The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.
Fracture of a ceramic component in total hip
replacement is a rare but potentially catastrophic complication.
The incidence is likely to increase as the use of ceramics becomes
more widespread. We describe such a case, which illustrates how
inadequate initial management will lead to further morbidity and
require additional surgery. We present the case as a warning that
fracture of a ceramic component should be revised to another ceramic-on-ceramic
articulation in order to minimise the risk of further catastrophic
wear.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
The treatment of substantial proximal femoral
bone loss in young patients with developmental dysplasia of the
hip (DDH) is challenging. We retrospectively analysed the outcome
of 28 patients (30 hips) with DDH who underwent revision total hip
replacement (THR) in the presence of a deficient proximal femur,
which was reconstructed with an allograft prosthetic composite.
The mean follow-up was 15 years (8.5 to 25.5). The mean number of
previous THRs was three (1 to 8). The mean age at primary THR and
at the index reconstruction was 41 years (18 to 61) and 58.1 years
(32 to 72), respectively. The indication for revision included mechanical
loosening in 24 hips, infection in three and peri-prosthetic fracture
in three. Six patients required removal and replacement of the allograft
prosthetic composite, five for mechanical loosening and one for
infection. The survivorship at ten, 15 and 20 years was 93% (95%
confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and
75.5% (95% CI 60 to 95), respectively, with 25, eight, and four
patients at risk, respectively. Additionally, two junctional nonunions
between the allograft and host femur required bone grafting and
plating. An allograft prosthetic composite affords a good long-term outcome
in the management of proximal femoral bone loss in revision THR
in patients with DDH, while preserving distal host bone.
Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation. After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups. Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.
We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions. The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee.
Fractures of the odontoid in children with an open basilar synchondrosis differ from those which occur in older children and adults. We have reviewed the morphology of these fractures and present a classification system for them. There were four distinct patterns of fracture (types IA to IC and type II) which were distinguished by the site of the fracture, the degree of displacement and the presence or absence of atlantoaxial dislocation. Children with a closed synchondrosis were classified using the system devised by Anderson and D’Alonzo. Those with an open synchondrosis had a comparatively lower incidence of traumatic brain injury, a higher rate of missed diagnosis and a shorter mean stay in hospital. Certain subtypes (type IA and type II) are likely to be missed on plain radiographs and therefore more advanced imaging is recommended. We suggest staged treatment with initial stabilisation in a Halo body jacket and early fusion for those with unstable injuries, severe displacement or neurological involvement.
There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.
The ideal form of fixation for displaced, extra-articular
fractures of the distal tibia remains controversial. In the UK, open
reduction and internal fixation with locking-plates and intramedullary
nailing are the two most common forms of treatment. Both techniques
provide reliable fixation but both are associated with specific
complications. There is little information regarding the functional
recovery following either procedure. We performed a randomised pilot trial to determine the functional
outcome of 24 adult patients treated with either a locking-plate
(n = 12) or an intramedullary nailing (n = 12). At six months, there
was an adjusted difference of 13 points in the Disability Rating
Index in favour of the intramedullary nail. However, this was not
statistically significant in this pilot trial (p = 0.498). A total
of seven patients required further surgery in the locking-plate
group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional
differences in patients treated with nail
The aim of this study was to determine the accuracy
of registration and the precision of the resection volume in navigated
hip arthroscopy for cam-type femoroacetabular impingement, using
imageless and image-based registration. A virtual cam lesion was
defined in 12 paired cadaver hips and randomly assigned to either
imageless or image-based (three-dimensional (3D) fluoroscopy) navigated
arthroscopic head–neck osteochondroplasty. The accuracy of patient–image
registration for both protocols was evaluated and post-operative
imaging was performed to evaluate the accuracy of the surgical resection.
We found that the estimated accuracy of imageless registration in the
arthroscopic setting was poor, with a mean error of 5.6 mm (standard
deviation ( In conclusion, given the limited femoral surface that can be
reached and digitised during arthroscopy of the hip, imageless registration
is inaccurate and does not allow for reliable surgical navigation.
However, image-based registration does acceptably allow for guided
femoral osteochondroplasty in the arthroscopic management of femoroacetabular
impingement.
It is accepted that resurfacing hip replacement
preserves the bone mineral density (BMD) of the femur better than total
hip replacement (THR). However, no studies have investigated any
possible difference on the acetabular side. Between April 2007 and March 2009, 39 patients were randomised
into two groups to receive either a resurfacing or a THR and were
followed for two years. One patient’s resurfacing subsequently failed,
leaving 19 patients in each group. Resurfaced replacements maintained proximal femoral BMD and,
compared with THR, had an increased bone mineral density in Gruen
zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95%
confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6%
(95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD
of the medial femoral neck and increased that in the lateral zones
between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6). On the acetabular side, BMD was similar in every zone at each
point in time. The mean BMD of all acetabular regions in the resurfaced
group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total
hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863).
A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8
to 9.0) of BMD was found above the acetabular component in W1 and
10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial
to the implant in W2 for resurfaced replacements and THRs respectively.
Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to
12.7) in W3 but the BMD inferior to the acetabular component was
maintained in both groups. These results suggest that the ability of a resurfacing hip replacement
to preserve BMD only applies to the femoral side.
The use of ultrasound in the diagnosis and management of disorders of the tendo Achillis is discussed. Some of the pathological processes which occur in Achilles tendinopathy can be identified by ultrasound, which may also be used to direct local treatment.
We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.
The use of two implants to manage concomitant ipsilateral femoral
shaft and proximal femoral fractures has been indicated, but no
studies address the relationship of dynamic hip screw (DHS) side
plate screws and the intramedullary nail where failure might occur
after union. This study compares different implant configurations
in order to investigate bridging the gap between the distal DHS
and tip of the intramedullary nail. A total of 29 left synthetic femora were tested in three groups:
1) gapped short nail (GSN); 2) unicortical short nail (USN), differing
from GSN by the use of two unicortical bridging screws; and 3) bicortical
long nail (BLN), with two angled bicortical and one unicortical bridging
screws. With these findings, five matched-pairs of cadaveric femora
were tested in two groups: 1) unicortical long nail (ULN), with
a longer nail than USN and three bridging unicortical screws; and
2) BLN. Specimens were axially loaded to 22.7 kg (50 lb), and internally
rotated 90°/sec until failure.Objectives
Methods
We describe the results of 81 consecutive revision
total hip replacements with impaction grafting in 79 patients using
a collared polished chrome–cobalt stem, customised in length according
to the extent of distal bone loss. Our hypothesis was that the features
of this stem would reduce the rate of femoral fracture and subsidence
of the stem. The mean follow-up was 12 years (8 to 15). No intra-operative
fracture or significant subsidence occurred. Only one patient suffered
a post-operative diaphyseal fracture, which was associated with
a fall. All but one femur showed incorporation of the graft. No
revision for aseptic loosening was recorded. The rate of survival of the femoral component at 12 years, using
further femoral revision as the endpoint, was 100% (95% confidence
interval (CI) 95.9 to 100), and at nine years using re-operation
for any reason as the endpoint, was 94.6% (95% CI 92.0 to 97.2). These results suggest that a customised cemented polished stem
individually adapted to the extent of bone loss and with a collar
may reduce subsidence and the rate of fracture while maintaining
the durability of the fixation.
We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone >
2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped. Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease.
Using the transverse processes of fresh porcine lumbar spines as an experimental model we evaluated the heat generated by a rotating burr of a high-speed drill in cutting the bone. The temperature at the drilled site reached 174°C with a diamond burr and 77°C with a steel burr. With water irrigation at a flow rate of 540 ml/hr an effective reduction in the temperature was achieved whereas irrigation with water at 180 ml/hr was much less effective. There was a significant negative correlation between the thickness of the residual bone and the temperature measured at its undersurface adjacent to the drilling site (p <
0.001). Our data suggest that tissues neighbouring the drilled bone, especially nerve roots, can be damaged by the heat generated from the tip of a high-speed drill. Nerve-root palsy, one of the most common complications of cervical spinal surgery, may be caused by thermal damage to nerve roots arising in this manner.
We retrospectively reviewed the hospital records of 68 patients who had been referred with an injury to the posterolateral corner of the knee to a specialist knee surgeon between 2005 and 2009. These injuries were diagnosed based on a combination of clinical testing and imaging and arthroscopy when available. In all, 51 patients (75%) presented within 24 hours of their injury with a mean presentation at eight days (0 to 20) after the injury. A total of 63 patients (93%) had instability of the knee at presentation. There was a mean delay to the diagnosis of injury to the posterolateral corner of 30 months (0 to 420) from the time of injury. In all, the injuries in 49 patients (72%) were not identified at the time of the initial presentation, with the injury to the posterolateral corner only recognised in those patients who had severe multiple ligamentous injuries. The correct diagnosis, including injury to the posterolateral corner, had only been made in 34 patients (50%) at time of referral to a specialist knee clinic. MRI correctly identified 14 of 15 injuries when performed acutely (within 12 weeks of injury), but this was the case in only four of 15 patients in whom it was performed more than 12 weeks after the injury. Our study highlights a need for greater diligence in the examination and investigation of acute ligamentous injuries at the knee with symptoms of instability, in order to avoid failure to identify the true extent of the injury at the time when anatomical repair is most straightforward.
Matrix-induced autologous chondrocyte implantation
(MACI) is an established technique used to treat osteochondral lesions
in the knee. For larger osteochondral lesions (>
5 cm2)
deeper than approximately 8 mm we have combined the use of two MACI
membranes with impaction grafting of the subchondral bone. We report
our results of 14 patients who underwent the ‘bilayer collagen membrane’
technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There
were 12 men and two women with a mean age of 23.6 years (16 to 40).
The mean size of the defect was 7.2 cm2 (5.2 to 12 cm2)
and were located on the medial (ten) or lateral (four) femoral condyles.
The mean modified Cincinnati knee score improved from 45.1 (22 to
70) pre-operatively to 82.8 (34 to 98) at the most recent review
(p <
0.05). The visual analogue pain score improved from 7.3
(4 to 10) to 1.7 (0 to 6) (p <
0.05). Twelve patients were considered
to have a good or excellent clinical outcome. One graft failed at
six years. The BCMT resulted in excellent functional results and durable
repair of large and deep osteochondral lesions without a high incidence
of graft-related complications.
We investigated the early results of modular porous metal components used in 23 acetabular reconstructions associated with major bone loss. The series included seven men and 15 women with a mean age of 67 years (38 to 81), who had undergone a mean of two previous revisions (1 to 7). Based on Paprosky’s classification, there were 17 type 3A and six type 3B defects. Pelvic discontinuity was noted in one case. Augments were used in 21 hips to support the shell and an acetabular component-cage construct was implanted in one case. At a mean follow-up of 41 months (24 to 62), 22 components remained well fixed. Two patients required rerevision of the liners for prosthetic joint instability. Clinically, the mean Harris Hip Score improved from 43.0 pre-operatively (14 to 86) to 75.7 post-operatively (53 to 100). The mean pre-operative Merle d’Aubigné score was 8.2 (3 to 15) and improved to a mean of 13.7 (11 to 18) post-operatively. These short-term results suggest that modular porous metal components are a viable option in the reconstruction of Paprosky type 3 acetabular defects. More data are needed to determine whether the system yields greater long-term success than more traditional methods, such as reconstruction cages and structural allografts.