A new method of vascularised tibial grafting
has been developed for the treatment of avascular necrosis (AVN)
of the talus and secondary osteoarthritis (OA) of the ankle. We
used 40 cadavers to identify the vascular anatomy of the distal
tibia in order to establish how to elevate a vascularised tibial
graft safely. Between 2008 and 2012, eight patients (three male,
five female, mean age 50 years; 26 to 68) with isolated AVN of the
talus and 12 patients (four male, eight female, mean age 58 years;
23 to 76) with secondary OA underwent vascularised bone grafting
from the distal tibia either to revascularise the talus or for arthrodesis.
The radiological and clinical outcomes were evaluated at a mean
follow-up of 31 months (24 to 62). The peri-malleolar arterial arch
was confirmed in the cadaveric study. A vascularised bone graft
could be elevated safely using the peri-malleolar pedicle. The clinical
outcomes for the group with AVN of the talus assessed with the mean
Mazur ankle grading scores, improved significantly from 39 points
(21 to 48) pre-operatively to 81 points (73 to 90) at the final
follow-up (p = 0.01). In all eight revascularisations, bone healing
was obtained without progression to talar collapse, and union was
established in 11 of 12 vascularised arthrodeses at a mean follow-up
of 34 months (24 to 58). MRI showed revascularisation of the talus
in all patients. We conclude that a vascularised tibial graft can be used both
for revascularisation of the talus and for the arthrodesis of the
ankle in patients with OA secondary to AVN of the talus. Cite this article:
We present the mid- to long-term results of the Chiari pelvic osteotomy for dysplastic hips. We followed 135 hips in 129 patients, with a mean age at the time of surgery of 24 years, for a mean of 16.2 years. We used the anterior iliofemoral approach without trochanteric osteotomy in the initial 31 hips. Thereafter, we used transtrochanteric approaches in an attempt to ensure that the osteotomy was at the most appropriate level, and to advance the high-riding greater trochanter distally. The next 79 hips therefore underwent a posterolateral approach and the most recent 25 hips an Ollier lateral U approach. The clinical result was excellent or good in 103 hips (77%). The outcome in 104 hips in which we used a transtrochanteric approach was superior, the osteotomy level was more appropriate and a Trendelenburg gait less common than in 31 hips in which we used an anterior approach. We therefore recommend the use of a transtrochanteric approach in order to ensure that the osteotomy is at an appropriate level and in order to achieve effective distal advancement of the high-riding greater trochanter.
Between 1978 and 1988 a total of 27 operations were performed on 26 patients for cervical myelopathy due to rheumatoid disease in the subaxial spine. Three different causes were recognised: the first group had cord compression due to subluxation of the cervical spine itself (6 patients); the second had cord compression occurring from in front, with rheumatoid lesions of vertebral bodies or discs (6); the third had compression from behind the cord due to granulation tissue within the epidural space (14). Group I was treated by closed reduction of the subluxation followed by surgical fusion either from in front or behind. Group II was decompressed by subtotal resection of the involved vertebral bodies and discs, followed by interbody fusion. The patients in group III were decompressed by laminectomy and excision of fibrous granulation tissue from the epidural space. Good recovery of neurological function was observed after 18 of the operations, fair recovery after five, poor recovery followed three, and one was worse. Myelopathy recurred in four patients, all of whom had had anterior interbody fusion.
We have used a modified technique of cervical osteotomy to treat a consecutive series of 23 patients with chronic slip of the upper femoral epiphysis. It has been successful in correcting both moderate and severe deformities with a low incidence of avascular necrosis, comparable to that seen after subtrochanteric osteotomies. We describe the operative details and discuss the features which make cervical osteotomy technically superior to intertrochanteric and subtrochanteric procedures.
Late-onset idiopathic scoliosis is associated with a rib hump in the thoracic region, and surgery is indicated when this deformity becomes unacceptable. Fifty patients with this deformity were treated by the Leeds procedure, which consists of segmental wiring to a kyphotically-contoured square-ended Harrington rod; this procedure not only derotates the spine but restores the natural thoracic kyphosis, thus avoiding subsequent buckling. All patients were followed up for a minimum of two years. Forty-two of these, who had a pre-operative Cobb angle of less than 60 degrees, were treated by one-stage instrumentation and fusion, while the remaining eight with greater curves underwent preliminary anterior multiple discectomy to provide flexibility with shortening. Postoperative loss of correction was not observed and there were no neurological complications.
Eleven patients with metastases in the cervical spine had operations for severe pain due to a pathological fracture which, in eight of the cases, was unstable. Conservative treatment had either failed or was unsuitable. In the first five patients internal fixation with tension band wires and bone grafts was supported by a halo-brace. The method has evolved to the use of posterior instrumentation with laminar wires from two levels above the lesion to two levels below. Stability is increased by the use of bone cement with or without bone autografts applied to one side of the spine. This technique enables the patient to get up within a few days of operation--a great advantage when life expectancy is limited. The operations were successful in all except one case.
Adults with deformities of the lower limb due to spasticity may be considerably improved by operation, but thorough pre-operative assessment as an inpatient is essential in order to pinpoint the disability. The commonest deformity is equinovarus which often responds to simple operative procedures. The results of seventy-seven operative procedures in fifty patients are recorded. Correction once achieved is stable and the deformity does not recur.
Simple pinning to fix the epiphysis in those patients in whom the position is acceptable is a valuable surgical procedure. It is safe and gives good results. It eliminates the danger of further displacement, promotes fusion of the epiphysial plate and allows the patient to return to full activity within one month, thus avoiding joint stiffness, muscle atrophy, osteoporosis and interference with growth at other sites. Fixation by small pins is preferable to the use of the trifin nail, the latter giving excessive trauma and predisposing to subtrochanteric fracture. Gentle replacement of the epiphysis, when loose, into an acceptable position is a valuable method of treatment. It is essential that replacement is not undertaken by force. The problem of major displacement of the epiphysis which cannot be so replaced is unsolved. Conservative treatment in this group is useless and harmful. Intra-articular osteotomy can give good results in most cases but is risky and may cause stiffening of the hip. Subtrochanteric osteotomy does not give a good anatomical result but in most cases the function of the hip is satisfactory. Slipping of the upper femoral epiphysis, however slight, should be regarded as a surgical emergency.
We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results.
Osteoarthritis of the wrist is a complication of a number of common traumatic conditions. Arthrodesis of the radiocarpal joint, proximal row carpectomy and excision of the scaphoid, combined with midcarpal arthrodesis, have all been reported as surgical options. There have been no randomised studies comparing these procedures, and the feasibility of conducting this type of trial is limited. We used decision analysis to compare the three surgical techniques. The variables for the model used were based principally on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The model indicated that the preferred treatment is proximal row carpectomy. Decision analysis allows a comparison between alternative treatments, when evidence from a randomised trial is lacking or unobtainable. The decision-analysis model may also provide insight into aspects of a problem which would be difficult, or impossible, to evaluate by a cohort study.
We reviewed 35 of 38 consecutive patients who had operative treatment for medial epicondylitis of the elbow after the failure of conservative management. Their mean age was 43 years and mean follow-up was 85 months. At operation residual tears with incomplete healing were consistently found in the flexor origin at the medial epicondyle and microscopy showed reactive fibrous connective tissue with varying degrees of inflammation. The mean subjective estimate of elbow function was improved from 38% to 98% of normal, while isokinetic and grip strength testing in 16 patients showed no significant difference from the unoperated elbow. Results were excellent in 25 cases, good in nine and fair in one; 86% of the patients had no limitation in the use of the elbow.
We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction.
1. A case of Behçet's syndrome in which the main complaint was severe pain in the manubrio-sternal joint is described. Arthrodesis relieved the pain. 2. Histological material from a mouth ulcer and from the manubrio-sternal joint showed non-specific inflammatory changes but failed to throw light on the etiology.
The results of 110 operations for the treatment of fractures through metastases in the femoral neck and intertrochanteric region have been studied. Of these, forty-four fractures were treated by internal fixation, forty-six by resection of the femoral head and neck, and twenty by prosthetic replacement. The following conclusions were reached. 1. Prosthetic replacement of the femoral head is a reliable procedure. 2. The long stem type of prosthesis has the advantages of greater stability and simultaneous fixation of the shaft. 3. Patients with 4. Resection is a less traumatic procedure and therefore useful in the palliative treatment of patients in poor general condition. 5. Internal fixation leads more often to complications and unfavourable results than do the other methods.
We treated 26 hips (24 consecutive patients) with residual dysplasia by a technique of incomplete triple pelvic osteotomy. The mean age of the patients was 21.6 years. The mean values for the pre-operative centre-edge angle of Wiberg, the refined centre-edge angle, the acetabular angle of Sharp, the modified acetabular angle and femoral head lateralisation were 7.7°, −3.1°, 49.3°, 53.2° and 17.2 mm, respectively. After a mean follow-up of 3.3 years they were 27.0°, 13.0°, 38.9°, 44.3° and 15.9 mm, respectively (p <
0.05). The osteoarthritic grading changed adversely in one hip. The mean pre-operative and latest Harris hip scores were 74.9 and 93.0, respectively (p <
0.05). This technique provides a stable osteotomy with maintenance of the posterior column which allows early mobilisation and minimal internal fixation. The technique is not complex and requires minimal blood transfusion. The use of an image intensifier is not necessary and harvesting of a subcristal bone graft avoids post-operative complications at the donor site.
A six-year-old girl with congenital sensory neuropathy with anhidrosis (CSNA) presented with bilateral hip dysplasia and subluxation on the right side. Conservative treatment of the hips by closed reduction and a plaster cast was unsuccessful. When aged seven years the patient had an intertrochanteric varus rotation osteotomy on the right side, but subluxation was again evident after five months. A Salter-type pelvic osteotomy was carried out followed by immobilisation, but one year later subluxation was present in the right hip and dislocation in the left. At the age of nine years, the right femoral head resembled a Charcot joint, although walking ability was preserved. In patients with CSNA, surgery may not always be advisable.
