The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.
The best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following excision of a malignant bone tumour. There were ten men and eight women with a mean age of 42.5 years (16 to 76). Mean follow-up was 58.5 months (20 to 141) for all patients and 69.3 months (20 to 141) for the 12 patients still alive. Cumulative patient survival was 59% (95% confidence interval (CI) 32 to 84) at five years. Implant survival was 63% (95% CI 35 to 90) at ten years. Four patients required revision to a proximal tibial replacement at a mean follow-up of 29 months (10 to 54). Complications included metastases in five patients, aseptic loosening in four, peri-prosthetic fracture in two, infection in one and local recurrence in one. The mean Musculoskeletal Tumor Society score and the mean Toronto Extremity Salvage Score were 23 (17 to 28) and 74% (53 to 91), respectively. Although rates of complication and revision were high, custom-made tibial diaphyseal replacement following resection of malignant bone tumours enables early return to function and provides an attractive alternative to other surgical options, without apparent compromise of patient survival.
Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use.
We retrospectively evaluated eight patients who underwent arthrodesis of the knee using cannulated screws. There were six women and two men, with a mean age of 53 years. The indications for arthrodesis were failed total knee arthroplasty, septic arthritis, tuberculosis, and recurrent persistent infection. Solid union was achieved in all patients at a mean of 6.1 months. One patient required autogenous bone graft for delayed union. One suffered skin necrosis which was treated with skin grafting. The mean limb-length discrepancy was 3.1 cm. On a visual analogue scale, the mean pain score improved from 7.9 to 3.3. According to the Knee Injury and Osteoarthritis Outcome score quality of life items, the mean score improved from 38.3 pre-operatively to 76.6 at follow-up. Cannulated screws provide a high rate of union in arthrodesis of the knee with minimal complications, patient convenience, and a simple surgical technique.
The ideal form of fixation for displaced, extra-articular
fractures of the distal tibia remains controversial. In the UK, open
reduction and internal fixation with locking-plates and intramedullary
nailing are the two most common forms of treatment. Both techniques
provide reliable fixation but both are associated with specific
complications. There is little information regarding the functional
recovery following either procedure. We performed a randomised pilot trial to determine the functional
outcome of 24 adult patients treated with either a locking-plate
(n = 12) or an intramedullary nailing (n = 12). At six months, there
was an adjusted difference of 13 points in the Disability Rating
Index in favour of the intramedullary nail. However, this was not
statistically significant in this pilot trial (p = 0.498). A total
of seven patients required further surgery in the locking-plate
group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional
differences in patients treated with nail
We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions. The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee.
To conduct a pilot randomised controlled trial to evaluate the
feasibility of conducting a larger trial to evaluate the difference
in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores
at six months between patients with Achilles tendinopathy treated
with a platelet-rich plasma (PRP) injection compared with an eccentric
loading programme. Two groups of patients with mid-substance Achilles tendinopathy
were randomised to receive a PRP injection or an eccentric loading
programme. A total of 20 patients were randomised, with a mean age
of 49 years (35 to 66). All outcome measures were recorded at baseline,
six weeks, three months and six months.Objectives
Methods
We describe 261 peripheral nerve injuries sustained
in war by 100 consecutive service men and women injured in Iraq
and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the
median interval between injury and first review was 4.2 months (mean
8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months
(mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly
focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis
in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed
between the upper and the lower limbs. Explosions accounted for
164 (63%): 213 (82%) nerve injuries were associated with open wounds.
Two or more main nerves were injured in 70 patients. The ulnar,
common peroneal and tibial nerves were most commonly injured. In
69 patients there was a vascular injury, fracture, or both at the
level of the nerve lesion. Major tissue loss was present in 50 patients:
amputation of at least one limb was needed in 18. A total of 36 patients
continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these
injuries and provides information about the depth and distribution
of the nerve lesions, their associated injuries and neuropathic
pain syndromes.
The purpose of this study was to evaluate the
long-term functional and radiological outcomes of arthroscopic removal
of unstable osteochondral lesions with subchondral drilling in the
lateral femoral condyle. We reviewed the outcome of 23 patients
(28 knees) with stage III or IV osteochondritis dissecans lesions
of the lateral femoral condyle at a mean follow-up of 14 years (10
to 19). The functional clinical outcomes were assessed using the Lysholm
score, which improved from a mean of 38.1 ( We found radiological evidence of degenerative changes in the
third or fourth decade of life at a mean of 14 years after arthroscopic
excision of the loose body and subchondral drilling for an unstable
osteochondral lesion of the lateral femoral condyle. Clinical and
functional results were more satisfactory.
We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.
The August 2013 Foot &
Ankle Roundup360 looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive calcaneal fracture fixation?; pes planus in adolescents; and subluxing peroneals and groove deepening
This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth. The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.
We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life.
The use of joint-preserving surgery of the hip
has been largely abandoned since the introduction of total hip replacement.
However, with the modification of such techniques as pelvic osteotomy,
and the introduction of intracapsular procedures such as surgical
hip dislocation and arthroscopy, previously unexpected options for
the surgical treatment of sequelae of childhood conditions, including
developmental dysplasia of the hip, slipped upper femoral epiphysis
and Perthes’ disease, have become available. Moreover, femoroacetabular
impingement has been identified as a significant aetiological factor
in the development of osteoarthritis in many hips previously considered to
suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognised
earlier in the disease process, these techniques may be used to
decelerate or even prevent progression to osteoarthritis. We review
the recent development of these concepts and the associated surgical
techniques. Cite this article:
The outcomes of 261 nerve injuries in 100 patients
were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in
18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)).
The initial grades for the 42 sutures and graft were 11 good, 14
fair and 17 poor. After subsequent revision repairs in seven, neurolyses
in 11 and free vascularised fasciocutaneous flaps in 11, the final
grades were 15 good, 18 fair and nine poor. Pain was relieved in
30 of 36 patients by nerve repair, revision of repair or neurolysis,
and flaps when indicated. The difference in outcome between penetrating
missile wounds and those caused by explosions was not statistically
significant; in the latter group the onset of recovery from focal
conduction block was delayed (mean 4.7 months (2.5 to 10.2)
Transarticular screw fixation with autograft
is an established procedure for the surgical treatment of atlantoaxial instability.
Removal of the posterior arch of C1 may affect the rate of fusion.
This study assessed the rate of atlantoaxial fusion using transarticular
screws with or without removal of the posterior arch of C1. We reviewed
30 consecutive patients who underwent atlantoaxial fusion with a
minimum follow-up of two years. In 25 patients (group A) the posterior
arch of C1 was not excised (group A) and in five it was (group B).
Fusion was assessed on static and dynamic radiographs. In selected
patients CT imaging was also used to assess fusion and the position
of the screws. There were 15 men and 15 women with a mean age of
51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6).
Stable union with a solid fusion or a stable fibrous union was achieved
in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid
fusion, four (16%) a stable fibrous union and one (4%) a nonunion.
In Group B, stable union was achieved in all patients, three having
a solid fusion and two a stable fibrous union. There was no statistically
significant difference between the status of fusion in the two groups.
Complications were noted in 12 patients (40%); these were mainly
related to the screws, and included malpositioning and breakage.
The presence of an intact or removed posterior arch of C1 did not
affect the rate of fusion in patients with atlantoaxial instability
undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article: