A displaced fracture of the scaphoid is one in
which the fragments have moved from their anatomical position or there
is movement between them when stressed by physiological loads. Displacement
is seen in about 20% of fractures of the waist of the scaphoid,
as shown by translation, a gap, angulation or rotation. A CT scan
in the true longitudinal axis of the scaphoid demonstrates the shape
of the bone and displacement of the fracture more accurately than
do plain radiographs. Displaced fractures can be treated in a plaster
cast, accepting the risk of malunion and nonunion. Surgically the
displacement can be reduced, checked radiologically, arthroscopically
or visually, and stabilised with headless screws or wires. However,
rates of union and deformity are unknown. Mild malunion is well
tolerated, but the long-term outcome of a displaced fracture that
healed in malalignment has not been established. This paper summarises aspects of the assessment, treatment and
outcome of displaced fractures of the waist of the scaphoid.
We performed a prospective study to examine the
influence of the patient’s position on the location of the abdominal
organs, to investigate the possibility of a true lateral approach
for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal
CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy.
Axial images in parallel planes of each intervertebral disc from
L1 to L5 were achieved in both supine and prone positions. The most
horizontal approach angles possible to avoid injury to the abdominal
organs were measured. The results demonstrated that the safe approach
angles were significantly less (i.e., more horizontal) in the prone
than in the supine position. Obstacles to a more lateral approach
were mainly the liver, the spleen and the kidneys at L1/2 (39 of
40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4
(33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach
from each side was possible for 30 of the 40 discs at L3/4 (75%)
and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more
horizontal approach for transforaminal endoscopic lumbar discectomy
is possible in the prone position but not in the supine. Prone abdominal
CT is more helpful in determining the trajectory of the endoscope.
While a true lateral approach is feasible in many patients, our
study shows it is not universally applicable.
Frozen shoulder is commonly encountered in general
orthopaedic practice. It may arise spontaneously without an obvious
predisposing cause, or be associated with a variety of local or
systemic disorders. Diagnosis is based upon the recognition of the
characteristic features of the pain, and selective limitation of
passive external rotation. The macroscopic and histological features
of the capsular contracture are well-defined, but the underlying
pathological processes remain poorly understood. It may cause protracted
disability, and imposes a considerable burden on health service
resources. Most patients are still managed by physiotherapy in primary
care, and only the more refractory cases are referred for specialist
intervention. Targeted therapy is not possible and treatment remains predominantly
symptomatic. However, over the last ten years, more active interventions
that may shorten the clinical course, such as capsular distension
arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features
of frozen shoulder. We also outline the current treatment options,
review the published results and present our own treatment algorithm.
We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage. At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012). Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.
We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal ‘tube’ realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score. There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the ‘four-in-one’ procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.
This retrospective study compared post-operative
epidural analgesia (E), continuous peripheral nerve blocks (CPNB) and
morphine infusion (M) in 68 children undergoing limb reconstruction
with circular frames. The data collected included episodes of severe
pain, post-operative duration of analgesia, requirement for top-up
analgesia, number of osteotomies, side effects and complications.
There was a significant difference between the number of episodes
of severe pain in patients receiving a morphine infusion and those
receiving epidurals or CPNB (M
Recurrence of back or leg pain after discectomy
is a well-recognised problem with an incidence of up to 28%. Once conservative
measures have failed, several surgical options are available and
have been tried with varying degrees of success. In this study,
42 patients with recurrent symptoms after discectomy underwent less
invasive posterior lumbar interbody fusion (LI-PLIF). Clinical outcome
was measured using the Oswestry Disability Index (ODI), Short Form
36 (SF-36) questionnaires and visual analogue scales for back (VAS-BP)
and leg pain (VAS-LP). There was a statistically significant improvement
in all outcome measures (p <
0.001). The debate around which
procedure is the most effective for these patients remains controversial. Our results show that LI-PLIF is as effective as any other surgical
procedure. However, given that it is less invasive, we feel that
it should be considered as the preferred option.
We evaluated 535 consecutive primary cementless total knee replacements (TKR). The mean follow-up was 9.2 years (0.3 to 12.9) and information on implant survival was available for all patients. Patients were divided into two groups: 153 obese patients (BMI ≥ 30) and 382 non-obese (BMI <
30). A case-matched study was performed on the clinical and radiological outcome, comparing 50 knees in each group. We found significantly lower mean improvements in the clinical score (p = 0.044) and lower post-operative total clinical scores in the obese group (p = 0.041). There was no difference in the rate of radiological osteolysis or lucent lines, and no difference in alignment. Log rank test for survival showed no significant differences between the groups (p = 0.167), with a ten-year survival rate of 96.4% (95% confidence interval (CI) 92 to 99) in the obese and 98% (95% CI 96 to 99) in the non-obese. The mid-term survival of TKR in the obese and the non-obese are comparable, but obesity appears to have a negative effect on the clinical outcome. However, good results and high patient satisfaction are still to be expected, and it would seem unreasonable to deny patients a TKR simply on the basis of a BMI indicating obesity.
We have investigated whether control of balance is improved during stance and gait and sit-to-stand tasks after unilateral total hip replacement undertaken for osteoarthritis of the hip. We examined 25 patients with a mean age of 67 years ( Before surgery, control of balance during gait and sit-to-stand tasks was abnormal in patients with severe osteoarthritis of the hip, while balance during stance was similar to that of the healthy control group. After total hip replacement, there was a progressive improvement at four and 12 months for most gait and sit-to-stand tasks and in the time needed to complete them. By 12 months, the values approached those of the control group. However, trunk pitch (forwards-backwards) and roll (side-to-side) velocities were less stable (greater than the control) when walking over barriers as was roll for the sit-to-stand task, indicative of a residual deficit of balance. Our data suggest that patients with symptomatic osteoarthritis of the hip have marked deficits of balance in gait tasks, which may explain the increased risk of falling which has been reported in some epidemiological studies. However, total hip replacement may help these patients to regain almost normal control of balance for some gait tasks, as we found in this study. Despite the improvement in most components of balance, however, the deficit in the control of trunk velocity during gait suggests that a cautious follow-up is required after total hip replacement regarding the risk of a fall, especially in the elderly.
We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular
We report a case of spontaneous physeal growth arrest of the distal femur in a nine-year-old child with Ewing’s sarcoma of the proximal femur treated with chemotherapy and endoprosthetic replacement. Owing to the extent of disuse osteoporosis at the time of surgery, the entire intramedullary canal up to the distal femoral physis was filled with cement. Three years later, the femur remained at its pre-operative length of 19 cm. Pre-operative calculations of further growth failed to account for the growth arrest, and the initial expandable growing prosthesis inserted has been revised to a longer one in order to address the leg-length discrepancy. To our knowledge, this is the only reported case of distal femoral physeal growth arrest following cemented endoprosthetic replacement of the proximal femur.
The effects of the method of fixation and interface conditions on the biomechanics of the femoral component of the Birmingham hip resurfacing arthroplasty were examined using a highly detailed three-dimensional computer model of the hip. Stresses and strains in the proximal femur were compared for the natural femur and for the femur resurfaced with the Birmingham hip resurfacing. A comparison of cemented
Patients with Bertolotti’s syndrome have characteristic lumbosacral anomalies and often have severe sciatica. We describe a patient with this syndrome in whom standard decompression of the affected nerve root failed, but endoscopic lumbosacral extraforaminal decompression relieved the symptoms. We suggest that the intractable sciatica in this syndrome could arise from impingement of the nerve root extraforaminally by compression caused by the enlarged transverse process.
Anatomical descriptions of the lateral retinaculum have been published, but the attachments, name or even existence of its tissue bands and layers are ill-defined. We have examined 35 specimens of the knee. The deep fascia is the most superficial layer and the joint capsule is the deepest. The intermediate layer is the most substantial and consists of derivatives of the iliotibial band and the quadriceps aponeurosis. The longitudinal fibres of the iliotibial band merge with those of the quadriceps aponeurosis adjacent to the patella. These longitudinal fibres are reinforced by superficial arciform fibres and on the deep aspect by transverse fibres of the iliotibial band. The latter are dense and provide attachment of the iliotibial band to the patella and the tendon of vastus lateralis obliquus. Our study identifies two important new findings which are a constant connection of the deep fascia to the quadriceps tendon superior and lateral to the patella, and, a connection of the deeper transverse fibres to the tendon of vastus lateralis obliquus.
A clinical and radiological study was conducted on 97 total hip replacements performed for congenital hip dislocation in 79 patients between 1989 and 1998 using a three-dimensional custom-made cementless stem. The mean age at operation was 48 years (17 to 72) and the mean follow-up was for 123 months (83 to 182). According to the Crowe classification, there were 37 class I, 28 class II, 13 class III and 19 class IV hips. The mean leg lengthening was 25 mm (5 to 58), the mean pre-operative femoral anteversion was 38.6° (2° to 86°) and the mean correction in the prosthetic neck was −23.6° (−71° to 13°). The mean Harris hip score improved from 58 (15 to 84) to 93 (40 to 100) points. A revision was required in six hips (6.2%). The overall survival rate was 89.5% (95% confidence interval 89.2 to 89.8) at 13 years when two hips were at risk. This custom-made cementless femoral component, which can be accommodated in the abnormal proximal femur and will correct the anteversion and frontal offset, provided good results without recourse to proximal femoral corrective osteotomy.
Abnormal knee kinematics following reconstruction
of the anterior cruciate ligament may exist despite an apparent resolution
of tibial laxity and functional benefit. We performed upright, weight-bearing
MR scans of both knees in the sagittal plane at different angles
of flexion to determine the kinematics of the knee following unilateral reconstruction
(n = 12). The uninjured knee acted as a control. Scans were performed
pre-operatively and at three and six months post-operatively. Anteroposterior
tibial laxity was determined using an arthrometer and patient function
by validated questionnaires before and after reconstruction. In
all the knees with deficient anterior cruciate ligaments, the tibial
plateau was displaced anteriorly and internally rotated relative
to the femur when compared with the control contralateral knee,
particularly in extension and early flexion (mean lateral compartment displacement:
extension 7.9 mm ( Our results show that despite improvement in laxity and functional
benefit, abnormal knee kinematics remain at six months and actually
deteriorate from three to six months following reconstruction of
the anterior cruciate ligament.
Large-head metal-on-metal total hip replacement has a failure rate of almost 8% at five years, three times the revision rate of conventional hip replacement. Unexplained pain remains a feature of this type of arthroplasty. All designs of the femoral component of large-head metal-on-metal total hip replacements share a unique characteristic: a subtended angle of 120° defining the proportion of a sphere that the head represents. Using MRI, we measured the contact area of the iliopsoas tendon on the femoral head in sagittal reconstruction of 20 hips of patients with symptomatic femoroacetabular impingement. We also measured the articular extent of the femoral head on 40 normal hips and ten with cam-type deformities. Finally, we performed virtual hip resurfacing on normal and cam-type hips, avoiding overhang of the metal rim inferomedially. The articular surface of the femoral head has a subtended angle of 120° anteriorly and posteriorly, but only 100° medially. Virtual surgery in a normally shaped femoral head showed a 20° skirt of metal protruding medially where iliopsoas articulates. The excessive extent of the large-diameter femoral components may cause iliopsoas impingement independently of the acetabular component. This may be the cause of postoperative pain with these implants.
We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain.
We describe a patient with a painful sciatic neuropathy after total hip arthroplasty. Treatment was confined to neuroleptic and analgesic agents until neurolysis at seven years abolished pain and restored function.
A 60-year-old man developed severe neuropathic pain and foot-drop in his left leg following resurfacing arthroplasty of the left hip. The pain was refractory to all analgesics for 16 months. At exploration, a PDS suture was found passing through the sciatic nerve at several points over 6 cm and terminating in a large knot. After release of the suture and neurolysis there was dramatic and rapid improvement of the neuropathic pain and of motor function. This case represents the human equivalent of previously described nerve ligation in an animal model of neuropathic pain. It emphasises that when neuropathic pain is present after an operation, the nerve related to the symptoms must be inspected, and that removal of a suture or irritant may lead to relief of pain, even after many months.