We report the results of revision total knee
replacement (TKR) in 26 patients with major metaphyseal osteolytic defects
using 29 trabecular metal cones in conjunction with a rotating hinged
total knee prosthesis. The osteolytic defects were types II and
III (A or B) according to the Anderson Orthopaedic Research Institute
(AORI) classification. The mean age of the patients was 72 years
(62 to 84) and there were 15 men and 11 women. In this series patients had
undergone a mean of 2.34 previous total knee arthroplasties. The
main objective was to restore anatomy along with stability and function
of the knee joint to allow immediate full weight-bearing and active
knee movement. Outcomes were measured using Knee Society scores,
Oxford knee scores, range of movement of the knee and serial radiographs.
Patients were followed for a mean of 36 months (24 to 49). The mean
Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20
(32 to 38) (p <
0.001) and mean American Knee Society scores
improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p <
0.001).
No radiolucent lines suggestive of loosening were seen around the trabecular
metal cones, and by one year all the radiographs showed good osteo-integration.
There was no evidence of any collapse or implant migration. Our
early results confirm the findings of others that trabecular metal
cones offer a useful way of managing severe bone loss in revision
TKR. Cite this article:
McFarland fractures of the medial malleolus in
children, also classified as Salter–Harris Type III and IV fractures,
are associated with a high incidence of premature growth plate arrest.
In order to identify prognostic factors for the development of complications
we reviewed 20 children with a McFarland fracture that was treated
surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven
children (35%) developed premature growth arrest with angular deformity.
The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot
Scale for all patients was 98.3 (87 to 100) and the mean modified
Weber protocol was 1.15 (0 to 5). There was a significant correlation
between initial displacement (p = 0.004) and operative delay (p
= 0.007) with premature growth arrest. Both risk factors act independently
and additively, such that all children with both risk factors developed
premature arrest whereas children with no risk factor did not. We
recommend that fractures of the medial malleolus in children should
be treated by anatomical reduction and screw fixation within one
day of injury. Cite this article:
The Ponseti and French taping methods have reduced
the incidence of major surgery in congenital idiopathic clubfoot
but incur a significant burden of care, including heel-cord tenotomy.
We developed a non-operative regime to reduce treatment intensity
without affecting outcome. We treated 402 primary idiopathic clubfeet
in patients aged <
three months who presented between September
1991 and August 2008. Their Harrold and Walker grades were 6.0%
mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient
taping regime over five weeks based on Ponseti manipulation, modified
Jones strapping and home exercises. Feet with residual equinus (six
feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent
one to three additional tapings. Correction was maintained with
below-knee splints, exercises and shoes. The clinical outcome at
three years of age (385 feet, 95.8% follow-up) showed that taping
alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure
of taping required limited posterior release in 20 feet (5.2%, ‘fair’)
or posteromedial release in eight feet (2.1%, ‘poor’). The long-term
(>
10 years) outcomes in 44 feet (23.8% follow-up) were assessed
by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good
(17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%).
These compare favourably with published long-term results of the
Ponseti or French methods. This dynamic taping regime is a simple
non-operative method that delivers improved medium-term and promising
long-term results. Cite this article:
Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions. Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis. Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.
The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip
This paper outlines the history of advances made in the treatment of open fractures that have occurred during wartime.
The October 2012 Trauma Roundup360 looks at: which patients die from pelvic ring fractures; monolateral distraction osteogenesis; surgical management of pelvic and peroneal blast injuries; weekend warriors at risk of going AWOL; early experience with the locking attachment plate; and fibula nailing - an alternate, and viable technique.
We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75). All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.
As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was ≥ 3 mm.
Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.
Recent studies have shown that modulating inflammation-related
lipid signalling after a bone fracture can accelerate healing in
animal models. Specifically, decreasing 5-lipoxygenase (5-LO) activity
during fracture healing increases cyclooxygenase-2 (COX-2) expression
in the fracture callus, accelerates chondrogenesis and decreases
healing time. In this study, we test the hypothesis that 5-LO inhibition
will increase direct osteogenesis. Bilateral, unicortical femoral defects were used in rats to measure
the effects of local 5-LO inhibition on direct osteogenesis. The
defect sites were filled with a polycaprolactone (PCL) scaffold
containing 5-LO inhibitor (A-79175) at three dose levels, scaffold
with drug carrier, or scaffold only. Drug release was assessed Objectives
Methods
The August 2012 Children’s orthopaedics Roundup360 looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot.
The August 2012 Trauma Roundup360 looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.
We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.
Small animal models of fracture repair primarily investigate
indirect fracture healing via external callus formation. We present
the first described rat model of direct fracture healing. A rat tibial osteotomy was created and fixed with compression
plating similar to that used in patients. The procedure was evaluated
in 15 cadaver rats and then Objectives
Methods
Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.