We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.
Aims. Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various
Aims. Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence.
Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) ( This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem.
We have treated 101 patients with scoliosis secondary to muscular dystrophy over a 13-year period; 64 had Duchenne’s muscular dystrophy, 33 spinal muscular atrophy and four congenital muscular dystrophy. The patients underwent a modified Luque (87) or Harrington-Luque instrumentation (14) combined with a limited Moe fusion in all except 27 cases. A mean of 13 levels was instrumented. The mean preoperative sitting Cobb angle was 84° (10 to 150) and the mean postoperative angle 40° (52% correction). Most patients (96%) were able to discard their braces and there was a high level of patient satisfaction (89.6%). Less correction was seen for severe curves, and there was a greater recurrence of postoperative pelvic tilt in those patients not instrumented to the sacrum. Although the incidence of minor or temporary complications was high, these occurred chiefly in the early high-risk patients with very severe curves and considerable pre-existing immobility.
Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab’s criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.
Nonunion of fractures of the olecranon fossa of the humerus presents a difficult surgical problem. The distal fragment is usually small and osteoporotic and stable fixation is not easy to achieve. We describe a modification of the technique of locked nailing by which the distal aspect of the nail is placed in the subchondral region of the trochlea. Good results were obtained in seven out of eight patients with this technique.
Between November 1983 and December 1992, 136 hips (119 patients) with coxarthritis were operated on using joint-preserving techniques based on the rationale of Pauwels’ osteotomy. The criterion for selection was a patient in whom the height of the joint space in the weight-bearing area of the hip was less than 1 mm. The mean age at operation was 48 years and the mean follow-up 109 months (60 to 171). Hips were categorised using Bombelli’s classification of osteoarthritis, into atrophic and non-atrophic types. The endpoint was defined as that at which the height of the joint space became less than 1 mm again. The Kaplan-Meier curve showed that the rate of survival of the non-atrophic group was significantly better than that of the atrophic group. Cox’s proportional hazard model indicated that the factors influencing the results of joint-preserving operations included Bombelli’s classification, postoperative incongruence of the joint and the height of the joint space.
Aims. It is not clear which type of casting provides the best initial
Aims. The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective
Aims. Clear cell sarcoma (CCS) of soft-tissue is a rare melanocytic subtype of mesenchymal malignancy. The aim of this study was to investigate the clinical and therapeutic factors associated with increased survival, stratified by clinical stage, in order to determine the optimal
We have used the Ilizarov technique for severe flexion deformity of the knee in 11 patients (13 knees) between 1986 and 1994 and have followed them up for an average of 4.1 years. The age of the patients at operation ranged from 1.7 to 18.8 years. The femoral and tibial components were connected by two anterior hinges, medial and lateral, and two posterior distraction rods. The deformity was corrected to a femorotibial lateral shaft angle of less than 20°. A permanent orthosis was applied after removal of the fixator. Fractures occurred in four patients and paralysis of the common peroneal nerve in another. There was a recurrence of the deformity in four patients. At the last review all patients were able to walk on their operated leg with or without an orthosis. We have found the Ilizarov method to be helpful in correcting severe fixed flexion deformity of the knee, with relatively few complications, but the basic principles of the method must be carefully followed.
Nonunion of intertrochanteric fractures is uncommon but its effects are disabling. We describe a modification of the medial displacement and valgus osteotomy of Dimon and Hughston (1967) which we used in seven fractures, six of which united within 16 weeks. Postoperatively, hip function was good. The method provides good initial stability, a source of cancellous bone graft, good postoperative hip abductor function and reliable healing of the nonunion without the need for intraoperative imaging.
Two neonates, treated by the Pavlik harness for congenital dislocation of the hip, developed inferior dislocation due to excessive hip flexion. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip in both patients.
Seventy-nine open tibial fractures were treated with unilateral uniplanar tubular external fixators. Excellent stability allowed early weight-bearing. All comminuted fractures, with or without bone loss, and some transverse or short oblique fractures with intermediate fragments were treated by early bone grafting through a posterolateral approach. The external fixator was dynamised as soon as periosteal callus was seen on the radiograph. Bone healing times ranged from 11 to 40 weeks (mean 20). Significant ankle stiffness occurred in 10.9% and leg shortening in 2.8%. Pin track infection was seen in 45.2% but was easily controlled with standard management. The external fixation frame allowed excellent functional freedom for Oriental patients to sit cross-legged and squat. Combined with early bone grafting, external fixation is an excellent method for the management of open tibial fractures.
We treated 249 patients for ingrowing toenails in a prospective randomised study which compared wedge excision with segmental phenol cauterisation. Follow-up of 97% was at a minimum of 14 months. The analgesic requirement was significantly lower after phenol cauterisation (p less than 0.001), and significantly fewer patients needed to miss school or work (p = 0.001). Recurrence of ingrowth was seen in 16% after wedge excision and 9.6% after phenol cauterisation (not significant), but re-operation was significantly less frequent after phenol (p less than 0.01). Phenol cauterisation gives better short-term and long-term results than wedge resection.
We treated 11 patients with chronic osteomyelitis of the tibia or the foot by local excision and transfer of a peroneal myocutaneous island flap. This flap, pedicled proximally or distally on the peroneal artery and veins, provides viable muscle to fill the dead space in bone and skin to close the defect. Ten patients reviewed more than three years after operation were all free of drainage with no clinical or radiographic evidence of recurrence.
We report a prospective study of 26 cases of fracture of the distal third of the femur treated with the Derby intramedullary nail. This new design controls rotation and allows compression of the fracture, permitting early weight-bearing. All the fractures united in good position within four months, 12 of them with minimal external callus. There were no implant failures and the only serious complication was one case of deep infection.