral origin basically tenable on presently available evidence. In order to distinguish between passengers and causative agents it will probably be necessary to demonstrate antigenic cross-reactivity in tumours of similar type collected from different geographical areas, and the oncogenicity in subhuman primates of extracts containing virus from human tumours. Such information is likely to become available in the next few years. 2. The demonstration of tumour-specific immune reactions in an increasing number of patients with various forms of neoplasm, including skeletal sarcomas, and the correlation of these reactions with the clinical status of the disease sustains the hope that eventually immunotherapy may contribute to the control of cancer in man. 3. Animal experiments have revealed that the potentiation of immune responses may lead to the elimination of small foci of neoplastic cells. The role of immunotherapy in the treatment of cancer may therefore be as an adjunct to surgery, radiotherapy and chemotherapy (Alexander 1968). Once the primary tumour has been removed it may be possible to employ immunotherapeutic measures to destroy the relatively few remaining cells that give rise to late metastases; this is particularly apposite to juvenile osteosarcoma.
Of 44 patients (55 hips) with slipped upper femoral epiphysis treated from 1963 to 1989, 13 (14 hips) developed chondrolysis. Eight hips had chondrolysis at the time of presentation, all in female patients who were either coloured or black and who had moderate or severe slips. The other six hips had persistent pin penetration of the joint; in five of these the pin penetrated the anterosuperior quadrant of the head. Removal of penetrating pins resulted in improvement in pain in all six hips and in the range of movement in four. Chondrolysis did not develop in any of 11 hips with transient intraoperative pin penetration. In hips with chondrolysis maximum joint-space narrowing developed within the first year; improvement in joint space and range of movement continued for up to three years after maximal involvement. At an average follow-up of 13.3 years no patient had pain but five hips were stiff.
It has been suggested that occult infection of joint prostheses contributes to a proportion of aseptic loosening. The aims of the study were to determine the incidence of occult infection in a sample of patients undergoing revision surgery for aseptic loosening and examine the role of ultrasound sonication in its detection. A prospective trial was conducted at Christchurch and Burwood Hospitals. At the time of revision surgery, intra-operative tissue and fluid samples were taken. The removed prosthesis was immersed in saline solution in a sterile plastic container, and then sonicated. The sonicate fluid underwent prolonged routine cultures (14 days) to increase the rate of detection of slow growing organisms. The cases were patients undergoing revision surgery for aseptic loosening or infection. The control group was comprised of patients having revision surgery for any other indication. These implants were subjected to the same protocol as the study group. A total of 122 patients were included in the study; 54 in the Aseptic Loosening [AL] group, 15 Infections and 53 controls. There were significantly more smokers in the AL group and less smokers in the control group (p=0.04 and p=0.04 respectively). The mean age for revision in the Infection and Periprosthetic fracture groups was less than those of other groups (p=0.007 and p=0.02) respectively. There were 18 cases with positive intra-operative cultures. Eight of those were in the aseptic group (i.e. 14.8% of the group). Conventional sampling techniques were positive in 17 of 18 cultures (94%). Sonication was only positive in 10 out of the 18 cultures (56%). Sonication was concordant with the conventional sampling techniques in half of the positive cultures in the AL group and overall. The only bacteria to be isolated from sonicate cultures were Staphylococcus Aureus and Coagulase Negative Staphylococci. Diabetes Mellitus was the only risk factor to have a significant association with having a positive culture result (p=0.03). There was also a significant association with having raised pre-operative Neutrophil differential count or inflammatory markers with having a positive culture (p=0.0001). However this association was not present when the AL group was examined separately. There was a significant rate of positive culture results in the aseptic loosening group of around 15%. Ultrasound sonication was less sensitive than current sampling techniques with no apparent added benefit. This paper does not support the hypothesis that occult infection is a significant driver of aseptic loosening.
Anterior knee pain has been relieved by resection of the infrapatellar plica (IPP). The question is: How? The hypothesis is: the IPP acts as an intra-articular ligament, a mechanical link between the forces of knee motion, the fat pad (FP) and the distal femur, holding the FP captive through the arc of motion. Release of the IPP severs this link, allowing the highly innervated FP to move freely. This may allow any underlying pathologic process to heal. Anatomic dissection: In 12 knees, the extensor apparatus was released from the femur and retracted distally allowing relationships to be examined. Cadaver studies: Lateral fluoroscopy was used as well as direct arthroscopic visualization to control implantation of tantalum beads or radiographic contrast material in the FP and IPP. The knee was taken through the arc of motion repeatedly. The femoral attachment of the IPP was then released and knee motion repeated. Traction on the extensor apparatus simulated active motion. In-Vivo Study: The IRB approved study of 12 volunteers undergoing planned knee arthroscopy under local anesthesia. Contrast was placed in the FP and IPP under lateral fluoroscopic control. Passive, then active motion then a quads-set manoeuvre was performed. The IPP was resected and knee motion again recorded.Purpose
Method