Receive monthly Table of Contents alerts from Orthopaedic Proceedings
Comprehensive article alerts can be set up and managed through your account settings
View my account settingsVisit Orthopaedic Proceedings at:
There are increasing opportunity of operative treatment for advanced aged patients with degenerative spinal disease aiming for better quality of life. We have studied such patients concerning operative result, complication and problem in pre- and peri- operative management, and achievement of their aims.
Control Group: All patients (n=23) went on to have surgery. The mean improvement in Constant score was two (Range: −16 to 12).
Congenital pseudarthrosis of the lower limb is not uncommon, with an incidence of approximately 1 in 150,000.
In contrast, isolated congenital pseudarthrosis of the fibula without tibial involvement is a very rare. There were only 11 cases of true isolated congenital pseudarthrosis of the fibula described in the English literature till 1999. We describe 3 patients diagnosed and treated in our institution. The current management is also discussed, highlighting the unique treatment options in this rare condition.
The patients were prospectively followed for two years.
Failure was defined as an increase of less than 20 points in the modified HSS knee score at the time of the review or the need for an additional operation related to the allograft. Thirteen knees were deemed to be failures giving a 75% success rate. Graft resorption occurred in five patients resulting in implant loosening. Four failed due to infection and non-union between the host bone and allograft was present in two. One patient with both knees grafted failed to gain a 20-point improvement. Survival analysis showed a 72% survival at 10 years. Clinically, the modified HSS score improved from a mean of 32.5 pre-operatively to 75.6 at the time of the review. Radiographic analysis of the surviving grafts showed no severe resorption, one moderate and two mild cases of resorption. Evaluation for loosening revealed one patient with a loose tibial component, while three patients had non-progressive tibial radiolucent lines. All four patients were asymptomatic.
Reported rates of dislocation after primary and revision total hip replacement (THR) vary widely, whereas subluxation after THR is not commonly reported. Importantly, it is now recognised that reported dislocation rates are likely to be an underestimate of the true dislocation rate. The primary aim of this study was to develop and validate a Patient Hip Instability Questionnaire and subsequently to use this questionnaire to determine the incidence of dislocation, subluxation and symptoms due to hip instability following primary and revision THR. In addition the associated costs, morbidity, disability and effects on health-related quality of life were examined.
A retrospective review of dislocation rates from 1996 to 1998 identified problems in determining the true dislocation rate from standard hospital and database records. Therefore, a patient-completed Hip Instability Questionnaire was developed and validated to monitor dislocation and subluxation rates. This was then mailed to patients three and 12 months following primary or revision THR. All dislocations were then confirmed by telephone interview and radiographs. Telephone interviews and patient completion of the SF-36 questionnaire were used to assess morbidity, disability and quality of life. Costs of treating patients with hip dislocation were also determined.
The response rate to the mailed questionnaire was greater than 95%. The questionnaire was shown to be a valid measure of the true rate of dislocation following THR and confirmed the inaccuracies in previous methods of determining dislocation rate based on hospital and database records. Using this questionnaire, the rate of subluxation was higher than previously reported and the significant morbidity and health care costs associated with with this complication were identified.
The use of this questionnaire will allow better assessment of morbidity and costs due to complications following THR.
Orthopaedics like all other branches of medicine is likely make tremendous scientific progress in the new millennium. The extent of this progress will depend on how we have done in last 1000 years. I feel it is important in a discussion of this nature to separate orthopaedic surgery from orthopaedic surgeons. Progress in orthopaedic surgery need not necessarily mean progress of the orthopaedic surgeon or for that matter the medical profession.
As an orthopaedic surgeon we have to deal with many issues such as taking care of all the patients who come our way; balancing our responsibilities to our patients and our families; fighting with the administration in the interest of good patient care and for our own economic well-being; and trying to keep up with advances in orthopaedics in order to stay, both competent as well as competitive. Unlike my generation you must deal with a host of health-care delivery systems, need to have a business acumen that rivals that of a corporate CEO and increasingly you require knowledge of coding that should qualify you as medical-records librarian. Before long you may become convinced unfortunately that medicine is really a business and not a profession. The essence of professionalism in medicine is the willingness of the physician to value the patient’s welfare above his or her own and to provide care when necessary without remuneration or at personal inconvenience. It is unselfish attention to the welfare of others and advancement of our patient interests that earns the public’s respect and trust. These in turn have caused the public to support the autonomy of medical practice, including the privilege of self-regulation. However, this trust has begun to erode. Financial return and economic security are important to all of us. But if and when the commercial ethic in medicine becomes so predominant that it is perceived by the society as greed replacing altruism, we will certainly face loss of autonomy and the ability to self-regulate. I believe that we are nearing that point when society will view medicine as a trade rather than as a profession and we will be treated accordingly.
Looking to the roots of western medicine, Hippocrates (466 to 370 BC) is recognized as the father of modern medicine. However the earliest mention seems to be in the Indian literature, the Rig Veda, the oldest book of Veda period (1500–99 BC) when the use of artificial leg as well as artificial eyes and teeth were recorded. Before the 20th Century, the practice of medicine employed little science and was mostly an art. Yet despite this its practitioners were held in the highest esteem. 100 years ago, a physician had few tools with which to work except those of compassion and caring. However, during this century a technological explosion has led to spectacular advances in medicine and as a consequence physicians are infinitely better equipped to bring good health-care to their patients. Our orthopaedic roots date back to 1743 when Nicholas Andre unveiled his splinted crooked tree. However, it was not until the use of plaster of Paris 100 years later that we moved out of the splint age. Modern fracture management rapidly accelerated during and after World War I with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and subsequent war has led great advance in the management of musculoskeletal trauma.
Operative practice however came into its own with the introduction of modern anesthesia by William Morton a dentist in 1846, sterility by courtesy of Joseph Lister in 1876 and antibiotics from Alexander Fleming in 1945. These advances made the outcome of surgery more predictable and the practice of orthopaedics, in particular expanded exponentially as operative risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation and reconstruction following trauma were all developed in the latter part of this century. Last 30 years has sen the rapid changes in technology and it may be a good time to pause and think where all are going and take an account of our games and losses.
Most important thing is “orthopaedic education” both at undergraduate and postgraduate level and continuing education. We must re emphasize that orthopaedic surgery means total care of the musculoskeletal system both conservative and operative. Most of us are interested in operative care because it is lucrative, and as Graham Apley use to say “Surgery in Fun” but 80% of our patients need conservative treatment. Scientific basis of our conservative treatment is appealing and is no better than the alternatives medicine providers. No wonders so many of our patients are now moving to “sinseh” and other providers, with dubious repetition.
Emphasizes in our residency is operative treatment and the residents enjoy it. Our continuation education if you may call it “Education” is sponsored one-way or other by multinational is mainly technology oriented to promote a particular product. This is not difficult to understand. These multinational are listed companies and it is not surprising that their motive is to make profit for their shareholders. Unfortunately I feel we are being caught and deviated from our goal of education and professionalism.
Type of education we are getting and type of education we need is quite different. What we need is an orthopaedic specialist with compassion but what we are becoming is a high-grade technician.
More emphasizes must be placed both at undergraduate and postgraduate level to have a better understanding of the biology of healing of the musculoskeletal system. We must emphasize on the conservative treatment and put it on a more scientific basis. We can no longer dismiss the alternatives as being substandard or even dangerous. We must therefore offer appropriate non-operative alternatives to our patients. If we do not adjust to this reality, we will be relegated to secondary status and will be called up only when operative intervention is a last resort. We are not just surgeons but we are physicians also lastly we may have gained in technology but may have lost in compassion. Medicine is both a science and art and even balance is necessary to provide good medical care. I am sure we will progress in the science of medicines but I hope we will not lose the art of medical practice. For future we must keep abreast with the new technological advances but should not forget the patient care is more than a technical achievement. As Ambre Pare said “we the physician treat the patient He cures them”.
The first decade of this century has been designated by the United Nations as the Decade of Bone and Joint Disease. The Decade was launched internationally in Geneva in January 2000, after almost two years of negotiations by health professionals, led principally by Orthopaedic Surgeons and Rheumatologists.
The Decade has four major aims:
To raise awareness of the growing burden of musculoskeletal disorders in society; To promote prevention of musculoskeletal disorders and empower patients through education campaigns; To advance research on prevention, diagnosis and treatment of musculoskeletal disorders; To improve diagnosis and treatment of musculoskeletal disorders
The Decade offers the opportunity for all those involved in the management of musculoskeletal disorders, patient support organisations and, most importantly, patients themselves to join together to impress upon governments around the world the enormous burden of these conditions.
In Australia musculoskeletal diseases are the second most common cause of presentation to a general practitioner and the third leading cause of health system expenditure. In 1993–94, musculoskeletal diseases accounted for nearly 300,000 hospital admissions, nearly 15 million medical services and over 13 million prescriptions. Significant disability due to musculoskeletal diseases has been noted in more than half of those aged over 55 and is also commonly self-reported in population samples. Indeed osteoarthritis, the most important form of arthritis, accounts for over 5% of years lost due to disability in Australia.
Over 100 countries have now established national coordinators and governments of over 50 countries have endorsed the Decade. A National Coordinating Committee comprising representatives of the Australian Orthopaedic Association, the Australian and New Zealand Bone and Mineral Society and the Matrix Biology Society have been established. The national launch of the Decade will be held in Melbourne on April 27 with the Federal Minister for Health and Aged Care in attendance.
The decade promises to be enormously exciting for patients with rheumatic disorders with a range of new technologies that can address some of the problems posed by these conditions. The Decade offers the opportunity for all of us to work together to further the interests of our patients with musculoskeletal disorders.
Injection of PMMA bone cement into fractured vertebral bodies has been used clinically and proved to be effective. However, there are concerns about thermal injury to the cord and interferece of bone remodling .The purpose of this study is to use the biodegradable bone substitute as an alternative for augumentation of fractured vertebral bodies .
Vertebroplasty is a radiologically guided therapeutic procedure that consists of percutaneous injection of surgical cement into unhealthy vertebra. Vertebroplasty originated from radiologists in Europe to stabilize malignant vertebral tumor by injecting PMMA cement (polymethyI methaerylate) percutaneously with a fluoroscopic guidance. With the achievement of an analgesic effect associated with vertebral reinforcement, Gangi (1996) and other radiologists (1998) extended the use of percutaneous injection of PMMA to the patients with spinal osteoporosis.
Since 1991, the authors have developed biomechanical augmentation of osteoporotic vertebral fractures by injecting self-hardening bioactive calcium phosphate paste, and reported in 1995 that the increased mechanical strength and osteoconductivity of the surrounding bone were achieved by the augmentation by bioactive calcium phosphate cement in the experimentally induced osteoporotic animals. In 1998, the authors reported clinical experiences of repair of osteoporotic vertebral fracture using transpedicular injection of calcium phosphate paste in 15 patients with fresh fracture or with vertebral pseudoarthrosis.
Various kinds of bone-substitutes including hydroxyapatite, calcium phosphate, carbonate and others have been currently utilized to stabilize the fractured osteoporotic vertebra. As the number of the patients with osteoporotic vertebral fracture is increasing with growing elderly population, the repairing of the spinal osteoporosis using biomaterials will be needed more and more. The current treatment and the future’s task will be discussed.
Since September 1999, a total of 45 senile patients with vertebral compression fractures have been randomly selected for this study. Three treatment modalities were performed including the medical treatment only(15; control group), PMMA cement(15; PMMA group) and HA cement(15; HA group) augmentation. The transpedicular injections of PMMA and HA cements were performed on the latter two groups respectively via posterior approach.
For all these patients, the subjective feeling and physical performance were evaluated by questionnaire (Modified Oswestry Questionnaire). The preop and postop X-rays, CT, bone density and bone markers were performed regularly for comparison and analysis.
In general, the subjective feeling and physical performance had at least one grade improvement. Even though the short-term results using questionnaire did not have significant differences among these three groups, many parameters did show the advantages of using cements. The back pain, self-esteem and quality of life resolved much earlier and persistent than that of control group. The non-progression in local kyphosis was also noted in the cement groups.
In addition, there were no significant differences between PMMA and HA cement groups. Both could be regarded as effective and reliable. However, due to the unique biological properties, HA cement is more promising in the future management of osteoporotic fractures.
The human genome project is the largest focussed project ever undertaken in human biology. Its initial aims were to determine the sequence of the 3 billion organic bases which form the genetic code, and to identify all genes. The draft version of the sequence was published in February 2001. Perhaps the most surprising outcome of this was the finding that humans have only have around 35,000 genes, fewer than early estimates had suggested. Approximately 75% of the genome is ‘intergenic’ with 25% forming the components of genes. The advent of the sequence will allow the ready isolation of genes for rare diseases much more rapidly than in the past. The project will not be completed until the functions of all genes and their roles in human health and disease have been determined. The common variant forms of all genes should be known by about 2003. Arising from this will be knowledge of the interactions of an individual’s genome with the environment and this will reveal susceptibility to common diseases. Predictive medicine will be the ability to determine, from genetic testing, those diseases which an individual has increased risk of developing later in life. Knowledge of the genes involved in disease susceptibility will provide a range of new targets for the development of drugs to prevent and treat disease. Testing for susceptibility genes for common diseases will allow specific strategies to be developed to delay their onset, and new drugs will be developed to allow specific treatments.
The Instructional Lecture will emphasise the advantages of multidisciplinary management for musculoskeletal tumours, which have produced marked improvement in survival rates in the past 10–15 years. The roles and contributions of individual team members in relation to the overall coordinated approach, which can be provided from a single Specialist Centre, or as a managed Clinical Network.
Clinical examples will be used to illustrate the advantages of this approach to the clinical management of these uncommon and challenging conditions. These will include aggressive benign giant cell tumour, malignant osteosarcoma, chondrosarcoma with pathological fracture, and a malignant fibrous histiocytoma of soft tissue.
It is frequently difficult to diagnose and treat of malignant sacral bone tumors. This tumor is diagnosed with lumbar disc hernia, instability coccygitis, hemorrhoids. We reviewed the surgical treatment of primary malignant (14) and secondary (metastatic) sacral tumors (11) in 25 patients from 1983 to 2000. Primary tumors consisted of chordoma in 11 patients, chordoma with spindle cell sarcoma, malignant peripheral nerve sheath tumor (MPNST), giant cell tumor of bone in 1 patient each. The secondary tumors consisted of invading carcinoma in 7 patients, metastatic carcinoma in 4 patients. Location of the sacral tumor was showed total sacrum in 2 patients, below S2 in 18, S3 in 2 and S4 in 3. Preserving nerves were L5 in 1 patient, S1 in 17, S2 in 2, S3 in 3, and 2 performed curettage. Posterior approach was used in 8 patients, and an anterior and posterior combined approach in 17. Sacrectomy only in 7 patients, and sacrectomy and colostomy in 8, including with rectum was performed in 8, and 2 patients had extensive curettage and bone graft or hydroxyapatite (HA) transplantation. Six tumor excisions were used modified T-saw which pass through the sacral canal preserving nerve roots. Surgical margin of chordoma in primary sacral tumors had wide in 10, wide excision with partial contamination in 2, except curettage in 1. MPNST had curettage and giant cell tumor of bone had marginal in 1 each. Secondary sacral tumors had wide in 9, marginal in 2.
Adjuvant therapy was used radiation therapy in 3 patients and chemotherapy in 2 and ethanol in 1. Musculocutaneous flap was reconstracted tensor fascia lata flap and gluteal muscle flap in 2 patients. Interval between initial chief complaints and diagnosis of chordoma detected from 6 months to 10 years, avarage 5 years 3 months by rectal examination, radiogram, genital ultra echo and MRI; invading carcinoma from 2 months to 3 years, avarage 8 months, and metastatic carcinoma from 2 months to 4 months, average 3 months. Six of 12 patients of chordoma in primary sacral tumors are alive from 6 months to 18 years, average 4 years 6 months; remaining patients were died 6 month to 8 years, average 3 years 2 months, except 2 patient died with infection. The patient with a MPNST died after 2 years 6 months, and a giant cell tumor of bone had no recurrence or lung metastases in 10 years.
One of 11 patients of secondary sacral tumor (initial surgery) is alive in 14 years 6 months, remaining 10 patients died 3 months to 4 years 6 months, average 1 year 10 months, except 2 patients died with infection. Complications were much bleeding, infection, skin slough, nerve injury. We recommend better surgical method that anterior and posterir approach use above S3, and posterior approach blow S4, A modified T-saw performed an osteotomy of the pars lateral of the sacrum, proved to be easier and faster than osteotomies performed using the old method.
Lower limb injuries are the main cause of temporary and permanent disability among motorcyclists in the developing world of the Asia –Pacific region. They cause non-fatal but serious injuries requiring hospitalisation. This study presents computer simulation of the crash behaviour of the carry basket of a small-engined motorcycle with the lower limb using finite element (FE) methods. The results suggest that the extensive deformation of the motorcycle basket may reduce the risk of injury to the lower limb. The behaviour of the basket during collision is analogous to the crumple zone of automobiles. The use of these deformable baskets is recommended for all small engined motorcycles.
All surgeries were minimally invasive using a single 2–4 cm skin incision.
We aim to present an 18 Month Review of one Surgeons Practice Involving 16 Patients with 3 or 4 part Fractures or 3 part Fracture-Dislocations of the Proximal Humerus in patients under 60 years of age.
Management principles include anatomic reduction, internal fixation and early movement.
The implants used in this series include:
The PLANTAN PLATE from ATLANTECH
The STRATEC 4.5 mm ANGLE BLADE PLATE
The POLARUS NAIL and various small cannulated screw systems.
3 patients were treared with minimal fixation, 5 with the AO Bladeplate, 4 with the PLANTAN plate and 4 with the Polarus nail.
Surgical Treatment, Radiographic and Clinical Outcomes will be reviewed. Anatomic considerations, surgical technique and outcomes will be discussed.
A cadaveric study was done to determine the relationship of intramedullary axis of femur and the anatomical landmarks of proximal femur. The sharp tipped intramedullary rod was placed in the medullary canal from the isthmus to the proximal femur in 20 adult femoral specimens. The point of exit was measured in relationship to the piriformis fossa, tip of greater tuberosity, and mid lesser tuberosity. The center of the femoral canal axis is 1.23 ± 0.92 cm superior and medial to the pirifomis fossa, and is located 1.55 ± 0.66 cm from greater tuberority and 5.21 ± 1.28 cm from mid lesser tuberosity. The clinical relevance of this study is that the starting point for closed antegrade intramedullary rod of the femur should be 1.2 cm superior and medial to piriformis fossa in order to avoid the difficulty and complications in intramedullary nailing.
86 children with 87 lateral condyle fractures were reviewed. Excellent clinical outcomes in 88.9% of Type 1 undisplaced or < 2mm displaced fractures treated by simple cast immobilisation.
In the Type 2 displaced fractures (2–3mm) treated by cast immobilisation, the risk of secondary displacement was 44%
For 2–3mm displaced fracture, we recommend percutaneous pinning or open reduction and Kirschner wire fixation.
For displaced or rotated fractures, the fragment should be reduced anatomically and fixed with K wire until radiological union.
The lateral condylar fractures of the humerus are the second most common injury around the elbow in children. Treatment of patients presenting late is controversial. We report our experience of treatment of these fracture over last thirteen years in 78 children seen between 1987 and 2000. Average age- 5.2 years ; 53 patients presented early and 25 patients presented more than 3 weeks after injury . In latter, 11 patients were treated conservatively and rest by internal fixation. Pseudovarus was observed in 30% cases on long term followup. Of 25 patients presenting late, open reduction, internal fixation with bone grafting was carried out in eight cases (those who presented between 3–6 weeks) and rest of the 17 cases were kept under observation on regular follow up. At final follow up, the cases operated late (n= 8) had preservation of 70–80 % of Flexion Extension Arc. Of the 17 cases kept under observation, 8 (showing non union) developed cubitus valgus. 9 cases (showing malunion) continue to have stiff elbow . The elbow function was better in the former group. We suggest that every effort should be made to fix the lateral condylar fragment in patients presenting even more than 3 weeks especially if the metaphyseal chunk is large, the fragment is not widely displaced and rotated and the fracture is type II Milch in a very young child (as those patients rapidly develop very severe cubitus valgus deformity with translocation of ulna).
Landmines continue to be a major cause of injury to both military and civilian personnel. This has lead to various strategies including the development of anti-landmine boots and vehicles. In an attempt to assess the efficacy of these strategies various physical and computer simulation models have been developed. International assessment technologies currently rely heavily on either live animal or human cadaver testing. Both these strategies are subject to wide individual variations and major practical and ethical problems. They are therefore not employed by the Australian Defence Organisation (ADO).
A multi-disciplinary team has been assembled by the ADO to develop both a “flesh and bone” human model and a computer simulation. The biomechanical human analogue is constructed from materials that have been developed to reflect the strength properties and performance of human tissues (biofidelity). The surrogates are also equipped with various sensory devices allowing analysis of the local and remote effects of load transmission throughout the body.
In the first stage of the program Frangible Synthetic Legs (FSL’s) were developed. These FSL’s have been blast tested in the presence of “protective” boots and vehicle platforms. These tests have yielded critical information on lower limb injury mechanisms and have highlighted the failings of some of these “protective” strategies.
These frangible surrogate humans can be reproduced with great consistency and, once sufficiently evolved, should remove the need for experimental assessment on either live animals or human cadavers. Whilst the Human Surrogate technology has application in the development of mine resistant boot technologies, it is also transferable to the various aeronautic and automotive crash test injury programs which are currently deficient in model biofidelity.
There is still some controversy about the treatment of nonunion of the lateral humeral condyle in children. Twelve patients with symptomatic long standing nonunion of the lateral humeral condyle were treated by internal fixation with iliac bone graft. The age range of the patients 8 years to 25 years. There were 10 males and 2 females. The time from the original fracture to nonunion ranged from 2 years 6 months to 13 years averaging 6 years 3 months.
The indication for surgery was pain and deformity and weakness in elbow. Follow up ranged from 16 months to 6 years averaging 32 months. Bony union was achieved in all cases. Strength of the elbow were restored in all cases. All patients were painfree in the elbow strenuous activities. Postoperative elbow motion was decreased in four patients with an average loss of 10.5 degree of the motion present before surgery. The valgus deformity was improved. Surgical osteosynthesis for long standing nonunion of the lateral humeral condyle is recommendable method.
Shortening 5% or less (none or epiphysiodesis) Shortening 6–10% (epiphysiodesis or lengthening) Shortening 11–30% (1–2 lengthenings) Shortening >
30% (multiple lengthening or amputation)
Upper extremities functional (amputation) Foot needed for prehension (no treatment)
A functional foot was defined as one which was or could be made plantigrade and stable with at least three rays.
Twenty-four patients had bilateral involvement. Twenty of 48 feet in these patients were Type II (nonfunctional). Nine patients with bilateral involvement had bilateral functional feet; these patients were short-statured, but were Type IA functionally.
The number of rays correlated directly with function: 100% of 5-rayed, 90% of 4-rayed, and 64% of 3-rayed feet were salvaged in this series. No feet less than 3-rayed were salvaged in this group; all such feet were associated with a completely absent fibula. Thirty-six of 63 limbs with completely absent fibula were classified as Type I. Eighty-two extremities in 65 patients have completed definitive management by virtue of skeletal maturity or amputation. A total of 39 extremities underwent Syme amputation, including 1 of 30 type IA, 1 of 11 type IB, 9 of 12 type IC, the single patient type ID, and all 27 type IIA deformities.
At present, multi-modality medical imaging including x-ray, fluoroscopy, ultrasound, CT, MRI, etc. allows to efficiently diagnose and plan for the majority of surgical interventions. So far, the resulting preoperative set of diagnostic and planning information could not be directly transformed to the real situation in the operating theatre. Additionally, there is a need to improve the accuracy and safety of surgical actions.
In the past few years a novel area of research and development – Computer Assisted Orthopaedic Surgery (CAOS) – has been established. Its primary goal is to provide a direct link between preoperative planning and intraoperative surgical action through advanced image-interactive surgical navigation. In addition, the use of computer hard- and software is promoted to enhance patient treatment and care pre- and postoperatively and to provide improved education and training of surgeons as well as advanced case documentation.
In this presentation an overview of the state of the art in CAOS research and development is given. Initial focus will be on image-interactive navigation based on preoperatively acquired three-dimensional tomographic image data sets. These techniques require intraoperatively a surgeon-generated transformation between the surgical object and the associated image based virtual object, the so-called registration procedure. Medical robots or free-hand navigation systems are then used to image-interactively perform various surgical actions. In addition, a novel approach to computer assisted orthopaedic surgery will be described, in which intraoperative images, such as ultrasound, endoscopy and fluoroscopy or ‘surgeon-defined anatomy’ complement or replace preoperatively acquired three-dimensional tomographic image data. Various applications for both strategies will be presented in different anatomical areas, such as spine, hip, shoulder, and knee. Surgical interventions ranging from joint reconstruction and replacement to trauma treatment will be covered.
Disc degeneration in the human spine is characterised by progressive fraying and dehydration of the nucleus pulposus associated with formation of clefts within the annulus fibrosus.
These have been classified on the basis of autopsy studies into radiating, circumferential and peripheral tears (rim lesions).
Outer tears allow neovascularisation of the outer third of the annulus fibrosus and ingrowth of nerve fibres.
Correlation with discographic findings had suggested the relevance of peripheral defects in the pathogenesis of discogenic pain.
Outer annular tears are likely to be linked to tensile strain onto the collagen fibres and, therefore, may have a mechanical aetiology.
In the animal model, peripheral tears of the outer annulus were proven to induce degenerative changes within the inner annulus and the nucleus pulposus.
The increased understanding of the role of discrete peripheral defects of the annulus in discogenic pain may support the potential therapeutic effects of thermal treatment using radiofrequency waves and specially designed probes.
At present, however, no in vivo studies have been able to demonstrate healing of outer annulus defects and reversibility of mechanical lesions to the intervertebral discs by thermal therapy.
While it is highly likely that discrete defects of the outer annulus may be responsible for acute episodes of self-limiting low back pain, it is unclear if annular pathology may be as relevant for chronic disabling back pain.
Recent studies using discography and other semi-invasive techniques have suggested that the main discriminating factors between benign, self limiting and chronic disabling back pain may not be anatomical but psycho-social.
The challenge remains, in the 21st Century as in the past, to devise appropriate strategies that may lessen the socio-economic burden of back pain.
Surgery, however, is highly unlikely to play a significant role in the future.
In Northern China, Ca intake and serum vitamin-D level of adolescents are low due to non-dairy-based diets and insufficient sunshine exposure. Maximisation of bone mineral accretion in childhood and adolescence requires adequate dietary calcium (Ca) intake and body vitamin-D status. This study focused on nutritional adaptation in Chinese adolescents under these adversed conditions by determining Ca absorption (CaAbn) and urinary calcium excretion (CaEx).
16 healthy individuals (12 girls, 4 boys) aged 9–17-y were recruited from Beijing during December. CaAbn was determined by a dual stable-isotope technique (44Ca and 42Ca) coupled with a Thermal-Ionization -Mass-Spectrometer.
Mean ±
The study showed that growing individuals with suboptimal vitamin D status are still capable of enhancing calcium absorption and reducing urinary calcium excretion to allow adequate bone Ca accretion.
We report a femoral shaft fracture that reduced spastic muscle hypertonus of the affected lower limb of a child with cerebral palsy. The child was a five years old boy. He was borne with spastic quadriplegia (total body involvement). He could not sit, stand and walk by himself. The femoral shaft fracture occurred during physiotherapy. The injury itself was iatrogenic although the bones were accompanied by roentgenological bone atrophy. Such bone atrophy comes from disuse or low physical activity.
The fracture was treated by a hip spica cast. The femoral bone was shortened at the time of immobilization. After removing the cast, the spastic muscle hypertonus was apparently reduced. This instructive case suggests osteotomy as a new effective treatment for spastic hypertonus. Osteotomies would make few scars in the muscles and tendons comparing to lengthening of multiple tendons and muscles. In this case, osteotomies are believed to be a non-invasive treatment rather than other available operative procedures.
Common cancer metastases in bone include those derived from the breast or prostate.
Associated with such metastases is considerable pain for the patient, a high incidence of pathological fractures (breast cancer metastases), and complications of spinal cord compression and paraplegia.
Attention has focussed on the properties of breast or prostate cancer cells that permit them to migrate from their primary site and to invade and grow in bone. Both breast and prostate cancer cell lines and primary cancers exhibit a number of phenotypic properties in common with bone cells, and it has been proposed that these properties may contribute to a breast cancer’s capacity to establish and grow in bone. Once established in bone, these cancers may induce an osteosceloritic or osteolytic lesion. Osteolysis is also noted in the establishment of an osteosclerotic lesion that is frequently associated with prostate cancers. Thus, paramount for a cancer to establish in bone is the requirement for limited bone destruction, and the magnitude of associated bone destruction is a function of the cancer cell.
Although it has been postulated that bone destruction by cancer cells is mediated directly by tumor cells, evidence indicates that breast cancer-induced bone destruction is mediated by the osteoclast. Support for the latter include: 1) breast cancers express cytokines [such as IL-1, IL-6, LIF, prostaglandin tumor necrosis factor and parathyroid hormone-related protein (PTHrP)] which can influence osteoclast formation; 2) histologic analyses of osteolytic lesions reveal tumor adjacent to osteoclasts resorbing bone; 3) and use of bisphosphonates, potent inhibitors of osteoclastic bone resorption, in women with breast cancer metastases to bone results in reduced skeletal morbidity.
The interaction of cytokines expressed by cancer cells in the bone microenvironment and their action on osteoblast/stromal cells to induce differentiation of haematopoietic cells of the macrophage / monocyte lineage into osteoclasts is now understood. The mechanisms involved in cancer metastasis, osteoclast formation, and ultimately bone destruction will be discussed, along with the potential new therapies to limit bone destruction.
Sarcoma is a malignancy of mesenchymal and neuroectodermal tissue, and as such, may arise in any location in the body. It is a rare tumour accounting for less than 1 in 1000 cancers and occurs with an incidence of 1.7–2 per 100000 head of population. Disease free survival following treatment of sarcoma has increased significantly over the last 20–30 years and five year survival for primary bone malignancies is approximately 75–80% and that for soft tissue sarcomas is approximately 70%.
Early attempts at limb sparing surgery was characterised by surgery with narrow margins, complicated incisions and substantial soft tissue bruising. Not surprisingly, the risk of local recurrence was high, but this was attributed to the nature of sarcoma rather than technique, and amputation became the treatment of choice for sarcoma.
In the mid 1970’s, the importance of surgical margins was recognised and guidelines were established for achieving oncologic surgical margins. Intralesional and marginal margins alone were regarded as inadequate, while wide and radical margins were acceptable for achieving local control of disease. The advent of magnetic resonance imaging improved the level of tumour delineation and allowed more accurate preoperative planning. This together with modern chemotherapy and radiotherapy increased the potential for limb sparing surgery.
Reconstruction following tumour resection is an exciting opportunity to protect the function of the limb and the mobility and independence of the patient. There have been a variety of techniques described and these involve either biological, prosthetic or a combination of these options. Reconstructions may be mobile or rigid. Mobile reconstructions frequently utilise prosthetic joints, but at other times pseudarthroses may function similarly, e.g. hip, shoulder. Osteoarticular allografts are also used to maintain joint function following tumour resection. Prosthetic joints incorporate advances in articulation and fixation to improve longevity as many of these devices are implanted into younger patients than normally anticipated for arthroplasty, and these joints are thus, exposed to an increased risk of wear and loosening. Osteoarticular allografts are prone to degenerative changes as well as graft disintegration and infection. Allograft prosthetic composites aim to reduce the articulation problems and may also assist in fixation of the construct. Biologic reconstructions using vascularised or non-vascularised bone are a useful technique for bridging defects and for replenishing bone stock. Adequate soft tissue coverage is vital following reconstruction.
The future of limb sparing surgery will depend on our ability to characterise the biological behaviour of the tumour because this will provide more information on the response of the tumour to treatment, the potential grade of the lesion and thus, its capacity to grown and spread. By understanding the process of tumour progression, we will be able to develop better strategies for treatment. Functional nuclear scanning using isotopes that are metabolised by tumours is a technique that is currently being evaluated as a complementary form of imaging. Chemotherapy has been the cornerstone in the treatment of bone sarcomas, but remains surprisingly disappointing when used for soft tissue sarcomas. Recent meta-analyses have demonstrated only a minimal improvement in disease–free survival with chemotherapy. Novel techniques or agents are required to improve the systemic role of chemotherapy. Patient selection is important and this may relate to their risk of developing systemic spread. Prognostic factors are therefore, important for identifying patients who may be candidates for novel or intensive chemotherapy. Molecular biology is providing an avenue for characterising these tumours but despite the identification of a multitude of distinctive chromosomal abnormalities with their associated gene products, only 2 abnormalities have been shown to be of prognostic significance (19p+ in MFH, and SSX/SYT in synovial sarcoma). Surgeon education is an area where significant advances may be made. Constant reiteration is required to ensure that the principles of proper diagnosis and referral are known. Successful treatment is dependent on knowledge of the criteria for and technique of biopsy, and the principle that the team that will be providing definitive treatment should perform the biopsy. Up to 30% of limbs are sacrificed each year because of inappropriate biopsy or surgery. This figure may be improved upon with greater understanding of the behaviour of sarcomas.
A regimented, multidisciplinary approach to the management of bone and soft tissue sarcomas is likely to improve the local and systemic control of this disease.
Primary disc space infections are thought to occur in children because of the abundant vascularity of the disc prior to skeletal maturity, and while they generally resolve with treatment, little is known about the long-term consequences on the spine.
An ovine model of discitis was used to investigate the effects of discitis on spinal development in the growing sheep. Six-week-old lambs underwent lumbar discography at multiple spinal levels using either radiographic contrast inoculated with Staphylococcus epidermidis (inoculated group) or radiographic contrast only (control group). Plain x-rays of the spines were taken at intervals up to 18 months before the animals were killed and the spines removed for histologic and morphometric analysis.
Discs from animals in the control group were radiologically and histologically normal at all time points, and as expected there was a steady increase in vertebral body and disc dimensions. Although not all inoculated animals showed histologic evidence of discitis, disc abnormalities were evident from an early stage. In particular disc height was significantly reduced from 2 weeks after inoculation and vertebral body dimensions were significantly reduced from one year.
Infection of discs at a young age, whether or not it progresses to discitis, has a significant effect on spinal development.
Tissue engineering in reconstructive surgery has many potential attractions, not the least to avoid donor site morbidity and reduce the potential need for allografts and prostheses. Currently there are only two products that have FDA approval in the United States, namely skin and cartilage. Other potential products being trialled are artificial blood vessels and heart valves. The common denominator of these is that they are essentially two dimensional and relatively avascular. Three dimensional tissue engineering has three essential components, (1) cells, (2) scaffold and (3) blood supply. Cells are most easily derived from an autologous source, by conventional tissue culture where they are expanded and implanted into the required site. They are committed cells and usually a large source of donor tissue is required to obtain an adequate source of cells for reconstruction. Stem cells have the potential to grow and differentiate, they may be embryonal which introduces ethical problems or adult stem cells. Cells can be genetically engineered to produce specific growth factors for the purpose of further cell proliferation, such as vascular endothelial growth factor for angiogenesis. The second essential is a scaffold for cells to adhere to and grow. This is particularly important for the development of the vascular network. Fibrin, PTFE (Dexon) Matrigel (a form of Laminen) or collagen are the most popular forms of matrix. The third and most essential component for three-dimensional tissue engineering is vascularization. To date, most tissue engineering research involves invitro studies of cell differentiation and growth but the invivo potential is limited because of inability to transfer a blood supply.
At the Bernard O’Brien Institute at St Vincent’s Hospital, Melbourne, we have developed a model of invivo tissue engineering which involves the initial creation of a vascular core inside a plastic chamber which can be moulded to any desired shape. This construct seems to be an ideal environment for seeding of cells, including stem cells which allows them to survive and differentiate into various mesenchymal tissues. To date we have been able to generate skin flaps, fat, tissue and skeletal muscle. Although our prime interest has not been bone or cartilage it is reasonable to assume that this can be relatively simply produced in the same model from either stem cell sources or by the use of differentiating factors.
Twenty-seven cases of baterial vertebral osteomyelitis during the period Dec. 1986 to Dec. 1995, were analyzed. The ages of the 13 men and 14 women ranged from 23 to 69 years. The main clinical symptoms were lower back pain and a knocking pain, with only 7 patients presenting with fever at the time of admission. Nineteen patients had white cell counts of more than 9000/cumm, and the sedimentation rate was significnatly elevated in 24 of 27 patients. Operation procedures were performed in 19 patients of which 15 patients underwent anterior fusion and bone graft and 4 patients had debridement only. One patient underwent posterior fusion 4 weeks after the anterior debridement with Harrington instrumentation. Other patients underwent bone biopsy under CT guidance and were treated by intravenous antibiotics and bed rest only. Bone union occurred after a period of between 2 months and eleven months. Surgery was indicated if an abscess was present, neurological complications occurred, instability
Pyogenic infection of the spine has been regarded as rare or uncommon. Kuloskil in 1936 reported the earliest large series of 102 cases. It may present diagnostic difficulties, as it often had an insiduous onset. Lower back pain is often ignored, and radiological changes may take weeks or months to develop. Neurological compromise can and does occur when treatment is delayed. Howerver, the increasing use of diagnostic instruments including CT scan and MR imaging has markedly improved the diagnostic rate. From 1986 to 1995 we reviewed 27 cases with proven osteomyelitis of the spine by pathology. This is a report of our experience with clinical presentation, diagnosis and surgical treatment of pyogenic osteomyelitis of the spine.
Post-tuberculous kyphosis in children is a ‘Dynamic deformity’ which changes till skeletal maturity. Children must not be discharged after disease cure and yearly follow up to monitor deformity is mandatory. Surgical intervention to prevent late profress will be needed in one third of children.
Lumbar disc herniations are quite common pathology in orthopedics. Percutaneous discectomy remains somewhat controvercial. It has limited indications and has not proven to be as effective as conventional or microscopic discectomy. Smith and Foley developed a new minimum invasive procedure for lumbar disc disease, Microendoscopic Discectomy (MED) in 1995.
We started MED from October 1998. Besides, we started the clinical application of MED for lumbar spinal canal stenosis from February 2000. The purpose of the presentations are to present operative technique, early clinical results and complications.
A) We operated upon 40 patients of MED from October 1998 to July 2000 for lumbar disc herniations. Male were 25, female were 15, and mean age was 38 years (15~64). In one patient, operated disc level was L2/3, in 21, L4/5, in 16, L5/S, and in two L4/5/S. Methods: We investigated: period of hospital stay, period of hospital stay postoperation, period to return to normal temperature, frequency of postop. NSAID, operation time, blood loss, period to begin to walk, JOA score, period to return to work or school, and complications. Results: The mean hospital stay was 17.9 days, the mean hospital stay postop. 9.7 days, period to return to normal temperature 1.3 days, frequency of postop. NSAID 1.1 times. The mean operation time was 105 ± 42 minutes, (65–180 min). The mean blood loss was 9.7 ± 18.5 Gm. (uncountable~ 120Gm.). All patients began to walk one day postoperatively. Mean JOA score was improved from 10.7 ± 3.8 preop. to 27.6 ± 0.9 4w. postop, to 28.1 ± 0.7 12w. postop., to 28.7 ± 0.6, 24w. postop. The mean period to return to work or school was 22.3 days. In one case, we had liquorrhea, and the damaged dura had to be repaired.
B)We operated upon five patients of decompression by MED for lumbar spinal canal stenosis from February 2000 to July 2000. Male were one, female were four, and mean age was 72 years (65–77). In four patient, operated disc level was L4/5, in one, L5/S. We will show the operative procedures by videotape. We investigated – operation time, blood loss, period to begin to walk, JOA score, and complications. Results: The mean operation time was 128+−31 minutes, (85m–170m.). The mean blood loss was 25 ± 29 Gm. (uncountable – 70Gm.). All patients began to walk one day postoperatively. Mean JOA score was improved from 15.7 ± 3.3preop. to 27.5 ± 0.5 4w. postop, to 28.0 ± 0.7 12w. postop.. There was no complication.
We analysed the histological findings in 1146 osteoarthritic femoral heads which would have been considered suitable for bone-bank donation to determine whether pathological lesions, other than osteoarthritis, were present. We found that 91 femoral heads (8%) showed evidence of disease. The most common conditions noted were chondrocalcinosis (63 cases), avascular necrosis (13), osteomas (6) and malignant tumours (one case of low-grade chondrosarcoma and two of well-differentiated lymphocytic lymphoma). There were two with metabolic bone disease (Paget’s disease and hyperparathyroid bone disease) and four with inflammatory (rheumatoid-like) arthritis. Our findings indicate that occult pathological conditions are common and it is recommended that histological examination of this regularly used source of bone allograft should be included as part of the screening protocol for bone-bank collection.
Primary bone tumours are rare and account for only 1% of cancer deaths. The commonest area for tumour occurrence is around the knee. With the advent of chemotherapy and improved survivorship of patients with osteosarcoma and Ewings of the extremities, excision of the primary lesion and reconstruction has become both a viable and routine option in specialist centres.
The surgical options include; excision alone, or excision and reconstruction with Autograft or allograft, or using massive prostheses to fill the defect.
In the UK, we have developed and used massive endoprostheses to fill the defect made following tumour excision and I would like to report our experience.
The first report of the use of massive endoprostheses was by Seddon & Scales in 1949 at The Royal National Orthopaedic Hospital, Stanmore. Since then both the number primary and revision procedures has continued to grow on a yearly basis. In the year 2000 we carried out 95 primary massive endoprosthetic replacements and 27 revisions.
In terms of functional score (Musculoskeletal Tumour Soc), following excision of tumours of the lower limb including excision of the affected joint, results are superior in those patients who undergo reconstruction using an endoprostheses (87%), as opposed to reconstructions using either osteoarticular allograft (68%), or rotationplasty (85%).
The long term survivorship of prosthetic replacement varies enormously between the upper and lower limbs due to the different forces acting upon them, indeed revision for aseptic loosening in the upper limb is rare.
In the lower extremity the probability of survivor-ship of a cemented proximal femoral replacement at ten years is 93.8%, whilst those for the distal femur or proximal tibia using a fixed hinge (Stanmore Mk4) are 67.4% and 58% respectively. The two factors that have a huge bearing on this are; the age of the patient and the amount of the diaphysis of the long bone resected.
To try and improve the long-term fixation of implants we have used porous coated collars at the prosthesis bone interface. These were first used in 1988, however subsequent retrieval specimens showed only fibrous tissue ingrowth although initial x-rays were thought to be encouraging.
Hydroxyapatite coated collars were first used in 1989 and have become standard use in all endoprosthetic replacement since. Indeed, retrieval specimens have revealed good bone ingrowth and no delamination of the HA.
Another huge advance has been the introduction in 1991 of the rotating hinge for implants of the distal femur and proximal tibia.
Subsequent studies have shown a significant reduction in aseptic loosening in distal femoral replacements which have both an HA collar and incorporate a rotating hinge.
Since 191 we have also developed fully uncemented endoprosthetic replacements for our younger patients with a satisfactory outcome. These results will be discussed.
In the future we hope to make further developments in the area of the non-invasive growing prosthesis, and soft tissue attachment around prosthesis especially those of the proximal humerus and the proximal femur.
Similar results with rigid external fixation have been reported in other animals. These findings are consistent with what we know about disuse osteoporosis resulting from muscular inactivity and reduction in weight bearing. Clinically such bone atrophy commonly occurs: after a fracture necessitating various degrees of immobilisation; after muscle inactivity due to diseases of joints and muscle, or bed rest; after long-standing systemic debilitating disease; after muscle paralysis; and after periods of weightlessness in space.
The results are also consistent with what we know about bone that is unloaded by various fixation devices. Woo and his colleagues have shown that in intact bone, fixed with a stainless-steel plate, there is significant stress shielding and that this results in loss of bone mass. Similar results have been reported by other investigators.
Likewise, in fractures fixed by rigid plate fixation there is similar stress shielding, which again results in loss of bone substance, together with persistence of woven bone at the fracture site.
Bone remodelling is very sensitive to small changes in cyclic bone stresses and changes representing less than 1% of ultimate strength can cause measurable differences in bone atrophy after a period of months.
Experimental studies have shown that greater bone remodelling and bone loss is observed when the rigidity of fracture fixation is increased.
Progressive bone loss may occur after fixation of fractures with metal plates. This leads to an ubiquitous clinical dilemma: if the plate is removed too early, fracture may occur because of insufficient union, whereas if the plate is removed too late, re-fracture may occur because of structural weakening and loss of bone mass.
In summary, removal of mechanical loads from bone, whether it be physiological, by rigid plate fixation or by rigid external fixation, results in negative remodelling and a net loss of bone mass.
That mechanical loading of intact bone results in cortical thickening and increased bone deposition has been confirmed by other studies. Physiological loading of intact bone produces the same increased bone deposition in laboratory animals. Similar effects have been shown in humans, for example, in tennis players, baseball pitchers and cross country runners, as well as in other sportsmen.
Resection of the radius or ulna, thereby increasing the load of weight bearing in the remaining bone, has been shown to result in hypertrophy of that bone in dogs and in various animals.
Fixation of fractures with less-rigid fixation results in healing with external callus formation, and earlier weight bearing.
In summary, these studies have shown that, in animals or humans, the application of physiological levels of strain to bone, either physiologically or mechanically, causes remodelling which results in a net gain of bone mass.
The effects of static compression produced at the fracture site by plate fixation have been reviewed extensively. Some investigators have claimed that compression promotes fracture healing, but there is no evidence of this from paired comparisons in the literature.
In summary, static compression does not directly stimulate fracture healing.
These findings have been replicated by others. Yamagishi and Yoshimura, as well as Woo and co-workers, have shown that those models which allowed some fracture movement produced proliferative external callus formation. This callus was inhibited proportionally as the rigidity of the fixator was increased. Similar studies have been performed in humans. Kenwright, Goodship and co-workers showed that controlled axial cyclic micromotion decreased the time to full weight bearing, compared with rigid tibial fixation33, and further studies showed the same findings.
In summary, both animal and human studies have shown that the application of controlled cyclic micromotion to fractures promotes bone healing.
Wide resection of bone tumour has become an accepted treatment in the limb salvage surgery. The reconstruction of the residual defect following wide resection is a major problem. Author had reviewed the results of five reconstruction methods. Osteoarticular graft is suitable for proximal tibial reconstruction and endoprosthesis for distal femoral reconstruction. Autograft is rarely used to reconstruct the large residual defect. Cement can reconstruct the larger defect, but it is not a suitable procedure on long term basis.
Health technology has been defined by WHO as the set of techniques, drugs, equipment and procedure used by health care professionals in delivering medical care to individuals and the system within which such care is delivered. Health technology assessment includes analyses of safety, efficacy and effectiveness, cost and cost effectiveness, infrastructure factors, social impact and fit, needs and capabilities of local health care delivery system.
The reimplanatation of resected autoclaved tumour bone graft is technically a simple, financially a cost saving and a biological solution for this difficult problem. This method of reconstruction fulfills all criteria of health technology. It is the suitable method of reconstruction in limb salvage surgery for all countries, but most suitable for the developing and poor countries where the resources for other methods are not available due to financial, technical or socio-cultural reasons.
Fracture healing results in increased markers of bone turnover and callus formation. The exact patterns of these changes after different type and locations of fractures as well as weight bearing are unknown.
Bone markers and the callus index were measured prospectively for 6 month following osteosynthesis of different fractures of the lower limb. Serum and urin samples were collected at day 0, 1, 3, 7 and after 2, 6, 12 and 24 weeks. X-rays were taken direct postoperatively and after 6 and 24 weeks. Labarotory parameters for bone formation were: bone-specific alkaline phosphatase (BnAP), Osteocalcin (OC), procollagen type I N- and type III C-terminal propeptide (PINP, PIIICP); markers for bone resorption were: free and peptid-bound forms of urinary pyridinium crosslinks (Dpd, Pyr,), N – terminal propeptides of type I collagen (NTx). All fractures healed within 6 month without complications.
Clavicle fractures represent 45% of all shoulder girdle injuries. Although clavicle fractures are usually readily recognisable and unite uneventfully with treatment, they can be associated with difficult early and late complications. Fractures of the middle third of the clavicle represent 80% of all clavicular fractures. Traditionally clavicle fractures are treated conservatively, with surgical treatment reported as being associated with an increased rate of complications. Indications for primary open fixation include significant displacement, fracture comminution and tenting of the skin, threatening its integrity which fail to respond to closed reduction. What constitutes significant displacement, is usually not defined; nor is consideration for open reduction of displaced fractures, which are not comminuted and do not threaten the integrity of the overlying skin. This paper reports on the technique indications and use of the “Rockwood Intramedullary Clavicle Pin” and the results achieved using this technique.
Clinical features and radiographic findings of three patients with dysplasia epiphysealis hemimelica (Trevor disease) are reviewed. In all patients the osteochondromatous lesions grow out from the epiphysis of the ankle joint with single lower extremity involved. The clinical symptoms, localization and roentgenogram are most important factors for confirming diagnosis. One patient presented with ankle varus deformity was found associated partial arrest of the distal tibial growth plate, surgical treatment including three arthrotomy with excision intraarthicular osteochondromatous lesions procedures, and one combined Langenskoid physeal bar excision procedure. Symptoms relieved and ankle function improvement were found in all three patients. MRI can provide further information such as: joint congruous, separation plane between the epiphysis and accessory osteochondromatous lesion; physeal plate growth disturbance conditions, and enabling precise localization and surgical treatment.
In Clinical practice damage to the growth plate is usually caused by trauma. In neonates and infants, sepsis involving the growth plate may lead to very severe deformities as well as limb length discrepancy. The management for the child with physeal growth arrest depends on the age of the child, the site and the extent of involvement of the physis. The assessment of the extent of involvement of the physis can be made by plain x-rays, tomograms and magnetic resonance imaging. In younger children epiphysiolysis with or without an osteotomy is usually performed. In cases where is there is severe limb length discrepancy additional treatment with limb lengthening is carried out. Children towards the end of growth benefit from a corrective osteotomy. Hemichondrodiatasis is not recommended in younger children as there is a risk of physeal fracture leading to further growth arrest. However it can be used for selected cases towards the end of growth.
Epiphysiolysis with the use of interposition materials such as fat, silastic or cement has been shown to be successful for bony bars occupying less than 30 % of the entire physis. In cases where the physeal injury is more extensive recent experimental work has shown that the use of tissue engineering techniques involving the transfer of cultured chondrocytes or mesenchymal stem cells may produce better results than conventional methods.
Posterior lumbar interbody fusion (PLIF) enables us to perform posterior decompression and anterior reconstruction with single posterior midline approach. We designed trapezoid titanium mesh cage (TPM type N cage) to realign postoperative normal lordotic curve that prevents the progressive degeneration of the disc adjacent to the PLIF-D
Surgery for back pain remains highly controversial in view of the significant complication rate and the low likelihood of a successful clinical outcome.
Over the last few years, titanium and carbon fibre interbody implants have been used to stabilise spinal motion segments following sub-total removal of disc tissue. These implants offer the theoretical advantage of immediate stabilisation, avoidance of late collapse and prevention of loss of correction of pre-operative deformity in combination with other types of segmental instrumentation such as pedicle screws.
Recent long term studies have suggested the possibility of late loosening, implant migration and recurrence of segmental deformity.
A recent prospective long term study of titanium cylindrical implants for lumbar degenerative disc disease has indicated that in the presence of multi-level disease, pre-existing olisthesis and levels proximal to the lumbosacral segment, the use of supplementary pedicle screw fixation is required.
It appears, however, that despite improved radiological results, the use of interbody cages may not lead to superior functional outcomes when the surgery is carried out for non-specific low back pain.
The results demonstrate that the failure modes of the device contain sufficient safety margins to support the use of the device in a prospective clinical study.
Between 1974 and 1998, 34 patients with primary bone tumors and 28 with soft tissue tumors, all located in the foot, were surgically treated at our institutions.
Of the 34 patients with a bone tumor, 27 (79%) had chondrogenic tumors: exostoses, 17; enchondromas, 7; benign chondroblastomas, 2 and chondrosarcoma, 1. This chondrosarcoma was misdiagnosed as a benign chondroblastoma at the initial biopsy. Five months after the initial curettage and bone grrafting, the tumor was recurred as a chondrosarcoma. This patient died with pulmonary metastasis another five months after the below the knee (BK) amputation. The differential diagnosis between benign chondrogenic tumors and low grade chondrosarcoma is very difficult as proposed by Mirra. Whereas the malignant tumor is very rare in the foot, the diagnosis of chondrogenic tumor should be made carefully.
Of the 28 soft tissue tumors, diagnoses were giant cell tumor of tendon sheath or pigmented villonodular synovitis, 8; angioleiomyoma, 4; ganglion, 4; hemangioma, 2; miscellaneous benign tumors, 7 and soft tissue sarcomas (STS), 3. All patients with a STS were treated by a BK amputation, a partial foot amputation or a marginal resection, and died with pulmonary metastasis. However the function of the operated limb and the emotional acceptance were better in a patient with the less abrasion surgery.
The purpose of this study is to report that patients of bone neoplasms were treated with external fixation.
The humerus is a common site for metastasis. Intramedullary nail fixation has been reported to be the best form of fixation for this disease but complications with this procedure have been reported. This study reports on the results of using a new humeral nail for the treatment of pathological fracture or impending fracture of the humerus. Twenty nine patients had 31 Austofix humeral nails, 25 for pathological fracture and 6 for impending fracture. Twenty-four nails were inserted anterograde and 7 retrograde. Cement augmentation was used in 4 patients. Adjuvant therapy was used in 26 patients. One patient was lost to follow-up. Fixation failed in six patients, two due to intra-operative fractures during retrograde insertion, one due to fracture through screw holes postoperatively, and three due to local progression of disease. Difficulties in locking the nail distally were encountered in an additional 3 patients. In conclusion, in the majority of patients, nailing of the humerus with metastatic disease resulted in a stable humerus. Retrograde nailing of the humerus was associated with an increased risk of intra-operative fracture. Adjuvant therapy cannot be relied upon to prevent loss of fixation due to local progression of disease. The longest possible nail should be inserted through the antegrade route and locked to minimise the risk of loss of fixation.
TRAIL/Apo2L is a member of the tumour necrosis factor (TNF) family of cytokines that induces death of cancer cells but not normal cells. Its potent apoptotic activity is mediated through its cell surface death domain containing receptors, DR4 and DR5. TRAIL binds also to three “decoy” receptors, DcR1, DcR2 and osteoprotegerin (OPG), which lack functional death domains, and do not induce apoptosis. The aim of this study was to investigate the cytotoxic activity of TRAIL as a single agent or in combination with clinically relevant anti-sarcoma drugs on human soft tissue sarcomas that are traditionally resistant to chemotherapy. Human soft tissue sarcomas known to be resistant to chemotherapy were taken at the time of biopsy and cultured to produce a cell line. This cell line was then tested against TRAIL, standard chemotherapeutic agents (including doxorubicin, cis platinum, etoposide, methotrexate and cyclophosphamide) and in combination. When used alone, TRAIL and/or the standard chemotherapeutic agents produced minimal tumour necrosis and this was mirrored in the clinical results. In combination, however, up to 60% necrosis was seen, with doxorubicin the most effective chemotherapeutic agent used. These results indicate that chemotherapy and TRAIL act synergistically to kill sarcoma cells and potentially opens up a new area of cytotoxic treatment for these difficult malignancies.
Of 22 flaps carried out there were only two flap failures. One was revised successfully with a gastrocnemius flap, whilst the other required a free latissimus dorsi flap which also failed requiring an above knee amputation.
Retrograde Interlocking Nail Femur was used in 35 cases of complex femoral fractures with follow up of two yr. The cases included with gross comm. femoral frx. with ipsilateral frx. of neck femur and tibia. This technique of fixation is also used in management of pathalogical frx. of upper third of femur and also in very obeese patients with frx. shaft of the femur in which antigrade nailing is a problem because of obesity. This method of fixation is a simple closed technique to manage such complex frx. with good results. Knee movements regained in all cases accept one, malrotation were observed in two early cases of the series. Non union and implant failure was nil. Bone grafting was required in one case of highly comm. segmental frx. with delayed union.
Orthopaedic surgeons are often found with critical procedures in trauma surgery that involve precise action on the underlying bony fragments without direct surgical access. This is exemplified by the intramedullary nailing technique, which is successfully used in many orthopaedic and trauma departments. Besides surgical actions on the surrounding soft tissues it involves fracture reduction as well as control of leg length and antetorsion angle. Distal locking of the inserted nail provides secure fixation to the bone fragments. To date accurate and safe performance of these steps remains a challenge in particular for the less experienced surgeon and can often only be achieved with extensive use of the image intensifier.
We have recently proposed a novel computer based technique, which was achieved combining intraoperative fluoroscopy based imaging using widely available C-arm technology with modern freehand surgical navigation. Modules were developed to automate digital X-ray image registration, which allows the real-time image interactive navigation of surgical tools based on one single registered X-ray image with no further image updates. Furthermore, the system allows the acquisition and real-time use of multiple registered images, which provides an advanced pseudo 3D control. Projection parameters were used effectively for intraoperative measurements on the patient’s anatomy, e.g. to determine bone axes, anatomic angles (e.g. femoral antetorsion), distances (e.g. leg length).
The system has been adapted to intramedullary nailing through the development of special stereotactic instruments and appropriate graphical user interfaces. A detailed validation of the prototype system was performed in laboratory settings and throughout early clinical trials. Currently the system is in routine use in various European clinics. Based on the resulting data the novel technique holds promises for improved accuracy and safety.
Periprosthetic fractures are becoming an increasing problem because of the number of total joint replacements that are performed yearly as well as the increase in longevity of the patients that receive total joint replacement. the risk factors for intraoperative fracture are rheumatoid arthritis, cementless arthroplasty, metabolic bone disease, Paget’s Disease, complex deformities, and revisions. The risk factors for post-operative fracture are weakened bone secondary to stress risers, screw holes, cortical perforations and stem tip protrusion, loose implants, and osteolysis. As a general rule the surgeon should make sure that all stress risers such as cortical windows and holes in the diaphysis should be bypassed at least two times the shaft diameter with a longer stem which restores the strength of the shaft to approximately 80%. Areas of transition between stem tips and plates or stem tips and stem tips should be avoided. Cortical strut grafts over holes, windows, and in areas of transition are of value. Johannsen’s Classification with a Type I fracture being proxmial to the tip of the stem, Type II fracture being around the tip of the stem, and Type III fracture distal to the tip of the stem is of value. In a cementless implant the majority of fractures are type I with the minority being Type II and Type III. In periprosthetic fractures with a well fixed prosthesis, the surgeon should maintain the components, restore alignment, and restore function. In periprosthetic fractures with a loose prosthesis, the surgeon should revise the components,restore alignment,and restore function. Treatment options for an intact prosthesis include cerclage wiring in high fractures and the use of plating and allograft struts in lower fractures. With loose implants, treatment options include removal of the implant while maintaining as much bone stock as possible. A loose implant must then be replaced and longer stems and cortical strut grafts are options in the reconstruction. Weight bearing is delayed to allow fracture healing. With this knowledge in hand, the orthopaedic surgeon can anticipate problems and reconstruct bony lesions causing periprosthetic fracture with some confidence in his mechanical constructs.
Thirty patients of infected nonunion of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Nonunion, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12cm (median bone gap of 7 cm), 10 cases of stiff non-union (6 of which had an associated deformity) and 5 cases of mobile non-union. The median time in Ilizarov frame was 150 days. Median follow up after frame removal was 33.5 months. Bone grafting at docking site was required in only 3 cases(10%). There were 3 cases of refracture(10%) and 3 cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in 3(10%), fair in none (0%) and poor in 6 (20%). The functional results were excellent in 8 patients (26.7%), good in 12 (40%), fair in3 (10%) and poor in 7 (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to appreciate the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.
A one-year-8-month-old girl who received radiotherapy and chemotheraphy after excision of embryonal rhabdomyosarcoma from left labium majus pudendi developed slipped capital femoral epiphysis (SCFE) over right hip when she was 9 years old. After mild limp had been noted for 6 months she was then referred to pediatric orthopedic surgeon and two Knowles pins were used to fix the slipping. The second case was a 17-year-old girl with Turner syndrome. SCFE developed during the growth hormone therapy and it was treated with percutaneous pinning with two cannnulated screws. The possibility of developing SCFE should always be kept in mind when treating and following these particular cases to avoid delay of diagnosis.
Open reduction for developmental dislocation of the hip (DDH) is invasive and sometimes results in femoral head deformity while open reduction has been the first choice in case non-operative reduction is failed in.
We treated 3 patients with 3 affected hips using minimum invasive arthroscopic reduction method. Pre-operative MRIs represented these 3 hips had obstruction of interposed thick limbus. The average age of patients treated by this method was 23 months.
This method consists of arthrogram, arthroscopic limboplasty, and arthroscopic reduction. This series of maneuvers was able to lead unreducable hips to the reduction position.
Post-operative MRIs represented that the interposed thick limbus had been removed to the outside of acetabulum and the limbus covered the reduced femoral head. There were no signs of residual subluxation of the hips in radiographic examination.
This new minimum invasive arthroscopic reduction method have a possibility to take the place of the invasive open reduction in the treatment of DDHs with obstruction of interposed thick limbus.
The MRC Working Party (United Kingdom) on CDH recently reported an ascertainment adjusted incidence of a first operative procedure for CDH of 0.78 per 1,000 live births, similar to the incidence before the commencement of the U.K. Screening programme. It also found that 70% of cases had not been detected before 3 months of age.
South Australia has had a similar clinical screening programme since 1964. This study determined the incidence of an operative procedure for CDH in the first 5 years of life among children born in South Australia between 1988 – 1993 (118,379 live births in total) and the proportion detected after 3 months of age.
Of 47 children identified as having non-teratologic DDH and operative procedures, 24 were diagnosed before one month of age. Some required operative intervention beyond 3 months of age despite early diagnosis. Only 22 (46.8%) had been diagnosed at or after 3 months of age 18 of the 47 had an open reduction and/or osteotomy while the remainder had arthrograms, closed reductions and/or tenotomy
The prevalence of non-teratologic DDH was 7.7 per 1,000 live births. The incidence of surgery in the first 5 years of life was 0.40 per 1,000 live births and only 0.19 per 1,000 for those late diagnosed at or after 3 months.
These results demonstrate that a screening programme can be successful, contrary to the findings of the UK MRC Working Party.
Over the centuries there has been a pattern of order developing from chaos in the behaviour of nations.
The 20th century has demonstrated major conflict between nations, and Defence Health has supported the core activity of the Australian Defence Force (ADF), which has been the aim of military medicine generally in all world defence forces. Preventative medicine and mass casualty treatment, as well as the maintenance of health and return to duty from minor injuries, has been a success for all traditional military medical structures.
It has been known that if the civilian population is supportive of the military effort, this is a significant advantage. The military medical assets directed in this manner to the local civilians builds bridges for lasting peace.
In 1989 the world changed, with the Cold War won and leaving the United States as the only super power. From that time, conflict has tended to be intrastate rather than between sovereign states, with a rise in communal or ethnic conflict. This situation is probably not going to change in the foreseeable future as there are no longer client states being controlled by super powers.
Since that time the Australian Defence Force has been involved in the treatment of indigenous Australian citizens, UN humanitarian missions and disaster relief. In fact the military medical assets of the ADF have been busier in the last 30 years in Military Operations Other Than War than in war itself.
The original concept of the Forward Surgical Teams developed in Adelaide was modular, encompassing a General surgeon, an Orthopaedic surgeon, an Intensive Care specialist and an Anaesthetist, and thus they were able to cover trauma sustained by most combat casualties. This module was man-liftable and able to be deployed by aircraft, by vehicle and also on board ship, augmenting existing medical facilities according to need.
This module in its varying forms has stood the Australian Forces well in Rwanda, Bougainville, East Timor, PNG, disaster relief and Aboriginal health missions.
It may be that further health modules can be developed, such as a Burns module, a Paediatric module and a Primary Care module, building on the increasing medical knowledge base, sub-specialisation and advancing technology. These building blocks can come together to form significant hospitals if necessary.
The ADF has provided first-world medicine and third-world medicine, producing a dichotomy in requirement for medical skills and technology, depending on circumstances. Being busy enhanced our logistical support systems and organisational skills. Medical experience was gained, and the foundation for lasting peace and building communities was established.
If war is considered the greatest social disease left then the pathology of war is in history. The diagnosis is easy but the treatment and prevention difficult.
Early in an emergency the military medical assets of any defence force are able to be deployed under difficult living conditions, and can provide health care for those who have survived the disaster whether it be man-made or natural.
A new and very unstable intertrochanteric fracture complex is described. The intertrochanteric fracture with extension into the femoral neck is rare but results in an extremely high failure rate because of its instability. A ten-year retrospectic analysis of patients (246) with intertrochanteric fractures treated with a sliding compression hip screw at Hennepin County Medical center was performed. Of these 246 fractures, 20 were classified as fractures with a major intertrochanteric component with extension into the femoral neck. These fractures were similar to intertrochanteric fractures type I-IV described by Kyle and Gustilo in demographics, osteoporosis, and surgical treatment, but this new fracture fracture now described as Type V had a statistically higher rate of mechanical complications 0.0001, reoperation 0.0002, and failure of fixation 0.0001. The overall failure rate was 50%. The majority of these fractures were the result of complete collapse of the hip screw. We feel this higher complication and reoperation rate is secondary to inherent instability in the intertrochanteric fracture which extends into the femoral neck. This instability leads to cmplete collapse of a sliding hip screw result ing in a rigid device that leads to failure of fixation. This fracture complex also has a higher rate of nonunion and avascular necrosis. Although rare, this fracture must be recognized in the fracture classification of intertrochanteric fractures because of its poor prognosis. Other forms of treatment than a sliding hip screw may be considered with this fracture complex because of its high failure rate with standard treatment.
“Subacute Synovities of the Hip”, which runs a more fluctuant clinical progress and slower response to treatment than those of acute transient synovitis, is always posing diagnostic and management challenge in children presented with acute hip pain. This study aims to identify the special features of this distinct entity, and the important diagnostic parameters in differentiation of acute transient synovitis, subacute arthritis and also septic arthritis in children presented with acute painful pain. From 1985–1999, 427 children have been admitted into our centre with subsequent diagnosis of acute transient synovitis, subacute synovitis & septic arthritis. 320 cases with full records are available for review, with 270 cases 85%) having acute transient synovitis, 35 cases (10%) of subacute arthritis and 15 cases (5%) of septic arthritis. Statistical results showed that patient having subacute arthritis different significantly from those with acute transient synovitis in terms of age of presentation & duration of symptoms before hospitalization. Moreover, patient having transient synovitis significantly different from those with septic arthritis in terms of temperature on admission, ESR and White Cell Count.
The ossific nucleus in Developmental Dysplasia of the Hip. A study of relative ossific nuceus size in hips treated in the Pavlik harness and its predictive value in treatment outcome.
Purpose
To assess the value of measuring relative ossific nucleus (ON) size difference in Developmental Dysplasia of the hip (DDH) as a potential predictor of outcome of hips treated in the Pavlik Harness.
Study Design
Prospective study of all unilateral cases (n=68) of DDH identified in Southampton by dynamic ultrasound and treated in a Pavlik harness studying changes in relative ON size and acetabular indices over a mean follow up period of 3.6 years.
Results
All cases responding to the Pavlik harness showed a progressive correction of ON size difference. Initial ON size difference was not associated with any difference in acetabular index at the date of last follow-up. Ultrasound grading of dysplasia did not affect the rate of normalisation of ON size difference.
Conclusion and clinical relevance
In patients responding to treatment of DDH in a Pavlik harness, ON size difference was not found to be a useful prognostic indicator of outcome.
The authors added a classification of posterior pillars to Herring’s classification of lateral pillars in a retrospective study of 33 patients with Perthes disease. Anteroposterior and frog position lateral radiographs taken approximately two months later from first visit, were evaluated. All patients were treated by a non-weight-bearing method (continuous traction and wheel chair activity). The outcome was evaluated by the Stulberg method.
The mean age at follow-up was 18 years (range,14.2 to 26.9 years).
Thirteen hips were in Catterall group II, 18 were in group III, and two were in group IV. Twenty-five of the 33 hips were in Stulberg class I or II (with good results), and eight hips were class III. Nine hips were in Herring group A, 20 hips were in group B, and four were in group C. Eleven hips were in our group A with the posterior pillar classification, 16 were in group B, and six were in group C. Group A, with a lateral or posterior pillar had good results without exception. Concerning Herring’s classification, all four heads had become aspherical in group C, however, 16 hips were good results and four hips were poor in group B. The outcome was poorly related to the classification in 20 patients with 20 affected hips in Herring group B when only lateral pillars were used in classification. When both lateral and posterior pillars are considered in classification, results can be predicted more accurately than when only lateral pillars are considered. This more accurate prognosis at an early stage of Perthes disease can facilitate effective treatment selection.
This paper is based on the experience gained from three recent earthquakes in India. Lature (Maharashtra 1993), Jabalpur (M.P. 1997),and Kutch (Gujarat 2001).
The importance of such studies and lessons learnt from the management of casualties cannot be under stated as we have had at least 6 major earthquakes in various parts of the world in the first two months of the New Millenium.
The uniqueness of an earthquake lies in its unpredictability. There is no warning & no time to take preventive measures. The event is sudden, takes a heavy toll of human life, leaves a huge injured population and very many trapped under the debris of fallen buildings. It also results in great fear psychosis in the injured/uninjured population as well.
Success of relief operations in earthquakes depends on:-
Preparedness for such eventualities by a clear established protocol of action before hand in earthquake prone areas. Establishment of immediate communication links between affected area and controlling authorities. Establishing a clear line of command from higher authorities to the rescue teams. Immediate Co-ordination between government agencies and Non-Government Organisations flooding the area with man power and relief supplies. An effective control centre should be established for this. Immediate mobilization of resources from nearby areas:- Medical services. Relief teams for removing debris to rescue trapped people. Supply of food/water/shelters/Medical supplies. Mobilization of Ambulance services/Helicopters for evacuation of injured patients after proper triage. Monitoring services to keep updated statistics of injured/trapped /dead, and to constantly advise change of strategies for more effective rescue operations. Minimize panic and boost morale of the affected population as well as rescue teams by preventing rumours of fresh quakes from circulating.
Early rescue operations to evecuate trapped people from debris/early evacuation of casualties by trained personnel in properly organised ambulance services help in drastically reducing the death toll.
Proper early management of polytraumatised victims on ATLS principles helps in saving a lot of lives in the first week after the earthquake. Systematic establishment of camps/mobile hospitals especially in remote areas further helps minimize mortality and morbidity in the second phase of relief services after the initial 2–4 days of emergency operations.
Psychotherapy of not only the injured but also the whole population is extremely important to minimize permanent mental scars which may take a lifetime to disappear.
It is important to conclude by stating that relief services require enormous manpower which should have a very high degree of motivation to perform under extreme physically and mentally stressful conditions.
Leadership is required at various levels to provide this motivation & is the key to success.
It must also be constantly kept in mind by medical personnel that the victims do not have only medical problems but far greater socio-economic and psychological problems from death in the family requiring completion of last rites, collapse of their houses & loss of all belongings & fear psychosis of further tremours.
The Journal of Bone and Joint Surgery published in the A and B volumes remains the premier Orthopaedic Journal of the world. Like other specialist scientific journals it is coming under increasing pressure from the move to more electronic publication on the Internet and the wider availability of freely downloadable information. The need to move to the new technology must be balanced against the needs of the majority of our subscribers, who still require the paper journal, and with the financial requirements of a charitable based not-for-profit publication.
The paper will discuss how these pressures might be met and the plans for the redesign of our website to deliver a wider range of material, including the possibility of electronic pre-prints. The future of the Combined subscription CD-ROM will also be addressed together with the exciting future possibilities offered by the developments in digital information technology.
We have performed short-segment posterior spinal instrumentation and fusion (PSIF) for cases with no neurological symptoms, and combined short-segment posterior spinal instrumentation and fusion with anterior decompression and fusion (PSIF with AF) for cases with obvious neurological symptoms.
In this report, we review the postoperative results of our methods.
The bone mineral density (BMD) can be measured by dual energy X-ray absorptiometry (DEXA) accurately and precisely. BMD measurements of proximal tibia, where the structure is dominantly trabecular bone, were made on 45 normal women, aged 24–91 (52.0±14.2) years, and on 46 normal men, aged 20–71 (53.7±15.5) years. The precision of BMD measurements of proximal tibia, expressed as the coefficient of variation, was smaller than 4%.
Throughout this cross-sectional study, the following results were acquired. The mean BMD in male is higher than that in female. The BMD show a decrease with age at different rates in women and men. The BMD in both genders is found to increase with body weight. A positive correlation is found between the BMD and body height in women, not in men. In right proximal tibia, the BMD of medial regions are higher than that of lateral regions significantly. Our study also demonstrates that the excellent symmetry of the BMD of the bilateral proximal tibias in both genders, but not in men with age less than 50 years old.
Through the study of BMD in proximal tibias using the DEXA, it may reflect the bone reactions to many factors, such as age, sex, body weight & height, and weight bearing etc. Such a kind of study might be an useful adjuvant tool to assess the bone remodelling around the knee joint following the different surgical procedures such as total knee arthroplasty or high tibial osteotomy and might predict the future surgical outcomes.
In order to predict more detailed outcomes of paralysis in patients with acute cervical cord injury, we have compared degree of paralysis at the time of admission and the time after more than 6 months by using our modification of Frankel’s criteria.
Between 1990 and 1998, twenty-nine patients with neurological deficits after acute unstable fracture of thoraco-lumbar spine were treatment by surgery at National Taiwan University Hospital. An attempt was made to contact all patients but 4 patients were unavailable for evaluation. The remaining 25 patients were followed for an average of 47.9 months (range 24 to 108 months). Postoperative improvement was observed in 56% and 60% of patients in Frankel grade and muscle power respectively. No patient had any neurological deterioration after surgery. None of these patients with initial Frankel grade A and B regained their ambulatory ability. However, 15 patients (60%) with initial Frankel grade C and D became independent ambulators after surgery (P = 0.0046). None of these patients with initial grade 0 muscle power regained his ambulation ability but all 15 patients (60%) with initial grade 1 to 4 muscle power became independent ambulators after surgery (P = 0.113). 10 patients with initial Frankel A or B had an average 0.4 grade of improvement and 25 patients with initial Frankel C or D had an average 0.9 grade of improvement (P = 0.11). However, those 10 patients with initial power 0 had an average 0.2 grade of improvement and the other 25 patients with initial muscle power 1 to 4 had an average 1.5 grades of improvement (P = 0.003). According to this study, we conclude that Frankel grade and muscle power are good predictors for the clinical outcome of surgical treatment for unstable thoraco-lumbar spine fracture. Patients with such injuries should be managed aggressively especially when residual muscle power could be elicited after the period of spinal shock has passed.
The purpose of this study was to investigate the bone anatomy in determining the rotational alignment in total knee arthroplasty (TKA) using CT scan. Axial CT images of eighty-four varus osteoarthritic knees undergoing TKA were analysed. On the images of the distal femur and the proximal tibia, base line for anterior-posterior axis of each component was drawn based on the epicondylar axis for the femur and medial one-third of the tibial tuberosity for the tibia. Angle between these two lines was analysed as the rotational mismatch between the components when they were determined based on the anatomical landmark of each bone. Thirty-eight knees (45%) showed more than 5-degree mismatch and seven knees (8.3%) showed the mismatch more than 10-degree. There was a tendency to put the tibial component in external rotation relative to the femoral component when they were aligned to medial one-third of the tibial tuberosity. The results have indicated that the landmark of each bone was the intrinsic cause of the rotational mismatch between the components. The surgeons performing TKA surgery should aware of this fact and should align the tibial component in a compromised position, if necessary, to have overall satisfactory clinical outcome.
Wear of UHMWPE and Clinical results of bioceramic total knee replacement have not been well reported yet. The ultra high molecular weight polyethylene surfaces of the tibial components were examined in 3 retrieved knees with non-infectious loosening, and were almost normal in appearance with only minor scratch lines 33 to 59 months after the initial arthroplasty. Bioceramic total knee arthroplasty was concluded to show satisfactory results except for the initial several cases done with rather poor surgical techniques. The wear of UHMWPE surface in ceramic knee was observed to be much less and milder than that of metal prosthesis.
Total knee arthroplasty (cementless) using Yokohama Medical Ceramic Knee was performed in 64 knees and, excluding 4 knees with the prostheses retrieved, was evaluated in 60 knees of 47 patients.
There ware 1 man (1 knee) and 31 women (44 knees) who had rheumatoid arthritis with a mean age of 56.8±11.9 years, and 2 men (2 knees) and 11 women (13 knees) with osteoarthritis with a mean age of 70.6±6.9 years. The mean follow-up duration was 48.1±9.2 months ranging from 33 to 60 months.
The maximum knee flexion was 115±24 degrees before and 104±20 degrees after arthroplasty in the rheumatoid group, and 107±40 degrees before and 101±26 degrees after arthroplasty in the osteoarthritis group.
Clinical evaluation using The Hospital for Special Surgery Knee Criteria showed 7 knees as Excellent, 34 as Good, 7 as Fair and 12 as Poor after surgery. Complications consisted of infection (1 case), tibial plateau fracture (1), avulsion fracture of the tibial tuberosity (1) and patellar dislocation (1)
Between 1990–92, 59 Primary TKA’s were performed in 55 Patients with a mean follow-up of 9 years (8–10). Mean age at review was 75 years (61–87). Materials and Method: All cementless TKA’s (Whiteside Ortholoc Modular 3). One surgeon (operating or supervising). Intramedullary guides(tibia and femur). Lateral retinacular release. Clinical evaluation according to the Knee Society Scoring System & Knee Society TKA Roentgenographic Evaluation and Scoring System. Median Knee Score 93.5 (41–97). Median Functional Score 77.5 (35–100). Median flexion 100 degrees (80–120). All but one knee came to full extension. No effusions or swellings. Radiolucencies in one TKA only. Discussion: Long term success of TKA’s (cementless or cemented) depends on correct alignment of the implants. Rigidity of fixation is the second most important feature in achieving pain free function in an arthroplasty. Success in this series was due to good alignment of components. Good alignment minimises polyethelene wear. Rigid tibial fixation prevents motion, tilting and malalignment reducing wear.
There is quite a high incidence of musculoskeletal disorders in the hemophiliac patients because of their insufficiency in blood coagulation. Knee joint disability is the most troublesome problem among the all. Repeated bruise and intra-articular hemorrhage may activate hypertrophic synovitis and progress to advanced arthritis. The characteristic clinical presentation is their fusiform limbs with moderate degree of contracture and deformity. Treatments include administration of specific coagulation factors, aspiration of hemarthrosis and proper bracing. Synovectomy will treat and retard the progression of the disease, while some advanced cases may end up to spontaneous fusion or need surgical arthrodesis. Total knee arthroplasty is another option for such a knee problem in hemophiliac patients.
We have done 26 total knee arthroplasties in 19 hemophiliac patients since 1986. Male is predominant with sex-linked inheritance with only one exception. The timing for them to have surgery is from 22 to 47 years old with mean age of 30. Gross patholgies of the knee lesion are quite universal as hypertrophy of hemosiderin deposited synovium, destruction of articular catilage, subchondral bone loss, marginal osteophytes formation, fibrous contracture around the joints. Two cases were excluded for other systemic disease.
With the help of supplementary coagulation factor, the surgical courses were rather smooth with one exception of septic shock episode. There were no infections in total series but three revisions of prosthesis were done because of loosening or malposition. All the patients were satisfied with the improvement of function score and range of knee motion. Total knee arthroplasty did a great success for the relief of pain and function for such a knee disorder. The only remained troublesome problem is the extremely high cost of the coagulation factor therapy which may be an economic shock to the patients.
Intramedullary devices have been used since 1989 for fractures around the trochanter. Standard PFN has been shown to be one of the stable and successful intramedullary devices for pertrochanteric fractures.
In order to minimise the intra-operative complications, small PFN has been designed to fit the Asian femora.
Before performing a clinical documentation series, the authors with the computer assisstance performed virtual templating of 60 asian femora.
After standardising the magnification of the radiograph with that of the template, best possible fit of the latter was achevied.
Various parameters such as:
Width of the remaining neck from the surface of femoral neck screw and hip pin. Height of the proximal end of the nail from the tip of greater trochanter. The distance between the actual and proposed take-off point of medio-lateral angulation. Width of intramedullary canal at distal end of the nail were measured.
After analysis of the measurements, we propose to further modify the small PFN in order to get best fit and minimal intra-operative complications.
To improve the accuracy of pinning at the iliac crest during external fixation of the unstable pelvic fracture, an aiming device has been innovated. The device consists of 3 parts: a sleeve, a handle and guide points. The guide points were designed to grasp the iliac crest to allow proper pin fixation. The device has been used in 50 patients who had unstable fractures of their pelvises. All pins were in proper position with out loosening at the time the pins were removed. The use of this device has given encouraging results.
Parameters assessed were patients’ nationality, nature of occupation, duration of working experience, time of injury, adequacy of safely measures provided by the employer, whether normal duty or overtime, mechanism and type of injuries sustained and treatment given. Disability caused by the injury, outcome of the treatment and duration of sick leave were not analyzed. During this period, 386 patients were admitted (343 males and 43 females). Ages were ranging from 17 years to 78 years. Most of the patients were less than 25 years old (n=106) and only 3 patients were above 75 years of age. Malaysians were 80.8% (n=312) and foreigners were 19.2% (n=74). Among the foreigners, Bangladeshi were the highest 43.2% (n=32) and the least were from Pakistan, Nepal and Burma, 1.4% (n=1) each. Mostly were unskilled workers (labourer) comprising 50.8% (n=196). Largest group of patients have working experience of between 2 to 5 years 23.8% (n=92). On hourly analyses, highest number of accidents took place between 10am to 11am comprising 11.4% (n=44). 60.6% of patient (n=234) claims they were not provided with adequate safety gears.
Out of a total of 112 children with displaced forearm shaft fracture treated with Percutaneous Kirschner (K) wire fixation in the past 9 years, 84 cases with fracture of both the radius and ulna were reviewed. 64 (76%) had fixation of both the radius and ulna, 10 (12%) the radius only and the other 10 (12%) the ulna only. In 60 (71%) patients were successful with one stage close reduction and pinning, while in the remaining 24 (29%) a semi- open reduction through a small incision was required. The K-wire was inserted through the radial styloid or the Lister tubercle for the radius, and through the tip of the olecranon for the ulna. All the patients reviewed were found to have good functional results with no non-union, deep infection or premature physeal closure at a mean follow-up of 48 months. Initial pre-operative shortening or translation of the fracture were associated with significantly higher chance of open reduction. We concluded that percutaneous K-wiring for forearm diaphyseal fracture in children is a convenient, effective and safe operation, with minimal complications.
All patients above 60 years of age who sustained a hip fracture following a trivial injury admitted to our institution between October 1995 and September 1996 were screened and treated according to a standard treatment protocol. They were followed up to a minimum of 4 years.
The 1 year mortality rate was 23% while that at 2 years was 50 percent. The mortality rate at the end of 4 years was 66%. The higher rate of death occurring in patients above 80 years of age. Analysis of results according to age, sex and fracture type was made. Definite correlation has been observed with the age, the increase being parallel to it, while age-specific mortality is higher in men. The mortality was also reviewed with relation to the associated medical conditions, and pre-morbid ASA grade, medical conditions and premorbid activity level index using the Barthel Index. There was no increase in mortality seen in trochanteric fractures.
The treatment of hip fractures in poses a challenge. Optimal anaesthesia, expeditious surgery and a co-ordinated multidisciplinary approach to care is essential in these patients.
Using the Kyle set-up, the forces required to initiate sliding were found to be lowest with the Synthes DHS (42.33±5.77N), Zimmer CHS (52.67±26.56N), and the IMHS (45.33±10.97N). These were closely followed by the Gamma nail (79.33±8.39N) and the Richards Classic hip screw (82.00±16.37N). The highest forces were for the RTN (98.00±18.52N) and the Austofix hip nail (283.00±70.62N). These results were significantly different. (p< 0.001, ANOVA)
The Surgery of resistant and relapsed club foot is always a great problem even for an experienced Orthopaedic Surgeon. Surgery on the bones in younger patient is contraindicated. The principle of differential fractional distraction technique invented by Prof. Joshi of Bombay is well accepted in many Countries. His technique using the JESS system (Joshi’s External Skeletal System) is used extensively for resistant and relapsed Club feet. In our Institute during this decade 57 feet in 45 children in the age group of one to five years were corrected using the above mentioned technique. Results were assessed as per SIMMON’S CRITERIA. 47 out of the 57 feet showed satisfactory results. Recurrence of the deformity observed in 10 feet. This study details the methodology of distraction, merits and pitfalls of the procedure.
In reality, the diagnosis of idopathic clubfoot is never delayed, however, treatment is often delayed in developing countries on account of socio-economic factors. The experience gained from treating children who present late in these countries can be effectively used in more developed countries to treat relapsed clubfeet.
The author considers any treatment for clubfoot offered after a child has started walking as “late treatment”.
The treatment options vary depending on the age of the child and the extent of deformities. The aim of treatment is to obtain a plantigrade foot, retaining the mobility of as many of the tarsal joints as possible.
Accordingly, an outline of treatment is suggested. Soft tissue release operations are recommended for children between 1 and 3 years; soft tissue release operations with or without bony surgery for children between 3 and 5 years; soft tissue release combined with mid tarsal and calcaneal osteotomies and tendon transfers in children between 5 and 14 years. The role of external fixators and distraction techniques advocated by Ilizarov and Joshi, and finally, the role of salvage operations like triple fusion and talectomy are discussed.
The author presents his experience over twenty three years as visiting orthopaedic specialist in the early management of neonatal and infantile clubfoot with annual visits to the Kingdom of Tonga, S.W. Pacific. This has involved three hundred and seventy two infants with five hundred and fifty eight feet.
The relative ease of assisting surgically those least able to afford treatment overseas in their own country where such treatment may not be available in their own country is discussed.
The equipment required; the surgical skills needed; the importance of safe anaesthesia; the importance in gaining the confidence of family, local medical, nursing and administration staff is emphasized.
The high incidence of clubfoot in Polynesians is noted. The incidence in Tonga approaches one per hundred live births ie. 1% so for Tonga where there are approximately 2500 live births per annum – this means an annual case load of 25 babies with upto 40 feet to correct on an annual basis: a formidable annual caseload.
Three orthopaedic visiting surgeons with one visiting anaesthetist plus another local anaesthetist utilizing two theatres can successfully complete this caseload in 3–4 days of operating.
In the absence of such visiting teams many of these babies would remain untreated or inadequately treated and would commence walking at 12–18 months on uncorrected feet with disastrous results. Early soft tissue correction in a baby under 12 months of age is highly desirable to ensure a corrected plantargrade foot before walking commences.
Clubfoot is therefore especially common in Tonga; Samoa; Tahiti; Hawaii and amongst Maoris in New Zealand yet it still occurs in Melanesians in Fiji; Papua New Guinea; Solomon Islands; Vanuatu; New Caledonia and in the Micronesian states in the Caroline Islands; Marshall and Mariana Islands.
There is a need for visiting orthopaedic teams to visit and surgically treat clubfoot on an annual basis.
The author in co-operation seeks to establish an Asian Pacific Foundation to ensure this important surgery is delivered annually to our near neighbours.
This study reports on postoperative changes of intra and epidural space of both degenerative lumbar spinal canal stenosis(DLSCS) and degenerative spondylolisthesis(DO)on MRI. 48cases(DLSCS:20cases, DO:28cases)were investigated in this study. All cases performed bilateral wide fenestration.
The average age of these patients was 65 years and average follow-up period was 60 months. The average improvement ratio(%) of JOA score was 68% at the last follow-up. Symptomes had deteriorated in 8 cases, according to an increase in the volume of the postlaminectomy membrane, at the last follow-up. There were 8 cases(29%)in DO. showing an increase of % slip on X-ray at the last follow-up, accompanied with both a slight decreasing of the cross-sectional area(CSA)of dural sac and a slight deterioration of clinical results.
To study the contribution of the special morphological features of lumbo-sacral spine as causes of the slipping in the spondylolisthesis, the roentgenographic measurements were performed in 47 cases of spondylolysis, 77 of spondylolisthesis and 597 of several low back pain as a control.
The transitional lumbo-sacral spine was more frequently seen in the spondylolisthesis group, but there was no d ifference between the spondylolysis and control.
The angle between the superior surface and the posterior border of the sacral vertebral body (posterior superior sacral angle) was apparently low in the spondylolisthesis, whereas no difference was noted between another groups.
In conclusion, special morphological features such as low prices of the posterior superior sacral angle is considered one of the risk factors for the cause of slipping.
The Graf technique of spinal stabilisation of the lumbar spine is a semi rigid pedicular screw system without spinal fusion. It is an unique system, which has both proponents and opponents. The mechanism of stabilisation is as yet not fully understood.
This retrospective study looks at the long term results of 35 patients with a minimum follow up of 4 years.
The age ranged from 35 years to 76 years with an average of 60 years of age.
89 percent of the patients improved considerably and no further surgery was performed on any of them. The complication rate was minimal. The Graf spinal system merits further study with prospective trials comparing it with pedicular screws and spinal fusion. The scientific basis should be established, as many surgeons are doubtful about this system.
In 141 patients with ossification of posterior longitudinal ligament, open-door expansive laminoplasty was done from 1980 to 1998. A follow-up study was made. 10 patients with cervical cord injury and cerebral diseases before or after operation were excluded. 121 of 131 patients were followd directly one to fifteen years(mean: 5 years and 3 months). Subjects included 93 male and 28 female. At the time of operation, their ages ranged from 40 to 80 years(mean:59.5). Operative results were evaluated using the Japanese Orthopaedic Association’s Score(JOA Score) and Hirabayashi’s improvement rate. X-ray was taken to measure the range of cervical spine motion, curvature of the cervical spine and progression of ossified masses.
Preoperative JOA scores ranged from 2 to 14 points(mean:9.1), postoperative JOA scores ranged 7 to 17 points(mean:14.1). The mean improvement rate was 62%. The range of cervical spine motion decreased from 26.6 degrees prior to operation to 10.8 degrees after operation. Lordotic curvature also fell from 11.8 degrees before operation to 6.6 degrees after operation. In 20 patients, the postoperative kyphotic curvature increased to 5 degrees of more, although no difference was seen in their improvement rates compared with patients whose lordosis remained unchanged. 80 of 121 patients experienced progression of ossified masses. Three patients underwent additional laminectomy due to progression of ossification or insufficient expansion.
Operation took an average 80 minutes and mean amount of blood loss was 215 ml. No patients had postoperative motor paralysis caused by C5 or C6 nerve damage and no serious complications were seen.
During the first 5-years period 1159 patients underwent decompressive surgery. 908 of them had spondylosis and 251 had degenerative spondylolisthesis (DO) as a contributing factors of neural compression. Fenestration was done in 740 (81%) of patients with spondylosis and in 176 (70%) of patients with DO.
Unreamed, small diameter nails with interlocking capability have become the preferred treatment for most unstable tibial fractures, but have been shown to have a high rate of hardware breakage and frequently require secondary procedures to obtain union. Reamed nailing may offer advantages for fracture healing due to the use of larger implants and increased stability, but may cause higher rates of infection and compartment syndrome. In order to determine if there is a difference in healing or complications in open and closed tibial fractures treated with reamed or unreamed intramedullary nailing, we performed a prospective, surgeon-randomized comparative study. Ninety-four closed and open, unstable tibial shaft fractures (excluding Gustilo Types IIIB and C) treated with intramedullary nailing were studied. Our findings support the use of reamed nailing in closed tibial fractures, which led to earlier time to union without increased complications. In addition, reaming did not increase the risk of complications in open tibial fractures.
Postoperative leg swelling after a total knee replacement is common complaint amongst patients.
We studied leg swelling by constructing a novel, simple and cost water volumeter. A pilot study was conducted on 15 volunteers by two observers and each observer took a total of three readings.
The mean intraobserver variation was 0.2 percent and mean interobserver variation was 0.3 percent, indicating a highly acceptable level of accuracy.
The water volumeterwas then used in a randomized prospective study was conducted to determine the relationship between postoperative leg swelling and Fraxiparine, a low molecular weight heparin.
From the period of 1st January 2000 till 31th October 2000, a total of 36 patients were enrolled in the study. 18 patients in the study group received fraxiparine and 18 patients in the control group did not.
The leg volume was measured preoperatively and on postoperative days 5, 7 and 10.
We found that both groups developed maximum swelling at postoperative day 5 and this decreased to almost normal at day 10. However the fraxiparine group was statistically less swollen (4%) than the control group (10%) on day 5 and also on day 7 (−0.2% vs 7%). These findings were independent of whether the patient underwent bilateral or unilateral surgery. We conclude that low molecular weight heparins are effective in reducing postoperative leg swelling in total knee replacement.
The use of contoured side plate screw attached to the sliding screw plate anchors the comminuted fragments thus gives better stability, compression, early mobility and bony union to this fracture where other implant fails.
The side plate is a narrow D.C.P. (4/5 hole) which is contoured to the fl are of greater trochanter proximally and is attached to the sliding screw plate. The proximal holes of side plate hold the comminuted fragment of greater trochanter with cancellous screw above the sliding hip screw The patient were encouraged to walk on 2nd post operative day with support to start with partial weight bearing followed by weight bearing at 4 wk.
One nonunion developed in each of the two treatment groups, and was unsuitable for mechanical testing. The remaining 22 tibiae (10 lengthened, and 12 contralateral unoperated, tibiae) were torqued to failure on the MTS testing machine. There were no significant differences between the unoperated tibiae of the Ibu-profen group and the unmedicated group measuring torsional toughness, stiffness, and strength. Similarly, there were no differences detected using these parameters between the lengthened tibiae of the medicated and unmedicated groups.
No adverse systemic affects were noted during the course of this experiment, in which low therapeutic levels of Ibuprofen were maintained for an average of 120 days. No affect on the torsional strength of the unoperated tibia was detected. No adverse affect on the torsional strength, stiffness, or toughness of the regenerate of the medicated group was noted compared to the control group.
The purpose of current study was to describe the results of complex acetabular fractures treated with open reduction using transtrochanteric approach and arthrotomy of the hip joint. Fourteen consecutive patients with both column fractures of the acetabulum were treated with open reduction and internal fixation. All patients had various associated injuries. Among them, one patient had pelvic abscess associated with traumatic bowel perforation. The acetabulum was approached with Y-shaped triradiate incision, osteotomy of the greater trochanter, and arthrotomy of the hip joint. During the operation, the osteochondral fragments were removed and torn labrum was resected. In 6 patients the fracture was fixed with reconstruction plates and in 8 patients the fracture was fixed with plates and wires. All the patients were followed for an average of 4.6 years(range, 2–8 years). The clinical evaluation was done by the method of Merle d’Aubigne. All the fractures and all osteotomies united at the latest follow up. One patient had delayed hematogenous infection at 5.5 years after the operation. Although myositis ossificans developed in 3 patients it was neither progressive after 1 year nor associated with significant limitation of hip motion. Four patients had narrowing of the hip joint space. Three of them had osteophyte formation around the femoral head. No femoral head necrosis was observed. Eleven patients had excellent or good outcomes in clinical score. No patient underwent total hip arthroplasty. This extensile approach allowed a good exposure of the fracture site, more accurate reduction, and easier fixation of fracture fragments. It also allowed the removal of osteochondral fragments and the resection of torn labrum. However, 3 patients showed osteophyte formation around the femoral head. We are concerned about the further progression of the osteophyte and its clinical implication.
The Os subfibulare, or round ossicles at the tip of the lateral malleolus, are often regarded as accessory bone. Some patients with such fragments, however, complain of ankle pain and repeated sprain. This study addresses whether these fragments are unnecessary and ignorable?
Type I a: only ATFL was attached to one fragment Type I b: ATFL and CF were attached to one fragment Type I c: ATFL, CF, and PTFL were attached to one fragment Type II : ATFL and CF were attached to two individual fragments
There were 7 Type I a, 37 Type I b, 6 Type I c, and 4 Type II. Fifty-one ankles (94%) developed bony union and three united fibrously. The talar tilt was restored from 9.8 to 4.7 degrees after surgery. The American Orthopaedic Foot and Ankle Societyñs clinical rating system for the ankle-hindfoot improved from 77 to 98 and ankle pain decreased dramatically.
Ankle sprains are very common, and usually tear or partly tear one or more of the ligaments on the outer side of the ankle. The ankle joint is only designed to move up and down, whereas there is another joint immediately below the ankle joint, called the subtalar joint, which is designed to do the tilting in and out movement. If the foot tilts over too far, the subtalar joint reaches the end of its movement and then the ankle ligaments stretch and tear.
It is possible that variations of subtalar range of movement may contribute to ankle sprains or symptoms of weakness or instability. In particular, if the subtalar joint is unusually restricted in its movement, then the foot does not have to tilt far before the lateral ligaments tear.
If on the other hand the subtalar joint is particularly mobile and has excessive movement, then the foot may go right over without actually tearing ligaments and feel insecure or unstable simply as a result of abnormal excessive movement.
Recent studies have demonstrated what we have always suspected, that clinical examination and assessment of subtalar range of movement is highly unreliable. In order to accurately assess whether your subtalar range of movement is unusually restricted or excessive, the only standard and accurate method to date has been to obtain a CT scan.
We are now undertaking a study to establish whether plain xrays with a small metal clamp applied to the heel might not be a simpler, cheaper, quicker and equally reliable method of assessment of subtalar movement.
If you would like to know if your subtalar movement might be a contributing factor to either stiffness or insecurity of your ankle, we invite you to be examined clinically, by plain xrays at SPORTSMED•SA, and by a CT scan at Jones & Partners Radiology at Burnside. The xray and CT investigations would be bulk billed under Medicare so that you would not incur any personal cost and the information could well be helpful in assessing your ankle problem, or at least be reassuring that the subtalar joint has a normal range of movement.
The investigations can be arranged through your treating doctor, physiotherapist or podiatrist or by contacting Dr Roger Paterson, Foot and Ankle Surgeon, or Mr Stephen Landers, his Research Assistant, on Ph: 8362 7788.
The CT scan would be a very limited investigation resulting in minimum radiation exposure, comparable to the normal xrays. Further information on what is involved in having a CT scan is attached.
Neither the CT scan nor the plain xrays should cause any more than minor discomfort as the foot is tilted through its full range of movement, or from the padded pressure of the G clamp.
SPORTSMED•SA remains committed to excellence in treating active people of all ages, and through these investigations, we plan to further enhance the quality of assessment and care of people who suffer ankle problems.
We set out to examine the role of bisphosphonates in protecting the bone against stress-shielding related osteopaenia during distraction osteogenesis. We used a NZW rabbit model with 2 weeks distraction to 10.5 mm then 4 weeks consolidation. We achieved positive results in the initial trial using the bisphosphonate pamidronate (Novartis). Not only were we able to abolish the decrease in BMD in the surrounding bone, we noted an increase in the mineral properties and strength of the new bone.
Moving on to zoledronic acid (Novartis), a third generation bisphosphonate designed for use in malignant hypercalcaemia and bone metastases, we achieved even more promising results. In a study of thirty rabbits, we gave saline to 10 controls, 0.1 mg/kg zoledronic acid to 10 rabbits at surgery and 10 further rabbits received 0.1 mg/kg zoledronic acid at surgery and at two weeks. The animals were scanned by DXA at 2, 4 and 6 weeks, and by QCT after culling. Mechanical testing was performed by destructive 4-point bend tests.
Second-weekly DXA scans documented faster mineral accrual after distraction between 2 and 4 weeks in both treatment groups (ANOVA p< 0.01). In the control group, the BMD in the segments around the lengthening fell by 0.16 g/cm2 between the 2nd and 6th week. The BMD showed a net increase over the same time period in all treated animals (ANOVA p< 0.01).
The cross sectional area of the regenerate at six weeks as measured by QCT was increased by 49% in the zoledronate group versus controls and by 59% in the re-dosed zoledronate group. (ANOVA p< 0.01). The final (6 week) BMC of the regenerate was increased by 92% in the zoledronate group versus controls and by 111% in the re-dosed zoledronate group (ANOVA p< 0.01). Bone mineral density was increased by a lesser but significant degree to normal values (28% and 34% respectively, ANOVA p< 0.01).
Four point bend testing revealed increases in peak load of 29% in the single dose and 89% in the re-dosed group (ANOVA p< 0.01).
Two patients are presented, one with congenital pseudarthrosis of the tibia, and one who had not united a distraction gap of 5 cm at six months, who were treated with pamidronate. Both showed successful responses in line with our research findings.
A clinical trial is being set up to establish a scientific case for bisphosphonate use in patients undergoing distraction osteogenesis with the aim of possible earlier frame removal and less refractures. Further research in other areas of bone healing is also planned.
The incidence of tarsal coalitions (TC) is not known. Most of the clinical studies report it as less then 1% but they disregard the asymptomatic coalitions. Two main theories have been elaborated regarding their etiology: 1) they result by incorporation of accessory bones into the nearby tarsals; 2) they occur as a result of the failure of differentiation and segmentation of the foetalmes-enchyme. Tarsal coalitions have been associated with degenerative arthritic changes. Computer tomography is the most commonly used diagnostic test in the detection of TC. The aims of our study were to establish the incidence of TC; the association between TC and accessory tarsal bones and between TC and tarsal arthritis; and to assess the sensitivity of CT as a diagnostic tool in TC. For this purpose we have undertaken coronal and sagittal CTs of 114 cadaveric feet which were subsequently dissected. The dissections identified 10 non-osseous tarsal coalitions, two talocalcaneal and eight calcaneonavicular. In nine cases we identified a synovial joint between the calcaneus and the navicular. We identified eight os trigonum, one accessory lateral malleolus bone, 38 sesamoid bones in the tendon of tibialis posterior and 19 sesamoid bones in the tendon of fibularis longus. Tarsal arthritis was identified in 37 cases. Both talocalcaneal coalitions were associated with talocal-caneal arthritis while none of the calcaneonavicular coalitions were associated with tarsal arthritis. The CT examination of five of the cases of calcaneonavicular coalitions showed one coalition and was suspicious of a coalition in another two instances. In conclusion our study demonstrated that the incidence of tarsal coalition is higher than previously thought (8.8%). The calcaneonavicular coalitions are more common (7%) but they do not seem to be associated with arthritic changes in the tarsal bones. The 7.9% of the calcaneonavicular synovial joint demonstrate that the “abnormality” of the calcaneonavicular space can take any form. Our preliminary CT results demonstrate a low sensitivity in the detection of nonosseous coalitions.
Thoracolumbar junction of the spinal column is the common site of spinal trauma and is often complicated by neurological dysfunction. From 1997 to 2000, there were 12 patients surgically stabilized. 8 of them were victims of major trauma while the rest was after a trivial fall in osteoporotic spine. Lengthen of follow-up ranged from 6 to 42 months.
Ages of the patients in the major trauma group were from 22 to 65. Except the one who had anterior approach because of multiple level lesions, all fractures after major trauma were initially relocated and stabilized posteriorly. Subsequent anterior procedures were necessary in three of them because of significant residual spinal canal stenosis. All except one had satisfactory lower limb function on follow up. Two patients who were paralysed on admission were able to walk independently and 4 others had improved by at least one Frankel grade. Return of neurological function was usually observed within the first week after the procedure. Residual sphincter dysfunction was however, a common problem.
The management of four osteoporotic spinal fractures in thoracolumbar junction was more unpredictable. Patients were from 66 to 92 years old. Anterior decompression was often performed because of the presence of retropulsed fragment. Although some improvement of lower limb function could be achieved, rehabilitation in three of them was complicated by loss of reduction or failure of the implant.
Recovery of the neurological function in the lower limbs was found to have no correlation with the amount of stenosis of the spinal canal. Most of the damage occurred probably at the time of injury. The sphincter control was most difficult to rehabilitate after an insult to the conus medullaris.
In cases above C4 cervical cord injury a respiratory distress and serious pulmonary complications occur with frequent obstruction of air way by increased excretion and difficult evacuation. Long term tracheal intubation often provides many general complications. We analized advantage and demerit of early tracheotomy in such cases of cervical cord injury patients.
In both cases, we used two half-thread cortical screws with a diameter of 2.7mm and a length of 30mm for the transarticular screw procedure.
There have been many reports on fracture-dislocation of the lumbar spine in recent years. Hyperextension as a mechanism for fracture-dislocation in the thoracolumbar spine was first described by Holdsworth accounting for only less than 3 percent of all fractures of the spine. De Oliverira reported an unusual pattern of sagittal shear fracture-dislocation secondary to posterior impact injuries. Hyperextension injuries result in the disruption of all ligaments & supporting elements of the spine starting with the anterior column. Sagittal translation and comminution of the posterior elements are the most common radiographic findings. Computed Tomography can accurately demonstrate the destruction of the posterior elements, and MRI is able to demonstrate the anterior ligamentous disruption. Nearly all cases suffered from paraplegia known as lumberjack paraplegia or severe neurological deficit.
A case of complete fracture-dislocation of the L4-5 resulting from hyperextensive injury without lumberjack paraplegia or neurological deficit is presented.
The diagnosis & treatment will be discussed.
We have reported that most of lower cervical cord injury patients had either improved or remained the same neurology following early operative stabilization done in our hospital. However, a few patients deteriorated with ascending paralysis in acute stage. Purpose of this paper is to present such cases and discuss the outcomes.
Charcot spondyloarthropathy is one of the late complications of traumatic spinal cord injury that produces further disability. Purpose of this paper is to introduce 5 patients who developed Charcot spine after traumatic spinal cord injury treated surgically in our hospital (SIC) and discuss the result.
28 knees underwent full clinical and radiological review at a mean of 25.8 months post-operatively, using the Hospital for Special Surgery Score and the Knee Society Score. 2 patients were interviewed by phone with recent radiological follow-up. One patient had died from unrelated causes.
The mean pre-operative alignment for the primary arthroplasties was 28° for the varus and 32° for the valgus knees. The mean postoperative alignment was 7°. The mean Hospital for Special Surgery score was 72.4 for primary arthroplasties and 72.7 for revision surgery. The mean Knee Society Knee Score was 79.8 and 75.1 respectively, and the mean Functional Score was 60.8 and 49.4 respectively. The latter reflects the elderly age, multiple joint involvement and constitutional status (including rheumatoid arthritis) of many of these patients. 4 patients experienced retropatellar pain. One patient with severe rheumatoid developed sepsis of the revision implant.
Difficulties with tibial tray lateralisation and stem fixation will be discussed.
Between December 1998 and December 1999 twenty-one patients with painful knee arthroplasties underwent assessment by radionuclide arthrography. There were eleven female and ten male patients, with an average age of 60 years at the time of the index procedure. The index procedure was a primary total knee arthroplasty, primary medial unicompartmental knee arthroplasty and revision medial UKA in seventeen, three and one patients respectively. Nineteen arthroplasties were uncemented and two were hybrids. All patients had previously been investigated by clinical examination, serological testing, fluoroscopic AP and lateral radiographs, and Tc99 bone scan with equivocal results. The presence of radionuclide about the tibial stem was considered diagnostic of tibial loosening. Nine patients underwent revision knee arthroplasty. The presence of radionuclide about the tibial stem correctly predicted a loose tibial component in four of five cases. Similarly, the absence of radionuclide about the tibial stem correctly predicted a stable tibial component in four of four cases. In the single misdiagnosed case the tibial component did not have a large central stem, had focal osteolysis about several screws, but remained stable. Radionuclide arthrogram is a useful tool in the investigation of painful knee arthroplasty. Radionuclide about the tibial stem is the key predictor of tibial component loosening.
Thirty-one patients (33 knees) with symptomatic patello-femoral osteoarthritis and minimal tibiofemoral changes underwent LCS total knee replacement without patellar resurfacing.
Average age was 73 years (range, 58–89 years) with a female to male ratio of 5:1. Average follow-up was 20 months (range, 12–40 months). All except four patients had grade 3 or 4 patello-femoral osteoarthritis.
Preoperatively all patients had significant knee pain. Sleep disturbance was reported in 21 patients. All but 10 patients required walking aids. Average range of motion was 1080 (80–125).
At latest review, 21 knees are pain-free, the remaining 12 knees describing only occasional knee pain. Two patients continue to have night pain. Average range of motion was 1040 (70–1350). Lateral patellar tilt improved in all but five knees by an average of 70 (1–260). Patellar congruency improved in all but three knees by an average of 18% (3–63%). None of the patients to date have required revision surgery.
We suggest that knee arthroplasty without patellar resurfacing is an effective option in older patients with isolated patello-femoral osteoarthritis.
The problem of chronic, haematogenous osteomyelitis is still a major one in developing countries. There are several patients who report with multiple discharging sinuses and a history of several operative procedures. The persistence of sepsis and repeated operations takes its physical, mental and financial toll.
The use of local muscle pedicle for filling saucerized cavities in chronic osteomyelitis was described by Starr and later by Ger. However, it has somehow not caught the fancy of Orthopaedic Surgeons.
The paper is a report of 55 cases of chronic osteomyelitis of long bones treated by use of the method. Anterior 1/3rd of Deltoid was used for proximal end of Humerus & lateral _ of brachialis for lower 1/3rd by a double breasting technique. The femoral shaft was filled by vastus lateralis by the author’s double breasting technique. The Medial Head of Gastrocnemius, soleus and Flexor Hallucis longus were used separately or in combinations for proximal 2/3rd of Tibia. The Abductor Hallucis was used for medial malleolus and calcaneum. A thorough debridement of necrotic and infected tissues preceded the application of muscle pedicle which was done as a single stage procedure.
The age of patients ranged from 8 yrs to 54 yrs with male preponderance. The followup of cases ranges between 18 months to 13 years with an average of 5.8 years.
All cases except 2 in femur showed no recurrence of sepsis. Two patients in femur had fracture through saucerized area.
It is concluded that filling of saucerized cavities with muscle graft obliterates the dead space as well as improves local vascularity. It adds only 20 minutes of operative time on an average and the technique is simple. It gives uniformly good results.
Between 1995 and 1998, eighty revision total knee arthroplasties were done for the primary reason of advanced polyethylene wear. The primary arthroplasties prosthesis that failed included thirty-four mobile bearing knees and forty-six fixed bearing knees. In thirty-four Low Contact Stress (LCS) mobile bearing knees, osteolysis was identified intraoperatively in sixteen knees (forty-seven per cent). There were varying of fixation methods included nine cemented, four cementless and three hybrids. In forty-six fixed bearing knees, osteolysis was identified intraoperatively in six knees (thirteen per cent). The fixation methods of prostheses included two cemented and four cementless. The incidence of osteolysis was statistically significant difference between the mobile bearing and fixed bearing knees (p< 0.02).
Both scattering electron microscope (SEM) and light scattering analysis were used to examine the UHMWPE wear debris collected from tissue sample. The particle size analyzed by light-scattering is coincident with the measurement by SEM. The major type of wear debris extracted from failed knee prostheses is granular shape. There are more granular wear debris appear in the mobile bearing knees than in the fixed bearing knees. The particle size of UHMWPE wear debris with osteolysis was significantly smaller than that without osteolysis. The high rate of osteolytic lesions in mobile bearing knee (LCS) is well illustrated in our result that a lot of fine UHMWPE wear debris generated in the Low Contact Stress knee. The result also illustrates that there is no relationship between fixation methods and the third body wear that associate with osteolysis.
Most total knee replacement designs incorporate the views of the designer relating to the function of the normal knee. A video of the normal cadaverie knee will be shown and depending on the loading regime the following movements can be clearly demonstrated: femoral roll-back, femoro-tibial rotation, medial pivot and lateral pivot. Knee replacement designs which do not allow all of the above movements risk Kinematic conflict. A knee replacement design will be shown which permits all of the normal knee movements.
Eighteen porous coated posterior stabilized prostheses, inserted without cement or screws have been reviewed. Six were revised within two years. One was infected. The remaining five were revised for persistent symptoms considered to be due to tibial component loosening. Three of the four improved after revision with cementing of the tibial component, the other has remained symptomatic. One patient was lost to follow-up. Clinical review of the remaining eleven was good or excellent at two years. Radiographs at two years, available in eight, revealed that all had a non progressive I mm radio-lucent line at the bone- tibial prosthesis interface. The lack of bony ingrowth and apparent symptomatic early loosening in the four revised, suggests that posterior stabilised tibial prostheses may require additional initial fixation. From our experience in this short series, it is recommend that the tibial component of this prosthesis and perhaps any other posterior stabilized design, be cemented or fixed with screws.
Antibiotic-impregnated polymethylmethacrylate beads, which are used to deliver antibiotic directly to infected sites in the musculoskeletal system has been evaluated most widely. The disadvantages include reduced biocompatibility with bone, short duration of drug release, very low release rate and thermal damage to the antibiotics. For solving this problem, we developed the antibiotic-impregnated calcium hydroxyapatite ceramic implant (HA) as a new drug delivery system. This study is to evaluate the clinical results of the antibiotic-impregnated HA used for the treatment of infected total hip and knee arthroplasty. Twenty-two patients with infected arthroplasty treated antibiotic-impregnated HA were evaluated. There were 5 men and 17 women with a median age of 65 (range, 54–86 years). The study included 14 hips and 8 knees. The duration from the initial arthroplasty to the detection of the infection was 16 years at the longest (median of 2 years and 2 months). The most common microorganism was Staphylococcus aureus, presented in 13 patients. Antibiotic most frequently impregnated was Vancomycin. In five patients, debridement without removal of the prosthesis was performed with antibiotic-impregnated HA implanted in surrounding bone. In another three patients, one-stage revision was performed with antibiotic-impregnated HA. In fourteen patients, antibiotic-impregnated HA was used to fill the dead space after removal of the prosthesis (two-stage revision was performed in 9 patients). No patients developed evidence of recurrent infection at an average follow-up of 18.7 months. Antibiotic-impregnated HA is an excellent drug delivery system for the infected total hip and knee arthroplasty.
Tuberculosis of short tubular bones is uncommon after childhood. “Spina Ventosa” is considered the classical radiological presentation and hallmark of this disease. The short tubular bones are uncommon loci for the manifestation of adult skeletal TB. We report our experience with 31 cases of tuberculosis of hand (excluding wrist) with the intention to call attention to its occurrence in infrequently documented areas, to stress upon its morphologic variability and to illustrate little emphasized radiological signs.
Eight of the current 9 cases of wound infection, included 4 verified cases involving methicillin-resistant Staphylococcus aureus, were successfully treated by topical application of Polytoxinol, either without (6 patients), or in combination with systemic antibiotics (3 patients). In 8 patients, Polytoxinol application was followed by reduced inflammation, rapid granulation and healing even where infection was of > 2 years standing. Adverse local tissue reaction shown by 1 patient quickly subsided on withdrawal of Polytoxinol.
The diagnosis of painful heel syndrome is quite common in any busy orthopaedics OPD. Though neoplasm and infections are not uncommon in calcaneum, the surgeon does not suspect infection unless there is an obvious history of punctured wound or constitutional symptoms. As such till date there is no series of large number of cases of calcaneal tuberculosis. We present our experience with 39 cases of calcaneal tuberculosis which include 2 cases of simultaneous bilateral symmetric involvement and 13 cases of tubercular lesion at the site of the attachment of Tendoachilles and Plantar Fascia. A classification of calcaneal tuberculosis is proposed.
Wear particles are thought to be a major factor causing osteolysis that leads to aseptic loosening. The aim of this study was to investigate the role of primary regulators of osteoclast development, RANKL (also known as osteoclast differentiation factor), its receptor RANK and natural inhibitor osteoprotegerin (OPG) in aseptic loosening. Cells were isolated from periprosthetic tissues taken at revision from more than 30 patients and the expression of these mediators in vivo was assessed using semi-quantitative reverse transcription polymerase chain reaction (RT-PCR). These cells were also cultured on dentine to determine their ability to become mature osteoclasts. In situ hybridisation using DIG labelled riboprobes specific for RANK mRNA was used to identify cells likely to become osteoclasts. We were able to compare revison tissues containing several different types of prosthetic wear particles.
RANKL, RANK and OPG mRNA were found in samples of periprosthetic revision tissues. Cells derived from this tissue developed into mature osteoclasts capable of resorbing dentine. Cells that rapidly formed osteoblasts expressed a fifteen fold higher ratio of RANKL:OPG mRNA. In situ hybridisation showed RANK expression by macrophages and giant cells, many of which contained wear particles. Significantly, cells from tissues containing silastic wear particles expressed higher levels of RANKL relative to OPG and more produced large numbers of osteoclasts in vitro. This study shows that different bio materials in a particulate form may differ in their ability to form osteoclasts and that the relative levels of RANKL and OPG are likely to be important in determining if osteolysis will occur. In the future molecules that inhibit RANKL binding, such as OPG, may be considered for therapy of periprosthetic osteolysis.
There is growing evidence that RANKL (also known as osteoclast differentiation factor), its receptor RANK and its natural inhibitor osteoprotegerin (OPG) are involved in bone loss in a number of pathologies. The aim of this study was to determine if these factors are expressed in a number of bone loss pathologies and what cell types were producing these factors in the tissues using reverse transcription polymerase chain reaction (RT-PCR), in situ hybridisation and immunostaining techniques. Periarticular tissue was obtained from 15 patients undergoing revision of aseptic loose implants. Rheumatoid joint tissue was obtained from the pannus region of 12 patients diagnosed with rheumatoid arthritis undergoing joint replacement or joint fusion. Inflamed gingival tissue from sites near bone erosion were obtained from 11 patients with periodontal disease. 6 normal periodontal and periarticular tissue from 6 osteoarthritic patients was used as controls.
RANK, RANKL, OPG and M-CSF mRNA were expressed in tissues obtained from all the pathologies. Higher ratio’s of RANKL to OPG were observed in the pathological tissues compared to their respective controls. In revision tissues many multinucleated giant cell containing particles expressed RANK mRNA. The pattern of staining of RANK mRNA was markedly different in the rheumatoid and periodontal tissues. Differences were also seen in the pattern of expression for RANKL using both in situ and immunostaining. Overall our results indicate that although similar osteoclastogenic factors are fundamentally involved in these bone loss pathologies, different cell types may be producing and/or responding to these factors. Identifying fundamental mechanisms such as these may indicate that similar treatments, such as using OPG or related compounds, may be used for a diverse range of bone loss diseases.
This paper will focus on the use and including a demonstration of Digital photography for the purpose of clinical documentation, audit, teaching and research. Digital photography is particularly suitable in upper & lower limb surgery because of the discrete regional anatomy and radiology. Digital images once created and stored do not deteriorate, unlike pictures or slides. Digital camera that uses a single floppy disc has an added advantage of simplicity and ease of storage. Pre-op, intra-op, and post-op images of patients undergoing hand surgery and treatment are easily documented with the camera. The information can be archived using commercially available filing software such as File MakerPro. The information can be retrieved at a later stage to be used in audit, teaching and research, with the images retained in their original, unmodified condition. Existing clinical, historical and teaching library slides, pictures or images can be archived to ensure the quality of the images do not deteriorate further, and for ease of retrieval and subsequent application. Archiving in this manner would require a slide scanner. The ease of file retrieval, reliability and accuracy of this imaging system has been tested using a minimum of 2000 patient files, using both PC and Macintosh systems, with no computer error and minimal operator errors found. The software used has “auto save” feature built in, hence computer “crash resistance.” The only limitation of the technology is the set up costs, and the resolution of the images. Fortunately, both these limitations are improving rapidly.
Successful reconstructive surgery with allografts is severely limited by a failure rate of 30 – 40%. Allograft failure is due to nonunion of the graft-host junction. The molecular mechanism by which this occurs is not yet fully elucidated. Using a sheep femoral allograft model, we have investigated the cellular and molecular mechanisms associated with nonunion of bone allografts. Five, from a total of twelve operations, resulted in the development of graft-host nonunion, reflecting a failure rate of 42%. Histological assessment revealed that allograft failure was due to the excessive accumulation of and resorption by, osteoclasts (Ocs) on the surface of the bone allograft. Three distinct layers, lying adjacent to the allograft bone surface, in the nonunion groups, were identified. The outer fibroblastic layer contained abundant fibroblasts and connective tissue. Underlying this layer were synovial-like cells and some multinuclear giant cells. The third layer, opposing the bone surface, consisted of Ocs and round mononuclear cells. Histomorphometric analysis showed that allograft unions, featured a large amount of newly formed bone on the surface, (OS/BS = 47.81%) with a small proportion of eroded surface (ES/BS = 20.59%). The number of osteoclasts associated with the allograft bone surface were few (Oc/B.Pm = 1.7190/mm) and activity (ES/BS = 46.68%) of Ocs with a reduced amount of new bone formation (OS = 6.35%). Both calcitonin receptor and H+ATPase mRNA, characteristically expressed by Ocs, were localised to the multinuclear giant cells, indicating that they were Ocs. Synovial-like cells in the histological layer above the Ocs, expressed gene transcript for the Osteoprotegrin Ligand (OPGL), a membrane bound factor that is critical for the induction of Oc activity and osteoclastogenesis. In conclusion, these findings suggest that failure of bone allografts is partially due to excessive resorption by host Ocs, accompanied by reduced bone formation. The production of OPGL by synovial-like cells, may be responsible for the recruitment and generation of Ocs.
The presence of microdamage in bone and its targeted repair by activating bone remodelling has been controversial partly because it is difficult to locate and difficult to quantify. A number of studies have now validated techniques to locate and quantify microdamage and microdamage repair in human cortical and trabecular bone samples. The purpose of this study is to determine if microcracks accumulate in the cancellous bone of the intertrochanteric region of the proximal femoral shaft and influence the strength of bone. We have used en bloc basic fuchsin staining to identify in vivo microcracks in 70 micron sections. Trabecular bone was sampled in 33 patients undergoing total hip replacement for primary osteoarthritis. The study sample had a median age of 73 years and included 18 women (aged 49 to 84 years) and 15 men (aged 45 to 85 years). Histomorphometry was used to quantify the number of cracks in each case. In a selection of 12 cases the bone sample was also biomechanically tested to determine the cancellous bone strength. We found that microcracks accumulate with age, particularly after the age of about 60 years. This indicates that the bone from the elderly is more susceptible to fatigue damage than bone from the young. In addition, an increased number of microcracks in the cancellous bone significantly reduced the ultimate failure stress of the bone. Bone screws or pins placed in cortical or trabecular bone create microdamage adjacent to an implant, and the area in which this microdamage occurs is the same as that which subsequently remodels. Microdamage may be the result primarily of procedures during prosthetic implantation, but bone screws or pins can create stress concentrations that can be sites for initiation of new cracks. Therefore, if bone remodelling targets bone microdamage for repair then accumulation of microdamage around prosthetic implants may be responsible for the biologic responses which lead to implant loosening. This phenomenon is understudied in orthopaedic research and is an area requiring further investigation.
Growth factors hold great promise for the treatment of various musculoskeletal conditions. Growth factors are small proteins that serve as signaling agents for cells. The discovery of these substances revolutionized the field of cell biology by revealing the mechanism of regulation of cell activities. Growth factors are present in plasma or tissues at concentrations measured in billionths of a gram yet they are the principal effector of such critical cellular functions such as cell division, matrix synthesis and tissue differentiation.
Several growth promoting substances have been identified in bone matrix and at the site of healing fractures. Among these are the transforming growth factor beta’s, bone morphogenetic proteins, fibroblast growth factors, insulin like growth factors and platelet derived growth factor. These growth factors are mainly produced by osteoblasts and incorporated into the extracellular matrix during bone formation. Small amounts of the growth factors can also be trapped systemically from serum and be incorporated into matrix. The present hypothesis is that growth factors are located within the matrix until remodeling or trauma causes solubilization and release of the proteins.
The discovery of growth factors and their study in in vitro cultures has allowed an understanding of the mechanism of the regulation of a broad range of cell activities. However, their presence in plasma and tissues in minute quantities limited their evaluation in vivo and precluded clinical application of the natural purified products. Advances in recombinant DNA methodology have allowed sufficient quantities of these materials to be produced and many are in various stage of in vivo pre-clinical and clinical evaluation.
Extensive efforts have been made to find methods by which growth factors can be used to stimulate local bone healing and bone formation in a variety of clinical models. The growth factors TGF-α, BMP and basic FGF are the only growth factors that have been demonstrated to possess substantial in vivo bone stimulatory capacity. The growth factors BMP-2 and BMP-7, also known as osteogenic protein-1, are in the final stages of pivotal human trials.
There are many challenges to the clinical application of growth factors. It is unlikely that cell signaling molecules act independently of each other or are present in isolation from each other at their sites of action. The therapeutic application of growth factors must also accommodate the fact that most factors have a widespread and varied distribution of target cells. A growth factor administered to elicit a desired response from one cell type may also influence other cell types possible in unintended or undesirable ways. Finally, in the current era of cost consciousness in health care, a growth factor treatment must demonstrate cost effectiveness along with clinical efficacy.
The cellular and molecular mechanisms that lead to particular trabecular structures in healthy bone and in skeletal disease, such as osteoarthritis (OA), are poorly understood. Osteoclast differentiation factor (ODF) is a newly described regulator of osteoclast formation and function, whose activity appears to be a balance between interaction with its receptor, RANK, and with an antagonist binding protein, osteoprotegerin (OPG). We have examined the relationship between the expression of ODF, RANK and OPG mRNA, and parameters of bone structure and turnover, in human trabecular bone. Intertrochanteric trabecular bone was sampled from patients with primary hip OA (n=13; median age 66 years) and controls taken at autopsy (n=12; median age 68.5 years), processed for histomorphometric analysis and RNA isolated for RT-PCR analysis of ODF, RANK and OPG mRNA expression. The ratios of ODF/OPG and ODF/RANK mRNA are significantly lower in OA (1.78±0.98; 0.59±0.31) compared to the controls (3.41±1.94, p< 0.02; 2.53±1.5, p< 0.001). This suggests that in OA there is less ODF mRNA available per unit RANK mRNA, and that osteoclast formation may be reduced. Furthermore, eroded bone surface (ES/BS[%]) was significantly lower (p< 0.05) in the OA group (6.37±3.17) compared to controls (9.74±4.53). Stong associations were found between the ratio of ODF/OPG mRNA and bone volume (ODF/OPG vs BV/TV[%], r=−0.67; p0.05) and bone turnover (ODF/OPG vs ES/BS, r=0.93; p< 0.001; ODF/OPG vs osteoid surgace (OS/BS[%], r=0.80; p< 0.001) in controls. In contrast to controls, these relationships were not evident in the OA group, suggesting that bone turnover maybe regulated differently in this disease.
We have used a culture system of human peripheral blood mononuclear cells (PBMC)as a source of osteoclast (OC) precursors and murine stromal cells to define the cytokine environment in which human OC form, and to determine the separate contributions of the stromal and haemopoietic elements. We designed a panel of reverse transcription-polymerase chain reaction (RT-PCR) primers that specifically amplify the respective murine or human mRNA species that correspond to cytokines and their receptors previously shown to promote or inhibit OC formation. Murine ST-2 cells and human PBMC were cocultured for up to 21 days in the presence of 1,25(OH) 2vitD3, dexamethasone and human macrophage-colony stimulating factor (M-CSF). OC formation was monitored by the appearance of cells that were positive for tartrate resistant acid phosphatase and able to form resorption lacunae on slices of dentine. We found that the ST-2 cells in these cultures expressed mRNA encoding a repertoire of many of the reported osteoclastogenic factors, as well as the recently described OC differentiation factor (ODF/RANKL). The stromal cells also expressed mRNA encoding osteoprotegerin (OPG), a potent inhibitor of OC formation. We found that agonists and antagonists of OC formation were expressed by both the stromal cells and the PBMC. RANK, the receptor for ODF/RANKL, was expressed only by the PBMC as were IL-1R2 and c-FMS. We identified three features of the cytokine environment that may be a characteristic of normal OC formation. Firstly, the ratio of mouse ODF:OPG mRNA was found to increase during the cocultures, consistent with a key role for ODF in the promotion by stromal cells of OC formation. Secondly, we found that mRNA encoding IL-1 and IL-17, as well as IL-6 and sIL-6R, were coordinately expressed by the PBMC. Thirdly, analysis of the culture medium showed that the PBMC secreted IL-1, IL-6 and TNF-alpha protein only in coculture with ST-2 cells during the first few days of osteoclast development. Similarly, prostaglandin E2, shown to synergise with ODF during OC development, was secreted only in cocultures. Together, these data show OC develop in a complex cytokine environment and suggest that haemopoietic cells provide signals to stromal cells during OC development. Work is in progress to extend these studies to human PBMC interacting with normal human osteoblasts.
Ozgene is a commercial venture established to produce genetically modified mice (GM-mice). GM-mice are the most sophisticated tools in functional genomics and drug target validation. Our Directors, CEO and COO provide internationally recognized expertise to produce GM-mice for the biotechnology & pharmaceutical industry and academic institutions.
Ozgene’s service includes the identification, isolation, sequencing and mapping of murine genes followed by the generation of classical or conditional knock-outs, knock-ins and transgenics.
We also offer phenotypic analysis of GM-mice; providing a complete service from gene discovery to gene function.
We are able to produce, supply, maintain and cryopreserve GM-mice in alliance with the Animal Resources Centre, Australia’s premier supplier of specific pathogen free (SPF) laboratory animals.
Ozgene’s senior management team has an established track record in the generation and analysis of GM-mice as published in leading scientific journals including Nature, Science, EMBO, PNAS. Our CEO and COO were amongst the first to produce C57BL/6 knock-out mice and NOD transgenic mice.
To determine and compare the biomechanical strength of the bone fixation construct with reinforcement by membrane and sponge of such bone defect which were rendered unstable by ulnar osteotomy.
In group 2, there were bone formation at the ends of both proximal bone stumps and distal bone stumps. There was no bone bridging the defect.
In group 3,4, there were bone formation across the defect. There was more bone formation in group 4, i.e. the defects were bridged by sponge.