This paper investigates whether cortical comminution
and intra-articular involvement can predict displacement in distal
radius fractures by using a classification that includes volar comminution
as a separate parameter. A prospective multicentre study involving non-operative treatment
of distal radius fractures in 387 patients aged between 15 and 74
years (398 fractures) was conducted. The presence of cortical comminution
and intra-articular involvement according to the Buttazzoni classification
is described. Minimally displaced fractures were treated with immobilisation
in a cast while displaced fractures underwent closed reduction with
subsequent immobilisation. Radiographs were obtained after reduction,
at 10 to 14 days and after union. The outcome measure was re-displacement
or union. In fractures with volar comminution (Buttazzoni type 4), 96%
(53 of 55) displaced. In intra-articular fractures without volar
comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular
fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106
of 145) displaced while in non-comminuted fractures (Buttazzoni
1), 16 % (13 of 81 ) displaced. A total of 32% (53 of 165) of initially minimally displaced fractures
later displaced. All of the initially displaced volarly comminuted
fractures re-displaced. Displacement occurred in 31% (63 of 205)
of fractures that were still in good alignment after 10 to 14 days. Regression analysis showed that volar and dorsal comminution
predicted later displacement, while intra-articular involvement
did not predict displacement. Volar comminution was the strongest
predictor of displacement. Cite this article:
The June 2014 Wrist &
Hand Roundup360 looks at: aart throwing not quite as we thought; two-gear, four-bar linkage in the wrist?; assessing outcomes in distal radial fractures; gold standard Swanson’s?; multistrand repairs of unclear benefit in flexor tendon release; for goodness’ sake, leave the thumb alone in scaphoid fractures; horizons in carpal tunnel surgery; treading the Essex-Lopresti tightrope; wrist replacement in trauma? and radial shortening reliable in the long term for Kienbock’s disease
Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.
Trabecular metal (TM) augments are a relatively
new option for reconstructing segmental bone loss during acetabular
revision. We studied 34 failed hip replacements in 34 patients that
were revised between October 2003 and March 2010 using a TM acetabular
shell and one or two augments. The mean age of the patients at the
time of surgery was 69.3 years (46 to 86) and the mean follow-up
was 64.5 months (27 to 107). In all, 18 patients had a minor column
defect, 14 had a major column defect, and two were associated with
pelvic discontinuity. The hip centre of rotation was restored in
27 patients (79.4%). The Oxford hip score increased from a mean
of 15.4 points (6 to 25) before revision to a mean of 37.7 (29 to
47) at the final follow-up. There were three aseptic loosenings
of the construct, two of them in the patients with pelvic discontinuity.
One septic loosening also occurred in a patient who had previously
had an infected hip replacement. The augments remained stable in
two of the failed hips. Whenever there was a loose acetabular component
in contact with a stable augment, progressive metal debris shedding
was evident on the serial radiographs. Complications included another
deep infection treated without revision surgery. Good clinical and
radiological results can be expected for bone-deficient acetabula
treated by a TM cup and augment, but for pelvic discontinuities
this might not be a reliable option. Cite this article:
We conducted an anatomical study to determine
the best technique for transfer of the anterior interosseous nerve (AIN)
for the treatment of proximal ulnar nerve injuries. The AIN, ulnar
nerve, and associated branches were dissected in 24 cadaver arms.
The number of branches of the AIN and length available for transfer
were measured. The nerve was divided just proximal to its termination
in pronator quadratus and transferred to the ulnar nerve through
the shortest available route. Separation of the deep and superficial
branches of the ulnar nerve by blunt dissection alone, was also
assessed. The mean number of AIN branches was 4.8 (3 to 8) and the
mean length of the nerve available for transfer was 72 mm (41 to
106). The transferred nerve reached the ulnar nerve most distally
when placed dorsal to flexor digitorum profundus (FDP). We therefore
conclude that the AIN should be passed dorsal to FDP, and that the
deep and superficial branches of the ulnar nerve require approximately
30 mm of blunt dissection and 20 mm of sharp dissection from the
point of bifurcation to the site of the anastomosis. The use of this technique for transfer of the AIN should improve
the outcome for patients with proximal ulnar nerve injuries. Cite this article:
Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function. Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all.
We present the long-term results of open surgery
for internal shoulder rotational deformity in brachial plexus birth palsy
(BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean
age 6.2 (0.6 to 34)) were operated on with subscapularis elongation
and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder
joints were relocated. The early results of these patients has been
reported previously. We analysed 118 (64 females, 54 males, mean
age 15.1 (7.6 to 34)) of the original patient cohort at a mean of
10.4 years (7.0 to 15.1) post-operatively. A third of patients with
relocated joints had undergone secondary internal rotational osteotomy
of the humerus. A mixed effects models approach was used to evaluate the effects
of surgery on shoulder rotation, abduction, and the Mallet score.
Independent factors were time (pre-and post-surgery), gender, age,
joint category (congruent, relocated, relocated plus osteotomy)
and whether or not a transfer had been performed. Data from a previously published
short-term evaluation were reworked in order to obtain pre-operative
values. The mean improvement in external rotation from pre-surgery to
the long-term follow-up was 66.5° (95% confidence interval (CI)
61.5 to 71.6). The internal rotation had decreased by a mean of
22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade
aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95%
CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves
good long-term results for patients with BPBP and an internal rotation
contracture, providing lasting joint congruency and resolution of
the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article:
The April 2014 Research Roundup360 looks at: scientific writing needed in orthopaedic papers; antiseptics and osteoblasts; thromboembolic management in orthopaedic patients; nicotine and obesity in post-operative complications; defining the “Patient Acceptable Symptom State”; and cheap and nasty implants of poor quality.
We retrospectively reviewed 30 patients with
a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented
villonodular synovitis) around the knee in order to assess the influence
of the type of surgery on the functional outcome and quality of
life (QOL). Between 1980 and 2001, 15 of these tumours had been
treated primarily at our tertiary referral centre and 15 had been
referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome
and QOL were assessed with range of movement and the Knee injury
and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour
Society (MSTS) score, the Toronto Extremity Salvage Score (TESS)
and the SF-36 questionnaire. There was recurrence in four of 14
patients treated initially by open synovectomy. Local control was
achieved after a second operation in 13 of 14 (93%). Recurrence
occurred in 15 of 16 patients treated initially by arthroscopic
synovectomy. These patients underwent a mean of 1.8 arthroscopies
(one to eight) before open synovectomy. This achieved local control
in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%)
after two. The functional outcome and QOL of patients who had undergone
primary arthroscopic synovectomy and its attendant subsequent surgical
procedures were compared with those who had had a primary open synovectomy
using the following measures: range of movement (114º Those who had undergone open synovectomy needed fewer subsequent
operations. Most patients who had been referred with a recurrence
had undergone an initial arthroscopic synovectomy followed by multiple
further synovectomies. At the final follow-up of eight years (2
to 32), these patients had impaired function and QOL compared with
those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who
are treated by arthroscopic synovectomy has an unfavourable outcome,
and that primary open synovectomy should be undertaken to prevent
recurrence or residual disease. Cite this article:
Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.
The April 2014 Children’s orthopaedics Roundup360 looks at: urgent supracondylar fractures; rotational osteotomy for synostosis; predicting slip in paediatric forearm fractures; progressive lengthening of the digit is possible; treatment of SUFE with the Dunn osteotomy; and the best way to apply the eight-plate?.
Short uncemented humeral stems can preserve humeral
bone stock and facilitate revision surgery but may be prone to malalignment
or loosening, especially when used in reverse total shoulder replacement
(TSR). We undertook a retrospective review of 44 patients with a
mean age of 76 years (59 to 92) who underwent primary reverse TSR
with a short uncemented humeral stem. There were 29 females. The
indications for joint replacement included cuff tear associated
arthropathy (33), avascular necrosis (six), post-traumatic arthritis
(two), and inflammatory arthritis (three). At a mean follow-up of
27 months (24 to 40), pain was rated as mild or none in 43 shoulders
(97.7%). The mean active elevation improved from 54° Cite this article:
We reviewed 22 children with cubitus varus who had been treated by a reverse V osteotomy and fixation by cross-pinning and wiring. The mean pre-operative humeral-elbow-wrist angle was −16.9° (−25° to +9°) and at the latest follow-up it was +7.3° (−2° to +14°). No child had a lateral prominence greater than 5 mm after correction. An excellent result was achieved in 20 children and a good result in two. We believe that this osteotomy has the advantages of better inherent stability, the avoidance of a prominent lateral condyle after correction and firm fixation allowing early movement.
Damage to the cartilage of the distal radioulnar
joint frequently leads to pain and limitation of movement, therefore repair
of this joint cartilage would be highly desirable. The purpose of
this study was to investigate the fixation of scaffold in cartilage
defects of this joint as part of matrix-assisted regenerative autologous
cartilage techniques. Two techniques of fixation of collagen scaffolds,
one involving fibrin glue alone and one with fibrin glue and sutures, were
compared in artificially created cartilage defects of the distal
radioulnar joint in a human cadaver. After being subjected to continuous
passive rotation, the methods of fixation were evaluated for cover
of the defect and pull out force. No statistically significant differences were found between the
two techniques for either cover of the defect or integrity of the
scaffold. However, a significantly increased mean pull out force
was found for the combined procedure, 0.665 N (0.150 to 1.160) This suggests that although successful fixation of a collagen
type I/III scaffold in a distal radioulnar joint cartilage defect
is feasible with both forms of fixation, fixation with glue and
sutures is preferable. Cite this article:
We present a case of idiopathic osteonecrosis of the humeral capitellum in a 44-year-old female in the absence of any associated risk factors. Arthroscopy was undertaken to remove the loose bodies and debride the capitellum, with a satisfactory outcome.
An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1°, which increased to 54.3° at four years. Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.
The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function. No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).
In this case report a four-year-old girl with ulnar dimelia is described. She had six digits without mirror symmetry in her right hand. The first pre-axial digit was excised and true pollicisation performed for the second pre-axial digit. The arterial anatomy was abnormal but there was not symmetrical development of the arterial tree.
We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both. We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children.