Flexor digitorum longus transfer and medial displacement
calcaneal osteotomy is a well-recognised form of treatment for stage
II posterior tibial tendon dysfunction. Although excellent short-
and medium-term results have been reported, the long-term outcome
is unknown. We reviewed the clinical outcome of 31 patients with
a symptomatic flexible flat-foot deformity who underwent this procedure
between 1994 and 1996. There were 21 women and ten men with a mean
age of 54.3 years (42 to 70). The mean follow-up was 15.2 years
(11.4 to 16.5). All scores improved significantly (p <
0.001).
The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved
from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up.
The mean pain component improved from 12.3 to 35.2 (20 to 40). The
mean function score improved from 35.2 to 45.6 (30 to 50). The mean
visual analogue score for pain improved from 7.3 to 1.3 (0 to 6).
The mean Short Form-36 physical component score was 40.6 ( Cite this article:
We retrospectively reviewed the outcomes of 33
consecutive patients who had undergone an extra-articular, total or
partial scapulectomy for a malignant tumour of the shoulder girdle
between 1 July 2001 and 30 September 2013. Of these, 26 had tumours
which originated in the scapula or the adjacent soft tissue and
underwent a classic Tikhoff–Linberg procedure, while seven with
tumours arising from the proximal humerus were treated with a modified
Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement
System for soft-tissue reconstruction in nine patients, but not
in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6
(95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to
19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95%
CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients
who had undergone a LARS soft-tissue reconstruction had a mean score
of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5
to 19.0) for those who did not. The Tikhoff–Linberg procedure is a useful method for wide resection
of a malignant tumour of the shoulder girdle which helps to preserve
hand and elbow function. The method of soft-tissue reconstruction
has no effect on functional outcome. Cite this article:
This study examined spinal fractures in patients
admitted to a Major Trauma Centre via two independent pathways,
a major trauma (MT) pathway and a standard unscheduled non-major
trauma (NMT) pathway. A total of 134 patients were admitted with
a spinal fracture over a period of two years; 50% of patients were
MT and the remainder NMT. MT patients were predominantly male, had
a mean age of 48.8 years (13 to 95), commonly underwent surgery
(62.7%), characteristically had fractures in the cervico-thoracic
and thoracic regions and 50% had fractures of more than one vertebrae,
which were radiologically unstable in 70%. By contrast, NMT patients
showed an equal gender distribution, were older (mean 58.1 years;
12 to 94), required fewer operations (56.7%), characteristically
had fractures in the lumbar region and had fewer multiple and unstable
fractures. This level of complexity was reflected in the length
of stay in hospital; MT patients receiving surgery were in hospital
for a mean of three to four days longer than NMT patients. These
results show that MT patients differ from their NMT counterparts
and have an increasing complexity of spinal injury. Cite this article:
A delay in the diagnosis of paediatric acute
and subacute haematogenous osteomyelitis can lead to potentially devastating
morbidity. There are no definitive guidelines for diagnosis, and
recommendations in the literature are generally based on expert
opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis
were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the
Cochrane Library and reference lists. A total of 1854 papers were
identified, 132 of which were examined in detail. All aspects of
osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur
are the most commonly affected long bones. Clinical examination,
blood and radiological tests are only reliable for diagnosis in
combination. Most studies were retrospective and there is a need for large,
multicentre, randomised, controlled trials to define protocols for
diagnosis and treatment. Meanwhile, evidence-based algorithms are
suggested for accurate and early diagnosis and effective treatment.
Ankylosing spondylitis (AS) is a progressive
multisystem chronic inflammatory disorder. The hallmark of this pathological
process is a progressive fusion of the zygapophyseal joints and
disc spaces of the axial skeleton, leading to a rigid kyphotic deformity
and positive sagittal balance. The ankylosed spine is unable to
accommodate normal mechanical forces, rendering it brittle and susceptible
to injury. Traumatic hyperextension injury of the cervical spine
leading to atlantoaxial subluxation (AAS) in AS patients can often
be fatal. We report a non-traumatic mechanism of injury in AS progressing
to AAS attributable to persistent hyperextension, which resulted
in fatal migration of C2 through the foramen magnum. Cite this article:
We describe our experience in the reduction of
dislocation of the hip secondary to developmental dysplasia using ultrasound-guided
gradual reduction using flexion and abduction continuous traction
(FACT-R). During a period of 13 years we treated 208 Suzuki type
B or C complete dislocations of the hip in 202 children with a mean
age of four months (0 to 11). The mean follow-up was 9.1 years (five
to 16). The rate of reduction was 99.0%. There were no recurrent
dislocations, and the rate of avascular necrosis of the femoral
head was 1.0%. The rate of secondary surgery for residual acetabular
dysplasia was 19.2%, and this was significantly higher in those
children in whom the initial treatment was delayed or if other previous
treatments had failed (p = 0.00045). The duration of FACT-R was significantly
longer in severe dislocations (p = 0.001) or if previous treatments
had failed (p = 0.018). This new method of treatment is effective and safe in these difficult
cases and offers outcomes comparable to or better than those of
standard methods. Cite this article:
Pigmented villonodular synovitis (PVNS) is a
rare proliferative process of the synovium which most commonly affects
the knee and occurs in either a localised (LPVNS) or a diffuse form
(DPVNS). The effect of different methods of surgical synovectomy
and adjuvant radiotherapy on the rate of recurrence is unclear.
We conducted a systematic review and identified 35 observational
studies in English which reported the use of surgical synovectomy
to treat PVNS of the knee. A meta-analysis included 630 patients, 137 (21.8%) of whom had
a recurrence after synovectomy. For patients with DPVNS, low-quality
evidence found that the rate of recurrence was reduced by both open
synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024)
and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI
= 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very
low-quality evidence found that the rate of recurrence of DPVNS
was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14
to 0.70; p = 0.01). Very low-quality evidence suggested that the
rate of recurrence of LPVNS was not related to the surgical approach. This meta-analysis suggests that open synovectomy or synovectomy
combined with peri-operative radiotherapy for DPVNS is associated
with a reduced rate of recurrence. Large long-term prospective multicentre
observational studies, with a focus on both rate of recurrence and
function, are required to confirm these findings. Cite this article:
The August 2013 Shoulder &
Elbow Roundup360 looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty
Radiological assessment of total and unicompartmental
knee replacement remains an essential part of routine care and follow-up.
Appreciation of the various measurements that can be identified
radiologically is important. It is likely that routine plain radiographs
will continue to be used, although there has been a trend towards
using newer technologies such as CT, especially in a failing knee,
where it provides more detailed information, albeit with a higher
radiation exposure. The purpose of this paper is to outline the radiological parameters
used to evaluate knee replacements, describe how these are measured
or classified, and review the current literature to determine their
efficacy where possible.
We undertook a retrospective comparative study
of all patients with an unstable slipped capital femoral epiphysis presenting
to a single centre between 1998 and 2011. There were 45 patients
(46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular
cuneiform osteotomy and 30 underwent pinning Pinning Non-emergency intracapsular osteotomy may have a protective effect
on the epiphyseal vasculature and should be undertaken with a delay
of at least two weeks. The place of emergency pinning Cite this article:
While the Cochrane Collaboration have been busy over the last four months, only a handful of their published reviews have been of any relevance to orthopaedic and trauma surgeons. Those that are provide the reader with an overview of work on imaging modalities, antibiotic therapy, changes to the surgical site dressing and practices surrounding post-operative wound management, including post-op bathing and negative pressure wound therapy for use in the treatment of diabetic foot wounds.
Pigmented villonodular synovitis (PVNS) is a
rare benign disease of the synovium of joints and tendon sheaths, which
may be locally aggressive. We present 18 patients with diffuse-type
PVNS of the foot and ankle followed for a mean of 5.1 years (2 to
11.8). There were seven men and 11 women, with a mean age of 42
years (18 to 73). A total of 13 patients underwent open or arthroscopic
synovectomy, without post-operative radiotherapy. One had surgery
at the referring unit before presentation with residual tibiotalar
PVNS. The four patients who were managed non-operatively remain
symptomatically controlled and under clinical and radiological surveillance.
At final follow-up the mean Musculoskeletal Tumour Society score
was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto
Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American
Academy of Orthopaedic Surgeons foot and ankle score was 89 (95%
CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically
without further intervention six years after surgery. Targeted synovectomy
without adjuvant radiotherapy can result in excellent outcomes,
without recurrence. Asymptomatic patients can be successfully managed
non-operatively. This is the first series to report clinical outcome
scores for patients with diffuse-type PVNS of the foot and ankle. Cite this article:
The purpose of this study was to assess whether
the use of a joint-sparing technique such as curettage and grafting was
successful in eradicating giant cell tumours of the proximal femur,
or whether an alternative strategy was more appropriate. Between 1974 and 2012, 24 patients with a giant cell tumour of
the proximal femur were treated primarily at our hospital. Treatment
was either joint sparing or joint replacing. Joint-sparing treatment
was undertaken in ten patients by curettage with or without adjunctive
bone graft. Joint replacement was by total hip replacement in nine patients
and endoprosthetic replacement in five. All 11 patients who presented
with a pathological fracture were treated by replacement. Local recurrence occurred in five patients (21%): two were treated
by hip replacement, three by curettage and none with an endoprosthesis.
Of the ten patients treated initially by curettage, six had a successful
outcome without local recurrence and required no further surgery.
Three eventually needed a hip replacement for local recurrence and
one an endoprosthetic replacement for mechanical failure. Thus 18
patients had the affected joint replaced and only six (25%) retained
their native joint. Overall, 60% of patients without a pathological
fracture who were treated with curettage had a successful outcome. Cite this article:
Progressive degenerative changes in the medial
compartment of the knee following lateral unicompartmental arthroplasty
(UKA) remains a leading indication for revision surgery. The purpose
of this study is to evaluate changes in the congruence and joint
space width (JSW) of the medial compartment following lateral UKA.
The congruence of the medial compartment of 53 knees (24 men, 23
women, mean age 13.1 years; Our data suggest that a well conducted lateral UKA may improve
the congruence and normalise the JSW of the medial compartment,
potentially preventing progression of degenerative change. Cite this article:
Guidelines for the management of patients with metastatic bone
disease (MBD) have been available to the orthopaedic community for
more than a decade, with little improvement in service provision
to this increasingly large patient group. Improvements in adjuvant
and neo-adjuvant treatments have increased both the number and overall
survival of patients living with MBD. As a consequence the incidence
of complications of MBD presenting to surgeons has increased and
is set to increase further. The British Orthopaedic Oncology Society
(BOOS) are to publish more revised detailed guidelines on what represents
‘best practice’ in managing patients with MBD. This article is designed
to coincide with and publicise new BOOS guidelines and once again
champion the cause of patients with MBD. A series of short cases highlight common errors frequently being
made in managing patients with MBD despite the availability of guidelines.Objectives
Methods
The December 2012 Wrist &
Hand Roundup360 looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures.
The December 2013 Spine Roundup360 looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.
Most fractures of the radial head are stable
undisplaced or minimally displaced partial fractures without an associated
fracture of the elbow or forearm or ligament injury, where stiffness
following non-operative management is the primary concern. Displaced
unstable fractures of the radial head are usually associated with other
fractures or ligament injuries, and restoration of radiocapitellar
contact by reconstruction or prosthetic replacement of the fractured
head is necessary to prevent subluxation or dislocation of the elbow
and forearm. In fractures with three or fewer fragments (two articular
fragments and the neck) and little or no metaphyseal comminution,
open reduction and internal fixation may give good results. However,
fragmented unstable fractures of the radial head are prone to early
failure of fixation and nonunion when fixed. Excision of the radial
head is associated with good long-term results, but in patients
with instability of the elbow or forearm, prosthetic replacement
is preferred. This review considers the characteristics of stable and unstable
fractures of the radial head, as well as discussing the debatable
aspects of management, in light of the current best evidence. Cite this article: