This study describes the surgical technique used for reconstruction and reinforcement of the lateral collateral ligament complex in patients with posterolateral instability of the elbow and the results. A triceps tendon graft from the ipsilateral elbow which was inserted through bone tunnels and fixed with bone anchors augmented the reconstruction. The operation was performed on 18 consecutive patients with instability after an acute traumatic dislocation. The mean follow-up was 44 months (14 to 88). There were no recurrent dislocations. The elbow was stable in 14 patients; three had some minor limitation of movement. Thirteen had no or only occasional slight pain, 15 returned to their normal level of activity and 17 were satisfied with the outcome. There was only one failure.
The efficacy of β-tricalcium phosphate (β-TCP) loaded with bone morphogenetic protein-2 (BMP-2)-gene-modified bone-marrow mesenchymal stem cells (BMSCs) was evaluated for the repair of experimentally-induced osteonecrosis of the femoral head in goats. Bilateral early-stage osteonecrosis was induced in adult goats three weeks after ligation of the lateral and medial circumflex arteries and delivery of liquid nitrogen into the femoral head. After core decompression, porous β-TCP loaded with BMP-2 gene- or β-galactosidase (gal)-gene-transduced BMSCs was implanted into the left and right femoral heads, respectively. At 16 weeks after implantation, there was collapse of the femoral head in the untreated group but not in the BMP-2 or β-gal groups. The femoral heads in the BMP-2 group had a normal density and surface, while those in the β-gal group presented with a low density and an irregular surface. Histologically, new bone and fibrous tissue were formed in the macropores of the β-TCP. Sixteen weeks after implantation, lamellar bone had formed in the BMP-2 group, but there were some empty cavities and residual fibrous tissue in the β-gal group. The new bone volume in the BMP-2 group was significantly higher than that in the β-gal group. The maximum compressive strength and Young’s modulus of the repaired tissue in the BMP-2 group were similar to those of normal bone and significantly higher than those in the β-gal group. Our findings indicate that porous β-TCP loaded with BMP-2-gene-transduced BMSCs are capable of repairing early-stage, experimentally-induced osteonecrosis of the femoral head and of restoring its mechanical function.
We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22). The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain relief and satisfaction were significantly higher in the lunotriquetral repair and reconstruction groups than in those undergoing arthrodesis.
We describe a 13-year-old boy with atrophic tibial pseudarthrosis associated with neurofibromatosis who had undergone nine unsuccessful operations. Eventually, union was obtained by the use of bone morphogenetic protein 7 in conjunction with intramedullary stabilisation and autologous bone graft.
We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space.
Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture
Aims. Perthes' disease (PD) is a relatively rare syndrome of idiopathic osteonecrosis of the proximal femoral epiphysis.
We performed one-stage lengthening using intercalary autogenous bone graft in 34 metatarsals and seven proximal phalanges in 21 patients with congenitally short metatarsals. At operation, in order to decrease the tension in the surrounding soft tissues, we gradually distracted the osteotomies of the affected bones for 20 to 30 minutes. The patients, all women, were followed up for a mean period of 2.1 years (1 to 6.5). The average gain in length for the 34 metatarsal procedures was 14 mm (6 to 21), equivalent to an increase of 32% (11 to 51), and for the seven proximal phalangeal lengthenings 8 mm (5 to 11), an increase of 54% (47 to 65). There was no evidence of neurovascular impairment. The technique of gradual distraction during operation is simple and effective. It overcomes the disadvantages of one-stage lengthening such as a small gain in length and neurovascular damage.
Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and is an important contributory factor to patellofemoral instability and recurrent dislocation. We studied prospectively a series of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, who were treated by a trochleoplasty by a single surgeon between June 2002 and June 2007. Pre- and post-operative scores were assessed by the patients and a satisfaction questionnaire was completed. Of the 54 patients (59 knees) in the series, 39 (44 knees) were female and 15 (15 knees) were male. Their mean age at surgery was 21 years and 6 months (14 years 4 months to 33 years 11 months). In 40 patients (42 knees) the mean follow-up was for 24 months (12 to 58). One patient was unable to attend for follow-up. An analysis of the results of those patients followed up for at least 12 months showed a statistically significant improvement in outcome (p <
0.001 for all scores). Overall, 50 patients (92.6%) were satisfied with the outcome of their procedure. The early results of trochleoplasty are encouraging in this challenging group of patients.
We have developed a method of measuring anterior displacement of the calcaneus on the talus in instability of the subtalar joint and have used the technique to demonstrate anterior instability in 50 patients (72 feet) showing a positive drawer sign. The angle of the posterior facet of the talus was also measured to assess the bony configuration. Our patients with subtalar joint instability could be divided into three categories. The first group had a history of trauma leading to ankle instability (26 cases), the second showed generalised joint laxity (10 cases) and the third were young females with a history of chronic stress on the foot and a poor bony block (14 cases). Satisfactory results were obtained by treating the instability with a brace or by reconstruction of the interosseous talocalcaneal ligament.
We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection.