Aims

To assess the extent of osteointegration in two designs of shoulder resurfacing implants. Bony integration to the Copeland cylindrical central stem design and the Epoca RH conical-crown design were compared.

We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin.

We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastastic disease.

We report the results of supramalleolar varus osteotomy on seven ankles (in six patients) for haemophilic arthropathy and secondary valgus deformity. The operation reduced pain and the frequency of intra-articular bleeding while preserving joint function for a mean of nine years. The procedure is an attractive alternative to the more commonly used surgical option of arthrodesis.

Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body.

We have reviewed 34 children who had been treated by open reduction through a medial incision and transarticular pinning for a severely displaced supracondylar fracture of the humerus. Follow-up ranging from nine months to 20 years showed that 27 of 34 elbows (79%) had excellent or good results, with satisfactory resolution of neurovascular problems and no complications due to the method of treatment.

Thirteen elbows affected by severe haemophilic arthropathy and treated by silastic interposition arthroplasty were followed up for at least five years. The severity of pain, the frequency and severity of spontaneous haemorrhage and the range of movement were assessed before operation and at review. All patients were much improved and needed less factor replacement. Three elbows were revised, one for infection and two because of fragmentation of the silastic sheet. They regained good function following revision.

The uptake of 99mTc-MDP was studied in 73 patients after a tibial fracture. The image obtained five minutes after injection during a period between one and four weeks after fracture was found to be related to the incidence of non-union after six months. A ratio of 1.3 between the uptake at the fracture site and at normal bone adjacent to it predicted non-union in an individual patient with a sensitivity of about 70% and a specificity of 90%.

Two girls with congenital postural deformity of the wrist associated with deformity of the feet are reported. Fetal position in utero is discussed as a likely cause, and treatment by simple manipulation is recommended.

Six patients with severe haemophilic arthropathy of the elbow have been treated by limited excision arthroplasty using a sheet of silicone rubber as an interposition membrane. There were no complications. The symptoms and signs before and after operation have been assessed using the grading system advocated recently by the World Federation of Haemophilia. In all cases there was relief of pain and increased movement. Moreover, the subsequent incidence of spontaneous haemorrhage into the elbow has been reduced with considerable cost benefit.

Two cases of coccydynia are presented. Their definitive treatment was excision of the coccyx and the pericoccygeal tissues. The histology in both cases revealed a glomus tumour of the coccygeal body and the symptoms were completely relieved after operation. Glomus tumours of the coccygeal body may be the cause of some cases of coccydynia.

Five patients severely affected by haemophilia, in whom six knees showed advanced haemophilic arthropathy, have been studied. The patients presented with painful limitation of movement and increasingly frequent episodes of spontaneous bleeding in the affected knees. These all showed secondary degenerative changes and varus deformity. A Corrective osteotomy of the proximal tibia was performed under full haematological cover without complications. Follow-up ranged from 6 to 36 months, with a mean of 18 months. At follow-up all patients were free of pain and had retained their range of movement. In the three patients with a longer follow-up there was radiological improvement. The most significant feature was that there was almost complete cessation of bleeding episodes into the knee in all patients and no progression of the arthropathy. The cost benefit implications of this corrective procedure are discussed.