We describe the treatment by subperiosteal resection of an aneurysmal bone cyst in the distal fibula in eight patients and highlight the role of the periosteum in the regeneration of bone defects. The mean age of the patients was 13.5 years (12 to 17). Seven had an open growth plate. The mean size of the resected specimen was 5.12 cm (3.5 to 8.0). None of the patients received instillation of bone marrow, autogenous bone graft, allograft or any synthetic bone substitutes. All had complete regeneration of the bone defect within three to nine months, with no joint instability or recurrence. The mean length of follow-up was 11.5 years (2 to 18). At the final follow-up there was no difference in the range of movement, alignment or stability of the ankle when compared with the opposite side. The periosteum played a major role in the complete filling of the bone defects and avoided the morbidity of other techniques.
We have investigated whether shape of the knee
can predict the clinical outcome of patients after an anterior cruciate
ligament rupture. We used statistical shape modelling to measure
the shape of the knee joint of 182 prospectively followed patients
on lateral and Rosenberg view radiographs of the knee after a rupture
of the anterior cruciate ligament. Subsequently, we associated knee
shape with the International Knee Documentation Committee subjective
score at two years follow-up. The mean age of patients was 31 years
(21 to 51), the majority were male (n = 121) and treated operatively
(n = 135). We found two modes (shape variations) that were significantly
associated with the subjective score at two years: one for the operatively
treated group (p = 0.002) and one for the non-operatively treated
group (p = 0.003). Operatively treated patients who had higher subjective
scores had a smaller intercondylar notch and a smaller width of
the intercondylar eminence. Non-operatively treated patients who
scored higher on the subjective score had a more pyramidal intercondylar
notch as opposed to one that was more dome-shaped. We conclude that
the shape of the femoral notch and the intercondylar eminence is predictive
of clinical outcome two years after a rupture of the anterior cruciate
ligament. Cite this article:
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:
We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients <
50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases >
50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p <
0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is <
50 years of age, and the pre-operative delay is <
seven months. If the patient is >
50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure.
Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.
The April 2014 Wrist &
Hand Roundup360 looks at: diagnosis of compressive neuropathy; relevant reviews; the biomechanics of dorsal PIP fracture dislocation; the more strands the better; and state of mind the best predictor of outcome.
A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.
There have been few reports regarding the efficacy
of posterior instrumentation alone as surgical treatment for patients
with pyogenic spondylitis, thus avoiding the morbidity of anterior
surgery. We report the clinical outcomes of six patients with pyogenic
spondylitis treated effectively with a single-stage posterior fusion
without anterior debridement at a mean follow-up of 2.8 years (2
to 5). Haematological data, including white cell count and level
of C-reactive protein, returned to normal in all patients at a mean
of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion
between the infected vertebrae was observed in five patients at
a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining
patient having partial union. Severe back pain was immediately reduced
following surgery and the activities of daily living showed a marked
improvement. Methicillin-resistant Single-stage posterior fusion may be effective in patients with
pyogenic spondylitis who have relatively minor bony destruction.
The purpose of this study was to establish whether
exploration and neurolysis is an effective method of treating neuropathic
pain in patients with a sciatic nerve palsy after total hip replacement
(THR). A total of 56 patients who had undergone this surgery at
our hospital between September 1999 and September 2010 were retrospectively identified.
There were 42 women and 14 men with a mean age at exploration of
61.2 years (28 to 80). The sciatic nerve palsy had been sustained
by 46 of the patients during a primary THR, five during a revision
THR and five patients during hip resurfacing. The mean pre-operative
visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean
post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement
of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were
significantly different (p <
0.001). Based on the findings of
our study, we recommend this form of surgery over conservative management
in patients with neuropathic pain associated with a sciatic nerve
palsy after THR. Cite this article:
The April 2012 Oncology Roundup360 looks at chondrosarcoma of the cervical spine, if excision margins matter, radiation-induced sarcomas, giant cell tumours and bone cement, enchondromatosis and malignant change, axial or appendicular Ewing’s sarcoma, and diagnosing a sarcoma
The June 2012 Trauma Roundup360 looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas.
Over recent years hip arthroscopic surgery has
evolved into one of the most rapidly expanding fields in orthopaedic surgery.
Complications are largely transient and incidences between 0.5%
and 6.4% have been reported. However, major complications can and
do occur. This article analyses the reported complications and makes recommendations
based on the literature review and personal experience on how to
minimise them.
Chondral damage to the knee is common and, if left untreated, can proceed to degenerative osteoarthritis. In symptomatic patients established methods of management rely on the formation of fibrocartilage which has poor resistance to shear forces. The formation of hyaline or hyaline-like cartilage may be induced by implanting autologous, cultured chondrocytes into the chondral or osteochondral defect. Autologous chondrocyte implantation may be used for full-thickness chondral or osteochondral injuries which are painful and debilitating with the aim of replacing damaged cartilage with hyaline or hyaline-like cartilage, leading to improved function. The intermediate and long-term functional and clinical results are promising. We provide a review of autologous chondrocyte implantation and describe our experience with the technique at our institution with a mean follow-up of 32 months (1 to 9 years). The procedure is shown to offer statistically significant improvement with advantages over other methods of management of chondral defects.
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.
Stem cells are a key component of regenerative medicine strategies. Particular areas of musculoskeletal application include cartilage and bone regeneration in arthritis and trauma. There are several types of stem cell and this article will focus on the adult derived cells. The review includes current issues and future developments.
We report the functional and socioeconomic long-term
outcome of patients with pelvic ring injuries. We identified 109 patients treated at a Level I trauma centre
between 1973 and 1990 with multiple blunt orthopaedic injuries including
an injury to the pelvic ring, with an Injury Severity Score (ISS)
of ≥ 16. These patients were invited for clinical review at a minimum
of ten years after the initial injury, at which point functional
results, general health scores and socioeconomic factors were assessed. In all 33 isolated anterior (group A), 33 isolated posterior
(group P) and 43 combined anterior/posterior pelvic ring injuries
(group A/P) were included. The mean age of the patients at injury
was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44). At review the mean Short-Form 12 physical component score for
the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score
for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42),
being significantly worse compared with the other two groups (p =
0.004 and p = 0.024, respectively). A total of 42 patients (39%)
had a limp and 12 (11%) required crutches. Car or public transport
usage was restricted in 16 patients (15%). Overall patients in groups
P and A/P had a worse outcome. The long-term outcome of patients
with posterior or combined anterior/posterior pelvic ring injuries
is poorer than of those with an isolated anterior injury. Cite this article:
While injury to the posterolateral corner is accepted as a relatively common occurrence associated with rupture of the anterior cruciate ligament, posteromedial meniscocapsular injury has not previously been recognised as such. In a prospective assessment of 183 consecutive reconstructions of the anterior cruciate ligament this injury was observed in 17 cases, giving it an incidence of 9.3%. Clinically, it was associated with a mild anteromedial rotatory subluxation and it is important not to confuse this with posterolateral rotatory subluxation. In no case was this injury identified by MRI. The possible long-term clinical relevance is discussed.
Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary.
We reviewed 5086 patients with a mean age of
30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate
ligament (ACL) in order to determine the incidence of secondary
pathology with respect to the time between injury and reconstruction.
There was an increasing incidence of medial meniscal tears and chondral damage,
but not lateral meniscal tears, with increasing intervals before
surgery. The chances of requiring medial meniscal surgery was increased
by a factor of two if ACL reconstruction was delayed more than five
months, and increased by a factor of six if surgery was delayed
by >
12 months. The effect of delaying surgery on medial meniscal injury
was also pronounced in the patients aged <
17 years, where a
delay of five to 12 months doubled the odds of medial meniscal surgery
(odds ratio (OR) 2.0, p = 0.001) and a delay of >
12 months quadrupled
the odds (OR 4.3, p = 0.001). Increasing age was associated with
a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal
injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The
gender split (3251 men, 1835 women) revealed that males had a greater
incidence of both lateral (34% (n = 1114) Cite this article: