The treatment of children with contractures involving the lower limbs is challenging. Many are confined to wheelchairs for several years till their potential to ambulate is discovered. The aim is to review the treatment and outcome of eight children treated for contractures and deformities of the lower limbs following confinement to wheelchairs. Eight children aged 4–14 years were treated for contractures of the hips, knees and feet between 2005 and 2011. The initial diagnosis was not made in 5 children. All children had never walked previously. Four patients were labelled “cerebral palsy”. All children were seen with a physiotherapist to assess their walking potential. Genetic and paediatric medical assessment was also made. Final diagnosis revealed arthrogryposis (n = 3) pterygium syndrome (n = 1) calcinosis cutis (n = 1) viral neuropathy (n = 1) and cerebral palsy (n = 2) Clinically all children were assessed to have good upper limb function for use of crutches. Surgical correction of the feet was required in 6 patients. Extension osteotomies of the knees were done in 8 patients following serial plaster cast treatment and hamstring release. Hip releases were done in 4 patients.Purpose
Methods
Chronic plantar fasciitis is a common condition but can be difficult to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam
The management of acute tendo-Achilles (TA) rupture still divides orthopaedic opinion. The advent of minimally invasive endoscopic or percutaneous techniques is thought to allow faster rehabilitation. We report the outcome of 30 patients with acute TA ruptures that have undergone percutaneous repair followed by an accelerated rehabilitation programme with early weight-bearing. A single centre, prospective cohort study was undertaken. 30 patients (21 men, 9 women; mean age: (40±9 years) with an acute TA rupture were enrolled and followed-up for an average of 12.5±2.9 months. All operations were performed under local anaesthesia, using a modified percutaneous technique, within 2 weeks of injury. Following surgery, patients were immobilised in an equinus cast for only 2 weeks then allowed to weight bear through a
Introduction. The current standard of care for postoperative support during ambulation is a
Background. Kohnodai Hospital merged with the National Center of Neurology and Psychiatry in Japan in 1987. Accordingly, we treat more patients with mental disorders than other hospitals. I treated two patients with schizophrenia for TKA. Case 1. A 44 year-old female with schizophrenia and malignant rheumatoid arthritis presented with bilateral knee pain and difficulty walking. Her range of motion (ROM) was: right knee; extension −95°, flexion 120°, left knee; extension −95°, flexion 120°. Her Knee Society Bilateral Score was 19 points, X-ray grade: Larsen 5, Steinbrocker grade: Stage 3, class 4. Pre-TKA, corrective casts improved her ROM (extension; right −75°, left −70°). She received right TKA in September, 2013, and left TKA in December 2015. Post-operation bilateral ROM: extension −15° and flexion 120°. After operation, she wore corrective casts. Post TKA, she received manipulation for bilateral knee contractions in 2015, and she began in-patient rehabilitation. Her progress was normal, and became able to stand easily with a
Total hip arthroplasty (THA) has been cited as one of the most successful surgical procedures performed today. However, as hip surgeons, we desire constantly improving outcomes for THA patients with more favorable complication rates. At the same time, patients desire hip pain relief and return to function with as little interruption of life as possible. The expectation of patients has changed; they have more physical demands for strength and flexibility, and aspire to achieve more in their recreational pursuits. Additionally, health care system constraints require the THA episode of care to become more efficient as the number of procedures increases with time. These factors, over the past fifteen years, have led to a search for improved surgical approaches and peri-operative pain and rehabilitation protocols for primary THA. The orthopaedic community has seen improved pain control, length of stay, and reduction in complications with changes in practice and protocols. However, the choice of surgical approach has provided significant controversy in the orthopaedic literature. In the 2000s, the mini-posterior approach (MPA) was demonstrated as the superior tissue sparing approach. More recently, there has been a suggestion that the direct anterior approach (DAA) leads to less muscle damage, and improved functional outcomes. A recent prospective randomised trial has shown a number of early deficits of the posterior approach when compared to the direct anterior approach. The posterior approach resulted in patients taking an additional 5 days to discontinue a
Aim. To evaluate the efficacy of infection elimination and functional outcomes of the resection hip arthroplasty (RHA) with m. vastus lateralis flap plasty in patients with chronic recurrent periprosthetic joint infection (PJI) one year or later after the surgery. Method. We retrospectively studied the outcomes of 61 cases with recurrent PJI (more than 3 relapses). All patients underwent RHA with m. vastus lateralis flap plasty from the year 2005 to 2016. There were 35 males (63.6%) and 20 females (36.4%) with the mean age of 54 years. At least in one year after the surgery, the cases were analyzed for the absence of inflammation during the physical exam, functional result with the Harris hip score (HSS), quality of life with the Instrument for measurement of health-related quality of life scale and level of pain with the visual analogue scale (VAS). The results are presented as means with CI95%. Results. The mean follow-up period was 40.8 months. The overall mortality rate was 12.2% (n = 6). Of all patients, 3 (5.5%) had severe concomitant pathology and died due to systemic infection within 90 days after the surgery. Two more patients died during the period of 1–3 years. Prolonged remission of PJI was achieved in 91% (n = 50) patients. In 9% of cases (n = 5) the relapse of infection was achieved. The HHS corresponded to an unsatisfactory outcome with the mean value of 49.3 (45.4–53.3). Most of the patients (56%, n = 31) used 2 crutches while walking, 23% (n = 13) - a cane or a crutch, and 11% (n = 6) – a
Aim. Infection after vertebroplasty (VP) is a rare but serious complication. Previous literatures showed most pathogens for infection after VP were bacteria; tuberculosis (TB) induced infection after VP was extremely rare. In this study, we reported our treatment experiences of 18 cases with infectious spondylitis after VP, and compared the differences between developed pyogenic and TB spondylitis. Method. From January 2001 to December 2015, 5749 patients underwent VP at our department were reviewed retrospectively. The causative organisms were obtained from tissue culture of revision surgery. Parameters including type of surgery, the interval between VP and revision surgery, neurologic status, and visual analog scale of back pain were recorded. Laboratory data at the time of VP and revision surgery were collected. Risk factors including the Charlson comorbidity index (CCI), preoperative bacteremia, urinary tract infection (UTI), pulmonary TB history were also analyzed. Results. 18 patients developed infectious spondylitis after VP (0.32%, 18/5749). Two were male and 16 were female. The median age at the time of VP was 73.4 years. The mean CCI score was 1.7. The causative organisms were TB in nine patients (Fig. 1), and bacteria in nine patients (Fig. 2). The interval between VP and revision surgery ranged from 7 to 1140 days (mean 123.2 days). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in most patients especially at readmission. The most common type of revision surgery was anterior combined posterior surgery. Seven patients developed neurologic deficit before revision surgery. Three patients died within 6 months after revision surgery, with a mortality of 16.7%. Finally, VAS of back pain was improved from 7.4 to 3.1. 7 patients could walk normally, 5 patients needed
Background. Infected total knee arthroplasties present in a variety of different clinical settings. With severe local compromise and draining sinus tract around the knee, after adequate debridement, the resultant patellectomy with need for free muscle transfer and split thickness skin graft for closure, usually results in loss of quadriceps function. This necessitates the need for drop lock brace. No good mechanisms are available for reconstruction of large anterior defects in total infected total knees where this occurs. Questions. Can proximal placement of the knee joint with longer tibial segments aid in closure in patients with large anterior skin defects, and can this placement aid in quadriceps reconstruction to alleviate the need for drop lock braces while ambulating?. Methodology. 10 patients with 2 year follow-up with stage III-C-3 McPherson infected total knees presented with large soft tissue defects over the anterior aspect of the knee with sinus tract and scarring from multiple surgeries. The patients underwent a one stage treatment of the infected total joint. 4 required a free muscle flap and split thickness skin graft. Patellectomy with some quadriceps resection was required in the debridement process. Distal femur and proximal tibial replacements were performed with proximal placement of the knee joint. The patients were analyzed for extension control in gait and soft tissue closure over the operational knee joint. The quadraceps mechanism was over attached to the proximal tibial component. Results. Of 10 with 2 year follow up, none recurred with infection. There was no erosion of the soft tissue over the knee joint commonly seen in free flaps directly over the joint in these type of resection –replacements. 50% of the patients had enough extensor use to walk with a cane or
Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic. Seven patients with infected nonunion of the diaphysis of femur (2) and tibia (2) were treated, aged 20–63 years, followed for 2–9 years (average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4) or Staph. epidermidis (1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3 to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed) loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin (7 cases) and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction. Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing, the 63 year old patients was noncooperative and not willing to walk in
Introduction. Reverse Total Shoulder Arthroplasty (rTSA) is currently advised against in patient populations with movement disorders, due to potential premature failure of the implants from the use of walking assistive devices. The objective of this study is to measure the amount of displacement induced by the simulated loading of axillary crutches on a rTSA assembly in a laboratory mimicking immediate postoperative conditions. Methods. 8 reverse shoulder baseplate/glenosphere assemblies (Equinoxe, Exactech, Inc) were fixated to 15 lb/ft3 density rigid polyurethane bone substitute blocks. Displacement of the assemblies in the A/P and S/I axes was measured using digital displacement indicators by applying a physiologically relevant 357N shear load parallel to the face of the glenosphere, and a nominal 50N compressive axial load perpendicular to the glenosphere. Westerhoff et al. reported in vivo shoulder loads while ambulating with axillary crutches had a maximum resultant force of 170% times the patient's bodyweight with the arm at 45.25° of abduction1. This was recreated by applying a 1435.4N compressive load (Average bodyweight of 86.1kg*170%) to a humeral liner and reverse shoulder assembly in an Instron testing apparatus at 45.25° of abduction as shown in Figure 1. The glenosphere was rotated about the humeral component through the arc of the axillary crutch swing, from −5° of extension to 30° of flexion as shown in Figure 2 for 183,876 cycles2. The number of cycles was based on number of steps taken in a day from pedometer data reported by Tudor Locke et al. for patients with movement disorders, extrapolated out to a 6 week postoperative recovery period3. A Student's one-tailed, paired t-test was used to identify whether or not significant displacement occurred, where p<0.05 denoted a significant difference. Results. Displacement in the A/P and S/I axes before and after cyclic loading are presented in Table 1. The S/I direction showed no significant difference in displacement (p≤.0801), whereas the A/P direction showed significant increase in displacement (p≤.0340). The average increase in displacement in the A/P and S/I directions was 43.5 and 35.8 microns, respectively. Discussion and Conclusions. This study was designed to represent a worst case scenario, as a patient is unlikely to bear full bodyweight on crutches immediately postoperatively, and is also unlikely to take as many steps as a healthy individual until full recovery occurs. For these reasons, early results indicate statistically significant displacement could occur if a patient bears full bodyweight on axillary crutches immediately postoperatively. This risk could be lowered after the postoperative recovery period in combination with non-full weight bearing devices such as a cane or a
The Stanford Upper Extremity Model (SUEM) (Holzbauer, Murray, Delp 2005, Ann Biomed Eng) includes the major muscles of the upper limb and has recently been described in scientific literature for various biomechanical purposes including modeling the muscle behavior after shoulder arthroplasty (Hoenecke, Flores-Hernandez, D'Lima 2014, J Shoulder Elbow Surg;
Introduction. Femoral neck fracture is a common injury in elderly patients. To restore the activity with an acceptable morbidity and to decrease of mortality, surgical procedures are thought to be superior to conservative treatments. Osteosynthesis with internal fixation for nondisplaced type, and hemiarthroplasty or total hip replacement (hip arthroplasties) for displaced type are commonly performed. Cemented arthroplasty has been preferred over non-cemented arthroplasty because of less postoperative pain, better mobility and excellent initial fixation of the implant, especially for osteoporotic and stove-pipe bones. However, pressurizing bone cement may cause cardiorespiratory and vascular complications, and occasionally death, which has been termed as “bone cement implantation syndrome”. To avoid the occurrence of this syndrome, non-cemented implants have been developed. However, most implants with the press fit concepts and flat wedge taper designs have a risk of intraoperative and early postoperative periprosthetic fracture. Recently, we have employed a non-cemented femoral component, which has a lateral expansion to the proximal body as compared to a conventional hip stem. Because of this shape, which is called a “lateral flare”, this stem provides a physiological loading on both the medial and lateral endosteal surfaces of the femur. This is in contrast to conventional hip stem which prioritizes loading on the medial and metaphyseal /dyaphyseal surfaces of the femur. Moreover, the cross section of this stem is trapezoid with the flat posterior surface. This shape provides the stem with rotational stability along the long axis of the femur, and maximizes loading transfer to the posterior aspect of the proximal femur. These mechanical features avoid the need for aggressive impaction of the stem at the time of insertion. It is necessary to only tap gently to achieve the secure initial implant fixation by a “rest fit”. Thus, this technique reduces the risk of fracture. Patients and methods. We employed this technique using a non-cemented lateral flare design device for displaced femoral neck fractures since 1996. Surgical procedures were performed with posterior approach under the spinal or epidural anesthesia. Full weight bearing ambulation with a
Introduction. Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided. Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties. Patients and methods. All patients prior to the surgeries are evaluated laboratory and duplex venous ultrasonography examinations to exclude thrombophilic or hemophilic conditions, and existence of DVT. Then, the thrombophilic, and also prolonged immobility, obesity, malignant tumors, cardiovascular dysfunction and DVT patients are regarded as high risk for VTE. These are offered a prophylaxis consisting of a removable inferior vena cava (IVC) filter, together with anticoagulant medication. Usually, the filter is removed three months after the surgery. In other patients, the arthroplasties are carried out under the spinal or epidural anesthesia with IPC on both feet. IPC is also applied, except for the periods of ambulation, usually two to three days of hospitalization after surgery. Full weight bearing ambulation with a
Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with
Hip osteoarthritis is prevalent in 8%–28% of patients with Down's Syndrome. Presence of disabling hip pain is increased along with prolonged life expectancy, suggesting total hip arthroplasty (THA). Seven consecutive patients (9 hips) with Down's syndrome had primary THA. Coxarthrosis was secondary to developmental hip dysplasia in 6 patients and slipped capital epiphysis in 1 patient. In 5 patients (7 hips) a previous hip surgery was performed. Average clinical and radiological follow up was 9.9 ± 6.4 years (range 2–22.5, median 9.3). Average age of patients at THA was 34.8 ± 7.5 years (range 25–47, median 35.4). In 2 patients (3 hips) a trochanteric slide was used for the surgical approach, while a lateral transgluteal approach was used in the remaining patients. One way ANOVA test was used to compare Harris Hip Scores (HHS) at post-operative follow-up. HHS improved significantly (p=0.008) improved from 4.1 ± 15.1 (range 18.5–65, median 45) to 84.3 ± 7.7 (range 70–93, median 85.8 at 4 year follow up. HHS (average 70.9 ± 6.2, range 66.5–80, median 68) remained essentially unchanged (p=0.43) at 8 year follow-up. Two patients required revision arthroplasty for stem loosening at 6 and 16 years post THA, respectively. The first patient is 7 years post revision and ambulates without aids. The second patient is 6.1 years post revision and ambulates with a
In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years. The improvement of general mobility was marginal, but those who were community
Introduction:. The direct anterior approach for total hip arthroplasty has shown to improve multiple early outcome measures. However, criticisms suggest improved results may be due to selection bias and protocol changes. This study compares mini-incision posterior approach to direct anterior approach performed by one surgeon, controlling for influences other than the surgical approach itself. Methods:. An IRB approved retrospective review was conducted on 150 consecutive primary total hip arthroplasty patients; the first 50 from mini-incision posterior approach, followed by 50 during the learning curve for direct anterior approach, and 50 subsequent cases when the approach was routine. Peri-operative protocols were alike for all groups. Data collection included patient demographics, anesthesia, operative times, discharge disposition, length of stay, VAS pain scores, progression from assistive devices, and narcotic use at follow-up of two and six weeks. Statistical methods included Wilcoxon rank sum, ANOVA, Kruskal-Wallis, chi-square, fisher exact and t-tests. P-value of <.05 was considered significant. Results:. The groups were well-matched for demographics. The anterior group trended towards higher age, BMI, ASA and pre-op VAS scores. Factors favoring the anterior group reaching statistical significance included: decreased length of stay of 1.02 (learning curve) and 1.26 (routine) days (p < .0001); discharge to home instead of a rehab facility, 80% and 84% anterior versus 56% posterior (p = 0.0028); VAS pain scores at two weeks 2.7 and 2.2 anterior versus 5.2 posterior (p < .0001); less narcotic pain medication use at two weeks, 44% and 30% versus 86% (p < .0001). In the anterior groups,
Background. The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the Pediatric Orthopedic Surgeon. Patient demographics, the Harrold &
Literature suggests in senile IT fracture group with osteoporosis and comminution, the rates of complications are very high. Documented figures show 16% deaths in non-operative treatment and 16% (late) non-union IT fractures in non operative treatment. The post fixation re-operation rate is 23% after two to three years. High rate implant cutout, penetration and plate cutout leads to increased morbidity and mortality again. The aim of this study is to find out the results of primary prosthetic replacement in comminuted, osteoporotic intertrochanteric fractures in elderly patients. Eight patients of the age group from 68 to 94 years (average 78.4) with four part fractures were operated primarily with bipolar hemiarthroplasty. They were operated by posterolateral approach and the hip joint was exposed through the fracture site itself. After pan release the proximal fragment was delivered and a modular locally manufactured cemented bipolar hemiarthroplasty was performed. Due care was taken to restore offset, limb length and soft tissue balancing. The patients were mobile early after two days with
