Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis.
Controversy surrounds the most appropriate treatment
method for patients with a rupture of the tendo Achillis. The aim
of this study was to assess the long term rate of re-rupture following
management with a non-operative functional protocol. We report the outcome of 945 consecutive patients (949 tendons)
diagnosed with a rupture of the tendo Achillis managed between 1996
and 2008. There were 255 female and 690 male patients with a mean
age of 48.97 years (12 to 86). Delayed presentation was defined
as establishing the diagnosis and commencing treatment more than
two weeks after injury. The overall rate of re-rupture was 2.8%
(27 re-ruptures), with a rate of 2.9%
(25 re-ruptures) for those with an acute presentation and 2.7% (two
re-ruptures) for those with delayed presentation. This study of non-operative functional management of rupture
of the tendo Achillis is the largest of its kind in the literature. Our
rates of re-rupture are similar to, or better than, those published
for operative treatment. We recommend our regime for patients of
all ages and sporting demands, but it is essential that they adhere
to the protocol.
The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p <
0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.
This is a prospective analysis on 30 physically
active individuals with a mean age of 48.9 years (35 to 64) with chronic
insertional tendinopathy of the tendo Achillis. Using a transverse
incision, the tendon was debrided and an osteotomy of the posterosuperior
corner of the calcaneus was performed in all patients. At a minimum
post-operative follow-up of three years, the Victorian Institute
of Sports Assessment scale – Achilles tendon scores were significantly
improved compared to the baseline status. In two patients a superficial
infection of the wound developed which resolved on antibiotics.
There were no other wound complications, no nerve related complications,
and no secondary avulsions of the tendo Achillis. In all, 26 patients
had returned to their pre-injury level of activity and the remaining
four modified their sporting activity. At the last appointment,
the mean pain threshold and the mean post-operative tenderness were
also significantly improved from the baseline (p <
0.001). In patients
with insertional tendo Achillis a transverse incision allows a wide
exposure and adequate debridement of the tendo Achillis insertion,
less soft-tissue injury from aggressive retraction and a safe osteotomy
of the posterosuperior corner of the calcaneum.
We have examined the deterioration of implant fixation after withdrawal of parathyroid hormone (PTH) in rats. First, the pull-out force for stainless-steel screws in the proximal tibia was measured at different times after withdrawal. The stimulatory effect of PTH on fixation was lost after 16 days. We then studied whether bisphosphonates could block this withdrawal effect. Mechanical and histomorphometric measurements were conducted for five weeks after implantation. Subcutaneous injections were given daily. Specimens treated with either PTH or saline during the first two weeks showed no difference in the mechanical or histological results (pull-out force 76 N
We identified 16 patients with a mean age of
56.5 years (31 to 86) from a large consecutive series of patients
with proximal humeral fractures over a 15-year period, who had sustained
a fracture with skin compromise after a blunt injury. The study
group represented 0.2% of 7825 proximal humeral fractures treated
during this period and all had a displaced Neer two-part fracture
pattern. Two patterns of skin injury were identified: in ten patients
there was skin penetration at the time of the original injury, and
the other six patients initially had closed injuries. These six patients
had fracture fragments penetrating the muscular envelope to lie
subcutaneously producing either early skin tethering (two patients)
or delayed skin penetration and sinus formation (four patients).
The pattern of injury to the soft-tissue envelope and the fracture
pattern were similar for all injuries. Treatment of these injuries
was determined by the initial severity of the soft-tissue injury
and the medical status of the patient. We currently favour open
reduction and internal fixation of these fractures wherever possible,
owing to the high rate of nonunion with non-operative management.
Disruption of the interosseous membrane is easily
missed in patients with Essex-Lopresti syndrome. None of the imaging
techniques available for diagnosing disruption of the interosseous
membrane are completely dependable. We undertook an investigation to identify whether a simple intra-operative
test could be used to diagnose disruption of the interosseous membrane
during surgery for fracture of the radial head and to see if the
test was reproducible. We studied 20 cadaveric forearms after excision of the radial
head, ten with and ten without disruption of the interosseous membrane.
On each forearm, we performed the radius joystick test: moderate
lateral traction was applied to the radial neck with the forearm
in maximal pronation, to look for lateral displacement of the proximal radius
indicating that the interosseous membrane had been disrupted. Each
of six surgeons (three junior and three senior) performed the test
on two consecutive days. Intra-observer agreement was 77% (95% confidence interval (CI)
67 to 85) and interobserver agreement was 97% (95% CI 92 to 100).
Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI
81 to 93), positive predictive value 90% (95% CI 83 to 94), and
negative predictive value 100%). This cadaveric study suggests that the radius joystick test may
be useful for detecting disruption of the interosseous membrane
in patients undergoing open surgery for fracture of the radial head
and is reproducible. A confirmatory study
Transient osteoporosis is an uncommon, self-limiting, reversible condition. We report a case involving the knee following trauma. The aetiology is unknown, but the association between transient osteoporosis and trauma has not been documented previously. The clinical presentation represents a degree of overlap among various clinical syndromes, including reflex sympathetic dystrophy and avascular necrosis. The diagnosis was confirmed by bone scan and MRI. The patient, a 47-year-old man, was treated with non-steroidal anti-inflammatory medication, protected weight-bearing and physiotherapy. He made a full clinical recovery and bone quality returned to virtual normality.
A delay in the diagnosis of paediatric acute
and subacute haematogenous osteomyelitis can lead to potentially devastating
morbidity. There are no definitive guidelines for diagnosis, and
recommendations in the literature are generally based on expert
opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis
were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the
Cochrane Library and reference lists. A total of 1854 papers were
identified, 132 of which were examined in detail. All aspects of
osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur
are the most commonly affected long bones. Clinical examination,
blood and radiological tests are only reliable for diagnosis in
combination. Most studies were retrospective and there is a need for large,
multicentre, randomised, controlled trials to define protocols for
diagnosis and treatment. Meanwhile, evidence-based algorithms are
suggested for accurate and early diagnosis and effective treatment.
Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (>
95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.
Although bone and soft-tissue sarcomas are rare, early diagnosis and prompt referral to a specialised unit offers the best chance of a successful outcome both in terms of survival and surgical resection. This paper highlights the clinical and radiological features that might suggest the possibility of a bone or soft-tissue sarcoma and suggests a succinct management pathway for establishing whether a suspicious bone or soft-tissue lesion could be malignant.
Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired
Systemic capillary leak syndrome, or the Clarkson syndrome, is an extremely rare condition in which increased capillary permeability results in a massive shift of fluid into the extravascular space. This is followed rapidly by hypotensive shock, haemoconcentration, and, potentially, substantial oedema of the limbs resulting in an acute compartment syndrome. It is important for orthopaedic surgeons to be aware of this syndrome as our medical colleagues, who initially care for these patients, are less familiar with the diagnosis and the need for emergency management of the associated compartment syndrome should it develop. There have been fewer than 100 cases of this entity reported. This case report is the first to describe the subsequent development of a compartment syndrome in all four limbs. Clinical vigilance and continuous monitoring of intracompartmental pressure is necessary in these patients in order to help reduce limb-threatening complications.
Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results. Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.
In order to clarify how intra-articular lesions
influence the survival of a periacetabular osteotomy in patients
with dysplasia of the hip, we performed an observational study of
121 patients (121 hips) who underwent a transposition osteotomy
of the acetabulum combined with an arthroscopy. Their mean age was
40.2 years (13 to 64) and the mean follow-up was 9.9 years (2 to
18). Labral and cartilage degeneration tended to originate from
the anterosuperior part of the acetabulum, followed by the femoral
side. In all, eight hips (6.6%) had post-operative progression to
Kellgren–Lawrence grade 4 changes, and these hips were associated
with the following factors: moderate osteoarthritis, decreased width
of the joint space, joint incongruity, and advanced intra-articular
lesions (subchondral bone exposure in the cartilage and a full-thickness
labral tear). Multivariate analysis indicated subchondral bone exposure
on the femoral head as an independent risk factor for progression
of osteoarthritis (p = 0.003). In hips with early stage osteoarthritis,
femoral subchondral bone exposure was a risk factor for progression of
the grade of osteoarthritis. Although the outcome of transposition osteotomy of the acetabulum
was satisfactory, post-operative progression of osteoarthritis occurred
at a high rate in hips with advanced intra-articular lesions, particularly
in those where the degenerative process had reached the point of
femoral subchondral bone exposure.
This annotation considers the place of extra-articular
reconstruction in the treatment of anterior cruciate ligament (ACL)
deficiency. Extra-articular reconstruction has been employed over
the last century to address ACL deficiency. However, the technique
has not gained favour, primarily due to residual instability and
the subsequent development of degenerative changes in the lateral
compartment of the knee. Thus intra-articular reconstruction has
become the technique of choice. However, intra-articular reconstruction
does not restore normal knee kinematics. Some authors have recommended
extra-articular reconstruction in conjunction with an intra-articular
technique. The anatomy and biomechanics of the anterolateral structures
of the knee remain largely undetermined. Further studies to establish
the structure and function of the anterolateral structures may lead
to more anatomical extra-articular reconstruction techniques that
supplement intra-articular reconstruction. This might reduce residual
pivot shift after an intra-articular reconstruction and thus improve
the post-operative kinematics of the knee.
We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy. Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high.
Fractures of the odontoid peg are relatively common in elderly people. Often they are minimally displaced and can be treated with a collar. However, a fracture which is displaced significantly may be difficult to manage. We describe the case of an 80-year-old man with a fracture of the odontoid peg which was completely displaced and caused respiratory distress. After initial closed reduction and application of a halo jacket, open and internal fixation was undertaken and relieved his symptoms. It is a safe and effective way to manage this injury.
Autologous chondrocyte implantation (ACI) is a technique used for the treatment of symptomatic osteochondral defects of the knee. A variation of the original periosteum membrane technique is the matrix-induced autologous chondrocyte implantation (MACI) technique. The MACI membrane consists of a porcine type-I/III collagen bilayer seeded with chondrocytes. Osteochondral defects deeper than 8 to 10 mm usually require bone grafting either before or at the time of transplantation of cartilage. We have used a variation of Peterson’s ACI-periosteum sandwich technique using two MACI membranes with bone graft which avoids periosteal harvesting. The procedure is suture-free and requires less operating time and surgical exposure. We performed this MACI-sandwich technique on eight patients, five of whom were assessed at six months and one year post-operatively using the modified Cincinnati knee, the Stanmore functional rating and the visual analogue pain scores. All patients improved within six months with further improvement at one year. The clinical outcome was good or excellent in four after six months and one year. No significant graft-associated complications were observed. Our early results of the MACI-sandwich technique are encouraging although larger medium-term studies are required before there is widespread adoption of the technique.
The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of congenital pseudarthrosis of the tibia has been investigated in only one previous study, with promising results. The aim of this study was to determine whether rhBMP-2 might improve the outcome of this disorder. We reviewed the medical records of five patients with a mean age of 7.4 years (2.3 to 21) with congenital pseudarthrosis of the tibia who had been treated with rhBMP-2 and intramedullary rodding. Ilizarov external fixation was also used in four of these patients. Radiological union of the pseudarthrosis was evident in all of them at a mean of 3.5 months (3.2 to 4) post-operatively. The Ilizarov device was removed after a mean of 4.2 months (3.0 to 5.3). These results indicate that treatment of congenital pseudarthrosis of the tibia using rhBMP-2 in combination with intramedullary stabilisation and Ilizarov external fixation may improve the initial rate of union and reduce the time to union. Further studies with more patients and longer follow-up are necessary to determine whether this surgial procedure may significantly enhance the outcome of congenital pseudarthrosis of the tibia, considering the refracture rate (two of five patients) in this small case series.