Avascular necrosis of bone is a well-recognised phenomenon in patients on long-term steroid therapy, especially after renal transplantation. There are only four cases reported in the literature of multifocal avascular necrosis after short-term high-dose steroid therapy, and three additional cases are reported in this paper. All the hips have needed reconstructive surgery within two and a half years of the onset of symptoms; in one patient, however, this has been prevented by other medical problems. In two of the three patients reported in this paper the shoulders also were affected; eventually they became pain-free but movement was restricted. Short-term high-dose steroid therapy has only recently been recognised as a cause of avascular necrosis and attempts should be made to prevent the incidence increasing.
Distraction fractures of the upper lumbar spine are most often associated with the wearing of seat-belts. Twenty patients with this spinal fracture were reviewed and half of them had intra-abdominal injuries. Eight patients required an exploratory laparotomy. Three distinct patterns of distraction fractures have been identified. Open reduction, local spinal fusion and Harrington instrumentation are recommended for unstable fractures and for those with neurological involvement. Four cases of non-union are included ln the series. Legislation for the compulsory wearing of seat-belts should encompass improvements in design and stricter criteria for installation.
Acute myelopathy is a rare complication of Scheuermann's disease. Three patients are reported where spinal cord compression occurred at the apex of a kyphos. All were male, aged 14, 18 and 20 years, and each had a profound neurological defect associated with a short, sharp kyphos in the low thoracic region. Each patient underwent anterior decompression and all made an almost full recovery. It is deduced that factors which may influence the onset of cord compression include the angle of kyphosis, the number of segments involved, the rate of change of the angle, local anatomical variations, trauma, and possible secondary impairment of the vasculature of the cord.
Twenty-three adults with fractures of the odontoid process are reviewed. Te possible reasons for the high rate of non-union in reported series are considered: these include the type of fracture, its displacement, the presence of a gap at the fracture site, imperfect reduction and inadequate immobilisation. Type 2 fractures (at the base of the odontoid process) are the commonest and also the most liable to nonunion. In their treatment, reduction is important; as seen in the lateral radiograph at least two-thirds of the fracture surfaces should be in contact. Skull traction is not advised and halo-cast fixation is the treatment of choice; with this method 87.5 per cent of recent odontoid fractures united.
One hundred and twenty-seven cases of intervertebral disc calcification in children, including 11 previously unreported cases, have been analysed. A distinction is made between symptomatic and asymptomatic patients, whose age, sex and spinal distributions of the calcifications have been shown to differ. Radiologically detectable protrusions and later resorption of the calcifications are common events in symptomatic children, but are unrecorded in asymptomatic children. The spinal distribution of paediatric calcifications is quite different to that of adult and canine calcifications of the nucleus pulposus.
Seventy-five Freeman-Swanson (ICLH) Mark I total knee replacements, all performed in one orthopaedic unit between 1972 and 1975, were independently reviewed. The fifty-eight surviving patients, with sixty-eight arthroplasties, have been interviewed and examined and the clinical records of the deceased patients inspected. Sixty arthroplasties (80 per cent) were successful and fifteen failed (20 per cent). There were no disasters. Twenty (33.8 per cent) of the successful arthroplasties were excellent. It is expected that modification of the prosthesis and improved instrumentation will increase this percentage of excellent results and reduce the failure rate.
The results of thirty synovectomies of the elbow for rheumatoid arthritis are reported. Satisfactory relief of pain was obtained in twenty-seven elbows and the range of movement was improved in twenty-one. The classical operation includes excision of the radial head but in this series approximately half the radial heads were conserved with comparable results. The results of synovectomy do not significantly deteriorate with time up to ten years and the operation can be done with good results, especially in respect of relief of pain, even in elbows with relatively advanced rheumatoid disease. Radiographic assessment is not of much help in evaluating the results of the operation, but is essential in selection of elbows for synovectomy.
Throughout 1976 orthopaedic surgeons in three regions of England forwarded details of all new patients with Perthes' disease attending outpatient clinics or admitted as inpatients. The incidence in the Mersey region (11.1 per 100 000 children under fifteen years) was twice that in Wessex (5.5) with Trent having an intermediate incidence (7.6). The ratio of male to female incidence varied between the regions as did the age distribution of male cases. These findings point to the importance of environmental factors in the aetiology of the disease, and suggest the need for further epidemiological studies.
Aneurysmal bone cysts are uncommon lesions, especially in the spine. Seventy-eight cases have been previously documented in the English literature and an additional fourteen cases are now reported. There is a definite predilection for the lumbar region and the neural arch is the part of the vertebra most commonly affected. It is recommended that treatment should consist of total excision or when this is not possible, curettage. Radiotherapy should be reserved for those few cases where operation is inadvisable.
In fifty-six patients with ankylosing spondylitis three types of arthroplasty had been performed in ninety-nine hips. Forty-one of the patients were men and fifteen were women, their average age at operation being forty-two years. Primary pseudarthrosis produced well-satisfied patients, but only a fair result in five hips, whereas cup arthroplasty resulted in a poor outcome for eight hips, all of which needed revision. Total replacement of eighty-six hips, however, led to 73 per cent being graded as good or excellent up to ten years later. The main complications were deep infection of five hips, para-articular ossification around nine hips (six leading to bony ankylosis), and fibrous ankylosis of six hips.
The results of excision of the head of the radius in forty-four elbows affected by rheumatoid arthritis are presented. Relief of pain was obtained in 90 per cent and an increase in the range of flexion and extension was seen in 70 per cent. Involvement of the humero-ulnar joint seen radiologically is no contra-indication to the operation; simple excision of the radial head often gives gratifying results; In our experience the relief of pain and increased range of movement have greatly reduced the need for total replacement arthroplasty.
Three unusual injuries of the cervical spine in wearers of safety belts are reported. In each case, the presence of diagonal bruising and abrasions in the line of the sash strap indicated its involvement in the mechanism of the injury.
Eighty-three Waildius arthroplasties, performed by one surgeon as a salvage operation on the knee joint between 1966 and 1972, were independently reviewed. The fifty-seven living patients with sixty-seven arthroplasties were interviewed and examined and the clinical records of the deceased patients were inspected. Sixty-seven arthroplasties (81 per cent) were successful and sixteen failed (19 per cent). Acrylic cement was used to secure the prosthesis on eight occasions only. There were two primary infections (24 per cent) and two delayed (24 per cent). Major loosening occurred in three arthroplasties (36 per cent). Minor loosening was compatible with a good result. Arthrodesis was successful on the two occasions on which it became necessary to remove the implant. There were no disasters. On the basis of these results it is considered that the Walidius arthroplasty can justifiably be offered as an alternative to primary arthrodesis of the knee.
1. A case of ulnar nerve compression at the wrist caused by rheumatoid arthritis producing motor and sensory changes is presented. 2. The diagnosis from compression at the elbow can be determined by electromyography. 3. It may be that lesions of the deep branch leading to motor changes only occur in rheumatoid arthritis more often than is suspected, their effects being hidden by the concomitant disease and its associated muscle wasting.
1. A case is reported of a benign osteoblastoma of the body of the second thoracic vertebra causing paraplegia in a woman aged twenty-six. 2. The tumour was resected, apparently entirely, through a costo-transversectomy approach, and the paraplegia resolved almost completely. 3. Five and a half years later symptoms recurred, due to a recurrence in the form of a large, partly calcified tumour in the left upper thorax which was resected 4. The considerable histological differences between the original tumour and the recurrence are discussed.
1. A diagnosis of upward translocation of the dens was made in eight patients with chronic rheumatoid arthritis selected from a group of patients who had radiographic studies of the cervical spine and from whom a number of patients with atlanto-axial subluxation were also identified. 2. Two of the patients presented with an acute neurological syndrome of serious import and required a stabilisation operation. Though this is an uncommon complication of rheumatoid arthritis it seems that urgent neurological syndromes are likely to be more common than in atlanto-axial subluxation.
1. This paper presents the neurological findings in forty-one patients with rheumatoid arthritis complicated by atlanto-axial subluxation. 2. A method of radiological measurement of the subluxation is described. The extent of neurological involvement was found not to correspond with the degree of subluxation. 3. Fusion of the atlanto-axial complex or of the occipito-atlanto-axial complex is indicated only in patients with progressive neurological signs and in those suffering from acute neurological episodes. 4. Difficulty in obtaining fusion with cancellous bone grafts alone was encountered and we recommend wiring of the laminae C.1 to C.2 in addition.
1. The results of excision of the distal end of the ulna in eighty-six wrists of seventy patients suffering from rheumatoid arthritis are presented. 2. There was relief of pain in 93 per cent and restoration of full rotation in 87 per cent. 3. Further destructive changes of the radio-carpal joint were seen in 85 per cent, but these did not affect the good clinical results.
1. The results have been reviewed of forty-two traumatic dislocations of the knee in forty-one patients, twenty-six of which were treated conservatively. 2. Primary operative repair was carried out in only three cases, although a further ten had operative intervention for various complications. 3. It was not possible to compare the results of operation with those of conservative treatment, because the operative procedures were so diverse in nature. 4. The conservative treatment of twenty-six dislocations yielded surprisingly good results with regard to stability, absence of pain, and range of flexion movement. 5. In general, immobilisation for long periods, like operative repair, led to reduced movement. 6. In the absence of complications, conservative treatment is the method of choice.
