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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.
As in other high-income countries, tuberculosis (TB), including musculoskeletal TB, occurs infrequently in Australia. Only 954 new TB cases (i.e. 5.15 per 105 population) were reported in 1997 with 44 cases of musculoskeletal TB. Hence, most Australian physicians and surgeons are unfamiliar with musculoskeletal TB, which can often present as a chronic slowly-progressive destructive disease. Consequently delays in diagnosis are common resulting in significant morbidity. In contrast, TB rates are more than 100 per 105 population in many countries in SE Asia and the Pacific. Medical staff are therefore familiar with the manifestations of TB but often lack the laboratory facilities to confirm the diagnosis or perform drug susceptibility tests (DSTs).
This presentation will provide research findings of interest to medical staff from both Australia and neighbouring countries. A review of musculoskeletal TB cases reported in South Australia over the last decade will be presented highlighting the delays in diagnosis and the resulting morbidity. Recent advances in TB diagnostics (i.e., novel agar media, Alamar blue, and Mycobacterium Growth Indicator Tubes) that represent appropriate technologies for low-resource countries will also be described.
Osteogenic proteins (OPs), also referred to as bone morphogenetic proteins (BMPs), are a family of bone-matrix polypeptides isolated from a variety of mammalian species. These proteins are members of the transforming growth factors-beta superfamily of molecules that contain a highly conserved 7 cysteine transforming growth factor domain in their C-termini. Implantation of osteogenic proteins induce a sequence of cellular events that leads to the formation of new bone.
In preclinical studies, the implantation of recombinantly produced human osteogenic protein-1 (OP-1, also referred to as BMP-7) in conjunction with bovine bone derived Type 1 collagen or various nonproteinaceous biodegradable carriers into surgically created, critical size diaphyseal segmental defects resulted in the regeneration of new bone that was fully functional biologically and biomechanically. Injection of an OP-1 solution into a fresh fracture model accelerated the bone repair process compared with control fracture healing. Significantly increased biomechanical strength was the result of greater and earlier new bone formation. Further study has demonstrated that OP-1 can be used as a bone graft substitute to promote spinal fusion, aid in the incorporation of metal implants, and improve the performance of autograft and allograft bone. OP-1 has also shown promise as an agent for the repair of osteochondral defects.
Clinical study of the OP-1 device for the treatment of tibial nonunion fractures has shown healing characteristics similar to that obtained with autogenous iliac crest bone graft. The randomized, prospective clinical evaluation included 30 patients with 31 tibal nonunion fractures. The mean time from injury was 27.2 months (minimum 9 months). All patients were treated with reamed intramedullary rods. At the 9 month evaluation 14 of 16 OP-1 and 14 of 15 autograft treated fractures were clinically and radiographically healed. Advantages of OP-1 included no donor site complications, less blood loss, an a shorter operative time.
Non-contained defects, Bi-polar lesions, Patients greater than 45 years, Uncorrected biomechanics, Regional pain syndrome type 1, Limited joint movement, Defective subchondral bone plate.
Articular cartilage has compressive stiffness determined primarily by the matrix which is quite characteristic and distinct from that of degenerative articular cartilage or regenerative fibrocartilage. Alterations evident when articular cartilage begins to degenerate include a decrease in proteoglycan content and water content and resultant reduction in stiffness. Regenerative fibro-cartilage has greatly reduced stiffness with functional implications. Identification of cartilaginous stiffness for various sites of normal articular cartilage in the knee is important to enable comparison measures of suspected degenerative cartilage and regenerative articular cartilage either hyaline, fibrocartilage or mixed. The aim of this study was to map the in vivo biomechanical properties of normal human articular knee cartilage using the Artscan 1000 arthroscopic cartilage stiffness tester (Artscan Oy, Finland). It has been shown that the Artscan 1000 is reliable when measuring the stiffness of thin articular cartilage (Lyra et al., 1999). Over a period of 12 months, 94 patients (age 15–69 yr) undergoing a knee arthroscopy consented to having their normal articular surfaces biomechanically evaluated for stiffness. Cartilage stiffness (N) was defined by the mean indenter force at each site where the applied force on the measurement rod equalled 10 ±1.5 N. Medial femoral condyle stiffness (M ±SD; 3.71 ±1.28 N) was greater than all other sites and was significantly greater than mean values obtained for proximal, distal and lateral trochlea (1.87 ±0.91, 2.44 ±1.02 and 2.69 ±1.52 N, respectively); medial (1.71 ±0.70 N) and lateral patella (2.18 ±1.03 N); and medial and lateral tibial plateau for all subjects (2.33 ±.1.26 and 2.27 ±1.19 N, respectively; p < 0.05). There were no significant differences between sexes for each site. There was no trend for cartilage stiffness to be lower in patients over forty compared to younger patients for both sexes for all sites. There was, however, statistically significant less stiffness of the distal trochlea for females under 40 years when compared to that of females older than 40 years. The clinical significance of this is under review. Further research involving the characterisation of cartilage stiffness in pathological situations and evaluation of stiffness following articular cartilage repair is now possible.
In comparative studies of various gait patterns of 20 healthy subjects who used a cane, the vertical reaction forces and the passages of the center of force on the foot were measured and recorded by a force recording and analyzing device (Foot-scan system). The results indicated that when a cane was used in the ipsilateral hand, the center of force did not shift significantly compared with normal gait. When a cane was used in the contralateral hand, the center of force shifted medially compared with normal gait. In analysis of the vertical floor reaction force acting on the foot, the most efficient way to use a cane was to control the pacing so that the tip of the cane and the foot touched the ground simultaneously. By doing so, the cane could share as much as 34.3% of force at heel strike, 25.3% at midstance, and 29.7% at toe off of the stance phase of the gait cycle. When prescribing use of a cane for a patient with varus gonarthritis, the patient should be instructed to use the cane in the ipsilateral hand so as not to shift the center of force medially; for a patient with valgus gonarthritis, the cane should be used in the contralateral hand to shift the center of force medially. Patients should be taught to control pacing so that the tip of the cane and the foot touch the ground simultaneously.
In recent years numerous growth factors acting on musculoskeletal tissues have been identified. This presentation summarizes our experience with IGF1 in the stimulation of growth of the physis and TGF beta in the formation of bone and cartilage.
IGF1 in a carrier, agarose, was instilled in a paraphsyeal region in rabbit tibias. The physeal height was measured over a period of time and was found to have increased in the group treated with IGF1 when compared to the control group. In addition there was delayed closure of the physeal plate.
These findings may have clinical applications in stimulation of physeal growth in small by length discrepancies
A polycaprolactone scaffold impregnated with TGF beta was implanted under the skin, in the muscle and under the periosteum in rabbits. Over a period of time the scaffolds were harvested and subjected to histological analysis with a variety to stains. Formation of bone and cartilage was found in these scaffolds implanted under the periosteum. Subdermal and intramuscular implantation of the scaffolds did not produce the same results. It is postulated that apart from TGF Beta local and environmental factors may play a part in bone and cartilage formation. This model may be useful in creating complex scaffolds in-vivo for subsequent transplantations.
The FBCI has been shown to be a better method for describing scoliosis correction because it takes spinal flexibility into consideration. 1
Video-assisted thoracoscopic surgery (VATS) has been in use since the 1980s for surgery of the spine. Initially it was used for anterior release of the thoracic spine in order to facilitate posterior instrumentation. With increasing experience, it has been applied to perform definitive correction and instrumentation. Video-assisted thoracoscopic spine surgery allows the surgeon to perform anterior thoracic spine operations with fewer levels of instrumentation, reducing the crankshaft effect and removing the morbidity associated with thoracotomy. From 1996 to November 2000, our center performed 19 such operations. 18 of them were completed successfully endoscopically and one was converted to an open procedure. An initial group of 10 patients underwent thoracoscopic anterior release and fusion followed by same day posterior instrumentation and fusion. Subsequently, 6 patients underwent anterior discectomies, fusion with instrumentation via thoracoscopic approach.
For the initial 10 patients, the average operative time was 190 minutes. The average post-operative correction was 62 % and blood loss was 350 mLs. For the 6 patients who underwent anterior discectomies, fusion and instrumentation via the thoracoscopic approach, the average operative time was 360 minutes; average post-operative correction was 70% and blood loss was 400 mLs.
Complications encountered were minor and included one case ofcontralateral pneumothorax, one patient complained of transient limb numbness which resolved within 6 weeks. It is our conclusion that thoracoscopic anterior spinal surgery, though with learning curve, a safe and effective procedure.
This study was designed to see if using a plastic punch instead of a metal punch reduces the extent of chondrocyte damage in osteochondral mosaic plasty.
Images were interpreted using a graphics analysis programme.
In scoliosis, it is well known that lateral deformity is coupled with vertebral axial rotation. Coupled motion in the sagittal plane, however, has not been investigated.
We report the long-term radiographic results of the total hip arthroplasty with use of the cementless porous coated Harris-Galante (H-G) stem. Seventy-five consecutive patients, eighty-eight hips formed the basis of this study. Fifty patients were male, twenty-five patients were female, and thirteen patients were bilateral. The mean age of patients at operation was 42 years. They were followed up for an average of thirteen years four months (ten years two months to fourteen years four months). The diagnosis was avascular necrosis of the femoral head in 49 cases, degenerative osteoarthritis in 32 cases. Clinical results were estimated by modified Harris hip score and thigh pain, and radiographic results by periodically checked plain X-ray film. The average Harris hip score increased from 60 points preoperatively to 83 points at the most recent follow-up examination. The hip pain score increased from 31 points to 41 points. Clinically severe thigh pain was observed in 3 cases (4%). In radiographic evaluation, subsidence more than 5mm was seen in 2 cases (2%). Periprosthetic osteolytic lesion was observed in 15 cases (17%), but the lesions do not influence stability of the stem. Femoral stem stability by Engh was stable in 72 cases, fibrous stable in 12 cases, unstable in 4 cases. Pedestal formation, cortical hypertrophy of the distal femur, and stress shielding was observed more than 40%. Subcollar resorption was identified in 29% and ectopic ossification in 15%. Revision of the femoral stem was needed in 4 cases for aseptic loosening. At 10 years probability of survival of the stem using Kaplan-Meyer method was 95.5%. Use of the cementless H-G stem yielded the excellent long-term outcome, but osteolysis and stress shielding would be the main problems to solve.
AIS is the most popular spinal deformity to search for surgical correction. Between 1988 to 1995, there were totally 146 patients who undergone CDI for the correction. Among them 63, were due to thoracic scoliosis. In the begining, only hooks were placed in the laminar region according under the teaching of CD group. Later pedicle screws were inserted in the upper lumbar and the lower thoracic region. Fusion was mostly done using iliac bone chip. there was no external jacket or PP cast to protect the trunk. The average Cobb angle at coronal plane before surgery was 51.7 deg. After surgery, the angle became 17.3 deg. At final follow, there was 4.2 deg. loss. Thus the correction rate was 66.5%, and the correction loss was 7.7%. The Sagittal curve still could be maintain in the normal range. The axial correction rate was 31.5% for the initial 50 cases.
Complication was minimal. Four cases had mild numbness in the r’t thigh, and two of them had sl. weakness of knee extension. All resolved within one month. “Crankshaft” was detected in 4 cases. Ten cases had hardware problems. These included 2 pedicle screw breakage, and two screw back-out. Six patients had lower upward hook dislodgement. Two patients had late deep wound infection, which needed debridement and delayed removal. In summary, CDI was effective to correct the deformity in the adolescent patients.
Initially, all the femoral canals were prepared with the routine cementless fixation technique modified by the author (rasp-ream-rasp technique). With insertion of the final-size rasp, reliable fixation was not obtained possibly due to poor bone quality or inherent canal geometry. To avoid fracture with insertion of the next-sized stem, bone cement was added as gap-filler to augment fixation of the final-sized stems.
To evaluate the results critically of cemented total hip arthroplasty using a fourth generation cement technique and polished femoral stem, a prospective study was performed in patients under 50 years of age who underwent primary total hip arthroplasty. 55 patients (64 hips) were enrolled in the study (43 were male and 12 were female). Average age of patients was 43.4 years (21–50 years). Elite plus stems (DePuy, Leeds, UK) were cemented and cementless Duraloc cups (DePuy, Warsaw, IN.) were implanted in all hips. 22 mm zirconia femoral head (DePuy, Leeds UK) was used in all hips. All surgeries were performed by one surgeon (YHK). The diagnosis was osteonecrosis (43 hips or 67%), osteoarthritis (5 hips or 4%), O.A. 2° to childhood T.B. or pyogenic arthritis (4 hips or 6%), R.A, (3 hips or 5%), DDH (2 hips or 3%) and others (7 hips or 11%). The average F.U. was 7.2 years (6–8 years). The 4th generation cement technique was utilized including: medullary plug, pulsatile lavage, vaccum mixing of Simplex P cement; cement gun, distal centralizer and proximal rubber seal to pressurize cement. Thigh pain was evaluated using a visual analog scale (10 points). Clinical (Harris hip score) and x-ray follow-up was performed at 6 weeks, 3 months, 6 months, 1 year and then annually. Cementing technique was graded. Abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion were measured in all hips. Linear and volumetric wear were measured by software program. Osteolysis was identified. There was no aseptic loosening or subsidence of components. One hip was revised due to late infection. Incidence of thigh pain was 11% (7 hips). All thigh pain disappeared at 1 year postoperatively. Preoperative Harris hip score was 47.2 (7–67) points and 92.2 (81–100) points at the final F.U. Femoral cementing was classified as grade A in 50 hips (78%), grade B in 6 hips (9%), and grade C1 in 8 hips (13%). There was no cases in grades C2 and D. All bones had type A femoral bone. The average linear wear and annual rate were 1.25 and 0.21 mm, respectively. The average volumetric wear was 473.48 mm3. There was statistically significant relationship between the liner wear, age (under 40), male patient, and the cup angle. Yet there was no statistical relationship between the wear and Dx., wt., hip score, R-O-M, anteversion, anbductor moment arm, femoral offset, neck and limb length and center of rotation of hip. Osteolysis was identified in zone 7A in 6 hips (9%). No hip had distal osteolysis. Advanced cementing technique, polished improved stem design, strong trabecular bone, and utilizing a smaller head and thick polys greatly improved the mid-term survival of the implants in these young patients. Good cementing technique eliminated distal osteolysis and markedly reduced the proximal osteolysis. Yet high linear and volumetric wear of polyethylene liner remains to be a challenging problem.
To determine the results critically of cementless third generation prosthesis (proximal fit, porous coated, and tapered distal stem), a prospective study was performed only in Charnley class A patients under 50 years of age who underwent primary total hip arthroplasty. 50 patients (50 hips) were included in study (37 were male and 13 were female). Average age of patients was 45.4 years (26–50 years). IPS(Immediate Postoperative Stability) stems (DePuy, Leeds, UK) were implanted in all hips. Cementless Duraloc cups (DePuy, warsaw, IN.) were used in all hips. 22 mm zirconia femoral head was used in all hips. All surgeries were performed by one surgeon (YHK). The redominant Dx. was osteonecrosis (30 hips or 60%), O.A. 2° to childhood T.B. or pyogenic arthritis (8 hips or 16%) and others (12 hips or 24%). The average F.U. was 6.3 years (5–7 years). Thigh pain was evaluated using a visual analog scale (10 points). Clinical (Harris hip score) and x-ray follow-up was performed at 6 weeks, 3 months, 6 months, 1 year and then annually. Linear and volumetric wear were measured by software program. Abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion were measured and the results were compared between normal and operated hips. All hips had satisfactory fit in A-P and lateral planes. There was no aseptic loosening or subsidence of components. Incidence of thigh pain was 14% (7 of 50 hips). All thigh pain disappeared at 3 years postoperatively. Preoperative Harris hip score was 52.3 (7–64) points and 92.9 (80–100) points at the final F.U. The values of abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion of operated hips were comparable to normal unoperated hips. The average linear wear and annual wear rate were 1.25 and 0.21 mm, respectively. The average volumetric wear was 473.48 mm3. There was statistically significant relationship between the liner wear, age (under 40), male patient, and the cup angle. Yet there was no statistical relationship between the wear and Dx., wt., hip score, R-O-M, anteversion, abductor moment arm, femoral offset, neck and limb length and center of rotation of hip. Osteolysis was identified in zones 1A and 7A in 4 hips (8%). No hip had distal osteolysis. Close fit cementless stem in coronal and saggital planes without having distal stem fixation were proved to have an excellent mechanical fixation and provided favorable mechanical loading. Close fit in the proximal canal with a circumferential porous coating reduced the incidence of osteolysis. Factors contributing to good results in this young patient group are improved design of the prosthesis, improved surgical technique, strong trabecular bone and the use of smaller femoral head and thick polys. Although there was no aseptic loosening of the hip, high incidence of linear and volumetric wear of polyethylene liner in these young patients remains to be a challenging problem.
The Harris Hip Scores and Pain Scores show a significant improvement comparing preoperative with postoperative results in this series.
One patient required revision of the femoral neck component for recurrent dislocation and three patients have significant rotational thigh pain due to varus implantation of the stem (the pilot has since been shortened and the diameter reduced by 1mm).
Clinical assessment, X-rays and Dexa analysis indicate satisfactory results with good incorporation of the prosthesis by the bone.
In radial polydactyly, the Wassel’s classification is most commonly employed. This classification depends upon the bifurcation site of the thumb. In this paper the author discusses his experience in the treatment of duplicated thumb at various levels.
In duplicated thumbs, the supernumery digit (thumb) is excised in patients in whom one of the two thumbs is extremely hypoplastic. When both of the digits have an equal amount of tissue, some reconstructive surgical procedure is employed to centralize the thumb to improve the cosmesis and/or function. If thumb excision is done in such a case, the thumb may develop instability, axial deviation and may require secondary procedures for stabilization. The thumb may develop vascular compromise, though rarely, due to anomalous vascular supply. The author has employed the Bilhautcloquet procedure or its modification in the treatment of 12 cases of duplicated thumb.
This paper discusses the entity, the surgical technique and the results in 12 cases of duplicated thumb. The mean follow up is 3 years.
Reconstruction of large composite tissue defects with expose tendons, neurovascular structures, joints and bones is difficult and challenging problem. Such difficult situations can be handled in a single stage with free tissue transfer provided microsurgical expertise is available.
A review of 12 cases of free scapular flap is being presented, performed over period of 20 months from December 97 to July 1999. Free scapular flap is based on transverse branch of circumflex scapular artery, which is branch of subscapular artery. All the patients in this series were male, with average age of 29 years. The mechanism of injury leading to tissue defects was, RTA 7 cases, industrial accidents 3 cases and bomb blast injury 2 cases. The various sites requiring free scapular flaps were, plantar aspect of foot, heel and leg in 5 cases, dorsum of hand, first web space and forearm in 3 cases, axilla and upper arm in 2 cases and one each for popliteal fossa and dorsum of foot. Only 4 cases presented to AKUH within 6 hours of injury while remaining 8 cases had prior treatment somewhere else and subsequent polymicrobial infection. In three cases, 2-3 debridements were done before coverage with free flap. Average defect size was 18cm long and 11cm wide. All of these cases had associated fracture
Free scapular flap is very robust flap with long vascular pedicle and large lumen artery, which can be anastomosed very easily. Donor site is closed primarily without any morbidity and scar is hidden. Scapular flap can be considered as workhorse for extremity defects.
The average time from primary procedure to revision was 72 months. The osteolytic group was younger than the overall group at the time of index surgery (53 years vs 63 years, p< 0.0001). There were 16 females and 7 males (p = 0.06). The osteolytic group were also less likely to have an initial diagnosis of primary osteoarthritis than the control group (p=0.05). Other diagnoses in the osteolytic group included dysplasia, previous trauma and inflammatory arthropathy.
Acetabular liner thickness was assessed for all patients. The osteolytic group had a significantly higher proportion of cases with polyethylene thickness of less than 7mm (p < 0.005), and less than 6mm (p < 0.0001). There was no difference in the mean height and weight of the two groups.
Athletes are more prone to injury because of their prolonged training, dedication and body contact, and the injuries they sustain, with some unusual exceptions, are the same as those occurring in the general population but there is more pressure to return the athlete to their chosen sport with some times, little concern for the future. Australia, and South Australia in particular, enjoys a wonderful climate that allows year round outdoor activities with a consequent potential increase in the risk of injury.
The history and clinical examination remain the mainstay of diagnosis and coupled with the knowledge of the type and extent of injury, sport involved and level of competition, appropriate investigation can be arranged leading to a conclusive diagnosis and a positive therapeutic approach.
Injuries to the wrist and hand vary from overuse type tenosynovitis through to major carpal injuries with possible neurological and vascular compromise. and as well as helping the athlete return to sport as effectively and quickly as possible, it is also important to consider the implications for the patient in the future, once he or she has retired from competitive involvement. This aspect is further accentuated by monetary gain which may influence the athlete, coaches, etc.
As well as discussing management of selected injuries to the wrist and hand, several more unusual “sporting injuries” will be addressed.
In 1980, Morrison and O’Brien reported their experiences with the reconstruction of an amputated thumb using a wrap-around neurovascular free flap from the great toe, but its indication has been limited distal to the metacarpophalangeal joint.
We have performed 37 wrap-around free flaps from the great toe for the reconstruction of thumbs amputated at distal or proximal to the MP joint. The amputation was distal and proximal to the MP joint in 25 and 12 cases respectively.
The opposition of reconstructed thumb to the other fingers was completely possible in all cases amputated distal to the MP joint. In the 12 cases amputated proximal to the MP joint of the thumb, opposition was completely possible in 6 cases in which the lilac bone block was fixated in the position of 30° flexion and 45° internal rotation. However, in the other six cases in the fixation of 30° flexion and 30° internal rotation, the opposition of the reconstructed thumb to the ring and little fingers was impossible in five cases and only to the little finger in one case.
We concluded that amputation proximal to the MP joint is not an absolute contraindication to the wraparound free flap procedure for thumb reconstruction. However, for a better functional outcome we recommend iliac bone block fixation in the position of 30° flexion and 45° internal rotation.
The mechanism of amputation was industrial accidents in 18 cases and domestic injuries in 6 cases. The various types of amputations were a avulsion type in 3 cases, guillotine in 7 and amputation with localized crush in 14 cases. These patients presented to us with average duration of 7 hours after injury ranging from 4–10 hours. Ten cases were operated under L/A and 14 cases under G/A. Four of 24 cases required revision surgery due to venous block. The average follow up was 16 months ranging from 3 months–3 years.
The results were graded according to Chen’s criteria. Four cases had grade I, 9 had grade II and 1 grade III functional outcome according to Chen’s criteria.
Two views of tendon healing’s capability have prevailed since the early 1940’s. This presentation will outline the change in perspective regarding the primary tendon repair potential of intrasynovial flexor tendons and the clinical innovations that have been devised to reduce the inflammatory response and to improve the functional and structural characteristics of repair. Specifically, advanced suture, rehabilitation, and salvage techniques for tendon injuries will be discussed.
During the last decade there has been an increasing interest in the management of cartilage lesions, owing to the introduction of new therapeutic options. Beside the improvement of the classical vascular techniques (mosaicplasty, microfractures, etc.), cell therapy and tissue engineering have opened new perspectives in this field. One of the most recent tissue engineering techniques is represented by the MACI‚ (Matrix-induced Autologous Chondrocyte Implantation). This method requires seeding of autologous chondrocytes on a type I-III collagene membrane, after their arthroscopy harvesting from the knee and subsequent in vitro expansion of the cellular population using autologous serum. The seeded membrane is implanted in the chondral defect using exclusively fibrin glue, through a limited exposure joint approach.
Membrane structure and its cellular population were investigated by light microscopy, SEM and electrophoresis (SDS PAGE 7%) before implantation. There was evidence of chondroblasts and type II collagen inside the seeded membrane.
The clinical and functional evaluation was performed using the ICRS (International Cartilage Repair Society) rating scale, the modified Cincinnati rating system, Lysholm II and Tegner scores for the knee, while the AOFAS (American Orthopaedic Foot and Ankle Society) score was used for the ankle. MRIs were taken before the operation as well as at 6 and 12 months postoperatively.
The average follow-up was 6.5 months (range, 2 to 15 months). No complications were observed in the postoperative period. The six patients with a minimum follow-up of 6 months showed an improvement in the clinical and functional status after the operation, as testified by the scores reached with the different rating systems used. MRIs showed the presence of hyaline-like cartilage at the site of implantation.
Lesions to articular cartilage have a poor capability of regeneration and by mechanical wear and enzymatic digestion they may progress to osteoarthritis. In Sweden more than 900 patients with chondral or osteochondral lesions have been treated with autologous chondrocyte transplantation (ACT) since 1987. Cartilage is harvested arthroscopically and the chondrocytes are isolated. After two weeks of culturing the chondrocytes are deposited in the cartilage lesion in a cell suspension. The chondrocytes start to produce matrix and gradually form new hyaline cartilage able to withstand the forces of the knee.
Lesions to the femoral condyles have shown the most promising results when treated with ACT (90% Good/Excellent, n=57), osteochonditis dissecans showed 84% Good/Excellent results (n=32), multiple knee joint lesions 75% Good/Excellent (n=53) and femoral condyle lesions with anterior cruciate ligament reconstruction 74% Good/Excellent (n=−27) at a long term follow up (2–11 years). The outcome after patella lesions treated with ACT were initially not as good (2 of 7 patients were graded Good or Excellent at a mean follow-up of 36 months) but better understanding of the nature of patellar lesions and development of the surgical technique have improved the result (65% Good or Excellent, n=32). Patients treated with ACT for cartilage lesion to the femoral trochlea showed Good/Excellent results in 58% (n=12).
At a second look arthroscopy biopsies were taken in 37 patients. In 80% of the biopsies the repair tissue was classified as hyaline like cartilage. Immunohistochemical analysis of collagen II, aggrecan and comp showed ++ to +++ for the hyaline like repair tissue compared to +++ for normal cartilage. There were also a strong correlation (0.73) between hyaline like repair and Good/ Excellent results.
Other areas have been transplanted as well such as the tibial plateau, the talus and the head of the humerus, but due to the small numbers of patients and short follow-up ACT to these areas is not yet recommended.
The clinical outcome after treating chondral and osteochondral lesions in the knee is good at a long term follow-up and the repair tissue is histological similar to normal articular cartilage.
Many methods have been described over the past 5 years for repair of articular cartilage defects. The best reported results have been from the use of autologous chondrocyte transplantation (ACT)(1) and mosaicplasty.(2) There have, however, been no prospective clinical trials of these two methods. In this trial 70 patients were prospectively randomized to receive either autologous chondrocyte transplantation (37) or mosaicplasty (33) in the knee. 37 patients were female and 33 male. The average age was 32 years (16 – 44). The indications for surgery were persistent pain and mechanical symptoms in the knee with an isolated defect of the articular cartilage. 38 (56%) were post-traumatic, 12 (16%) due to osteochondritis dissecans, 10 (14%) due to previous meniscectomy, and 10 (14%) due to chondromalacia patellae. The size of the defects ranged from 2cm2 to 12cm2 (mean 4.8cm2). There were 35 defects on the medial femoral condyle, 13 on the lateral femoral condyle, 17 on the patella and 5 on the trochlear. 31 patients were undergoing primary surgery and 39 secondary surgery. All were independently reviewed using the Visual Analogue Pain Score, the Cincinatti Pain Score and the Stanmore Score. Patients were arthroscoped at one year with MRI scan and biopsies where possible.
The ligamentous anatomy of the carpus has been well described in recent years. This presentation will review the most important fundamental aspects of carpal anatomy, the presentation and clinical evaluation of the injured wrist, and the management of the most common carpal abnormalities. Specifically, acute and chronic scapholunate instability, dynamic scapholunate instability, and perilunate dislocations will be reviewed. In addition, the characteristic sequence of scapholunate advanced collapse arthritis and its recommended treatment will be described.
Unicompartmental knee replacements (UKR) have many advantages over total replacements (TKR), including better function and less morbidity. However, in general, they have a higher failure rate. To minimise the UKR failure rate it is essential that the implant should not wear out, and that the appropriate indications and surgical techniques are used. The Oxford UKR has a fully congruent mobile bearing and has been shown in a retrieval study to have minimal wear.
The indications for the use of Oxford UKR are clearly defined. It is recommended for medial compartment osteoarthritis, with a functionally intact Anterior Cruciate Ligament. The Varus deformity should be correctable and there should be full thickness cartilage in the lateral compartment, which is best demonstrated on a valgus stress radiograph. It is appropriate for about one in four osteoarthritic knees needing replacement.
The designer, Mr Goodfellow, achieved a 98% (CI 93% to 100%) survival at 10 years, using the appropriate indications. However, data from the designer is open to bias. An independent series of 420 Oxford UKR from Dr Svard achieved a 94% (CI 86% to 100%) survival at 15 years, with no loss to follow-up. In the Swedish Knee Arthroplasty Register, in centres implanting at least 2 UKR per month, the survival rate of the Oxford UKR was 93% at 8 years. In centres doing very few UKR the failure rate was higher. These poor results were probably because of inappropriate indications or technique. To address the problem of inconsistent results new simplified instrumentation (Phase 3) has recently been introduced. This instrumentation has been specifically designed for a minimally invasive approach.
Patients recover three times quicker after minimally invasive UKR than after TKR. A Radiographic comparison demonstrated the Oxford UKR can be implanted as precisely through a short incision as through a standard incision. A fluoroscopic study demonstrated that knee kinematics after minimally invasive UKR are virtually normal and are substantially better than after TKR. At one year the first 58 minimally invasive Oxford (Phase 3) UKR implanted by a single surgeon had an average flexion of 135°, Knee Society knee score of 97 and function score of 92.
We conclude that UKR is the treatment of choice for medial compartment osteoarthritis provided appropriate implants, indications and surgical techniques are used.
Few controversies in total knee arthroplasty have persisted for as long as the debate over the appropriate role of the posterior cruciate ligament. Excellent long-term results have been obtained with a posterior cruciate substituting design in which the tibial post and femoral cam function as a mechanical PCL. The constraint created by conforming surfaces and the spine-cam mechanism has not lead to increased loosening or polyethylene wear. Important new information in the area of biomechanics, histology, gait analysis, kinematics and clinical results have strengthened the belief that a posterior cruciate substituting design is the implant of choice for most primary and revision total knee arthroplasties.
TGF-β1 and BMP-2 are abundant proteins in bone matrix, their interaction in controlling osteoblastic differentiation is, however, not clearly understood. To gain more insight into the role of TGF-β1 in the control of osteoblastic differentiation, murine and human bone marrow stromal cells were transduced with an adenovirus carrying the human TGF-β1 cDNA or LacZ gene. The transduced cells assessed for alkaline phosphatase(ALP) activity, cell proliferation and matrix synthesis. The murine TGF-β1 transduced cells synthesized and secreted about 25 ng/ml of TGF-β1, while the human cells secreted about 120 ng/ml of TGF-β1 over 24h. Both the murine and human TGF-β1 transduced cells failed to respond to rhBMP-2 as indicated by non-expression of ALP activity, while the LacZ transduced cells expressed ALP activity under similar conditions. Treatment of the bone stromal cells with the human TGF-β1 protein in presence of BMP-2 demonstrated that the inhibition of the ALP activity expression is dose dependent.
This paper reports the authors’ experience of over 850 unicompartmental knee replacements beginning in 1985 with the MG2 uni and then the LCS uni in 1995, and more recently with the Allegretto, Oxford and PFC minimally invasive uni.
Minimally invasive unicompartmental knee arthroplasty (MIU) offers the knee arthritis patient significant benefits compared with total knee arthroplasty. Some of these are especially important for Asian patients, in particular range of movement and ability to squat.
The ideal indications for the MIU are not yet fully established but are becoming clearer. Contraindications are also clearer.
These issues will be discussed in detail. The results in 100 cases of unicompartmental arthroplasty will be presented and discussed along with the complications in these patients. Special considerations and recommendations for the commencement of MIU will also be discussed.
This recent and popular procedure also presents the knee surgeon with significant challenges. However, there are also disadvantages which will be outlined.
The surgical technique of the MIU will be shown in detail. The paper closes on a brief discussion into recent developments by an 8 member international group of knee surgeons of a new MIU offering a choice of fixed or mobile bearing MIU, with precise instrumentation of both the femoral and tibial sides, and the early result of the first 18 procedures in 15 patients (3 bilateral).
With clearly defined indications, high tibial osteotomy offers a good outcome, provided the correction is performed as accurately and as early as possible. Ideally, in a varus osteoarthritis knee, there should be an over correction of the leg’s axis by a minimum of 2 degrees but not greater than 4 degrees.
The Balansys high tibial osteotomy instrumentation provides the surgeon with the means to determine the extent of the correction intraoperatively, with reference to clearly identifiable skeletal points. This intraoperative determination improves the accuracy of the osteotomy over conventional methods based on x-ray planning. The instrumentation controls the fulcrum of the wedge to be removed during the procedure as well as controlling the width of the residual bone bridge. The precise nature of the saw cuts offer the best conditions for fast, reliable consolidation.
For stabilization an 8 or 9 hole pre-contoured semi-tubular AO plate is used.
The cost of the plate is RM 72.80 (US$19.15). No external immobilization is done. The patient is mobilized non-weight bearing with crutches on the 1st postoperative day and discharged from hospital on the 2nd post-operative day.
From 1.6.1998 to 30.6.1998 we performed 20 consecutive cases of high tibial osteotomy using the Balansys system. The average follow up is 24 months. The indication for operation was painful varus knee with or without medial unicompartmental osteoarthritis.
The results were analysed and showed early union with excellent knee flexion and good cosmesis.
The only complication that was encountered was transient lateral popliteal nerve palsy. This complication can be avoided if attention is paid to the lateral popliteal nerve when the fibular head is osteotomised.
Diagnostic indices for the determination of involved nerve root in cervical radiculopathy have been described by Yoss (1957), Murphey (1973) and Hoppenfeld (1976). However, there has been criticism that their indices are inappropriate for the diagnosis, because involved nerve root can not necessarily be determined using them. Difficulties in diagnosis have been attributed to the variable patterns of symptoms and signs caused by nerve root compression.
We recorded the data both preoperatively and postoperatively as follow: Standing height, Cobb’s angle, Kyphotic angle (T5 to T12), coronal trunk balance (plumb line), shoulder height difference, Rib hump difference, vertebral rotation, alignment index, coronal hump difference.
Regarding vertebral rotation, we use the CT scan measurement by the method introduced by Aaro and Dahlborn and the angle we use was called RaMI which is defined by the angle formed between 2 lines, one line drawn from the sternum to the most posterior corner of the spinal canal and the other drawn from the most posterior aspect of the spinal canal and extending anteriorly to equally bisect the vertebral body. The alignment index is calculated by the equation as follow: -AI=|apex-(T+B)/2| where AI = alignment index, apex = average apical RaMI rotation angle, T= average upper end vertebral Raml rotational angle and B = average lower end vertebral Raml rotation. This represented the overall segmental vertebral rotational alignment, the closer the value to zero, the better the alignment. Coronal hump difference is used to evaluate the rib cage deformity and is measured from CT-scan film by first create the Raml line and the second line was made perpendicular to Raml line and touch the posterior aspect of the more prominent rib cage as shown in figure. We measure the distance from point B to rib cage on the less prominent hump in mm and this is the virtual coronal hump difference which can converted back to coronal hump difference by magnificating factor.
The lumbar or sacral root compression is frequently associated with degenerative spinal diseases. It may be caused by the hypertrophic facets, hypertrophic ligamentum flavum, or protruding disc. Canal stenosis, epidural hematoma, the cyst of pseudo-joint from degenerative or lytic-type spondylolisthesis, or tumors are less common. We present one unusual case with the severe progressive symptom of bilateral S2-4 root compression. The 80-year-old active male suffered the intermittent claudication for 4 months and got the worse symptom including bilateral painful buttocks in recent one month. The bilateral radiation pain cannot be changed at any position and taking a rest. Plain x-ray showed the degenerative spondylolisthesis over L4-5 level. The magnetic resonance imaging showed the cyst-like mass indented the dura posteriorly. During the operation, one huge psudo-joint capsule created from the interspinous ligament compressed the dorsal side of the cauda equina. We performed the posterior decompression and removal of the pseudo-joint capsule and ligamentum flavum with posterolateral fusion. The patient was completely resolved from all the symptoms after surgery. Therefore we present the unusual case and discuss the differentiation from synovial or ganglion cysts of the spine.
Thirteen patients with symptomatic disc herniation in the cervical spine were treated with percutaneous laser disc decompression (PLDD). Patients included 10 males and 3 females with a mean age of 41.4 (range, 24–60) years old. Preoperative symptom was divided into 2 types; myelopathy in 8 and radiculopathy in 5 patients. The level of the treated disc, which was diagnosed from the provoked cervicobrachial neuralgia during discography, distributed to C4/5 in 1, C5/6 in 8, C6/7 in 4 patients. The Nd:YAG laser (1064 nm) was percutaneously irradiated to the involved disc through a needle of 1.5 mm with a mean energy of 600 joules. Clinical evaluations were assessed with modified Macnab`s criteria at a mean follow-up period of 3 years (range, 0.5–5.7 years) excluding one patient who received open surgery 3 weeks after PLDD. Six patients (46.2%) showed good to excellent results without any significant complications. Four patients of 7 with unsuccessful results received a subsequent open surgery. There was no significant difference between successful and unsuccessful group in gender, disc level, preoperative duration of symptoms, positive provocation during discography, and the total amount of irradiated energy. Patients with successful results tended to be younger with a mean age of 35.7 years compared to those with unsuccessful results with a mean of 46.3 (p=0.053). Clinical outcome in two patients with radiculopathy were judged as excellent. Although postoperative MRI revealed few morphological changes on the disc in 2–3 weeks after PLDD, MRI at the final follow-up showed remarkable decrease of signal intensity in the disc. On postoperative radiographs, the disc height and the range of motion during flexion to extension in the treated discs significantly decreased, indicating the acceleration of disc degeneration and the resultant stabilization of the segment.
There exists two important pathologies in degenerative lumbosacral kyphosis (flat back), such as loss of lumbar lordosis and posterior rotation of the pelvis. Patients with this deformity complaint marked fatigue in lumbosacral region and disturbances on standing and walking.
Conservative treatment is seemed to be difficult, and surgical treatment may be selected for this deformity. Our surgical strategy is posterior shortening and anterior rotation of pelvis. Surgical procedure is tranvertebral decancellation closed wedge osteotomy, correction by shortening and lumbosacral fixation by intrasacral method. Radiographic assessment around the hip axis was performed by Jackson method on standing entire spine film.
5 females and 2 males were operated on by this method. Mean age at the operation was 67 yrs (57–82). Mean follow-up was 24 months (12–36). Mean operative time was 480 minutes (320–600). Mean estimated blood loss was 1440ml (985–2415). Mean pelvic angle was 41 degrees before the operation. At follow-up, mean value was 33 degrees. Preoperative mean local kyphosis was 4.7 degrees. Postoperative mean local lordosis was 24.1 degrees, average correction was 30 degrees. No loss of correction occurred in fused area. Clinical symptoms were remarkably improved after the operation. There was no major complication in this series.
There has been significant advancement in the principles and practices of Tissue Banking in Australia over the last two years. Those advances relate to scientific development, regulatory modulation and inter-relationships between both Federal and State governments. Licencing issues
The Therapeutic Goods Administration of the Federal Department of Health and Aged Care Prior to 1997, Code of Ethics Formal government regulations Code for Good Manufacturing Practice Freeze dried materials First national licence Synthetic osteogenic proteins Centralisation of processing Number of Tissue Banks in Australia Considerable variation amongst Tissue Banks Financial statistics Difficulty in attaining and maintaining TGA licence Inherent inefficiencies Core activities Nonstandardisation of processing regimen International precedence Further potential benefits Consideration by Federal Government through Health Minister’s Advisory Council Probable end point
The size selection of the outer metal shell to fit the acetabulum is a dilemma to the surgeons for the bipolar hemiarthroplasty. However, no body ever mentioned the final results of motion behaviour of bipolar hip endoprostheses by different size selections of outer metal shell. The purpose of this study was to evaluate the motion behaviour of bipolar hip endoprostheses under different sizes of outer metal shell.
A fresh cadaver of size of 50 mm and three different sizes of bipolar hip endoprostheses were used to evaluate the motion behaviour of bipolar hip endoprostheses under the MTS machine. Each size had six sets of bipolar hip endoprostheses to get statistical data. The single axial load scaled from 300 N to 3000 N with increment of 300 N was applied on both the inner bearing and outer bearing to obtain the frictional torque of two bearings randomly. The axis was rotated from 0° to 90° under the speed of 1 deg/sec. The motion behaviour of bipolar hip endoprostheses was predicted and verified by the comparison of the frictional torque of both bearings and repeat the experiments again.
The dynamic frictional torque of 48mm was larger than the dynamic frictional torque of the 50mm at the inner bearing. The size of 52mm had the largest value of dynamic frictional torque for the outer bearing under any load condition. The prosthesis that had larger outer metal shell than the acetabulum had the same relative motion behaviour as the design hypotheses, because the difference of frictional torque was much higher.
In conclusion, the motion of the bipolar hip endoprostheses is influenced by the frictional behaviour of the both bearings. The relative motion of bipolar hip endoprostheses with a larger outer shell size will have an idea relative motion behaviour, because the larger difference of frictional torque. The thickness of the UHMWPE has a positive effect to reduce the friction between the UHMWPE liner and metal head.
The congenital or acquired contracture of gluteus maximus is relatively rare, and its clinical feature of chronic lower back pain and extension contracture of the hip joint had been confused with herniations of lumbar disc disease or sequelae of cerebral palsy. The authors successfully treated these contracture of gluteus maximus, so report these cases and results. 9 patients suffering from Difficulty in squatting position or gait disturbance were surgically treated in our department from 1979 to 2000. There were eight men and a woman, mean age was 17.3 years old, and seven patients were bilateral. Four patients revealed past medical history of multiple intramuscular injection at gluteal region, but five patients revealed unremarkable history. Preoperative mean further flexion, internal rotation and external rotation of hip joint were 42°, 15°, and −5°. These patients revealed specific features of frog leg position in squatting position. Intraoperatively, the authors released the fibrotic band of the gluteus maximus, the short external rotators, the gluteal attachment of the iliotibial band and the joint capsule. After anesthesiologic recovery, active and passive joint motion exercise of flexion and rotation was started to prevent recurrence of contracture. Postoperatively, mean further flexion of hip joint were increased to 105°, and no Difficulty in sitting or squatting position, but slight limitation in rotation was remained. In follow up visit, no decrease of articular motion were observed. Conclusively, severe limitation of joint motion due to contracture of gluteus maximus can be successfully treated with surgical maneuver accompanied with postoperative aggressive physical therapy.
This presentation will provide an update of peripheral nerve anatomy and the classification of injury with pertinent clinical examples of each type. Recommendations for primary and secondary nerve suture and repair techniques for nerve injuries with and without segmental loss will be described.
This technique consists of making of two small incisions, one at the distal wrist crease and a second one on the mid-palm 2.5 cm from the first incision. Through these two incisions, the proximal and distal extent of the transverse carpal ligament (TCL) was identified and two specially designed dissector-retractors are introduced. One is isolating the deep surface of the TCL protecting the median nerve. One is isolating the superior surface of the ligament. The TCL is then divided under direct vision.
179 cases were studied from 1996 to 1999 with a minimal follow-up of 3 months. The patients were assessed using the scoring system put forward by Levine et al 1993.
The shape of the femoral canal is variable, infact more variable than most contemporary designs of femoral components would suggest or accommodate. Clinical and experimental studies of total hip replacement have demonstrated the need for a close geometric fit between the femoral component and the supporting bone for a durable implant fixation. In order to provide a basis for design and selection of femoral components in future, we undertook an anthropometric study of proximal femoral geometry on Indian specimens.
74 cadaveric femorae were studied to analyze the difference in the endosteal and periosteal geometry between Indian and Western population. Standard extra-cortical and endosteal dimensions were determined by direct measurements of radiographs. To enable comparison standard horizontal and vertical axis were established using the geometric center of lesser trochanter and the bisecting axis of the medullary canal at the level of the isthmus. Statistically significant differences were found for the following measurements: Femoral head offset, Width at lesser trochanter, Width at lesser trochanter-20mm, Proximal border of isthmus, Neck shaft angle.
A hydroxyapatite/type I collagen(HAp/Col) composite, in which the hydroxyapatite nanocrystals align along the collagen molecules, has been prepared. The bio-compatibility, osteoconductive activity and efficacy as a carrier of rhBMP-2 of this novel biomaterial were examined. Following three studies were performed – (1) The composite materials (4×4×1mm3) were implanted in the back of Wistar rats, and specimens collected for histological observations until week 24. (2) The composite materials (5×5×10mm3) containing rhBMP-2(0, 200, 400μg/ml) were grafted in radii and ulnae in beagle dogs. X-ray images were prepared, and specimens collected for histological observation at week 8 and 12. (3) The implants(15mm in diameter and 20mm in length) containing rhBMP-2 (0, 400 mg/ml) were implanted in tibiae in beagle dogs and fixed with Ilizarov method. Soft x-ray images were prepared each week. The bone mineral density was measured and the implants were harvested at 12, 18 and 24 weeks after surgery. The period until bone union after implantation of the HAp/Col implant was between 10 and 12 weeks after operation, and approximately the same as that of autogenous bone graft. Histological analysis revealed that osteoclasts appeared in a Howship’s lacunae-like structure formed on the composite and osteoblasts arranged on the newly formed bone. These findings suggest that the HAp/Col composite has a character similar to that of natural bone. X-ray images and histological findings for the composites support the idea that HAp/Col has a high osteoconductive activity and is able to induce bone-remodeling units. In cases where the implants are grafted at weight bearing sites, treatment with rhBMP(400μg/ml) may be useful to shorten the time until bone union.
The cancellous bone adjacent to major load-bearing joints such as the hip and knee has complex architecture. The loading patterns across these joints influence the architecture of the cancellous bone, which varies according to the magnitude and direction of these forces. Articular lesions are associated with alterations in the loading patterns and hence change to the cancellous architecture. The fractal dimension, as a numerical descriptor of complex shapes, enables these changes to be quantitated.
The fractal analysis was performed by a box counting method. The perimeter of binary profiles of cancellous bone samples was measured for different box sizes. The fractal dimension is 1-D (where D is the slope of the straight-line segments from the plot of log of perimeter versus of log box size). Samples of cancellous bone were taken at autopsy from three subchondral regions, superior to the fovea in the femoral head (n=56) and the tibial (n=25) and femoral (n=25) condyles of the knee. There were three straight-line segments identified on the log-log plot, for each subject, indicating a fractal dimension over three different ranges of scale. Fractal 1 describes the complexity of bone surface detail influenced by osteoclast and osteoblast activity, fractal 2 describes the shape or form of individual trabeculae and fractal 3 describes the overall spatial complexity of the cancellous structure.
The results show that for fractal 1, all three regions are the same. For fractal 2, the femoral head is greater than the condyles (1.40±0.07 versus 1.36±0.05 and 1.36±0.05) and for fractal 3, the femoral head is significantly greater than the condyles (1.76±0.06 versus 1.73±0.04 and 1.70±0.05).
These data show that cancellous bone architecture differs between skeletal sites. In particular, the fine surface detail influenced by bone cell activity and described by fractal 1 is the same in each region, while the shape of individual trabeculae as described by fractal 2 is more complex in the femoral head. The overall spatial complexity of the cancellous structure as described by fractal 3 is the same in each condyle of the knee while in the femoral head it is significantly greater. The fractal dimension, as a descriptor of complexity, enables the effect of differences in the mechanical micro-environment on cancellous bone architecture to be quantified so that pathology affecting these regions can be studied.
In femoral locked nailing, the distal locking screws is vulnerable to mechanical failure. The stress on these screws is substantially affected by fitness of the nail in the medullary canal. In this study a closed form mathematical model based on elastic column-beam theory is developed to investigate how the nail-cortical contact which is simulated by a linear elastic foundation affects the stress of the distal locking screws. The model is comprised of a construct of a fractured femur with an intramedullay locked nail loaded by an eccentric vertical load. The stress of the locking screw is analysed as a function of the depth of the locking screw in the distal fragment under two situations: with or without nail-cortical contact in the distal fragment. In situation with nail-cortical contact, the screw stress is decreased as the length of nail-cortical contact and the depth of the screw in the distal fragment increases, but this stress contrarily increased when the nail is inserted beyond a certa
Osteoporosis, the disease of aging, is a major health problem and its clinical end point: – Fracture is a major cause of mortality and morbidity. Osteoporosis is a silent, relentlessly progressive disease that is best treated by early diagnosis and prevention. To elucidate the predictors of fracture proneness in patients with osteoporosis the following study was undertaken.
32 patients with fractures of the hip and spine due to osteoporosis were studied with a control group of 30 patients with osteoporosis but no fractures. Osteoporosis was established by using the gold standard: Dual Energy X-ray Absorptiometry. Of the biochemical parameters studied lower values of, hemoglobin, total serum proteins & albumin, and alkaline phosphatase were found along with higher values for serum tartarate resistant acid phosphatase, urinary hydroxy proline and acid phosphatase, in the fracture group when compared with the non fracture group. It was inferred that biochemical parameters are reliable indicators of fracture proneness in patients suffering with osteoporosis and also that in the treatment of osteoporosis, anemia and hypoproteinemia must also be considered and corrected.
Thus, the rotation of the femoral component was referenced from the posterior condyles.
The second subset of 100 cases, the distal femoral cut was followed by the tibial resection. The susequent femoral resection was referenced from the tibial cut. Thus the rotation of the femoral component was dependent on the tibial axis, and not on the posterior femoral condyles, which in deficient condyles can lead to a significant rotational error.
In the second subset, where the femoral rotation was referenced from the tibial axis, excluding the severe valgus knees, the incidence of lateral release was 0% with asymptomatic patellar tilt of 6%. since all other factors were unchanged i.e. patella replacement, rotation of the tibial prosthesis, same prosthesis, the single variable factor being the femoral rotation leads us to conclude that femoral rotation is a major in appropriate patellar tracking. As a corollary ‘Patellar tracking is the index of orientation, sizing of all components of the prosthesis and soft tissue balance’.
This retrospective study compared the perioperative morbidity of two consecutive groups of patients having primary total knee arthroplasty thru subvastus approach and conventional medial parapatellar approach.
The arthroplasties were performed in consecutive cases of the subvastus group(SV) (21 TKAs in 21 patients) from Dec. 1999 to May 2000 using a subvastus approach and in the control group(CY) of same operator(Y) (26 TKAs in 26 patients) from May 1999 to Nov. 1999 using medial parapatellar approach, and in the second control group(CB) (24 TKAs in 24 patients) from May 1999 to May 2000 using medial parapatellar approach by another operator (L).
The patient perioperative morbidities were evaluated including blood loss, blood transfusion, lateral release, pain condition, time to ROM 90 degrees, skin complication, admission days.
The subvastus group showed less time to gain 90-ROM(6.09, 6.8, 7.85), and less hospitalization days(10.43, 11.3, 12.15). But the SV group also showed higher rate of lateral release(13%, 8%, 12%) and skin complication(9%). Although the difference is not statistically significant.
The authors concluded that the subvastus approach led to early ROM rehabilitation and discharge.
The subvastus approach to the knee has been described as early as 1929. This approach for primary total knee arthroplasty (TKA) maintains the integrity of the quadriceps mechanism and maintains the vascularity of the patella.
We have conducted a prospective, double blind, randomised trial to evaluate the quadriceps function in TKA after the paramedian and the subvatus approaches in 40 patients with osteoarthitis. Patients were randomised to the two groups and were evaluated by an independent observer blinded to the approach used. The two groups were compared as regards function (range of motion, quadriceps lag, quadriceps power); functional outcomes (Hospital for Special Surgery scores); patellofemoral alignment (Patellar tilt); and operative time, blood loss and hospital stay.
There was a statistically significance difference between the two groups as regards quadriceps power and lag in the first post-operative week. The subvastus group performed better than the paramedian group. The range of motion was also better in the subvastus group, though this difference was not statistically significant. The subvastus approach avoids the painful inhibitory arc of the quadriceps and allows for better and rapid rehabilitation in the early post-opertaive phase.
There were fewer lateral retinacular releases in the subvastus group. The presence of an intact extensor mechanism allows for more accurate assesment of the patellofemoral alignment intraoperatively. The patello-femoral alignment readings were better in the subvastus group. The subvastus approach does not interfere with the vascular supply of the patella.
The patients operated by the subvatus group were discarged from hospitals early.
100 patients who have undergone this procedure have been identified. 81 percent initially presented with patella subluxation or dislocation. The remainder complained of anterior knee pain with evidence of abnormal patella tracking on examination. 52 percent of our patients had undergone at least one previous patellofemoral realignment procedure which had failed. 43 percent of the patients had generalised ligamentous laxity.
Using the functional category described by Crosby and Insall for patellofemoral symptoms 66 percent had a good-to-excellent outcome, 23 percent had a fair outcome and 10 percent of the patients stated they were worse following the procedure with increased anterior knee pain. 100 percent of these patients had grade 3 or 4 cartilage defects on retropatella surface. 57% of patients returned to sporting activity. 14% of the remainder had not returned to sporting activity because of persisting symptoms in the knee.
57 percent of patients had lost a mean 12.5 degrees of flexion of the knee at follow-up [range 5–30]. 5 percent of patients developed minor complications following surgery. No radiological deterioration was seen in any patients although coexistent patellofemoral osteoarthritis was seen in 25 percent of patients. There was no loss of fixation in any of the patients.
The aim of this study is to review the relation of polyethylene wear in patients underwent Anatomic Medullary Locking total hip replacement with respect to the types of acetabulum used.
85 cementless primary AML joint replacements were performed in the 10 years period from 1988 to 1998. The average age at operation was 46.6 with a range from 22 to 63. Two different types of acetabulum design namely the Acetabulum Cup System (ACS) and Duraloc were used. 39 of them were followed up from 2 to 10 years with an average of 69 months. Xrays were performed at the review visit and the thickness of the insert was calculated. The cup abduction angle was measured and the size of the cup and initial insert thickness was also recorded. The findings were correlated and subjected to statistical analysis.
Our findings suggested that the wear of the ACS cup was significantly higher than that of the Duraloc cup. The size of the cup but not the age of the patient at the time of operation also affects the wear rate. It appears that wear rate started to accelerate from year 8 onwards. The risk is higher with cups of less than 50mm diameter
We conclude that it is advisable to review closely those patients with the ACS cup implanted. Revision surgery should be considered if eccentric wear started to be seen on Xray to avoid complicated procedure.
Seventy-four mobile bearing total knee arthroplasties (LCS) without patellar resurfacing were analysed in 54 patients who were followed for a minimum of one year. We examined the congruence angle on Merchant’s view, the component rotation to the epicondylar line of the femur on computed tomography(CT), the femorotibial angle on weight-bearing anteroposterior radiograph to assess the contributing factors for the patellofemoral malalignment. The statistical analysis was performed by ANOVA test, student t test, and chi sguare test.
The patellofemoral pain was noted in 17 knees(23%). The incidence of patellofemoral pain was significantly increased in the knee when its congruence angle was more than 16 degrees (p=0.034). But the pain did not correlate with the status of the articular cartilage of the patella on operation. The average congrunce angle was 4¢ªdegrees preoperatively and 24.2 degrees postoperatively. The congruence angle in 29 knees with lateral release was significantly lower than that in 45 knees without lateral release (p=0.037). All femoral components were internally rotated on CT scan with average of 6.7 degrees. More significant increase of the congruence angle was observed in 42 knees with femoral or tibial component rotation than in 15 knees with normal or minimal rotation of both components(p=0.017). Pre-operative congruence angle and postoperative femorotibial angle also affected the patellofemoral alignment, which increased postoperative congruence angle respectively.
Based on our findings, it seems that the excessive internal rotation of one component and excessive valgus of the femorotibial angle should be avoided to prevent the patellofemoral maltracking. We believe that “no thumb test” should be done carefully and the lateral release performed without hesitation if patellar tracking is a concern.
Modern Metal on Metal hip resurfacing originated from Birmingham in the early 1990’s and is now well estabilished in the U.K. This procdure is gaining acceptance in other parts of the world and is now being performed in many countries in the Asia Pacific region including Australia and India.The demographics of the patient population with hip arthritis in south Asia and western europe is very contrasting. Primary osteoarthritis of the hip is virtually non-existent in the Indian subcontinent wheras it is by far the commonest hip disorder in Europe.Sixty nine percent of patients had primary osteoarthritis as the presenting pathology in the pilot series of metal on metal hip resurfacings from Birmingham. Most patiens in India with hip arthritis are very young and have developed secondary degenerative in the joint due to other specific causes. Thus procedures like the Birminham hip resurfacing which addresses the difficult problem of hip arthritis in the young active adult have a greater role to play in this.
Thirty nine Birmingham Resurfacing Hip Replacements were inserted between March 1999 and December 2000. The very early results are very satisfactory in a high demand group of patients.
Because of the relative ease of revision the implants have a role as a “pre” total hip replacement. The also have an important role in cases such as osteopetrosis and previous femoral osteotomy were an intra medullary stem is difficult. The series includes two cases of arthrodesis take down.
Complications have included one dislocation in a patient with cerebral palsy and one intra operative fractured neck of femur.
However, the early studies suggest that the large metal on metal bearing does produce serum chrome and cobalt levels which may be elevated in comparison with Metasul bearings at one year. The clinical significance of this is unknown.
Aseptic loosening which may lead to osteolysis and massive loss of bone, remains the major cause of failure after total hip arthroplasty. Reconstruction of acetabular bone stock defects by means of bone grafting is mandatory to create a stable construct to support the cup, recreate anatomy, and restore lower limb length. Numerous classification systems for acetabular bone stock deficiencies have been recommended to date. The one proposed by the American Academy of Orthopedic Surgeons (AAOS) is the most comprehensive and most consistent. This system classifies acetabular defects into segmental (type 1), cavitary (type 2), combined segmental and cavitary (type 3), pelvic dissociation (type 4), and hip fusion (type 5).
The aim of this study is to present a long term review of our experience with reconstruction of acetabular bone stock deficiencies in conjugation with revision hip arthroplasties using bone grafting, based on the AAOS classification system.
Between 1987 and 1998, 88 revisions using bone grafting to reconstruct acetabular bone stock defects were performed. Of them 4 patients were classified as type 1, 47 as type 2, 29 – type 3, and 8 as type 4. The mean follow-up period was 8 years (range: 2–3 years).
The mean Haris Hip Score improved from 35 points preoperatively to 75 postoperatively. All patients improved.
The complications included nonunion in 5 cases, joint instability in 6 cases, graft lysis in one case, and neurologic injury in one case. Five cups were considered radiographicaly loose. One case was infected.
The optimal wrist position between extension and flexion to achieve the highest grip strength, was assessed on the dominant hand of 20 normal female subjects aged 18–25. Seven fixed wrist positions between 60 degrees flexion and 60 degrees extension were assessed as well as a “self selected” position which was chosen by the subjects. Other variables were recorded and analyzed such as hand length, wrist circumference, height and weight of the subjects. Grip strength was recorded using an electrodynamometer. The mean self selected angle was 28 degrees wrist extension, and this position had the highest mean strength of all angles tested. The self selected angle was positively correlated with hand length. Grip strength decreased dramatically in marked wrist flexion compared to extension. The self selected wrist position increased with hand length, height, and weight.
There were 78 Crowe I & II, and 18 Crowe III & IV hips. The more dysplastic hips required the versatility of the SROM stems to avoid excessive lengthening or femoral osteotomy. These cases also had significantly more inferior reconstruction of the hip centre, and medialisation of the hip centre.
Complications occurred in 8/106 (8%) of cases, the mean time to occurrence being 25 months. The majority were dislocations 7 (7%). There were no sciatic nerve palsies. Revision was required for 5 cups and 1 stem. Clinical evaluation showed all patients were living at home and 85% had no activity restrictions. Mean Harris Hip Score was 92/100. None or mild thigh pain only was reported in 90% of cases. In 98% of cases patients were satisfied with their outcome. Radiographic evaluation showed stem ingrowth occurred in all cases. Minor osteolysis was apparent in 6% of cases. Spot welds were identified in 76% of cases. One case demonstrated pedestal formation.
The reduced operation time, economic implant, least periosteal stripping, least blood loss and subsequent easy implant removal are the advantage of this procedure.
Fracture or periosteal elevation near epiphysis induces inflammatory vascularity which is reported in early bone lengthening literature. In this study, corticotomy and periosteal elevation were put to use to induce new inflammatory vessels as collaterals in an ischaemic limb. In this prospective investigation between May 1990 and May 2000, seventy-two patients suffering from severe occlusive arterial disease (44 TAO, 13 atherosclerosis, 11 Raynaud’s disease, and 4 diabetics), who had not responded to previous non-surgical or failed surgical treatment, and had progressively deteriorating ischemic limbs, were subjected to corticotomy near major neurovascular bundles and the periosteal elevation along the whole length of the bone. There was complete relief from rest pain and an indefinite postponement of amputation in sixty-one out of seventy two patients. Longest follow up is ten years and shortest is six months. This new approach is based on principle of inflammation which is the universal reparative biological process. Digital Subtraction Angiography (DSA) studies before and after operation convincingly showed the continuance of a new vascular collateral network across the affected arteries, a process, which saved the ischemic limbs from certain amputation. This new Inflammatory vascular leash acts as a biological ‘bypass’ and appears to be an answer to small and diffuse artery disease, where vascular reconstruction is otherwise impossible.
In the Bunge repair strategy, a tube containing a Schwann cell cable bridges the cord lesion. Regenerating axons penetrate the proximal cord-graft interface and grow through the Schwann cell cable but the axons do not grow across distal cord-graft interface and into distal cord stump. Regeneration of axons can be promoted by applying neurotrophic factors in graft. Adding a matrix containing genes encoding for neurotrophic factors in the SC bridge between the proximal and distal cord-graft interfaces may promote axonal regeneration into the graft and the distal cord stump.
Vertebroplasty (VP) is a new prophylactic treatment for preventing osteoporotic compression fractures of vertebral bodies. During this procedure polymethylmethacrylate (PMMA) is injected into several vertebral bodies. However, there is the concern, that fat embolism (FE) and acute hypotension could occur as in a variety of other orthopaedic procedures.
This study was undertaken to investigate whether FE and acute hypotension are potential complications of VP using an animal model.
In six sheep 6.0 ml PMMA were injected unilaterally into L1. Transesophageal echocardiography was used to monitor the pulmonary artery for bone marrow and fat particles until 30 minutes postoperatively. Pulse, arterial and venous pressure were also recorded. Post mortem the lumbar spine and the lungs were harvested. The lungs were subjected to histological evaluation.
The first showers of echogenic material were visible approximately 7.0 seconds after the beginning of the cement injection and lasted for about 2.5 minutes.
Injection of bone cement elicited a very rapid decrease in heart rate after 2.0 seconds followed by a fall in mean arterial pressure after 6.0 seconds. A maximum fall in heart rate was accompanied by a delayed fall in mean arterial pressure of 33.0 mmHg (P=0.0003) at 36.0 seconds. Heat rate had returned to baseline by 89.0 seconds and had increased by 10.0 beats/min (P=0.02) at 25 minutes. Mean arterial pressure had recovered by 209.0 seconds and was not different to the baseline at 25 minutes.
The post mortem inspection revealed disseminated haemorrhages on the lung surface and throughout the parenchyma mainly in the caudal lobes of all six animals. No leakage of cement into the spinal cord was detected. In histology fat globules and bone marrow cells were observed in both the smaller and larger vessels throughout the lung.
This study clearly shows that VP resulted in a two-phase decrease in heart rate and arterial blood pressure. The first phase was probably due to an autonomic reflex and the second phase was due to the passage of fat emboli through the right heart and obstructing the lungs.
The periacetabular osteotomies are effective but technically demanding surgical procedures in the treatment of adult dysplastic hips. We developed a modified technique which combines the two most popular surgeries: the rotational acetabular osteotomy (RAO), and the Bernese osteotomy. Transtrochanteric approach was used in our new spherical osteotomy and provided a good surgical exposure for redirecting the acetabulum with minimal complications. This article describes the surgical procedures in detail and reports the preliminary results in the first 32 hips. As the experiences are encouraging in terms of technical ease and reproducibility, the authors feel that this new osteotomy with transtrochanteric exposure is an ideal choice of surgery in treating residual hip dysplasia in the adult. Key words: osteotomy, periacetabular, hip dysplasia, adult.
The external fixation has been an established method in management of musculoskeletal disorders. Various prototypes are available Majority of these have specific application in trauma specially soft tissue injuries, infections and non unions. The Illizarov fixator is probably the most versatile of these with application in majority of congenital and acquired musculoskeltal disorders. However, very few of these devices are useful in management of disorders of writ, hand, foot and ankle mainly because of their size, weight, complexities of technique and patient acceptance. This paper deals with innovative mini external fixator device which is a modular system. The device is light weight, simple to use and is modular. The technique offers static and dynamic distraction, has short learning curve, light in weight and patient friendly. The device is useful in congenital conditions like CTEV, radial club hand, ulnar club hand and lengthening of meta carpals and meta tarsals. It is also useful in acute and neglected trauma including infections in forearm, wrist, hand, ankle and foot. Its special indication extends to its application in upper tibial plateau fractures as neutralization device. The basic unit with a small clamp which off loads the deforming forces in the bone by purchase of a simple K wire 1.2 to 2.5 mm and is connected to outer rod which knurled. The device has been mechanically tested and is found to be strong ad safe for use in clinical practice. The stability of device has been tested on Instrom 6556 testing machine for pull out and crush strength proving its safety in clinical use. We have used this device in clinical practice on about 3000 patients and have found t be very useful, simple and cost effective. The paper presents the basic design, biomechanics, basic special techniques and its clinical application. The paper includes example case presentation and its application.
There is a lack of properly undertaken comparative studies of total hip replacement (THR). A randomised trial was established to examine the hypothesis that there are no important differences in clinical outcome at 2 years and at long-term follow-up between cemented and uncemented primary THR in middle aged patients.Eighty-three patients with 90 osteoarthritic hips were randomised to a cemented Exeter THR involving a matte or polished tapered stem (n=47, median age 68yrs) or an uncemented PCA proximally porous-coated cobalt-chrome stem and porous coated press fit cup (n=43, median age 66yrs). Patients underwent immediate full weight bearing post-operatively. The follow-up period is 8 to 16 years. The median Harris hip scores for the cemented and uncemented groups respectively were 92 and 95 at 2 years and 89 and 96 at long-term follow-up. Four cemented hips have been revised for aseptic loosening. There have been no failures of the polished stems. An analysis of a larger series of matt versus polished cemented stems also found that the results of the polished stems were superior. Four uncemented hips have been revised, two more recently for acetabular wear and osteolysis. There was a high rate of radiographic demarcation of the cemented cups. There were no important differences in the clinical scores between cemented and uncemented THR. Some matte surfaced femoral stems failed and this trend was confirmed by analysis of a larger series. Osteolysis around the uncemented acetabular components is a concern. Importantly immediate weight bearing was associated with good results of uncemented stems.
Pre-operative and postoperative radiographs of both hips and pelvis of 160 Malaysian and Australian patients who had undergone Total Hip Replacement (THR) were reviewed.
The purpose of the study was to determine morphometric differences in each group that could influence sizing and positioning of cemented total hip implants.
In order to measure distances and diameters, we used OSIRIS, a digital radiographic analysis tool provided on the internet by the Department of Medical Imaging, University of Geneva.
The known head sizes of the implants were used to calibrate OSIRIS.
The patient groups were subdivided into three. We discovered that in general the sizes of the Malaysian population began 1 size below that of the Australian patients.
The dimensionally larger 2 groups of the Malaysian patients were similar to the smaller 2 groups of the Australian population leaving a group of small Malaysian femora for whom there were fewer suitable implants
We conclude that more work needs to be done to provide suitable implants for South East Asian patients.
The purpose of health outcomes monitoring is to assess the benefits and risks of health care processes, to enable benchmarking and to allow comparative studies of new technologies and variations in clinical practice. This paper critically reviews the discipline of health outcomes monitoring in joint replacement surgery. We reviewed over 250 papers published over the last 20 years in the major English speaking journals were reviewed. We conclude that there are considerable shortcomings of clinical studies which make it difficult to determine the results of different joint replacement designs. The shortcomings include inadequate study design and the lack of comparative data. Despite repeated calls for standardisation of outcome measures, this has yet to be achieved. Considerable resources are often invested in outcomes monitoring programs.It is therefore important that instruments are selected based on them meeting strict psychometric criteria, that adequate follow-up is achieved and that appropriate data analysis techniques are utilised, otherwise interpretation of results is difficult. We have found that patients’ reporting of symptoms and outcomes after hip arthroplasty were found to be consistent with those reported by their reviewing doctor. We therefore suggest that for uncomplicated joint arthroplasty cases, the marginal costs of their regular review in outpatients probably outweighs the marginal benefits and important resources and doctors time would be made available for other patient care activity if these patients were reviewed by patient self-administered questionnaires. Our studies have shown that SF-36 health survey and the WOMAC instruments are useful when administered by mailed survey, however, the cost-benefits of using these outcomes instruments is an important consideration. The lack of comparable outcomes data should encourage greater orthopaedic participation in multi-centre outcomes studies including randomised trials.
So far 15 patients, (6 male and 9 females) with a median age of 55 years (range 42–62) have been evaluated in group 1 and 14 (9 male and 5 females) with a median age of 55 years (range 45–70) in group 2. The penetration of the femoral heads has so far been measured postoperatively (all hips supine), after 3 month (17 hips supine and standing) and after 6 month (11 hips supine and standing) using radiostereometry.
1-year follow-up on approximately 50% of the patients will be presented at the meeting.
Arthroscopic soft tissue debridement of the AC Joint without excising the distal clavicle, is a bone sparing procedure that, to our knowledge, has never been reported in the literature.
This paper is a retrospective review of patients with chronic recalcitrant AC joint injuries, who underwent arthroscopic soft tissue debridement of the AC joint.
The surgery involves a glenohumeral joint arthroscopy, subacromial bursoscopy and AC joint arthroscopy. Excision of the torn AC joint meniscus, AC joint synovectomy and soft tissue clearance were performed in all cases. Surgery was performed as a day-only procedure.
Five patients had previously undiagnosed SLAP tears.
Arthroscopic soft tissue debridement for recalcitrant AC joint injuries gave good results in 77% of cases. Arthroscopy of the glenohumeral joint in patients with presumed isolated AC joint disease is important as there is a significant proportion of patients who have associated significant superior labral tears. Soft tissue arthroscopic AC joint debridement allows quick post-operative rehabilitation, an early return to sport and work and avoids having to excise bone from the distal clavicle. Arthroscopic AC joint debridement is contraindicated in patients who have grade II or grade III AC joint instability.
We present a surgical technique through an axillary incision to perform scapular neck osteotomy and insertion of bone graft for recurrent anterior dislocation of shoulder. Fifty patients in the age group 09–40 years with the history of anterior dislocation of shoulder more than three times were operated during 1988–1998. The dominant shoulder was involved in all cases and there was no history of epilepsy, addiction to drugs and psychosomatic ailments. The surgery was performed through an axillary incision. The lateral border of the scapula was palpated and infraglenoid tubercle identified. The scapular neck was osteotomised parallel to the glenoid margin, from infraglenoid tubercle to the lateral border of the base of coracoid leaving the superior cortex intact. The osteotomy was prised open and a 3 cmx1.5 cmx1 cm corticocancellous bone graft was wedgedwhich projected 10 mm anteriorly and 6 mm inferiorly. The graft remained secure and compressed in the osteotomy without any need of metallic fixation.The shoulder was immobilised in arm chest bandage for 4 weeks followed by mobilisation aimed to regain full movements in 12 weeks. The bone graft got incorporated in all patients in 6 months.There were no recurrence at follow up of 2–10 years. All the patients returned to their previous occupation. Rowes shoulder evaluation revealed excellent result (85–100 units). This surgical technique is extra-capsular, requires no muscle cutting, blood transfusion or metallic fixation. The projecting bone block anteriorly increased the depth of glenoid resulting in glenohumeral stability in larger arc of shoulder movements.
At this time the majority of acetabular replacements in total hip replacement rely on bone ingrowth or bone ongrowth. Long term success has been well established but is this success the result of good luck or good management? Numerous systems exist with the simplest perhaps being that of the placement of a hemispherical cup in a hemispherically reamed acetabulum. Beyond this, a wide variety of added complexity exists with the presumption that these increased complexities provide improved stability and hence more secure primary and secondary fixation.
The computer model that has been established demonstrates the geometry of fixation of hemispherical cups as compared to rim fit cups and looks at the requirements of acetabular distortion before secure fixation can be achieved. The model attempts to explain why on some occasions an apparently ideally reamed acetabulum is not secure without some form of augmentation of fixation.
The model provides a basis for considering the various options of acetabular fixation.
Post operative stability is of paramount importance to obtain bone in growth and a tight interface in uncemented implants. Although hemispherical press fit cups are widely used different opinions exists according optimal fixation and a variety of principles are preferred. Lab studies show better stability if a cup is augmented by screws or pegs. However, cups with screws and holes increases penetration of joint fluid, pressure and particles to the interface with a risk for osteolyses. HA coating is in many studies favourable to obtain a quick in growth but is by many regarded unnecessary or even a risk for increased wear. This RSA studie was done to investigate stability and wear in cups with different fixation.
Mann-Whitneys U-test was used on signed values for evaluation of group differencies.
Wear was 0.45 mm proximally and in total 0. 6 mm without any sign of differences between the HA and porous coated groups. HA coated cups had less radiolucent lines after 2 years. (p=0.01)
We performed a new operation for ulnar neuropathy caused by recurrent dislocation at the medial epicondyle.
There were eleven patients, eight men and three women, with an average age of 52 years (24–74 years) at the time of surgery. The mean duration of symptoms was 23 months. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in five patients, and grade 3 in one patient. The operation consisted of ulnar groove plasty proximal to the cubital tunnel. The ulnar nerve was replaced into this reconstructed groove. The nerve was confirmed to be stable throughout the full range of elbow motion.
The cubital tunnel retinaculum of all patients was hypoplastic and the dislocated portion of the ulnar nerves was hard. One nerve showed severe adhesion around the dislocation site. One patient had a pseudo-neuroma. All patients were relieved of discomfort, and motor and sensory function were recovered. The ulnar nerve in the groove showed neither irritation nor adhesion. In patients with grade 1, symptoms or numbness of the fingers was relieved within three months of the operation. Sensory disturbances in patients with grade 2 symptoms also improved within six months. Grade 2 patients with intrinsic muscle weakness regained normal muscular power, and these with patients with intrinsic muscle atrophy had showed increasing muscular power. The patient with grade 3 symptomes recovered normal sensation after 1 year; clawing of the ring and little fin-gers recovered, and the muscle volume was increased.
Friction ulnar neuropathy has been treated traditionally by anterior transpositon or medial epicondylectomy. The ulnar nerve may become entrapped in scar tissue after these operations. We believe that this anatomical position is optimum for the nerve and that this procedure is essential for treatment of friction neuropathy.
Patients were managed with radial head excision and insertion of the Wright Medical titanium radial head replacement. The lateral ligamentous complex was stabilised. A back slab was applied for a period of one week and then the elbow mobilised.
The patients were followed up for a minimum of one year. The Mayo elbow performance index was used.
There were 9 patients with a delayed insertion of the radial head replacement. There were 3 patients who had an isolated radial head fracture and 6 patients with associated injuries, there were 2 excellent, 3 fair and 4 poor.
Three of the 4 poor results had associated capitellar chondral injury. Two patients with fair results had other significant pathology in the upper limb.
In the delayed presentation group the average flexion arc improved from 78 degrees to 102 degrees and the pro-supination improved from 117 degrees to 142 degrees. The average level of satisfaction on a visual analog score was 92 per cent.
The recommended surgical treatment of osteoarthritis (OA) of the shoulder remains controversial.
Recent published and presented trials evaluating hemiarthroplasty (HA) vs total shoulder arthroplasty (TSA) have been underpowered to detect a clinically relevant difference between the treatments.
A meta-analysis was carried out using methodology as described by the Cochrane Collaboration. Comprehensive search strategy was used including Medline, Science Citation Index, a review of references of relevant papers and abstracts of recent orthopaedic meetings. All articles were reviewed in a blinded fashion to select qualified articles based on population, intervention, outcome and methodological rigor. 4 RCT’s were identified. One was excluded due to selection bias introduced by the timing of randomization. The data of the 3 remaining trials was combined for analysis.
In each trial multiple tools were used to assess patient outcome however, the UCLA score was the only one consistent to all 3 studies.
The results demonstrated a statistically significant difference in change scores from baseline to 1 year (TSA 15.6; HA 11.2, p=0.012) in favour of the total shoulder arthroplasty group. This meta analysis demonstrated that in this selected group of patients, (primary osteoarthritis with intact rotator cuff and without excessive glenoid erosion), total shoulder arthroplasty provided a more predictable improvement in pain and function than hemiarthroplasty at 2 years.
Driving is an important part of a modern life style. ACL injury is the most common ligamentous injury of the knee. However, there is a paucity of information about the pre and post-operative ability of an ACL injured knee to respond to stimuli for specific situation such as braking reaction in an emergency. Does an ACL unstable knee affect braking reaction time? If it does, is there a difference between left and right injured knee? When is it safe to resume driving after an ACL reconstructive surgery? Is there any simple clinical test to assess patient’s recovery after surgery?
Braking reaction time of 73 patients who underwent arthroscopic ACL reconstruction and 25 normal controls was prospectively studied using a computer-link automobile simulator. Majority of these patients had autologous hamstring tendon graft. Every patients and controls were tested pre-operatively, and every 2 weeks after surgery up to 8 weeks. At each time point, two clinical tests namely stepping and standing test were also performed.
The pre-operative results did not differ significantly between controls, left ACL group and right ACL group for the braking reaction time and the two clinical tests. Post-operatively, it took 6 weeks for braking reaction time of the right ACL group to be equivalent to that of the controls, compared to 2 weeks for the left ACL group. There were a strong corelation between the stepping and standing test and the braking reaction time at each time point.
Conclusion: an ACL unstable knee does not affect patient’s braking reaction time. After a right ACL reconstruction, patient should delay at least 6 weeks before resuming driving. However, patient may resume driving as early as 2 weeks after a left ACL reconstruction. The stepping and standing test can be used at follow-up to assess patient’s recovery after surgery and to suggest appropriate time to resume driving.
The clinical implication: ACL tears should be treated initially conservatively since in a small percentage of patients, the ACL tear can heal.
Yachting is dangerous sport due to weather conditions. But, before this study, no data was available in the medical literature on yachting injuries. We undertook this study to analyze the yachting injury mechanism and to make inquires about this prevention. The players were asked about the details of yachting injuries they had experienced, in a questionnaire. 114 players (40.6%) out of 281 responded to the questionnaire. 35 players had experienced at least one injury (30.7%). Injury incidence of 470 class (66.7%) was significantly higher of other class; snipe38%, sea hopper 23%, FJ 22% (P< 0.05). Heads and faces were involved in 30.8% of the injuries, and upper and lower extremities in 26.8%. 44% of injury mechanism is attributed to free running injuries, which occurred during a Gybing or wild Gybing predominantly. The boom was part of the yacht which most commonly caused injury, followed by the sheet, side stay, spinnaker pole. We concluded that advancement of performance level, protection equipment, and proper judgement about weather conditions were necessary to prevent these yachting injuries.
Current issues being debated in ACL reconstruction include injury prevention, graft choice, graft positioning, graft fixation, graft remodelling and rehabilitation. Tissue engineering, the alteration of biological mechanisms by application of novel proteins, enzymes and hormones, is rapidly changing the way we approach all aspects of surgery. Tissue engineering techniques in ACL/PCL reconstruction focus on new biosynthetic ACL material, fixation of soft tissue grafts to bony tunnels and graft remodelling
OP-1 is recombinant human Osteogenic Protein 1 (BMP-7). It is a member of the Transforming Growth Factor β (TGFβ) super family. OP-1 promotes the recruitment, attachment, proliferation and differentiation of pluripotential mesenchymal stem cells. It promotes both osteogenesis and chondrogenesis. The carrier is highly purified bovine bone type 1 collagen, which provides an osteoconductive matrix.
We have completed a study assessing the use of OP-1 as a means of enhancing early biological fixation of soft tissue grafts within bone tunnels in a sheep ACL model.
We have commenced a clinical trial using OP-1 in adult ACL reconstruction, believing that OP-1 will enhance early biological graft fixation, and hence, improve clinical results, speed up rehabilitation and prevent tunnel widening.
Other studies have shown the beneficial effects of BMP-2 on an extraarticular bone tendon fixation model, the use of TGF-B to enhance graft remodelling and the application of gene therapy to deliver BMP’s for enhanced graft fixation.
Several projects are underway looking at creating biosynthetic ACL grafts using tissue engineering techniques. As opposed to purely synthhetic grafts, bioACL grafts are made of a collagen scaffold, allowing for remodelling and revascularisation.
ACL reconstructive surgery is constantly evolving. Tissue engineering may provide us with a means of minimising morbidity, accelerating rehabilitation and improving the clinical outcome following this common surgery.
The majority of the scientific literature is based on data obtained from elderly cadaveric material. Little is known about the biomechanical properties of the soft tissue grafts currently used prior to implantation. The correct preconditioning and intraoperative tensioning of the soft tissue grafts has also not been investigated.
The initial graft biomechanical properties are important. Inadequate tension will lead to continuing instability whilst excessive tension may cause accelerated joint arthrosis. The tension in the graft may decrease by 30% if it has not been cyclically pretensioned.
This device will also allow the accurate preconditioning of the graft, providing objective data that can then be compared to the subsequent clinical progress of the patient.
All testing will be accomplished during the time it takes to prepare the tunnels for insertion of the graft, and as such will not prolong unnecessarily the operative time.
This set-up will be immersed in a saline water bath maintained at body temperature during testing. The load cell will be hermetically sealed, with clamps and water bath being autoclavable. With the facilities for draping, the test area will remain sterile. The auto graft clamps will be designed to allow fixation of various graft materials (eg semitendinosus, gracilis, bone-patella tendon-bone) and adjustable for graft lengths. The water bath will house a thermocouple, heating mat and controller to maintain the saline temperature to within 1°C.
The testing system will be mounted on a stainless steel trolley for mobility in the operating room with an underlying shelf to house the associated electronics and a retractable side draw for storage of the laptop computer.
The autograft will be preconditioned between two known loads for 20 cycles recording load and displacement simultaneously on a laptop computer. Once preconditioned, the autograft will then be used for the ACL reconstruction in the standard way.
Increasing crosslinking has been shown in vitro and in vivo to markedly improve the wear resistance of ultra-high molecular weight polyethylene (UHMWPE). However, the reduction in the mechanical properties of polyethylene under certain methods used to produce crosslinking has been a concern. These reductions are known to result from the processes used to increase the crosslink density and could affect the device performance in vivo. We present a novel method of increasing the crosslink density of UHMWPE in which UHMWPE is irradiated in air at an elevated temperature with a high dose rate electron beam and is subsequently melt-annealed. This treatment markedly improves the wear resistance of the polymer as tested in a hip simulator while maintaining the mechanical properties of the material within national and international standards. This method also leads to the absence of detectable free radicals in the polymer and, as a result, excellent resistance to oxidation of the polymer.
The Pulmonary Embolism Prevention (PEP) Trial was designed to assess the effects of a 35 day course of aspirin (160 mg daily) on the risks of thromboembolic events, other cardiovascular outcomes and bleeding among individuals undergoing surgery for hip fracture or joint replacement. From 1992 to 1998, 148 hospitals in Australia, New Zealand, South Africa, Sweden and the United Kingdom randomised 13,356 hip fracture patients, and 22 hospitals in New Zealand randomised 4,088 elective arthroplasty patients. Among hip fracture patients, aspirin produced proportional reductions in PE of 43% (95% confidence interval [CI] 18% to 60%; 2P=0.002) and symptomatic DVT of 29% (95% CI 3% to 48%; 2P=0.03). PE or DVT was confirmed in 105 (1.6%) of 6679 patients allocated aspirin versus 165 (2.5%) of 6677 allocated placebo, representing an absolute reduction of 9±2 per 1000 and a proportional reduction of 36% (95% CI 19% to 50%; 2P=0.0003). Aspirin prevented 4±1 fatal pulmonary emboli per 1000 treated (18 aspirin vs 43 placebo deaths), representing a proportional reduction of 58% (95% CI 27% to 76%; 2P=0.002), with no apparent effect on deaths from other vascular (hazard ratio 1.04; 95% CI 0.86 to 1.26) or non-vascular cause (1.01; 95% CI 0.84 to 1.23). Deaths due to bleeding were rare (13 aspirin vs 15 placebo), but there was an excess of 6±3 post-operative transfused bleeds per 1000 allocated aspirin (2P=0.04). Among elective arthroplasty patients, venous thromboembolism rates were lower but the proportional effects of aspirin appeared similar to those among hip fracture patients.
UHMWPE implants are made from small powders which are formed by one of three methods. The powders are either compression molded into sheets and then implants machined from the compression molded material, ram extruded into rods and then machined into implants, or molded directly into the final shape. With each method the powders are exposed to variable temperatures and pressures to consolidate the material. It may not be possible to directly mold some implants such as those with complex geometries or modular locking mechanisms.
Clinical and implant retrieval studies of UHMWPE sterilized by gamma irradiation in air have demonstrated that wear behavior may be influenced by resin type and manufacturing method or both. Directly molded Hi-fax 1900 total knee tibial components were found to have more surface wear (scratching and embedded metallic debris) and less fatigue wear (delamination) than similar components which were machined from ram extruded GUR 415 resin (1). The molded Hi-fax 1900 components also demonstrated less oxidation than the machined GUR 415 components. Both groups of implants were sterilized by gamma irradiation in air suggesting that the resin type and manufacturing method or both may influence resistance to oxidative degradation and associated wear behavior. However, most currently available UHMWPE implants have not been sterilized by gamma irradiation in air and it is not clear if wear behavior of these implants will be affected by resin type or manufacturing method.
During the past five years, much research has focused on the effects of sterilization on UHMWPE wear and mechanical properties. Gamma irradiation sterilization of UHMWPE causes polymer chain scission and oxidation which adversely affects both wear and mechanical properties. However, gamma irradiation can also produce cross linking of the polymer chains which improves wear resistance. Enhanced polyethylenes or highly cross linked polyethylenes have been developed to further improve the wear resistance of the material. Highly cross linked polyethylenes demonstrate markedly improved wear behavior in hip simulator studies, but they also have a decrease in mechanical properties (yield strength, ultimate tensile strength, and fatigue strength). In a highly conforming joint such as the hip where contact stresses are relatively low due to the large surface area of contact, surface wear mechanisms (abrasion and adhesion) predominate while in a less conforming joint such as a fixed bearing knee replacement, where contact stresses are high, fatigue wear mechanisms occur more typically (delamination and pitting). Modifications to improve the wear resistance of UHMWPE such as the highly cross linked materials may therefore be more appropriate for hip replacements than for fixed bearing knee replacements.
Previous efforts to improve the wear behavior of polyethylene such as the addition of carbon fibers (carbon reinforced polyethylene), hot isostatic pressing (Hylamer), and heat pressing have not demonstrated improvements in-vivo. While current joint simulator studies may accurately predict in-vivo wear behavior, clinical studies will ultimately be necessary to determine if highly cross linked polyethylenes enhance the longevity of total joint arthroplasty.
Metal-metal total hip replacements were commonly used in the 1960’s and early 1970’s. Failures usually occurred as a result of aseptic loosening although many of these implants provided long term function similar to metal-UHMWPE bearings.
Metal-metal bearings used in total hip arthroplasty are made of cobalt chrome. The volume of wear generated from a metal-metal bearing is considerably less than that from a metal-UHMWPE bearing. Factors which may affect the metal-metal wear rates include the clearance (difference in radius between the femoral head and acetabular bearing surface), surface roughness, and carbon content of the cobalt chrome alloy. A small clearance provides more contact area between the two surfaces which decreases contact stress while a large clearance permits more fluid flow into the joint. If the clearance is too small, and exceeds manufacturing tolerances, the joint articulation may become excessively tight and equatorial rather than polar contact occurs between the bearing surfaces which can increase frictional torque and cause loosening. This has been implicated as a cause of failure of the McKee-Fararr metal-metal hip replacements. Wear is also increased with increased surface roughness but the effect of other material variables such as cast vs. forged and carbon content are less clear.
Early clinical results with modern metal-metal hip replacements demonstrate clinical results which are comparable to metal-UHMWPE bearings and less aseptic loosening than metal-metal designs used in the 1960’s and 1970’s. However, concerns with metal-metal hip replacements include the generation of metal particulate debris which may travel to the distal sites as well as local osteolysis.
In patients with metal-polyethylene total joint replacements, metal as well as polyethylene particles can be found at distant sites. Urban et al. (1) reported that in a study of postmortem specimens from patients with metal-polyethylene total joint replacements, metallic wear particles were identified in the para-aortic lymph nodes in 68 percent and in the liver or spleen in 38 percent of the patients. The serum and urine levels of cobalt and chromium are elevated in patients with metal-metal articulations. Metals can travel to distant sites in ionic form and little is known about the long term clinical effects of elevated serum and urine metal levels. Cancer risk has not been shown to be increased in patients who have received metal-metal hip replacements. However, long term studies with large numbers of patients are needed to accurately asses this risk.
The main problem of modern total hip replacement is the reduction of wear debris. Hence, new tribological partners such as ceramic on ceramic, metal on highly crosslinked polyethylene and metal on metal have evolved. Of these new combinations metal on metal has the longest history. The early problems of high friction using a “micro-fit” between acetabulum and femoral head have been solved by introducing an optimal clearance between the head and the cup to allow for small deformations of the acetabulum during activities without locking. The annual wear rate of metal on metal combinations has been shown to be extremely low ranging from 2 to 5 micrometers/year only. A further advantage of Metasul may be the “wearing in of small scratches” as well as forgiving slight malpositions of the acetabulum, which is not the case in ceramic – ceramic combinations. However, Metasul should not be implanted in patients with renal failure or severe allergies. Metal-metail pairing has proven a valuable alternative in young and active patients over the last 10 years.
Traditional hip prostheses, which involve metal on poly-ethylene articulations, have shown good survivorship at ten years, but in the long term, wear debris induced osteolysis has been found to cause loosening and failure. Specifically, micron and submicron size polyethylene wear particles generated at the articulating surfaces enter the periprosthetic tissues, activate the macrophages causing adverse cellular reactions and bone resorption. Recent laboratory, retrieval and clinical studies have shown that oxidation of the traditional polyethylene irradiated in air, causes wear to increase by a factor of three following either storage on the shelf for five years or following implantation in vivo for 15 years. Furthermore, damage or scratching of metallic femoral heads has been shown to increase wear by a factor of two. In vitro cell culture studies with real polyethylene wear particles, have shown that the intensity of the adverse cellular reactions is critically dependent on the size of the polyethylene wear particle with the smallest particles 0.1 to 1 mm being the most active. A novel model has been developed to predict functional biological activity and osteolytic potential, by integrating wear rates, particle analysis and cell culture studies.
Stabilised and crosslinked polyethylenes have been investigated and been found to reduce wear rates by a factor of three compared to oxidised and aged materials. A moderate level of crosslinking reduced wear from 50 to 35 mm3 per million cycles compared to non crosslinked materials. However, against scratched femoral heads, the wear rate of both stabilised and cross-linked polyethylene was elevated to levels where the functional biological activity remains a concern in the long term. Alternative bearing surfaces, metal on metal, and alumina ceramic on ceramic provide potential to substantially reduce wear. Metal on metal bearings have shown mean wear rates of 1.5 mm3/year in the hip joint simulator, with very small, 30 nm size particles. Alumina ceramic ceramic have also shown very low wear rates of approximately 1 mm3/year, even in the presence of microseparation and rim contact, with small 10 nm size wear particles and larger particles up to 1 mm in size caused by grain boundary fracture. The functional biological activity and osteolytic potential of the alumina ceramic couple is predicted to be at least ten times lower than crosslinked polyethylene.
New ceramic materials (zirconia toughened alumina) have been shown to further reduce ceramic ceramic wear. Furthermore, novel differential hardness ceramic on metal bearings have shown even lower wear rates. The currently available hard on hard bearings and the recent further improvements of these bearing couples, indicate that osteolysis free lifetimes well beyond 20 years are now possible.
Late aseptic loosening of total hip arthroplasty (THA) components due to wear debris especially sub-micron Polyethylene induced osteolysis has been identified to be the major cause for revision. Therefore, the use of wear resistant designs and materials is imperative for the long-term success of articulating implants. One of the most promising articulations for THA regarding extremely low wear is the hard-on-hard Alumina/Alumina combination with a long history in orthopaedics accumulating to now 30 years of experience.
Density, purity and grain size in combination with an optimised manufacturing process are crucial for the final properties of Alumina and have been sub-optimal at the early pioneering times. Also the design has to be adapted to the critical properties of this ceramic.
The biological activity of Alumina is graded as bio-inert and no direct osteointegration is to be expected, also proven by clinical experience. Alpha Alumina is bio-stable and practically insoluble in the body environment. Therefore, ageing or any systemic reaction in the human body with this ceramic is of no concern.
A comprehensive retrieval study using a systematic analysis of two different designs confirmed that Alumina/ Alumina couples have a low clinical wear rate and identified the main risk factors that can lead to early failure of such devices. The wear rate of those historic Alumina / Alumina articulations is in the range of less than 5 microns per year. This is one to two orders of magnitude less than for any articulation with Polyethylene cups. Reaction to Alumina wear particles, mostly encountered on catastrophic failure of the historic implant designs is sparse and mostly benign.
Improved purity and reduced grain size (Figure 1) for better properties Improved density, HIP for enhanced toughness and bending strength Less stress raisers due to laser marking instead of mechanical engraving Optimised head internal geometry Rounded and polished rim for risk reduction of runaway wear on sub-luxation Improved safety due to 100% proof test on heads and inserts
These improvements result in a significant increase in mechanical properties. The risk of head fracture has been reduced for this 3rd generation Alumina ceramic heads from 1 per 500 (0.2%) to 1 per 25 000 (0.025%).
The wear resistance of the couple Alumina/Alumina has also been enhanced which was measured in simulator tests to be around 1 micron per year. Tribological investigation involved a series of screening, pendulum and anatomical hip simulator tests with actual Alumina/ Alumina components in respect to the effect of clearance and cup angle (45° & 60°) in a series of tests for up to 5 million cycles. Adverse testing conditions for Alumina e.g. dilution of lubricant, dry and water, high load in swing phase, stop-start, etc in ascending aggressiveness (each at 1 million cycles) have also been investigated. No significant difference in wear volume was found comparing clearance or cup angle for all components tested. A new simulator test set up using a microseparation mode during every single cycle was also run for 5 million cycles combining Alumina from one single manufacturer and also mixing Alumina’s from different manufacturers. The wear in all cases was low and lower than for the first generation Alumina’s.
A series of implantations with Alumina/Alumina articulation has been performed since November 1996 according to a prospective multicentric FDA IDE protocol comparing the same implant with CoCr metal heads/PE combinations. Short-term results demonstrate no early complications with this third generation Alumina/Alumina articulation if implanted correctly. The benefit of the dramatically reduced wear rate will show only after longer-term follow-up.
Problems with earlier designs of Alumina/Alumina articulation have been successfully addressed by taking the identified risk parameters into consideration. Components of the third generation Alumina ceramic and design have been extensively tested. All components pass the mechanical tests. Alumina heads and liners of the third generation in the size and under the conditions tested are safe and efficient. Their wear rate even under the influence of adverse condition is minimal.
Further clinical trials parallel the application of this superior articulation couple in an innovative and modern design.Alumina/Alumina is, therefore, the material combination of choice for the active patient with high life expectancy.
Two-stage reconstructive technique has been proved to be a safe and effective method in the treatment of deep infection of hip joint implants. Between stages, however, the patients may be uncomfortable with limited mobility and activity because the joint function is severely restricted by the removal of the infected prosthesis and a thorough debridement. Furthermore, the delayed reimplantation procedure after a Girdlestone-like surgery is often complicated by shortening, bone loss, and dislocation due to scar formation, disuse osteoporosis, and distorted tissue planes.
We reported the technical details of a new method to make a cement-on-cement prosthesis as a temporary spacer for the period between resection and reimplantion. The doughy cement, mixed with antibiotics, was introduced into a metal mold made with the shape of a unipolar prosthesis to form the femoral component. Several large K-wires were placed in the mold in advance to act as strut support in order to prevent late fracture of the cement prosthesis. The remained cement was put into the acetabular cavity and molded into a hemispherical shape with a retrieved unipolar prosthesis of identical femoral head size. After consolidation of the cement, the femoral component was taken out from the metal mold and implanted into the femoral canal with fixation by antibiotic-loaded cement on the proximal portion.
Between the year 1999 and 2000, we have treated 42 infected hip implants by this technique with few complications. This new molding method has been a routine procedure in our practice. We believe it to be a simple, safe, and inexpensive way to eradicate local infection and provide comfort and mobility for the patient and an easier reimplantation procedure for the surgeon.
The concept of two-stage revision of infected total hip arthroplasties is well established in the literature. What has been lacking has been a user friendly, simple, safe, cost-effective interim prosthesis which can achieve hip stability, maintain ambulatory status and still deliver antibiotics at high local concentrations. Other commercially available products are expensive, difficult to implant and prone to dislocation. We have developed a modular, antibiotic-laden spacer hemiarthroplasty of the hip which has been fully bench tested. The prosthesis consists of a head/neck module utilising antibiotic impregnated bone cement (PMMA) as the bearing surface and a stainless steel neck. This can be assembled onto a polyacetal (Delrin) stem of varying lengths and diameters. Bone defects are accommodated with hand moulded PMMA at the time of implantation.
We have inserted 47 of these implants in the period 9/97 to 5/2000. 28 of these have been retrieved and submitted for biomechanical analysis at the Royal Perth Hospital Implant Retrieval Laboratory.
This paper presents the concept of the implant, the clinical results, the results of retrieval analysis and elutional studies on antibiotic release from the implant.
We have analysed the retrieved implants and there have been no implant failures. Two implants have been fractured during extraction and one has dislocated secondary to subsidence. Wear analysis has shown polishing of the PMMA in the weightbearing area of the head.
Elution studies are ongoing but suggest that antibiotic release is continuing for up to 8 weeks post implantation providing ambulation is encouraged. Clinical results indicate success rates comparable to other published reports of infected total hip arthroplasties.
This implant in the hands of a variety of orthopaedic surgeons has proven itself simple to use and to maintain ambulatory status to patients whilst maximising antibiotic delivery to the infected hip.
The purpose of this study is to describe a surgical procedure for unstable osteochondritis dissecans (OCD) of the capitellum and its results.
Between 1992 and 1997, 11 elbows of 11 patients with OCD of the capitellum were treated in our institution. The average age at surgery was 14.7 years and the ages ranged from 12 to 16 years. All patients were male baseball players affected in the throwing side. The follow-up period was from 31 to 95 months (average: 57 months). All patients underwent internal fixation using the pull out wiring method and bone graft (this procedure was established by Kondo in 1989). All lesions of OCD were not only softening or cracked but also unstable with early separation or partially detached fragment. After surgery, a long arm cast was applied for 3 weeks. After confirming bony union of OCD by X-ray, the wires were removed ranged from 15 to 21 weeks (average 17 weeks) postoperatively. Throwing activity was allowed 6 months after surgery.
At the follow-up, all patients were relieved pain and all except one returned to previous throwing levels. Radiographs showed good healing of OCD and minimum degenerative changes were found in only a few joints.
We concluded that this surgical procedure was an effective treatment for adolescent baseball players with unstable OCD of the capitellum.
Repair of large rotator cuff tears can be a demanding technical exercise, particularly when patients are elderly and tissue quality for repair is poor. In 25 patients we have used a method of tying rotator cuff sutures over a screw fixation post at the level of the surgical neck to secure the torn cuff to the greater tuberosity while healing occured. This study reports the results of these patients. 25 patients (27 shoulders) of average age 68.5 years were reviewed at an average of 22 months post surgery (range 3– 52 months). 4 patients (6 shoulders) were workers compensation injuries. The Constant method of shoulder assessment and visual analogue pain scores were used. Constant scores improved from an average of 30.6 pre-operatively to 75.2 post operatively. Pain scores improved from an average of 7.2 pre-operatively to 2.2 post operatively.
Over 80 % of patients reported being very satisfied with the results of their procedure. 2 patients reported being unsatisfied with their procedure. Workers compensation patients had poorer results for pain and function than the group average but still reported good satisfaction with the procedure. 4 complications occurred. 2 patients had re- tears of their cuff after falls. One was repaired with side to side suturing and the other was re-repaired to the post. 1 wound infection occurred requiring arthroscopic shoulder lavage and final removal of the implant.
This shoulder subsequently healed with good function. One patient had significant shoulder pain requiring surgery and removal of the fixation post. There were no other cases of screw irritation and no axillary nerve palsy or deltoid avulsions were found.
In all the patients, the Bankart lesions were repaired or reconstructed by using at least 2 Suretac devices after extensive, sufficient superior-medial shift of the anterior-inferior glenohumeral capsuloligamentous complexes(GHLC) down to the 6 o¡Çclock positions of the glenoid rim. As for the patients with concomitant TUBS and AMBRI group shoulder instability, we did not only the plication of the anterior capsule for AMBRI component, but also the repair of Bankart lesion for TUBS component. Follow-up time averaged five years and six months (range: 4 years 5 months to 6 years 3 months).
In clinical Orthopaedic research we often need better tools for follow up investigations and evaluation of new methods. One alternative is Radiostereometric analyses (RSA) which can be used for high precision measurements of migration, micro movements and wear. Since developed 25 years ago it has now been used in a few thousand patients and made into a comprehensible computerized, PC based system. Recent development has made it much faster, more accurate and user friendly enough for more common use.
RSA can basically measure 3D movements between rigid bodies as bone or implants and is used for many sorts of applications as bone growth, fracture healing, joint kinematics, bone elasticity, spinal fusion etc where a high accuracy is needed. It has, however, mostly been used for research in hip and knee arthroplasty since early migration has been found a good predictor for later implant failure. As also wear in artificial joints can be accurately measured the technique is definitely a useful tool for implant research.
With modern digital x-ray technique we obtain an in vivo precision of about 50 microns longitudinally, 80 horizontally and 200 sagittaly, for rotations 0.1°–0.3°depending on direction, (95% confidence limit).
Some general findings are: In cemented stems the loosening starts at the stem-cement interface and the cement mantles are very well fixed to bone, loosening being a secondary phenomenon.
A low temperature curing, non-vacuum mixed cement had equal fixation to bone and stem as a standard vacuum mixed.
Some stem designs move a lot inside the cement, possibly with a big risk for cement fractures and abrasion. Especially subsidence and retro version seems ominous.
Repeatedly HA coating has shown excellent implant stability, in the same range as cemented components and better than porous coated ones.
We have found good and reproducible stability with impaction grafting in both acetabulum and femur using both cemented and uncemented non tapered implants. Structural grafts seem to imply increased migration.
Wear has been increased with non irradiated plastic components, in younger patients, if cement contains ZrO as opacifier and together with unstable cemented stems. No correlation has been found between wear and HA coating, head or stem material or weight but decreased wear found for high cross-linked plastics.
RSA has been a big asset for Implant research over the years. With the more stable implants and modern bearings of today a high accuracy method is even more needed for to measure fixation and wear, or the actual results will be lost in a lot of noise. The new focus and interest in synergistic effects of implant micro movements, interface stress, hydrostatic pressure and particles for the development of osteolyses is a new area were RSA should be a useful tool to study inducible implant movements and fixation quality in vivo.
This will be a review of the various surgical approaches which are available for approaching the elbow and will include details of the global approach which can allow exposure of the medial and or lateral sides of the elbow via a common posterior midline incision.
Distal biceps tendon avulsion requires surgical treatment but is uncommon. The average orthopedic surgeon will come across a case only occasionally. The two-incision technique of Boyd is technically difficult. One-incision methods are easier for the occasional surgeon. Methods using Mitek Bone Anchors and Endobuttons have been described in the literature. This presentation compares those techniques and a technique using anterior cruciate interference screws against the Two Incision Technique in a model consisting of sheep bone and sash cord.
The models were then tested on a dynamometer to failure to assess the ultimate strength of the various methods of fixation. In this model Mitek Anchors and Endobuttons gave comparable fail points to the two Incision Technique. The Interference Screw Technique was stronger.
The aim of this prospective, randomised study is to compare outcomes within three groups of patients undergoing either open, one-portal or two-portal endoscopic carpal tunnel release. The study population consisted of 90 hands in 59 patients presenting with idiopathic carpal tunnel syndrome and symptom duration greater than 6 months, or those patients who had not gained satisfactory symptomatic relief from conservative treatments. Only patients with positive nerve conduction studies were included in the study. All patients were assessed using a standardised protocol which included a questionnaire on activities of daily living and symptoms experienced rated using a visual analogue scale. An examination followed which included; provocative tests; grip, pinch and abduction strengths; light touch; moving two-point discrimination; and vibration testing. Each patient was subsequently randomly allocated to one of the three surgical groups. All patients were assessed postoperatively, using a standa
We found no significant differences between the three surgical groups with regard to postoperative pain, level of satisfaction and objective return of grip and pinch strengths. The ability to perform activities of daily living postoperatively, however, was significantly reduced in the open technique group compared with patients treated with either endoscopic technique. There was also a significant difference in the time taken to return to work in the open group compared with both the endoscopic groups.
No neurovascular complications occurred in our series. The only complications that occurred were in the open group and included; prolonged scar tenderness, severe post-operative bruising of the forearm, and infection.
The concept of bipolar hemiarthroplasty has been described in the hip for over twenty years, its role being to decrease acetabular wear. Shoulder bipolar hemiarthroplasty is a more recent concept. The purpose of this study was to determine if the prostheses acted as a bipolar device, moving primarily at the inner metal on polyethylene bearing as intended or as a unipolar hemiarthroplasty moving at the outer metal on cartilage surface.
Eleven bipolar shoulder hemiarthroplasties with a minimum follow up of twenty two months were examined fluoroscopically. The proportion of arm abduction occurring in the scapulothoracic plane as well as that between the two components of the bipolar hemiarthroplasty was assessed and compared to that of normal patients and those with total shoulder replacements, previously reported in the literature.
The results of this study show that the majority of movement occurring in active arm abduction occurred in the scapulothoracic plane and that the bipolar hemiarthroplasty acted predominantly as a unipolar device.
The joint stability were measured with stress x-p using TELOS device. The anterior displacement ratio improved from 73±4.9%(mean ±
31 consecutive patients (mean 54.7 years) were examined mean follow-up time of 47 months. Patients were evaluated clinically; using Lysholm, Cincinnati, IKDC and Tegner Activities Scores. Objective assessments were made with KT1000 Arthrometer and Isokinetic strength testing.
Lysholm scores improved from 62 preoperatively to 93 at review; Cincinnati 48 to 89; Tegner 3.6 to 5.2. 81 percent of knees were considered normal or nearly normal to IKDC, 6 abnormal, none severely abnormal. KT1000 manual max difference 2.9mm; Isokinetic flexion strength 102 percent; extension strength 95 percent. Poor results were mainly associated with advanced articular cartilage degenerative changes at time of surgery. This also correlated with increased time from injury to surgery, and increased preoperative injury rates.
This study demonstrates that the anterior cruciate ligament can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to activity.
The outcomes were assessed by stress radiographs, maximal manual test with KT-2000 arthrometer, IKDC grading and OAK knee score.
Average OAK score improved from 64.3 to 86.4
From 1992 to 1999, 713 total joint arthroplasties were performed in The Department of Orthopaedic Surgery, The University of Hong Kong. Since January 1993, a uniform prophylactic antibiotic regime was employed: one dose of first generation cephalosporin (one gram cephazonlin) on induction and every 4-hourly. In case of sequential bilateral total knee arthroplasty, one gram of cephazolin will be given on induction for the first knee and one hour before the operation on the opposite knee. Antibiotic will be discontinued post-operatively. No significant difference was identified between the infection rate before (1.4%) and after (1.2%) the adoption of the prophylactic antibiotic guidelines (p > 0.4). The study had shown that one dose of first generation cephalosporin is as effective as multiple dose of prophylactic antibiotic, either first or second generation cephalosporin, in preventing infection in total joint arthroplasty.
The isolated arthroscopic lateral release has been already presented in the literature as an effective alternative for surgical treatment of different degrees of patellofemoral instability. This paper is to evaluate the long term results of this procedure in patients with recurrent dislocation of the patella (RDP).
Material of this study is a group of patients who underwent isolated arthroscopic lateral release for RDP with a minimum 10 years follow-up. All the patients included presented 1) clear clinical history of RDP 2) positive apprehension test 3) patella able to be dislocated under anesthesia. Were excluded from this study patients who presented 1) generalised ligamentous laxity 2) habitual dislocations of the patella 3) avulsion fracture of the patella 4) marked malalignment 5) age over 40 years. 42 patients met these criteria and 27 (28 knees) were available for follow-up. There were 13 females and 14 males with an average age of 20, 1 years and an average follow-up of 13, 4 years.
All the patients were evaluated for patellar stability and functional outcomes with both Miller and Bartlett and Crosby and Insall scores. According to the evaluation scores above mentioned 16 knees (57%) were rated as excellent /good results.
The isolated lateral release can be considered as the first approach for the treatment of RDP. The outcomes are adversely affected by long term-follow-up, however, it does not compromise any further treatment.
A recent systematic overview of 213 studies of more than 50,000 patients showed that ectopic bone formation (EBF) is present on the radiographs of about 40% of all patients who have undergone elective hip arthroplasty and in at least half of these, EBF is rated moderate to severe and is associated with an increased risk of an impaired functional outcome. A recent meta-analysis of more than a dozen trials of NSAIDs in patients at risk of EBF has demonstrated that perioperative treatment reduces the risk of EBF by about 50%. However, prophylaxis is rarely given in clinical practice due to concerns about perioperative bleeding, gastrointestinal events and implant loosening, combined with a lack of data on the clinical importance of EBF. The HIPAID study involves the conduct of a randomized double blind clinical trial, designed to assess the effects of a 15 day peri-operative course of ibuprofen (1200mg daily) on the clinical consequences of EBF in individuals undergoing total hip replacement surgery. The trial will be conducted in 20 orthopaedic centers throughout Australia and New Zealand, and will involve 1,000 patients aged 60 to 80 years, scheduled for elective total hip replacement surgery. The primary study outcomes are self-reported pain and physical function, assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC), six months after surgery. Secondary outcomes include EBF, health-related quality of life (SF-36v2), patient’s global assessment, hip flexion and the 50ft walk time. Peri- and early postoperative events will be assessed including bleeding and gastro-intestinal complaints.
With increasing primary joint replacement procedures and an ageing population surviving longer, the rate of revision surgery will increase. Revision surgery, however, is associated with increased morbidity and mortality and has a far less successful outcome than primary joint replacement. The mid- to long-term survival rate of the large variety of replacement prostheses remains unknown. Inadequate outcomes data for the majority of prostheses, as well as variability related to different surgical techniques and diagnostic groups, have made it difficult for surgeons to identify the relative effectiveness of different prostheses and treatments. The Federal Government provided funding to the Australian Orthopaedic Association (AOA) to establish the National Joint Replacement Registry (NJRR) in March 1998. The AOA has appointed a committee to manage the Registry and has contracted with the Data Management and Analysis Centre at the University of Adelaide to establish and manage the data systems for the Registry.
The primary aim of the AOA NJRR is to evaluate the effectiveness of different types of joint replacement prostheses and surgical techniques at a national level.
Implementation methods, aspects of database design and early progress in data collection are presented.
A review of 100 consecutive patients who underwent knee arthroscopy within 1 month of Magnetic Resonance Imaging (MRI) of the knee took place to assess the role of Magnetic Resonance Imaging in regard to assessment of intra articular pathology. The study period was from 15th April 1998 to 19th September 2000. The study compared the MRI report with the operative findings of one surgeon documented with average of 20 photos per patient.
The enclosed tables document the sensitivity and specificity in regard to articular cartilage of the patella, trochlearand medial femoral condyle. Medial meniscal and lateral meniscal pathology was reviewed as was anterior cruciate ligament.
The study would suggest that whilst MRI is useful for assessment of meniscal pathology it is not highly accurate for assessment of articular surface lesions and anterior cruciate ligament pathology.
Since the Medial Patellofemoral ligament was first described in 1979, its importance as a prime patella stabiliser has been defined, and procedures for its repair and reconstruction have been described.
We believe that the MPFL has a pivotal role in the stability of the patella, and is disrupted in all patients with acute patella dislocation. Failure to address this will inevitably lead to ongoing patellofemoral symptoms.
We present our own experience of treating acute patella dislocations by repair of the Medial Patellofemoral Ligament, in acute cases.
A lesion can occur anywhere along its length from the superomedial patella to a point superoposterior to the adductor tubercle. The technique of repair has to address the site of primary disruption, as well as any associated intraarticular knee injuries.
Anterior cruciate ligament (ACL) reconstruction is a common procedure; HIC figures for 1999 in Australia include 4652 primary reconstructions, and 279 revisions (6%). We all see many good results, with some being excellent; but I also see a lot of ‘ordinary’ knees, and large group of unhappy patients following this type of surgery. Second opinions are frequently sought, because the patients feel that they have not progressed as expected. I looked prospectively at 50 patients in this category. The most common symptoms were pain, crepitus, catching, and functional insecurity or instability - and subsequent failure-to-progress. They presented four months to 15 years following ACL surgery, many having unrealistic expectations, often brought about because of media reports. Many patients complained of ‘failure of communication’ with their surgeon, and were prompted to seek a second opinion by a vocal third party. Their problems were generally complex combinations of:
Ligamentous laxity. Meniscal, chondral, or other internal derangements of the knee. An inflammatory response. ‘Neuromotor dysfunction’ (this group struggles from the start, often develops patellofemoral symptoms with persisting quadriceps wasting and insecurity). Those with significant degenerative arthritis. Failure to distinguish instability of patellofemoral and neuro-motor origin; from that of ACL deficiency; can lead to inappropriate revision surgery.
Reviewing these patients who sought second opinions, emphasises the importance of a surgeon’s being an excellent technician, (as 60% of those reviewed had anterior placement of the drill holes); but equally being a team leader; understanding tissue responses, psycho-emotional factors and having good communication skills, time to listen to patients and offer adequate follow up.
KT-1000 side to side differences in anterior knee laxity were significantly greater in the HS group from four months through to three years. There were significantly greater peak quadriceps torque deficits in the PT group at four months and at eight months. Sports activity levels were significantly higher in the PT group at four months but this difference had resolved by eight months. Cincinnati scores were significantly higher in the HS group at one year but not thereafter. There was no difference in IKDC ratings between the two groups. Radiographic femoral tunnel widening was significantly more prevalent and greater in the HS but did not correlate with any clinical differences. Radiographic tunnel widening was present at four months and did not change significantly thereafter.
Patients underwent a continuous follow up evaluation including clinical examination IKDC, Lysholm knee score and KT-1000 man max testing. Tibial tunnel widening was calculated from lateral radiographs digitalised and corrected for magnification. The tunnel shape was classified according to Peyrache.
A paper was presented two years ago reviewing evidence of absorption of the Bio Interference screw and tunnel widening at three, six and 12 months following anterior cruciate ligament reconstruction using double-stranded hamstrings. The femoral fixation was with an Endobutton with a double loop of Mercylene tape with a Bio Interference screw and an extra small staple for the distal fixation. This paper presents further magnet resonance imaging (MRI) studies at least two years after surgery on 10 of those patients to assess if there was any MRI evidence of absorption of the Bio Interference screw or tunnel widening (in particular ganglion formation) in the femoral or tibial tunnels.
The results showed that at least two years after surgery there was little evidence of Bio Interference screw absorption. There was no evidence of tunnel widening.
1)Intact.
2)1 cm medial wedge osteotomy (proximal metaphysis).
3)1 cm gap osteotomy.
Twenty proximal tibial fractures treated with the LISS system were reviewed to assess union rates, complications, knee motion and secondary procedures.
The patients’ outcomes were assessed with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score.
The natural history of scapholunate ligament injury is unknown. In fact, as far as we can tell, there has been no study examining the long-term natural history of this condition. It has, however, been assumed that the long-term progression of this injury leads to secondary osteoarthritis – scapholunate advanced collapse (the so-called SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with proven scapholunate ligament injuries that had declined further treatment in an attempt to quantify any long-term disability. Whilst there was on-going pain and functional limitation in the injured wrist, there was no rapid progression of the osteoarthritis or SLAC wrist deformity.
An anatomical cadaver dissection was used to compare two approaches to the volar aspect of the distal radius. The traditional approach between flexor carpi radialis and the radial artery limits the exposure of the ulnar aspect distal radius. In the trauma setting, it is difficult to perform a carpal tunnel release whilst protecting the palmar branch of the median nerve and gain sufficient exposure of the volar ulnar fragments and the DRUJ. An extensile ulnar sided approach to the distal radius is described which permits wide exposure of the volar aspect of the distal radius including the DRUJ and radial styloid. This exposure utilises the plane between flexor carpi ulnaris/ulnar neurovascular bundle and flexor digitorum profundus. It permits easy and safe release of the carpal tunnel and Guyon’s canal.
Its use in the trauma and post traumatic setting will be shown with intra-operative pictures.
Sixty-three prostheses were implanted in 54 patients. Follow-up was from 55 to 144 months. Eighteen patients had died. Eight prostheses had been revised between four to 82months after the initial surgery. Of the patients who were reviewed, the average Oxford Knee score was 20. Two patients were not satisfied with the prosthesis.
Survival analysis: 99% at 12 months 98% at 24 months 98% at 36 months.
The scores on SF36 and WOMAC were adjusted to the Australian Population Norm. The WOMAC score showed an increase in function, and a decrease in the pain and stiffness scores. The physical and mental component summaries of the SF-36 both indicated an increased quality of life post-operatively. Implant failure was due to loosening of tibial and femoral components and progression of arthritic changes in the lateral compartments.
The surgical technique involved an arthrodesis at the acromio-clavicular joint and coraco-clavicular space using autogenous iliac crest bone graft and fixation with both tension band wires and a cancellous screw.
The fusion rate was 75% (six out of eight). Pain, measured using a Visual Analogue Scale (0 to 10), was reduced from 8.5 pre-operatively to 3.1 post-operatively. The patient’s perception of instability reduced from an average of 9.0 to an average of 1.0. The range of motion increased in five patients, decreased in two and remained the same in one. All of the patients would have the operation again and seven out of eight were very satisfied. The complications included the two non-unions, mild sterno-clavicular pain in two cases and a need to remove K-wires in seven instances.
A modified Bosworth technique was used in all patients. The shoulders were immobilised in collar and cuff slings for six weeks. The screws were removed after six to eight weeks. The patients were assessed using the modified Constant Score. The average follow up was 35.2 months (range: seven to 60 months).
Using the modified Constant score:
– Twenty-six patients (74%) scored 100; – Five patients (14%) scored between 90 and 99 and – One patient (3%) scored 87 (against a score of 96 on the other side) – Three patients scored poorly.
We concluded that this technique produced good to excellent functional results and we would recommend its use for Tossy III ACJ dislocations. The technique is not obsolete!
The mean blood loss as a percentage of calculated blood volume was 38% (SD 35). There was a strong suggestion that patients with medical abnormalities, particularly those with muscular dystrophies, had much higher blood losses (63%, SD 59). There were no differences between the different patient groups in the pre-operative haematological investigations.
This was a retrospective review with minimum two-year follow-up of 52 patients treated between 1989 and 1998 with a variety of fixation methods. All patients had posterolateral fusions (after McNab). In addition, 27 patients had interbody fusions (23 with Brantigan or Harms cages). Fixation was by interlaminar screws in 13 (modified Nagerl technique), 18 with Roy Camille or AO notched spinal plates and in 21 with rigid fixation (6 VSP and 15 Diapason).
A good result was defined as a pain level of less than four out of 10 and an Oswestry Disability Score of less than 30%. Only 13 patients achieved a good result. The best results were seen in the patients with rigid fixation (8 out of 21). A fusion rate of 100% was achieved in patients who had an interbody cage and rigid fixation.
These results were compared with results from other papers in the literature. Social factors are important criteria for patient selection. No patient without a “significant partner” achieved a good result.
We compared magnetic resonance imaging (MRI) scans and plain antero-posterior (AP) and lateral radiographs of 100 randomly selected patients in order to detect segmental abnormalities of the lumbar spine. We started by identifying those who appeared to have a segmental defect of the lumbar spine on MRI scan. We then checked all 100 plain radiographs to detect the true rate of segmental abnormality. We detected 17 patients with a segmental abnormality that correlates well with other studies. We believe that MRI scanning alone is not sufficient to detect reliably all segmentation defects in the lumbar spine, and that a plain lateral and an AP x-ray is also required. Of those who do have a segmentation disorder we have identified a sub-group who are at risk of surgery at the wrong level, if the correct pre-operative work-up is not performed. The difficulty will occur when a segmental abnormality is present (as determined by plain radiographs) and it is missed by MRI scan, and plain films are not taken, and the correct level is determined by counting upwards from the lumbosacral take-off angle using the image intensifier in theatre. We believe that all patients undergoing nerve root decompression should have an AP and lateral plain film and an MRI scan as well as pre-operative image intensification in theatre. Although the number of patients that would be affected by this is small, the consequences of operating on the wrong level are well recognised and can be avoided by being aware of the potential problem and by adhering to the above recommendations.
Percentage slip Slip angle Rounding of the sacrum Trapezoid index of L5 vertebral body Progression of a lumbar lordosis was defined as an increase in slip of 5% or more.
For patients who had sustained a subcapital fracture (n=117), 21% (P< 0.05) of those who had been treated with cannulated screws required further surgery compared with 2–14% who had the other types of surgery.
Patellar resurfacing was combined with realignment and an ‘anteriorisation’ procedure in 77 knees. We found that 96.7 % of repairs for grades I & II disease were seen with rods on the patella, when combined with a mechanical correction, compared with 66.0%, when used on the patella without a realignment procedure. However, when the use of pads was combined with mechanical corrections the score was 76% and a lower proportion were grade I repairs (13%) than with rods (30.0%).
The mean Waddell Score (0–4) was 2.9. From the survey 81.8% regarded the procedure as worthwhile and 9.1% were doubtful.
Articular cartilage defects of the knee occur commonly in sports injuries and trauma. Increasing evidence suggests that the only technique that enables the regeneration of articular hyaline cartilage in chondral defects is autologous chondrocyte implantation (ACI). Here we have reported our clinical experience of autologous chondrocyte implantation using biodegradable type I/III collagen membrane (CACI). A total of 26 patients (age range from 19 to 60 years, average 37 years) was conducted with CACI. Pre-operative magnetic resonance imaging (MRI) scans were performed on all patients. Post-operative MRI scans were planned for approximately three and 12 months after the surgery to determine the success of integration of implanted chondrocytes.
The results demonstrated that the initial post-operative MRI scans at three months showed the presence of oedematous tissue at the defect sites in 23 patients, contrasting with the fluid filled defects seen preoperatively and with and MRI signal differing from that of the surrounding normal hyaline articular cartilage. MRI scans in nine patients at 12 months after their operations showed maturation of cartilage graft in all patients. Apopototic testing of the chondrocytes using Annexin IV before implantation showed that the viability of the chondrocytes was over 85% where the apopototic rate of chondrocytes was less than 2%. One patient with an apopototic rate of over 10% has a delayed repair in cartilage defects as shown by MRI.
In conclusion, early phase clinical studies showed that autologous chondrocyte implantation remains promising for the treatment of chondral defects with restoration of hyaline cartilage. Longer clinical follow-up of the patients and better assessment of cellular phenotype of chondrocytes before implantation are required.
Arthroscopy and removal of the metal implants were performed nine months following implantation. The ICRS score was used to assess the repairs.
Seventy lesions in 58 knees (56 patients) have been assessed; four eligible patients were not assessed arthroscopically. The ICRS scores (maximum 12) were: tibial condyle 11.5; patella 11.3; femoral condyle 11.0, and trochlea 10.7. Synovitis was markedly reduced in all knees with well-healed defects. Adhesions between the periosteal graft and the synovium caused a click in 11 patients, which was relieved by arthroscopic resection. Incomplete healing occurred in one patient with a wound dehiscence, in two following a fall in the post-operative period, and in one patient with a non-contained defect. Biopsies at arthroscopy showed predominantly hyaline cartilage.
The limping or non-weight bearing child can present a difficult diagnostic dilemma. It may be possible to avoid admission of a large proportion of these patients if septic arthritis or other serious pathology can be exclude d.
We have established a continuing, prospective study of all patients admitted for hip pain (with normal radiographs) to Starship Children’s’ Hospital between two and 13 years of age. Forty-two patients had a final diagnosis of transient synovitis. Only two patients during an eight month period had septic arthritis. Due to small numbers of patients with serious pathology we compared the transient synovitis group with a retrospective review of those with septic arthritis treated at Starship Hospital in the previous four years.
Following comparisons of these two groups, we found that there was a greater incidence of septic arthritis in Maori and Pacific Islanders and septic arthritis tended to occur in younger children. The patients’ initial history, temperature, white cell count and ESR were sensitive in discriminating between septic arthritis and irritable hip.
Once the diagnosis of “irritable hip” was made it was unlikely to be altered. We therefore would recommend that it is possible to avoid admission in a large number of these patients. We would however continue to recommend admission for those with a clear history of current illness, Maori or Pacific Islanders, children under the age of four, those with an elevated temperature, and any patient with an elevated white cell count especially neutrophil count or ESR.
Deep vein thrombosis is uncommon in children but can occur given certain circumstances. Protein C deficiency has recently been described in a child with deep vein thrombosis complicating septic arthritis. We present four case reports of children who developed deep vein thrombosis in association with musculoskeletal sepsis. All had evidence of musculoskeletal sepsis and thrombosis. One child died. Prothrombotic screens were performed demonstrating normal haematological parameters in the three surviving children. The high mortality of deep vein thrombosis complicating musculoskeletal sepsis is emphasised, particularly the potential for septic embolic complications. Deep vein thrombosis should be considered in any child with musculoskeletal sepsis and generalised limb swelling. Early recognition and treatment can lead to favourable outcomes.
The bisphosphonate, pamidronate, has been used successfully in our hospital for the management of osteogenesis imperfecta with an excellent safety profile in growing children. We have performed several research studies on distraction osteogenesis in New Zealand white rabbits showing significant increases in new bone formation and the abolition of stress shielding osteopaenia using both pamidronate and zoledronic acid. Recent studies have shown that bisphosphonates positively effect osteoblasts as well as inhibiting osteoclastic bone resorption.
We present a series of early cases where this research has been used in humans. Two cases of pamidronate assisted distraction osteogenesis are presented, one of which also had congenital pseudarthrosis of the tibia, which united after pamidronate administration.
Two cases of post-traumatic avascular necrosis have been successfully treated such that osteolysis and collapse of the necrotic femoral head did not occur. Bisphosphonates may act to slow bone resorption while simultaneously increasing new bone formation, such that the mechanical integrity of the necrotic segment can be maintained during revascularisation.
A randomised controlled trial of bisphosphonates in distraction osteogenesis at our hospital has now received ethical approval. Newer bisphosphonates have proven their clinical value in osteogenesis imperfecta and adult osteoporosis, but other potential roles are emerging for these compounds, which have extremely potent effects on bone.
We used standard saw-bone preparations of two prosthetic hip systems: Friendly (Lima) and Exeter (Stryker). In each hip system we performed five preparations for each entry point (trochanteric fossa, posterolateral corner and mid point of the cut neck). The only variable was the entry point. Preparation was performed according to the manufacturers’ recommendations. The preparations were x-rayed and cement mantle alignment and thickness were measured on the x-rays. Saggital sections with digital imaging and radial measurements were also performed.
A cannula was placed through the capsule into the hip joint and another was placed through the periosteum and bone of the ilium into the osteolytic lesion above the ingrown cup. The continuity of these two spaces through the holes in the cup was confirmed by the injection of methylene blue. Pressure transducers were then connected to both cannulae. Measurements were taken while applying compression and distraction forces across the artificial hip joint.
A subject’s response to commonly used knee assessment scores is variable, even in the presence of a normal knee. The subjective response to a knee score is dependent on age and cultural expectations.
Radial cleavage tears of the lateral meniscus are uncommon and may be associated with a meniscal cyst. There is a recognised association of these lesions with radiographically visible erosions of the lateral tibial plateau; however, this association is reported to be rare. We believe this radiographic feature is more common than previously reported and as most reports are limited to the radiology literature it is not widely appreciated by Orthopaedic Surgeons. The aim of this study was to determine the prevalence of this valuable radiographic sign in patients with a proven radial cleavage tear and draw attention to it among Orthopaedic Surgeons.
We identified 20 patients from our prospectively collected database that had undergone an arthroscopic partial lateral meniscectomies for radial cleavage tears of the lateral menisci. A consultant radiologist (NS) independently assessed the pre-operative radiographs of these patients, specifically looking for the presence of erosions of the tibiae below the lateral joint line. Of 20 patients assessed 9(45%) had radiographically visible bone erosions.
Our study confirms our clinical experience that patients with symptoms and signs suggestive of a radial cleavage tear of the lateral meniscus frequently have an associated plain radiographic sign to support the clinical diagnosis.
Proximal humeral fractures may be treated by joint replacement or internal fixation. We have been concerned by the unpredictable results of hemiarthroplasty in the trauma situation. At The Alfred hospital, we have used the ACE proximal humeral plate over the last three years. This is a retrospective study of 55 cases, looking at the outcome of internal fixation, the incidence of avascular necrosis, and the functional results. The results were very favourable when compared with the results of other series that have been published in the literature. Our conclusion is that it is better to internally-fix these fractures whenever possible.
This is a review of the literature detailing the causes, presentation and appropriate investigations of patients with suprascapular nerve compression. The choices of treatment are discussed in the context of the pathology found. The recommended surgical procedures are described. Suprascapular nerve compression is an uncommon cause of persisting and diffuse shoulder pain that arises from direct trauma to the shoulder or as a result of repetitive, overhead manoeuvres producing a traction type injury.
The presence of tenderness over the suprascapular notch, weakness in external rotation and especially the presence of infraspinatus or supraspinatus atrophy (either separately or in combination) with positive nerve conduction studies confirm the diagnosis of suprascapular nerve entrapment. MRI is recommended for identification of a cause of the nerve compression. Fibrous transverse ligaments have been seen causing stenosis and entrapment at the suprascapular and spinoglenoid notch. A variety of space-occupying lesions can be found in the notches including supraglenoid ganglia and tumours.
Initial conservative management of the shoulder is recommended when the neuropathy results from repetitive activity in the absence of a space-occupying lesion. Early decompression of the nerve using arthroscopic debridement of the labrum and open release of the ligaments at the suprascapular and spinoglenoid notch is advocated in the presence of a ganglion cyst.
Sixteen revisions had EIG to femur and acetabulum. Four acetabular cups and 10 femoral stems were revised with EIG alone or in combination with a replacement component.The average period of follow-up was 34 months. One acetabulum was revised for recurrent dislocation. Three other hips dislocated in the post-operative period. Two femoral stems (one patient) were revised again with EIG for subsidence. One is now stable, the other has been exchanged for a Solution stem because of repeated subsidence. The histological specimens taken from these showed the grafted bone was necrotic. One other stem subsided 2mm. There were two intraoperative femoral shaft fractures.
The proximal locking is achieved by the protrusion of a wire into the medullary bone of the humeral head. Distally the EXP nail has two small wings shaped to sit on the medial and lateral columns of the olecranon fossa.
The hips were approached posteriorly. A step cut was used to secure the host to allograft junction. The femoral component was cemented within the allograft and with a press-fit in the host bone. All but three cases had iliac crest bone graft and/or residual host bone chips added to the host-allograft site. The acetabulum was revised concurrently in 13 (two whole acetabular allografts).
Subsequently the patients were booked into routine orthopaedic clinics without prior knowledge of the investigator and after the face-to-face assessment a letter to the GP was generated. Correlation between the mock and real GP letter was carried out in all cases.
The correlation between the mock and real letter was outstanding and in over 90% of the cases the face to face assessment did not alter the outcome of the paper assessment.
Recently released New Zealand guidelines recommend that HRT should be stopped for at least 30 days prior to elective surgery and withheld for 90 days following surgery. Less than 3% of surgeons appeared to be routinely following this recommendation. Most manufacturers of combined oral contraceptive pills recommend stopping the medication for at least four weeks prior to elective surgery. Only 25% of surgeons routinely practice in accordance with these recommendations.
Although described by Gattelier and Chastang in 1924, the transfibular approach to the ankle has been slow to emerge as a conventional orthopaedic technique. To date, applications have been confined to the treatment of tibiotalar arthrodesis, ankle joint incongruity and exposure of the fractured talus, where the distal fibula is also fractured. While seemingly undocumented, it is also proving effective in mosaic-plasty of the talus. This paper outlines an innovative technique of segmental distal fibula osteotomy and its role in the treatment of osteochondritis dissecans of the postero-lateral talar dome.
Various assumptions must be made during total hip replacement when placing the acetabular component within the reamed acetabulum with regards to its orientation. Various methods have been described for different acetabular components, some relying on knowledge of the existing anatomy and some relying on the use of jigs to align the component. Many of these assumptions are based on opinion rather than science and the current study was designed to define the position of the acetabulum in relation to a fixed position of the pelvis.
A neutral position of the pelvis must be defined and this is represented by having a line from the anterior superior iliac spine to the pubis fixed in the coronal plane and taking measurements of the perpendicular axis of the pelvis taken from this.
A variety of measurements were made using measurement techniques and the conclusion was reached that the average angle for operative inclination is 43 degrees ± 5 degrees and the average angle for operative anteversion is 29 degrees ± 8 degrees. These figures should give a preliminary guide to the correct placement of the acetabular socket in total hip replacement although other factors may need to be taken into account.
From July 1985 to April 1996, 394 PCA total hip replacements were performed using proximally, porous-coated, femoral components. A prospective study using a specifically designed database has been used to follow these patients. There have been 10 deaths and five patients were lost to follow-up (F/Up), leaving 379 for review.
Revision of 33 acetabular components has been performed for loosening; four acetabular liners were revised for recurrent dislocation; and three acetabular liners were revised because of wear. Only three femoral stems have been revised for loosening.
The fully proximally, porous-coated, cementless stem resulted in good survival in the mid-term.
The problems of the acetabular component of cement-less total hip replacement have been the cause of early failure, but close follow-up of patients has enabled the femoral components in these patients to be preserved.
Improved acetabular components, with lower wear characteristics, may prolong the survival of the femoral components of proximally porous –coated femoral components.
We have performed 466 metal-on-metal total hip replacements (THR) in our hospital, since November 1993. Forty-seven of these have been the TPP (Thrust plate prosthesis - Sulzer Medica). We present here the results of our experience with this prosthesis when used for the “younger” patient. Forty-two patients received 47 THRs The age was 40 years (range: 21 – 53 years) There were 25 female patients.
At the latest review: one patient (with two THRs) had died from a pulmonary embolus one patient had a revision for an aseptic loosening (one hip) one patient was lost to follow-up (one hip). The remainder were satisfactory although two hips had subsided into a varus position. The early results were satisfactory in this high-demand group of patients.
Loosening was classified as possible if there was between 50 and 99 percent c-b radiolucency, probable when there was complete radiolucency, or definite when vertical subsidence was more than 5mm. The presence and type of radiological features analysed according to surgeon and whether a centraliser was utilised.
In law, doctors owe “a duty of care” to their patients to ensure that they are properly informed of treatment risks and are not harmed by their doctor’s negligent acts. This term is well established, however, a recent case in the New South Wales Supreme Court has considered the proposition of whether a duty of care, of this type, extends to ancillary medical staff; in this case the receptionist.
The court in the case Alexander v Heise [2001] NSW SC 69 has found that ancillary non-medical staff can owe patients a duty of care, for which a medical practitioner can be vicariously liable, and furthermore that this duty of care can begin when a person books an appointment either for or as a prospective patient and even before the prospective patient has been seen by the doctor. It is clear from this decision that the duty of care has widened somewhat.
Many important issues arise from this case; ensure that your practice has adequate insurance to cover all staff. There is no excuse for lack of training. Training should be focused, regular and documented. Extra care needs to be exercised when a patient is disclosing symptoms on behalf of a third party.
There were 14 patients in the beginners’ group, 32 intermediate, 20 advanced and nine at an extreme-skill level. Thirty-eight patients sustained injuries of the lower extremities, 24 of the upper extremities, 13 of the spine, and one of the pelvis. Lower extremity injuries were more common in skiers (59% of lower limbs, versus 25% of upper limbs), while in snow boarding upper extremity injuries were more common (43% upper limbs versus 36% lower limbs). Ulnar collateral ligament injuries of the metacarpophalangeal joint of the thumb, were far more common in skiers (six in skiers versus one on snowboard). Sixteen patients (nine skiers and six snow-boarders) sustained diaphyseal fractures of their tibiae. In all nine patients in the skiing group, the mechanism of injury was failure of the binding to release resulting in a twisting force to the leg, while in the snowboarding group, three patients (50%) fractured their tibiae on landing badly from a jump and in the other three on colliding with another person or a fixed object.
The complications included instability requiring a constrained acetabular liner, an intra-operative femoral fracture requiring a long-stem prosthesis, the breaching of a femoral cortex by a prosthesis requiring a revision and recurrence of infection in a patient who was non-compliant with the prescribed antibiotics.
Total hip arthroplasty (THA) using modular components offers many advantages such as a reduction in the implant inventory required and increased intra-operative flexibility with component sizing and selection. However, it also comes at the price of the additional complication of component dissociation, in particular at the non-fixed interface between the polyethylene cup and the acetabular metal backing.
A review of 110 patients requiring revision THA from June 1993 to December 2000 performed by the senior authors revealed seven patients presenting with the triad of signs suggestive of this complication – a previously successful, painless THA that had become acutely painful and with radiographic evidence of femoral head asymmetry in the acetabular cup. Each of these patients had Harris - Galante II porous acetabular cups. At the time of the revision, these patients were found to have dissociated polyethylene cup liners and several with broken locking mechanisms warranting replacement of the acetabular cups, the liners and the worn femoral heads.
This is an uncommon complication of THA, with characteristic presenting symptoms and signs. The importance of comparison of previous radiographs with those at presentation and the postulated mechanisms for dissociation is stressed. Certain precautions are imperative when using modular implants and the pitfalls of the Harris - Galante II porous acetabular component locking mechanism should be acknowledged.
Histomorphometric analysis showed an increase of bone-implant contact between one and two weeks from 0 to 15% for Ti and 0 to 20% for HA coated implants. At four weeks Ti and HA implants showed 44% and 60% bone-implant contact respectively. There was a significant increase in bone-implant contact over time for both coatings. HA implants had significantly higher bone-implant contact at two and four weeks. Light microscopy revealed that bone grew into HA coated surfaces in the form of feet, spreading over the surface. Whereas for Ti the newly formed bone looked like a bridge linking the original bone with the implant surface.
The data can be expressed in a number of ways, including plotting the ratio of GH/ST movement versus overall shoulder movement. Polynomial equations to fit these curves describe movement patterns. We have developed software to calculate cumulative averaging of data.
Conclusions:
Significant unloading of the osteoarthritic compartment could be observed by applying manually a valgus force to the knee. Significant unloading of the arthritic compartment of the knee was not observed by applying a brace (up to 10%). Measurement of pressures within the osteoarthritic knee is difficult and variable.
Twelve patients ranging in age from 10 to 35 years have undergone 14 Ganz Osteotomies. The surgical approach used to define the anatomy is described and questions asked as to its safety with regard to the vascularity of the acetabular segment.
The complications encountered in the learning curve of this operation are described together with the early outcomes.
Bone mineral density values, were used to compare the non-operative femoral neck to the operative femoral neck before surgery. These values were then used as a predictive risk of subsequent femoral neck fracture in this patient group. Bone mineral density assessments were repeated 12 months after the surgery to compare the subsequent changes in the osteoporotic values. The bone mineral density evaluations were carried out on one hundred patients, both male and female between the ages of 28 and 87 years. The criterion for entry into this group was a bone mineral density value of no lower than 1.5 standard deviation points below the young reference value.
We report our experience at the Pediatric Hospital “Ricardo Gutierrez” in Buenos Aires. 11 diplegic patients (8 male, 3 female) who presented severe neurological valgus feet were treated with the Dennyson Fulford technique between 1996 and 2000. 7 patients had a bilateral deformity and 4 unilateral deformity . Patients’ ages averaged 9.5 years (range, 7–12 years). The average follow up was 2 years and 3 months (range, 7 months–5 years).
We took into consideration the following parameters to evaluate the results: 1- hind foot position, 2- adaptation to the orthosis 3- pain. The results were excellent in 10 feet, good in 6 feet and poor in 2 feet.
The results obtained with the subtalar fusion using a screw for fixation coupled with bone graft were considered satisfactory on obtaining 88% of good and fair results and a good acceptance among patients. We consider that the Dennyson Fulford technique allows an proper reduction with few complications and we emphasize it as the best option among other current surgical techniques for this pathology.
Our objective is to show the results of the unstable slipped capital femoral epiphysis treatment with reduction and threaded screw fixation.
A retrospective analysis of 21 patients (13 boys and 8 girls) with unstable slipped capital femoral epiphysis was performed between 1993 and 1998. The right hip was involved in 13 patients and the left hip in 8. The patients presented acute pain and functional difficulties. The diagnoses were based on the clinical presentation, neutral and Lowestein hip x-rays. The treatment consisted on gentle manipulative reduction of the unstable slip (flexion and internal rotation), threaded cannulated screw fixation on orthopaedic table and image intensifier control.
Results showed 2 avascular necrosis, 2 bone shortening, 3 limited range of motion. The rest showed satisfactory clinical results in the short term.
The thoracoscopic technic is a minimal surgical approach that minimizes the skin, muscle and ribs trauma without altering the effectiveness of the treatment.
This type of surgery has been gaining importance due to its advantages: excellent lighting, visualization and magnification. It offers an acute visual control during manipulation and dissection of delicate structures. We aim to assess the anterior release and the thoracic spine arthrodesis through thoracoscopic approach and measure the effectiveness and security of anterior thoracoscopic instrumentation in an experimental study in pigs.
The study was performed on 18 pigs which weighed between 40 and 60 kg. The surgical procedures were conducted at the Hospital Italiano in Buenos Aires. A thoracoscopic surgery was performed as an access to the spine.
The quality of the anterior release ranged significantly from cases in which the incision of the common anterior vertebral ligament could not be finished to cases in which more than 75% of the anterolateral disk circumference was released. In the subjective thoracoscopic assessment of the surgeon the screws were placed successfully in all The radiographic assessment confirmed the surgeon’s presumption, all the screws had been placed correctly. The rod presented complications in several cases.
The radiographic assessment showed that 40.6% (13 patients) of the disc spaces were pseudoarthrosic or with a delayed union. The macroscopic examination confirmed this finding and raised the number of pseudoarthrosic spaces up to 46.8% (15 patients) revealing 4 discs that still had a nucleus pulposus. The data were reinforced by histologic examination.
This histologic cuts were performed using the E & O method. The fibrous ring was clearly identified in the pseudoarthrosic cases as well as the processes of the osteochondral bone formation in its different phases of maturation.
It is very important to highlight that in our experience we had found a direct relationship between the quality of the disectomy, the fusion technique and the experience of the surgeon.
The surgical technique, the rod placement on the screws needs proper positioning and depth. The radiographic and microscopic examination confirmed that the posterior longitudinal ligaments was not damaged.
The thoracoscopic instrumentations in pigs using a rod and screws of third generation is a secure technique. It is essential the development of instrumentation which allows effective thoracoscopic distraction and compression.
We report 16 patients (18 hips) treated between 1997 and 1999. The average age was 5 years and 3 months (range, 2–9 years). Of all the hips evaluated, 13 (72%) corresponded to diplegic patients and 5 (28%) to tetra-plegic patients. The surgical plan consisted on femoral osteotomy combined with Dega pericetabular osteotomy coupled with adductor and psoas tenotomy using as a variable the reduction of the hip by the anterior approach depending on each case. We used the following criteria to evaluate results: 1 – pain, 2 – abduction range, 3 – Reimmers index, 4 – acetabular index.
Diplegic patients had good (78%), fair (12%) and poor (12%) results. Tetraplegic patients had good (25%), fair (50%) and poor (25%) results in this short follow up. On analyzing the cases, we observed an adequate development of the neurologic hips when using the acetabuloplasty with the Dega technique because it minimized the risk of coverage loss, as commonly seen in these kind of patients due to the progressive valgus during the postoperative period.
11 patients (7 girls and 4 boys) with multidirectional instability of the shoulder were treated between 1999 and 2000. The average age was 15 years 8 months (range, 14–17), with a follow-up of 1 year 6 months. In the examination under general anesthesia it was confirmed that the luxation had more than one direction. The surgery was performed with general anesthesia using a standard arthroscope with video camera and classic approach for the shoulder. In order to decrease the capsular volume, capsular plicature and retraction by heat were used The plicatures were anterior, inferior and posterior.
Patients were immobilized postoperatively in plaster splints or casts during 3 weeks and then they were placed in a rehabilitation program. The patients were followed up postoperatively, the UCLA Score was used during this period. Results were excellent and good in 90% of the patients, who were pain free and had full external rotation. Only one patients (10%) presented recurrence of the instability.
Patients showed the same pre surgical sport performance. Only one case presented capsule laxity and an open surgery was performed. This patient was reexamined and was labeled as a psychiatric case wrongly selected. Only 2 patients presented capsule inflammation with limited external rotation. They were treated with intensive rehabilitation.
The arthroscopic method allows for capsular volume reduction. Results were similar to the ones described with the open technique. The reduction of the capsular volume is done mixing capsular plicature and retraction by heat.
This arthroscopic techniques, previously described for adult patients with multidirectional instability, proved to be useful in adolescents.
Malignant hyperthermia (MH) is a pharmacogenetic disorder, potentially lethal, due to the exposure to anesthetic drugs that triggers, a high increase of corporal temperature, progressive muscular stiffness, severe rabdomiolisis and death due to cardiac dysfunction. Many research works relate Malignant Hyperthermia to muscular illnesses or to the King Syndrome. Through this study we present the incidence of MH in patients with congenital vertebrae malformations. (CVM)
The objective is to establish the incidence of the MH in patients who were operated on CVM and to alert about this association.
1029 patients with CVM were treated between 1972 and 2000. 390 with congenital vertebrae malformation were operated on. 3 patients (0.76%) (1 girl and 2 boys) developed MH while they underwent surgical treatment for the CVM. 1 patient presented an isolated congenital vertebrae malformation. 1 patient presented King Syndrome and the other presented Robert Syndrome. Only 1 elevated amount of preoperative CPK was found (the are no reports on the others).
No muscular biopsy was done to test sensitivity. Two of them were biopsied for a post episode study. At the surgical moment, any patients reported personal or familiar antecedents of MH. No deaths were reported, although it is considered as a potentially lethal disorder.
We found no reports in the literature in this subject. Most of the bibliographic data belonged to anesthesiologists or geneticists. Our approach as spine surgeons leaded us to the detailed analysis of this studies and the 0.76% (3 out of 390) incidence suggested us to have an alert attitude when facing patients with surgical MVC and take the necessary precautions.
We evaluated 28 patients, 52 feet with flaccid paraparesis (27 MMC, 1 neonatal paraplegia) in which a posterior transference of the tibialis anterior was performed for talus deformities. Between 1987 and 2001 in two institutions.
Mean age at surgery 6+6 ( from 0+4 to 12+10) 16 males, 12 females,
Neurological last level functioning was 1 Toracic, 2 lower lumbar, 25 sacral
There where 23 bilateral cases
Asociated surgeries 17 extension calcaneal osteotomies 5 peroneal z plasties, 4 short peroneal to posterior tibialis transfer, 2 vertcal talus correction, 2 Evans lenghtenings, 1 IF arthrodesis
Follow up in 25 patients (3 lost) was 3+11 (0+3 to 12+1)
All patients were independent walkers at follow up.
Nonsurgical treatment is gaining importance nowadays due to the complications that a surgery involves: over-correction, subcorrection and joint stiffness.
A comparative and prospective study of longitudinal cut was performed between May 2000 and July 2001 in 16 patients (26 feet) with varus equinus supination club-foot. It aimed to evaluate the results of the nonsurgical treatment. All the patients were younger than 1-year-old and virgin of treatment
The technique described by Ponseti was used and its rules were followed strictly. All the components where corrected simultaneously except the equinus which was treated with percutaneous Achilles tenotomy when the initial treatment proved no to be successful. 3 patients (11%) required subtalar released.
The study shows that if Ponseti indication are strictly followed in the clubfoot treatment, only 11% of the patients would require surgical treatment within the first year of life, in contrast with the 70% of surgical indications we have had upto now. Proper training in the use of the technique and a personalized follow up improves the possibility of a successful treatment.
Taking into consideration that distal epiphysis of the tibia is responsible of the 45% of its longitudinal growth, we emphasize the importance of this pathology trying to clarify which cases should be treated nonsurgically and which should undergo a surgical treatment in order to obtain the best possible results.
Seventy-five patients with distal epiphyseal fractures of the tibia and/or tibia and fibula were reviewed from 1993 to 2001. Sixty-two of them were male and 13 female, age of the patients ranged from 10 to 15 years old. They were evaluated according to the Lauge Haunsen classification which was modified by Dias and Tachdjian.
The results depended directly on the type of lesion and on the opportunity to perform a surgical reduction. The more frequent complications were in type III and IV of Salter and Harris. We believe that the future of these lesions, frequently seen in the orthopaedic field, with a higher incidence during the last years due to the increase of sports demands on children, depend directly on the initial physeal damage and the articular congruence obtained through the chosen treatment.
Due to the increasing rate of relapses and the morbidity degree that this implies, we report our experience and results in the treatment of clubfoot in patients with myelomeningocele.
Between February 1996 and February 2001 12 patients with myelomeningocele (16 feet with clubfoot deformity and 4 bilateral cases) underwent surgical treatment. 5 were boys and 7 were girls. 3 relapsed cases were referred to our institution, 1 of them had a bilateral involvement. The average age at time of surgery was 27 months (range 7 months–5.3 years).
Levels of functional involvement were recorded according to Caneo (Argentina Chapter of Neuroorthopaedics) classification: Caneo 0: 2 patients, Caneo 1: 4 patients, Caneo 2: 8 patients, Caneo 3: 1 patient.
Relapses occurred in 3 cases; 2 with tendon lengthening technique and 1 tibialis posterior transfer to lateral peroneus brevis, split tibialis anterior tendon transfer. The complications were postoperative infection in 3 cases with wound dehiscence, tibia fracture after cast removal in 1 case and residual tibia intrarotation in 1 case. AFO were used in patients older than 2 years old with Caneo type 2 and 3 and RGO in patients with Caneo type 0 and 1.
The final results after solving all the complications were: 6 plantigrade feet, 1 intrarotated plantigrade foot and 1 relapsed inverse foot undergoing release of filum terminale with tethered spinal cord.
In conclusion, we consider the most effective technique the one that presents the lower rate of relapses and with efficient functional outcomes. We agree with Luciano Dias opinion that regional resection of all the tendinous elements is the best option to fulfill our goals.
We strongly advice a tendon lengthening or transfer in patients belonging to Caneo classification type 3.
The corticosteriods in the treatment of Duchenne’s or Becker’s muscular dystrophies causes muscular weakness and osteoporosis characteristic of these patients and result in different fractures which are of difficult resolution because prolonged immobilization increases morbidity. How can this problem be solved in highly risk patients? The diverse models of external fixators have given us the possibility of treating them without immobilization and in consequence obtain a quicker return to previous functional status including gait .
4 patients with Duchenne’s and Becker’s muscular dystrophies were treated. 1 patient recovered its ambulatory ability and the rest maintain their gait. 1 of them still has an external fixator but he is able to walk. Patients presented a diaphyseal fracture of the femur, a proximal fracture of the tibia, an introchanteric fracture of the hip and a supracondylar fracture of the femur.
We consider that external fixators open an endless range of options, not very much used until recently, that help our patients to extend their functional status and gait. Patients accept them easily because they give them independence and avoid the depression that stems from the loss of capabilities.
Femoral osteotomies of pelvic support was performed in patients with hip instability, axial malalignment and leg length-discrepancy. Possibly inspired by techniques previously described by Schanz, Milch. Ilizarov and Rozbruch, 5 patients had neonatal hip sepsis sequelae (2 cases and 3 hips), septic arthritis (2 cases) and proximal femoral focal deficiency (1 case) were reviewed.
X-Rays of both limbs in neutral position to measure the deviation degree of the mechanical axis and other with the limb in maximal adduction to measure the osteotomy level of the pelvic support were taken before surgery.
The technique consists of a proximal femoral osteotomy in the intersecting axis in maximal adduction and a second distal metaphyseal osteotomy which allows the compensation of the mechanical axis and the elongation of the limb. Both are fixed with an external fixator.
This technique gives a pelvic support improving the Trendelemburg gait and tighter abductors muscles due to simultaneous correction of LLD and knee alignment.
Developmental dysplasia of the hip presents different presentations and its treatment depends on early detection. 2975 patients younger than 6-month-old with hip ultrasonographies were studied between March 1998 and March 2001. In 26 patients, 33 ultrosonographically pathologic hips were detected and treated. 81% of the treated hips (27 patients) returned to their normal position before the 3rd week, only 6 remained dislocated and underwent surgical resolution. Patients with dislocated hips required an average of 12 week to complete the treatment protocol. Hip instability and subluxed hips healed between the 6th and 8th weeks. Those patients who began their treatment at one month old (10 hips – 33%) obtained the best results. To conclude, we agree with others authors on the effectiveness of the ultrasonographic method for early diagnoses and its use along treatment.
The functional outcome was excellent in 64% of the cases, good in 21.5% of the cases. Pins removal was almost necessary for proximal pins migration in 45% of the cases and distal migration in 7.5% of the cases.
Complex fracture patterns of the proximal humerus can be difficult to understand and to treat. Classification systems are inadequate and the exact mechanisms of injury are obscure. From inspection of 73 cases of proximal humeral fractures culled from a large number of museum specimens, we propose a hypothesis as to the nature and configuration of these injuries. It is suggested that the glenoid is the “anvil” upon which the humeral head is broken and that the particular fracture personality reflects the position of the head vis a vis the glenoid at the time of injury. From this perspective, proximal humeral fractures present in a comprehensible and progressive sequence. Five different fractures patterns are identified and account for the vast majority of these injuries. X-ray examination, especially CT 3-D reconstructions, in a small group of clinical cases (30 patients) substantiated the usefulness of looking at these fractures in this way. From a combination of the museum studies and patient material, we have constructed a “fracture wheel” diagram for the presentation of these injuries in a format which may be helpful in organizing a new and clinically useful classification system.
Fractures of the proximal humerus account for 4 to 5% of all fractures. Most occur in elderly individuals caused in part by osteoporosis.
Conservative treatment frequently led to poor clinical results because of the inability to gain and maintain satisfactory reduction.
The preferred method for these fractures was open reduction and internal fixation especially in those fractures with displacement and in young patients.
In 18 patients the fracture was operatively reduced and was secured with a plate and screws.
Methods of plating: T plate, clover leaf plate or blade plate modified. Delayed union and non-union of humeral head fracture is also an indication for open reduction and internal fixation by plate and screws.
A consecutive series of 18 patients with displaced fracture and fracture dislocation, followed for a minimum period of one year were analyzed.
The age of the patient range from 16 to 62 years.
The fractures were classified according to Neer 91970).
The aim of treatment was accurate reduction and stable fixation of the fracture with plate and screw.
The most common technical error was a too high positioning of the plate caused implant impinged under the acromion during abduction. No aseptic necrosis of the humeral head was observed. There was no deep infection.
11 patients had an excellent or good result, 7 had a fair result, and 1 had a poor result.
Koval in a biomechanical cadaver study was to compare the mechanical stability of ten different fixation, techniques used of stabilize surgical neck fractures of the proximal humerus in both osteopenic and non osteopenic bone.
The AO five holes T plate provided significantly greater resistance to displacement than all other methods tested the fresh-frozen specimens. Their effectiveness diminished in the presence of osteopenia.
9/13 (69%) of young patients with 4 part fractures treated by closed percutaneous minimal fixation had good functional results. In four other patients the clinical results were poor and two of them developed AVN of the humeral head. 5/8 (62.5%) of young patients with 4 part fractures treated by ORIF and minimal fixation had good functional results. In three other patients the clinical results were poor and one of them developed AVN of the humeral head.
Fractures of the proximal humerus occur predominantly in the elderly patient population. There has been a tendency over the last 15 years to perform surgical procedures to reduce and hold these fractures while the bone and soft tissue heal. The osteoporotic nature of the bone does not allow adequate fixation of the bone and therefore fixation techniques are inadequate to allow optimal soft tissue rehabilitation.
A study was performed to observe the results of non-surgically treated displaced fractures of the proximal humerus in the elderly.
The encouraging results are presented and discussed.
Non-surgical management of displaced fractures of the proximal humerus achieves a good functional shoulder although not normal in this predominantly sedentary population. The question arises as to quality of function after surgical management of these difficult fractures compared to non surgical management and if surgical management is indicated in these elderly usually frail patients with low demand from their shoulders.
Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation.
The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF.
Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises.
Forty-two revision knee replacements were performed in our department between 1992–2000. We report our experience in 18 cases of stiff knees with a range of motion from −5° – 75° (average 50°) where an oblique incision through the quadriceps tendon combined with medial capsular incision (the “wandering resident” incision) was used for exposure. This exposure allowed us to expose the stiff knee with no hazard of avulsion of the patellar tendon and with easy removal of the old prosthesis and implantation of the new one. In 5 of these cases, this exposure was used twice in two stage revisions of a septic prosthesis.
Post-operative rehabilitation was slower, a knee brace was used in extension for 6 weeks and daily physiotherapy and CPM from 0°–70° only. Full range of motion was started after 6 weeks. Follow-up in 1–8 years (average 3.5 years).
All patients had good clinical results with range of motion from 0°–110° (average 86°). One patient had a lag of 10° in active extension. The knee score of the American Knee Society ranged from 35–52 (average 40) and improved to 72–89 (average 84).
In 3 cases, we used a non-constrained prosthesis (PCL) sacrificing condylar prosthesis), in 11 cases a constrained prosthesis (CCK type) and in 4 cases a rotating hinge prosthesis.
Four threaded pins were inserted retrograde and trimmed under the skin. Two antegrade pins were left out of the skin and banded to prevent migration to the axilla. Patients were immobilized in shoulder immobilizer for 6 weeks when pins were removed in outpatient clinic. Control X-ray was taken at 2, 4, 6, 12 weeks. If fracture was noted to be unstable, X-ray was taken every week up to 4 weeks. In case of any deterioration after 12 weeks X-ray was taken to detect signs of AVN.
Rehabilitation program commenced after clinical union with passive and assisted active for 4 weeks followed by active mobilization. Follow-up ranged from 10–34 months (mean: 22) and range of motion with X-ray description were documented.
Mean range of motion for all groups was: Elevation – 144 (60–180), External Rotation – 54.6 (−10–80), Internal Rotation – L1 (Throchanter – T8). Statistical analysis for fracture groups showed best results for impacted valgus and greater tuberosity fracture after open reduction and worst results were noted for 4 parts fractures and fracture dislocation. Although the study was not randomized there was no significant difference between the group of closed pinning and open surgery.
We present our experience with 40 infected total knee arthroplasties that were treated in our department during the last 10 years. Three patients suffered from early postoperative infection and were treated by debridement and antibiotic therapy with complete cure.
25 patients had chronic infection with loosening. 17 patients were treated by two-stage revision, six were treated by arthrodesis and in three patients excision arthroplasty was performed due to general poor conditions. 12 patients had late acute hematogenous infection and nine of them underwent debridement, either open or arthroscopic, and antibiotic therapy. Overall, 90% of the patients had no clinical, radiological or laboratory evidence of infection.
The purpose of this study is to evaluate the results of revision surgery in the treatment failed TKR with the TCP III like prosthesis.
In 81 of them the implanted prosthesis was TCP III or CCK and were evaluated in this study. 33 were males and 58 females. The average age at revision was 72 years. Most of the cases were performed by the senior author. All cases were osteoarthritic except one which was rheumatoid. The distribution of TCP III like prosthesis was as follows: 47 were TCP III, 33 were CCK and 2 dual. The infected cases were treated whether by one stage or two stage surgery. Patella was not resurfaced but reshaped if patella bone stock was not adequate.
Between 1983 and 2001, 25 revision of total knee arthroplasties were performed in our department. 16 tibiofemoral, 9 tibial revisions and 9 operations on the patella were performed.
The original implants of the 16 tibio femoral revisions were 8 total condylar, 2-IB1, 2-IB2,
1 AGC, 1 cruciate retaining AGC and 2 porous coated J& J.
The revision prostheses were: One IB1, 1 kinematic II, 7 CCK, 4 dual articular, 1 sigma and 2 Guepar.
The results were: very good 2, good 9, failure 2 (sepsis, removal of implants and knee fusion), 3 patients died during the study period of unrelated causes to surgery. One of them was followed for 13 years, having a very good result (Kin II) until his death.
Tibial component revisions were performed on 9 knees.
The original implants were: 5 total condylar, 1 IB-1 and 3 IB-2.
The revision implants were: 5 total condylar, tibiae, 1 IB-1, 1 IB-2 and 2 IB-2 with augments and intramedul-lary rods.
The results for the tibial revisions were: good – 4, fair 1, failures – 2 (sepsis and eventually arthrodesis. Two patients died within the study period of unrelated causes.
The patella posed a special problem, of 9 patients, 7 were operated for patellar component loosening, and the component was removed. In one patient a patellec-tomy was performed because patellar osteomyelitis was suspected. In another patient a tibial tuberosity transfer for patellar dislocation was performed.
The results of patellar surgery were: 4 – fair, 1 – unknown, and 4 patients died during the study period of causes unrelated to surgery.
Our series reflects the gathered experience in our department. During the early years tibial and patellar loosening were the main problems. Special revision prostheses were not available and were not needed in most cases. Later, with increasing number of arthroplasties performed, and with longer follow up periods, the need for special revision prostheses became overt. The most commonly used implant was the constrained con-dylar knee and was later replaced by the dual articular prostheses. The latter appealed to us because of its partially mobile tibial articular surface.
Our failures were due to Staphylococcus aureus sepsis, which we were unable to eradicate, in spite of performing staged procedures, repeated joint debride-ments and the use of gentamycin impregnated bone cement.
In all but one of these cases the implants had to be removed and the knee had to be fused. In one of our 4 failures even after solid fusion, the infection was not eradicated. We succeeded to revise only one infected knee with Staph. Aureus with a good functional result. In one case of candida infection, we succeeded to eradicate the infection and replaced the loose implants with a CK achieving a good result now for 4 years.
No doubt that revision TKR is a challenging procedure. This procedure may be divided into three steps. First, a careful clinical examination is needed to assess range of motion, stiffness and possible difficulty in exposing and extracting the prosthesis. Second, an examination of joint stability is needed. Finally, radiographs should be evaluated for any bone deficiency that may require bone grafting or special prosthesis.
Exposure approaches may change in cases when second stage implantation is performed when an infected total knee replacement exists and when a cement spacer is used. In the cases when the cement spacer is left in place for a longer period of time, stiffness is much more prominent and therefore exposure may be even more difficult.
Subvastus and midvastus approaches are not suitable for this kind of revision. Usually in revision of total knee replacement or after cement spacer procedures, a larger exposure with the use of either snip incision, or osteotomy of the tibial tuberosity, or VY exposure is required. There are some cases where one can perform revision total knee without the extra exposure mentioned.
In revising total knee replacement, it is imperative that the joint line be restored to its original position. There are a few techniques that can be used to achieve this task by using a few landmarks. They include:
The residue of the menisci. The distance measured from the medial epicondyle to the joint surface. The distance measured from the head of the fibula to the original joint surface.
This can be done by comparing the other non-operated knee too.
The decision to which kind of prosthesis to use depends on the amount of bone loss and the injury to the surrounding structures and ligaments. One should be prepared for all options during surgery, in other words, using constrain or unconstraint prosthesis in the same patients. This depends solely on the findings during surgery.
In our hospital, we have used all the exposure approaches of the knee in revision surgery. We prefer the snip excision in the first stage, and if this is not sufficient then a tibial tuberosity osteotomy is preferred to the VY incision of the quadriceps mechanism. We found that using the meniscal residue is a very useful landmark for the joint line and we use it constantly.
Frequency is probably under evaluated and their treatment and consequences subject to discussion.
Dislocation has to be differentiated from knee instability, subluxation and expulsion of the PE tibial insert.
The purpose of this review was to study their mechanism, treatment and consequences.
A modification of the surgical technique and the insert design was deduced.
A prospective analysis was performed to compare the following variables of these patients (study group) to 56 cases who did not experience that complication (control group): age, sex, weight, component size, surgical approach, importance of release, pre and post surgical scores, alignment, stability, patella and component thickness. Statistical analysis of these parameters was performed.
Conservative treatment was successful in 10 cases, but 3 recurrent dislocations and a neglected dislocation were treated surgically after modification of the tibial insert.
After modifications of the stabilizer concerning height and slight posterior displacement, in a personal series of 129 TKA, dislocations disappeared.
With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.
Correction of spinal deformities such as those seen in idiopathic scoliosis, are one of the challenging aspects of the spine surgeon’s routine. A significant progress has been made in sense of the surgical approaches, implants design and methods of correction during the last two decades. Since the pioneer conception of Paul Harrington that a scoliotic curve can be corrected by distraction, other methods such as derotation and translation came out as an alternative ways to get a straight and balanced spine. Recently, a new concept of correction for spinal deformities named in-situ contouring, has brought to our attention. This method is based on a 6mm Titanium rod (SCS Eurosurgical Inc.) connected to the spine with a multiple hooks and screws system. The rod is bend according to the curve in the coronal plane and loosely secure with setscrews. Following primary application of the rod, the surgeon begins to bend it manually in situ, in a contrary direction to the curve’s shape. By applying a combination of a sagittal and coronal plane forces, the surgeon is able to achieve a final result of a straight and nicely balanced spine.
Combined anterior/posterior scoliosis surgery is the mainstay of scoliosis surgery in large curves with Cobb angle more than 65°, in stiff curves that correct to above 40° only on the pre-operative bending films and in Steersman’s kyphosis greater than 90°. The combined anterior/posterior scoliosis surgery allows better correction of the curve, saving motion segments in the spine and eliminating the occurrence of the crankshaft phenomenon. Video-assisted spinal surgery (VATS) and Mini open thoracotomy, thoracoscopically assisted (MOT-TA) allow for the performing of multi level discectomies and soft tissue release, as an anterior adjunct to posterior spine fusion, through minimal approach to the thoracic spine in scoliosis surgery. During the last year we have begun using the MOT-TA for anterior thoracic spine release and fusion, as the first step in releasing, reducing, and fusing large and stiff scoliotic curves, utilizing standard surgical instrumentation and techniques.
Treatment of congenital kyphosis with severe angular dysplastic spine in children with myelomeningocele (MMC) is one of the most difficult spinal procedures. Most of the surgeons support kyphectomy with long segmental spinal instrumentation and postoperative immobilization by thoracolumbosacral orthosis.
Several spinal deformities are seen frequently in patients who have MMC. The deformity may be congenital or paralytic. Congenital lumbar kyphosis is less common, but most difficult in patients with MMC, occurring in 10–20% of patients. Most curves are congenital and rigid, often more than 80° at birth, and rapidly progresses.
With progression of kyphotic deformity, patients experience recurrent skin breakdown over the apex of the kyphos; impaired sitting balance; the necessity of using their hands for support; collapsing spine and decreasing of lumbar height reduce the capacity of the abdominal cavity and resulting in reduced respiratory capacity and malnutrition. The poor posture and short abdomen make it difficult to manage the patients’ urological needs. A severe deformity raises difficulties in social and psychological development.
Non-operative treatment with spinal orthoses may provide only temporary correction of a kyphotic deformity, but does not prevent progression and skin breakdown.
The goal of surgical treatment is correction of spinal deformity by long segmental instrumentation and achievement of a solid spine fusion in order to allow a balanced sitting position and to prevent complications.
From 1983 to 2001, 6 patients with thoracic level myelomeningocele and severe kyphotic deformity were referred for surgical correction. There were 5 males and 1 female patients with average age at the time of surgery of 8.3 years (range 4.3–13 years). All patients suffered from severe kyphosis, range 90° to 130°, average – 108°. All of them underwent posterior ligation of spinal cord during resection of lordotic segment of the kyphos, and segmental spinal fixation of the deformity from the thoracic spine to the sacrum. In all cases following the resection of the vertebrae it was possible to correct the deformity.
All patients were available for follow-up with range of 6–216 months, average 85 months. All of them were satisfied with the surgical outcome and presented in their final clinical examination with balanced and comfortable sitting, without soft tissue complications. In all cases a significant correction of the deformity was achieved (15°–30°) and enabled comfortable and stable sitting. Two patients suffered post-operative complications, one from surgical wound infection which required surgical debridement followed by soft tissue covering, and the other suffered from distal migration of the rod which was shortened later on.
The relatively large diameter of currently used cages dictates extensive manipulations, damaging structures that are crucial for spinal stability.
The Expandable Spinal Fusion System, is 5 mm in diameter in closed configuration, applied in a minimally invasive technique, through a 6mm entering opening by an open or percutaneous posterior procedures. Once in position, its dimensions are increased to a precut size in a controlled procedure. Thus, this system maintains the integrity of facet joints, with no or minimal laminectomy, and minimal damage to the surrounding tissues.
Patient questionnaire pain and quality of life was evaluated using the Oswestry questionnaire and VAS measurement. The patient fill those pre-operatively and at each follow up visit.
Segmental lordosis, measured on the fused discs at the last follow up showed a mean angle of lordosis of 6.9o (4.8° on L4–L5, 8° on L5–S1).
They were allocated into 3 groups according to the duration of symptoms before surgery. Group A with symptoms lasting up to 24 months, B with 25–48 months and C with symptoms lasting for more than 48 months. The average age at the time of the operation was 68.9, 72.6 and 71.3 years, respectively. Forty-eight patients died and 18 refused or were not able to participate in the study. The average time of follow-up was 43.3 months, 42.2 in group A, 47.4 in B and 42.8 in C.
No significant differences were noticed in the demographic, anesthetic and surgical parameters among the 3 groups.
There were no mortality cases in the immediate postoperative period. The overall complication rate was 43.5%, nearly identical in all 3 groups. Two patients had cerebrovascular accident and 5 had myocardial ischemia but no one turned into infarction. Mild complications included 11 urinary retention, 24 urinary tract infections and 11 patients with superficial wound infection. Twenty-two patients were re-operated along the follow-up period.
There was remarkable improvement in the perception of pain, walking distances and in the ability to perform basic activities of daily living in all 3 groups. Self-assessment of the final results disclosed 70% satisfied patients in group A, 67% in B and 67% in C.
Therefore, a partially constrained rod-implant link was conceived allowing for free rotation in the sagittal plane while maintaining the possibility for transverse loading during correction maneuvers. One of the possible benefits of this system is the preservation of the adjustment between hook and lamina.
Antibiotic polymethylmethacrylate (PMMA) beads are known as an effective drug delivery system for local antibiotic therapy in bone and soft tissue infections. Over the years it has become an efficient method to treat osteomyelitis and other infections in orthopaedic surgery. Whilst this method has gained popularity primarily in infected arthroplasty, trauma and chronic osteomyelitis, its application in spine surgery is less known.
This revision consisted of PMMA bead removal, debridement as necessary and irrigation. Primary closure over a suction drain was performed in all cases. No hardware removal was done in any of the cases. Follow up studies included radiographs and gallium bone scan.
Radiofrequency (RF) lesions have been used for over 25 years in the treatment of intractable pain of spinal origin. The conventional understanding of this technique is that the heat which is produced in the tissue surrounding the electrode tip causes destruction of nervous tissue, which in turn reduces the input of noxious nerve stimuli and alleviates pain. Neuropathic pain is usually a contra-indication to the use of RF nerve lesioning. For treatment of patients with severe radicular pain we use pulsed radiofrequency who has been recently described as a technique to apply a relatively high voltage near a nerve but without the usual effects of rise in temperature or subsequent nerve injury.
This study reports the effect of pulsed RF in 21 patients with severe radicular pain who had previously failed to respond to conventional therapy.
It is non-destructive procedure and it can therefore be used for different indication which were not suitable for conventional RF. Post-procedure discomfort does occur but it is less pronounced than following conventional RF. Although permanent sensory loss is a rare complication of RF it does occur. Pulsed RF does not have this complication.
There are also intraoperative risks of neural damage: sciatic nerve as well as gluteus medius nerve. On the other hand , modern surgical technique including an alumina against alumina bearing could allow very long term survival without any activity limitation and this even in very young patients.
Secondary procedure after a failed osteosynthesis provides statistically worse functional results than primary total hip. The surgery is more difficult because of hardware retrieval, nerve dissection, bone reconstruction and remaining muscular dysfunction.
There were 22 neural disorder; 19 sciatic palsies; 13 post trauma; 4 post osteosynthesis; 2 post THR; 3 gluteus medius palsy. 7 sepsis: 4 post osteosynthesis, 3 post THR (including 2 post osteosynthesis).
Many weak results could have been avoided by doing fine primary surgery. We could expect better functional results with less complications regarding sepsis, nerve damage, muscle preservation if we perform a primary total hip in conjunctions with acetabular reconstruction. Osteosynthesis is still recommended for simple acetabular fracture with large displacement involvement of the posterior wall or one column not comminuted.
The authors’ early experience using this prosthesis is presented.
29 males and 19 females underwent the procedure with a mean age of 60 years (45–74).
In 20 hips a posterior approach was used and in 28 our saggital trochenteric osteotomy.
A cementless prosthesis was implanted in 30 patients and the femoral prosthesis was cemented in 18 patients.
The principles of metal on metal bearing surfaces, Resurfacing Arthroplasty of the hip and the early clinical results and complications are discussed.
The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose a metal-on-metal prosthesis with improved tribology was developed. Our early results of using this system are presented.
4 patients had bilateral THR. There were 3 revision cases due to loosening of cemented cup and 3 post surgical hip procedures. The etiology of the hip pathology was OA in 23, AVN in 10, CDH in 3, two post surgical procedures and one Paget’s disease. The THR prosthesis system consisted of a Wagner type uncemented cup with a factory-assembled Metasul inlay. An uncemented collarless hydroxypaptite coated, Spotorno stem, with a modular 28mm head was used. Long stem was used in 3 cases and reinforcement cage in one. Additional screws (average of 3,4) were used for primary cup fixation. The anterolateral approach, laying either supine or on the side was performed. Average hospitalization time was 12 days. Full weight bearing was allowed as tolerated.
Results: The average follow-up was 30 months. Average Harris Hip Score pre-operatively was 45 (15-74) and post-operatively 75 (15–99). Subjectively, 87% of the primary cases with various etiologies were satisfied with the outcome. The majority of patients had pain-free range of motion and returned to improved daily function. One technical intra-operative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring due to a femoral crack. Immediate post-operative complications included 2 cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intra-operative culture was treated successfully with 6 weeks of intravenous antibiotic therapy. Late complications included one case of cup loosening and one of a painful hip with suspected infection that required revision with a cemented prosthesis. Radiographic examination included measuring of radiolucent lines around the femoral stem according to the zones described by Gruen et al. and acetabulum as described by DeLee and Charnley. No femoral radiolucent lines were found. Seven cases revealed partial ace-tabular radiolucent lines.
Complications included 3 early and one late dislocations – one patient required an early cup revision, one patient suffered a fracture of the femur during stem insertion, and 3 patients (4%) had deep vein thrombosis. There was one case of a femoral vein injury and one resolving superficial infection. No deep infections were noted.
13 patients had undergone cup revision due to severe polyethylene wear and periacetabular osteolysis. Of them 5 were diagnosed during this retrospective study and 8 were referred for revision due to clinical symptoms. Thus the revision rate of the entire operated population is 13/162 = 8.0% and 13/75 = 17.3% of the studied patients. The true loosening rate should be between these 2 figures.
In 2 patients the entire cups were removed and revised due to loosening. In 11 patients following the removal of the polyethylene inserts the metal back proved to be stable. In these cases the bone defects were filled-up with bone graft substitute, and a highly cross-linked polyethylene (22 mm head) were cemented into the metal shell. No stems needed revision.
The imaging parameters that were collected from patient X-rays were: radiolucent line, osteolysis, subsidence, cortical hypertrophy, cortical thinning, undersizing, distal pod, rounded calcar, cupping and sagging.
No sign of loosening were observed in any patient, 23 stems were implanted in neutral position, 2 stems in valgus and 6 in varus position. In 15 patients stem was undersized. In 23 patients distal pod was observed, 19 patients had trochanteric osteopenia, in 10 patients cupping was noticed and in 6 patients cortical thinning was observed. Five patients showed proximal osteopenia and in 5 patients sagging of few millimeters was noticed during the first years after surgery. No radiolucent line, osteolysis, subsidence and cortical hypertrophy were observed up to 11 years follow-up.
13 hips (11.8%) had mid-thigh pain, most of them mild. One hip (0.9%) showed clinical and radiographic signs of early loosening and was revised.
Based on our experience, our recommendations are that:
Ceramic bearing surfaces T.H.A.-s should be performed in specialized centers. The use of 32 mm. heads should be considered in order to avoid dislocations. With 28 mm. heads, full profile cups should be considered. Conservative physical therapy and range of motion exercises for 6–12 weeks.
Usually the literature is not in favor of THA in young patients, and the reports are on patients older than 32 years of age.
Antibiotic treatment and second stage revision surgery were followed successfully.
In all three cases consumption of unpasteurized dairy products was documented. All three patients had serum brucella antibody titer of 1:1600.
Vertebral fracture due to a metabolic bone disease or a neoplastic disease is a common and debilitating condition. It most often is associated with either osteoporosis or metastatic bone disease. Some of the patients suffering from such fractures continue to complain of back pain and deformity despite optimal medical therapy, including radiotherapy and biphosphonates.
Vertebroplasty, i.e. transcutaneous injection of bone cement into the vertebral body can serve as an internal fixation device and allows restoration of mechanical strength and partial restoration of the vertebral height.
During the year 2000, 17 vertebrae in 12 patients were injected. These were either lumbar or thoracic vertebrae. All patients reported decrease in pain and improved ambulation capacity.
Two minor complications were encountered including headache lasting for 72 hours prior to spontaneously resolving. This possibly indicates a transarachnoidal approach, the other complication has been cement leak below the posterior longitudinal ligament. The patient reported pain amelioration. No emergency surgical interventions were necessary to date.
Treatment of metastatic bone disease should be staged, with only a few vertebrae injected in each session, to prevent pulmonary embolization.
Vertebroplasty appears to allow excellent palliative treatment in patients suffering from unresectable primary tumors of the vertebrae, or more commonly, metastatic bone tumors as well as osteoporotic fractures.
Vertebroplasty has been developed during the last decade in France as a method to relieve pain in patients suffering from a metastatic disease of the spine, that are poor surgical candidates. The indications include: mechanical pain, compression fractures, lytic bone metastasis.
Contra-indications include neurological compromise, breaching of the posterior wall, complete pedicle destruction or a large anterior soft-tissue mass. Relative contra-indications include a single resectable metastasis and a radiation sensitive tumor.
The method has been refined during the last few years by the introduction of specialized delivery systems and tailor-made bone cements.
The state of the art of this emerging technique will be discusses as well as some exciting future developments such as cements that can actively destroy tumors by physical or chemical modifications.
Between the years 1999 and 2001, approximately 3000 expandable intramedullary nails were used worldwide in various surgical procedures. From this number, 250 of these nails were used for traumatic fractures and are the focus of the study presented here. The subjects consisted of 160 males and 90 females with a mean age of 41 years. Initial radiographs were obtained for all subjects. Additional X-rays and follow-up data were reported for only 75 patients (30%) with follow-up time averaging 18 weeks. Most of the fractures occurred in the midshaft (64%), followed by distal thirds (22%), and then proximal (14%). The group was then divided according to fracture location: humerus, tibial and femur.
The nail was used in 92 humerus fractures. Follow-up data was available for 35 patients with a follow-up time averaging 16 weeks. The nail was inserted retrograde in 61% of the patients and antigrade in 39% of the patients. Partial reaming was done in 42% of the cases. Mean operating time was 52 minutes and fluoroscopy time was 3.8 minutes. Anatomical reduction was achieved in 96% of the cases and in 4% of the cases, acceptable reduction was achieved with a varus < 10°. Surgical outcomes included 28 complete bone union, and 7 partial union. Eight nails were removed after complete union was achieved.
In addition, the inflatable nail was used for treatment of 114 tibial fractures. In 39% of the cases a partial reaming was done. Average operating time was 39 minutes and fluoroscopy time was 3.4 minutes. All the fractures were reduced anatomically. In 25 patients with mean follow-up of 18 weeks, 14 united completely and 11 united partially. Nine nails were removed after completion of the union.
Data on 44 patients with femoral fractures treated by the inflatable nail were also reported. Only 15 patients were available for follow-up with an average of 21 weeks follow-up time.
Nail insertion by the antegrade approach was used in 89% of the patients and the retrograde approach was used in 11% of the patients. Partial reaming was done in 44% of the cases.
Mean operating time was 60 minutes and fluoroscopy time 7.5 minutes. Anatomical reduction was achieved in all with the exception of two patients with mild valgus deformity (< 10°). By the end of the study period, 8 had complete union, 7 had partial union.
In summary, the nail was found to be very effective and safe. The surgeons who performed the surgery reported that surgical and fluoroscopy time were both reduced by half. Reaming was not mandatory and this contributed to the shortened operating time. No complications were encountered during extraction of all the nails after completion of union, even in those patients in whom the nail developed an hour glass configuration according to the size of the medullary canal.
It is still too early to conclude if this nail will produce better or equal results to the conventional interlocking nails. Nevertheless, the lack of reaming, locking, and the low contact area of the nail with the medullary canal, may explain the rapid healing observed in some cases.
Secondary reinforcement of the patellar tendon is recommended for extension lag of more than 20°.
During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well.
Upper limb salvage involves treatment of traumatic amputations or devascularization proximal to wrist level. Their management differs from that of more distal lesions because of the muscles involved.
We want to report our experience of 25 upper limbs salvage (23 revascularizations and 2 replantations). Four times the lesions were situated at shoulder level, 7 times at arm level, and 12 times at forearm level. Even though several patients were referred for completion of the amputation, all the limbs but two were finally saved.
The quality of the functional recovery bore no relationship to patient’s age or duration of the ischemia at the time of the accident.
All patients were allowed to weight bear from the first postoperative week. Physiotherapy was started immediately after operation and continued until normal knee and ankle function was regained. Dynamization was done in all cases 2 weeks before removal of frame. Following removal, the patients were advised to use crutches for an additional two weeks.
All were treated by retrograde intramedullary nailing.
The surgical procedure was done closed or open by insertion of a retrograde intramedullary nail. Distal interlocking was achieved by two transversal screws.
Clinical and radiological follow-up was performed during the first year after operation.
In our study we will review 28 patients suffering from mal- nonunion, whom were treated by an Ilizarov external fixation, and the results of the treatment concerning radiological alignment and consolidation rate.
Malunions were treated either with acute or gradual correction of the deformity, following low energy osteotomy. For hypertrophic nonunion and mal-nonunion in general only distraction compression technique (mono-focal) was used. Atrophic and infected nonunion were treated with a bifocal technique (so-called bone transport), except for one case treated with monofocal technique only.
The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain.
Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications.
With obesity on the rise in Israel, most of the medical staff will probably encounter the unique challenges that result from the pathophysiological changes in this population. Morbid obesity is a chronic disease manifesting itself in a steady and slow-progressive increase in body weight. Currently, BMI is considered the best score for morbid obesity definition and it is calculated by dividing the body weight (kgs) in body surface area (m2). The score for morbid obesity is above 40 kg/m2 and has many systemic implications such as hypertension, diabetes, cardiovascular changes, especially it effects the musculoskeletal system. Complex multiple trauma in morbid obesity patients present a challenge throughout all stages of treatment: assessment of injury, preliminary care, and definitive surgical approach.
In the last two years five morbid obese patients (all weighted more than 150 kgs) sustained various degrees of high-energy multiple-trauma and were operated on in our institution. The patient presented with the following injuries:
Femoral fracture. Femoral fractures and contralateral tibial fracture. Neck of femur fracture, comminuted forearm fracture and ARDS. Pelvic fracture and ARDS. Pelvic fracture and bilateral segmental fractures of femora, bilateral patellar fractures and ARDS.
The preoperative, operative and post-operative care presented special curative dilemma and pitfalls which required modifications in regular treatment modalities such as improvisation in special equipment and surgical techniques. The operating tables had to be changed so they could sustain the increased patient’s weight and allow, in the same time, modified percutaneous surgical approaches to overcome the anatomical problems. In all patients we were able to achieve the main goal of trauma treatment, i.e. stable fixation of fractures and mobilization.
The experience we have gained in managing and overcoming these obstacles may serve as a basis for devising guidelines for the comprehensive treatment of these patients.
We believe that soft tissue release and articulated hip distraction distinguishes itself in the short term as a good salvage procedure for late onset severe Perthes disease of the hip.
Our series is made of 10 patients with late onset Perthes disease. All 10 patients were above 9 years of age at diagnosis (average = 11 years). There were 7 boys and 3 girls in the series. All patients had significant limp and pain with positive Trendelenburg sign. All patients used crutches or wheelchairs and had symptoms for a period of 0.5 to 3 years before the operation; all hips had limited ROM. Two patients had previous soft tissue release. There were 2 children with Down syndrome and 1 child had Gleophysic Dysplasia. On preoperative radiographs, 8 patients had a saddle shape subluxating femoral head with hinge abduction and 2 subluxations only. Nine hips were graded Catterall IV and Herring C and 1 hip Catterall III Herring B. There were at least 3 and mostly 4 Catterall prognostic risk signs for these hips. All patients had a broken Shenton line, increased medial joint distance and low Epiphyseal index before surgery.
After adductor and ileopsoas release an orthofix hinged apparatus for distraction is applied to the hip. The distraction continues until overcorrecting of Shenton line achieved. The external fixator is left in place for 4–5 months while in the apparatus flexion and extension of the hip is possible and encouraged. The follow-up ranged from 0.5 to 3 years. At last follow-up all patients were walking freely with improved hip ROM. All patients resumed daily ambulatory status and 2 were involved in regular sports. Latest radiographs showed that the saddle shape disappeared in 7 of 8 hips, in all patients hip subluxation decreased as measured by medial joint distance and Shenton line was corrected to between 0.6 mm. The Epiphysis index and joint congruency improved in most cases.
The level of satisfaction from the operation was very high for all patients and their parents.
Drawing of final conclusion will be possible only after assessing the long-term results.
It is a rare abnormality in children of which consequences are cosmetic and functional too.
The age of our patients ranged from 6 months to 13 years old. 50% of them were younger than 9 at the first visit. Functional consequences consisted in a modification of the plan of the movements of shoulder. Besides the omovertebral bone, many important abnormalities – mainly of the spine – have been noticed in our series.
The cases were classified using the degree of elevation of the superomedial angle of scapula. Three grades could be set up.
Concerning the treatment, 2 children have not been operated on. In the other cases, we used a modification of the Woodward procedure.
79% were considered as good on both aspects, cosmetically and functionally, with no complication.
The age at which surgery has been performed seems to have no influence on the result. On the opposite, the number and the severity of the anatomic anomalies have to be taken into consideration for the prognostic assessment.
DNA was prepared in all patients and examined for specific mutations.
Type A – Five patients presented with multiple infections requiring many surgical procedures ranging from local debridement to below knee amputation.
Type B – Three patients presented with fractures and growth disturbances of the lower limbs as well as avascular necrosis of the talus or femoral condyle. Two patients underwent corrective osteotomies due to deformities. Type C – Five patients presented with Charcot arthropathies, joint dislocations, fractures and infections. Four of them were mentally retarded.
Patients underwent multiple surgical procedure to control infections.
Attempts surgical stabilization of joints were unsuccessful.
Mutations were found in four patients.
Patient education, shoe ware and periods of non weight bearing are important in prevention and early treatment of decubitus ulcers. Differentiation between fractures and infections is difficult and should be based on aspiration and cultures in order to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities should be treated by corrective osteotomies and shortening should be treated with shoe lifts or epiphysiodesis. Joint dislocations should be treated non-operatively as attempts at surgical stabilization gave poor results.
Despite the impressive advancements in prenatal planning and assessment, obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth.
Although the majority of infants with plexopathy recover with minor or no residual functional deficits, a number of children do not regain sufficient limb function and develop significant functional limitations, bony deformities and joint contractures.
Recent developments in the technique of microsurgical reconstruction of peripheral nerve injuries proved to be effective in selected cases of children with obstetrical brachial plexus injury.
Many of these children and those who were defined as having minor injury will remain with considerable functional limitation and deserve late orthopaedic reconstruction.
Based on that, we developed a multidisciplinary Brachial Plexus clinic gathering a microsurgeon, a pediatric orthopaedic surgeon, an electrophysiologist clinician, physiotherapists and occupational therapist in order to assess and evaluate these children.
A total of 105 children were seen and followed up in our clinic during the last 2 years.
Most of these children were referred to our clinic from other centers and from physiotherapists treating these children on an out-patient basis.
We report the orthopaedic reconstruction operations performed in 9 cases of residual functional disabilities in children born with obstetric palsy.
4 patients had latissimmus dorsi and teres major transfer.
2 patients had derotation osteotomy of the humerus.
1 patient had Steindler flexorplasty of the elbow.
2 patients had open reduction and capsulorrhapy for a dislocated shoulder.
Video assessment of these children was performed before and after the operation. Function was also analyzed before and after operation by a physiotherapist and an occupational therapist.
Significant functional improvement was achieved, to the satisfaction of patients and parents.
Incipient spondylolysis was diagnosed when on T1 sequences a hypointense area was found within the pars interarticularis of any lumbar vertebra while on T2 sequences a corresponding hyperintense zone was detected. Brace and activity restriction was recommended. Follow-up MRI studies were performed after treatment at 3 months interval.
A method of treatment is described whereby the affected tibia is united and lengthened.
All patients suffered from Boyd 1 or 2 Psuedoarthrosis of the Tibia. All patients had had previous surgery (three to thirteen operations) and three to ten centimeter of shortening. All patients were treated by lengthening of the tibia and open debridement and compression of the pseudoarthrosis till union using Ilizarov techniques.
Eight patients achieved union length and normalization of the tibial axis with the first operation and two patients had recurrence of the pseudoarthrosis and had re-operation with success.
To achieve this success a number of basic principles need to be followed.
These principles are:
Correction of the axis of the limb. Debridement of the pseudoarthrosis and opening of the intra medullary canal with insertion of one of the ends of the tibia into the other. Lengthening of the tibia with proximal osteotomy and concurrent compression of the fracture site. Absolute correction of the tibial axis.
This treatment regime has shown success in the failed management of the pseudoarthrosis and if these principles are adhered to this regime will have success in the management of this pathology and prevent re-operation.
Indication for surgery were: 1. Multidirectional instability with less than 3 frank dislocation. 2. Symptomatic subluxators with positive apprehension test after failed non-operative rehabilitation program. 3. High demands first dislocators sportsman with failure of non operative rehabilitation program.
The arthroscopy was performed in sitting position with posterior and anterior portals as a day surgery or overnight hospitalization. Anterior portal was used for VAPR probe first and portals were switched if needed.
All patients were immobilized in shoulder immobilizer for 6 weeks. Rehabilitation program was planed on individual basis and patients were instructed not to return to full contact sport or activities at least 6 months post operatively. Patients were checked at 2 and 6 weeks before commence rehabilitation and than at 3, 6, 24 months. Mean follow up was 17.6 months (range 6–27 m.).
The second patient, a 16 years female elite judoka, commenced judo matches after 3 months and was asymptomatic with 24 months follow-up time.
Impingement syndrome confirmed and successfully treated by ASD in 10, a rotator cuff tear in 3. Loose bodies removed in 1. Arthroscopic washout was performed in 1 patient for acute septic joint. 6 of 7 with capsular fibrosis underwent a successful arthroscopic capsular release. Loose or worn components were found in 4, a florid synovitis in 1, loose cement in another and in 1 no abnormality could be found.
Carpal Tunnel Syndrome (CTS) is the most common peripheral neuropathy. The pathology is due to pressure on the median nerve at the wrist.
Ultrasonography shows the soft tissues as well as other pathological conditions as edema, synovitis, soft tissue tumors or bonny pathology of the carpal tunnel and its contents. The test can be dynamic and can provide the clinician with important information regarding the flexor tendons/muscles movement into the canal.
The present study aimed to find sonographic criteria for the diagnosis of CTS. Pressure on the median nerve under the carpal ligament causes narrowing of the nerve (hourglass deformity). The ratio between nerve width proximal to the canal and the width of the most compressed part of the nerve under the ligament was selected as our indicator. Our assumption was that in healthy individuals the ratio would be 1 or close to 1. Standardization was based on values taken from a group of healthy volunteers (47 hands). Mean value of this ratio in the healthy group was x-=0.95, standard deviation 0-=0.13. 79% (37/47) of the control group were in the range of ±1 and 97% (44/47) were in the range of ±2 standard deviations from mean value.
Based on these figures, we defined a probable diagnosis of CTS as a ratio under two standard deviations from the mean value.
Our database included 450 patients operated for CTS at our department between 1998 and 2000. Out of this group, 99 patients had met our inclusion criteria (positive anamnesis, positive clinical examination, complete Ultrasound and EMG studies).
We could define an indicator and analysis of the results of our study show a significant and positive statistical correlation between this indicator and a positive motor latency electrodiagnostic finding.
Conclusion: EMG is the current Gold Standard for the diagnosis of CTS. Based on our findings concerning the indicator we have defined Ultra Sonography is a reliable, readily available, low cost auxiliary test to help diagnose CTS.
A larger scale study of this indicator is in progress.
Although articular chondrocalcinosis is a frequently seen disorder, the broad clinical variations of forms affecting the wrist are more recently and more rarely described. Chondrocalcinosis of the wrist is an evolutionary disorder, which can initially be well treated medically. Further in the natural evolution, scaphoradial joint destruction occurs followed by midcarpal wear. Until now one form of chondrocalcinosis, developing scapholunate dissociation and tending towards a SLAC (Scapho-Lunate Advanced Collapse) wrist, has been well documented.
We state that there exists a pathway which does not lead to any scapholunate gap and is less often associated with a ST (Scapho-Trapezium) osteoarthritis. This isolated form of chondrocalcinosis of the wrist has been mistaken for SLAC or SNAC (Scaphoid Non-union Advanced Collapse) wrists, because its clinical and radiological resemblance. We propose to call this form the SCAC (Scaphoid Chondrocalcinosis Advanced Collapse) wrist. It is seen in elderly patients. There is a long evolution for several years, and most patients have an extensive medical history before the correct diagnosis is being made.
We describe the typical clinical and radiological evolution on five patients. According to the amount and pattern of cartilage destruction we propose a radiological classification in four grades. The five cases presented were all seen in grade III.
Two of them underwent previous surgery; a styloidectomy in one and a scaphoid replacement by a titanium prosthesis in the other. Three patients had previous carpal tunnel release. All five have been treated by a hamatoluno-capitate arthrodesis, with resection of the scaphoid and triquetrum (according to Delattre’s technique). Results are described and discussed.
Follow-up included physical and radiological evaluation and functional evaluation.
In order to avoid the consequences of polyethylene wear in a high-risk population, 128 alumina-alumina total hip arthroplasty were implanted in 116 consecutive patients of 40 years old or less. Osteonecrosis and sequellae of congenital hip dislocation were the main etiologies representing 71% of the hips. The same titanium alloy cemented stem was implanted in all hips. Four alumina acetabular component fixations were used: cemented plain alumina socket (41 hips), screw-in ring with an alumina insert (22 hips), a press-fit plain alumina socket (32 hips) and a press-fit titanium metal back with an alumina insert (33 hips).
Eight patients (11 hips) died during the follow-up period. Sixteen revisions were documented, 12 for ace-tabular aseptic loosening, 3 for bipolar loosening (2 were septic), and 1 for unexplained pain. Eighty-nine hips were followed radiologically for two to twenty years. No femoral nor acetabular osteolysis were observed with an average follow-up of 8.4 years. Wear was unmeasurable. Four additional sockets showed definite migration. The respective survival rate at 7 years were 91.4% for the cemented cup, 88.8% for the screw-in ring, 95.1% for cementless press-fit plain alumina socket and 94.3% for the metal-back press-fit component.
The ten-year survival rate was 88.0% for the cemented socket and 88.8% for the screw-in ring. The fifteen-year survival rate was 76.7% for the cemented socket. The occurrence of a graft was the only prognostic factor with a 62.6% survival rate at ten years for the grafted hips and a 90.1% for the non-grafted hips (p=0.004).
The alumina-alumina bearing surfaces for young patients appeared as a valuable alternative to standard metal-polyethylene system. There is a need to improve socket fixation if we want to have a survival of the arthroplasty as long as the life expectancy of this increasing and demanding population. The last design with a fully coated HA titanium shell and an alumina liner seems to fulfill the requirements.
Cartilaginous tissues such as articular cartilage and the intervertebral disc are called upon to function under very high pressures which they can do, thanks to the very special properties of their two major components, viz., the proteoglycans (PG) and collagen. The PG, a flexible polyelectrolyte of high fixed charge density has a high osmotic pressure and therefore a tendency to imbibe water and maintain tissue turgor while the collagen mesh, with its good tensile properties, prevents undue swelling, thus enabling the proteoglycan-water mixture to exist as a concentrated solution. Moreover, by resisting instantaneous deformation, the collagen network ensures the dimensional stability of cartilage. The combination of the two components enables a cartilaginous tissue to exhibit flexibility and to withstand tensile stresses as well as high compressive loads.
Moreover, cartilage is an avascular tissue, hence the transport of nutrients and different substrates is controlled by the properties of the matrix. In addition to common nutrients, various regulatory substances, such as growth hormones and cytokines, also have to reach the cell. These substances are often required in extremely small amounts which, however, need to be rigorously controlled. This again, depends on transport through the extracellular space. At the same time, metabolic waste products are secreted by the cells into the matrix and have to pass through the latter in order to reach the synovial fluid for removal from the joint space. The same must happen to matrix macromolecules degraded in the course of normal turnover, whether the degradation happens intra- or extracellularly. Finally, macromolecules, newly synthesized by the cells, are secreted into the matrix and must move through it before being assembled at some distance from the cell.
The concentration of a solute within the matrix, apart from being an important factor in determining the rate of transport, is also able to modify the properties of the matrix itself. Thus, ionic concentrations are largely responsible for determining the level of the osmotic pressure within the cartilage matrix in general, and in the immediate environment of the cell in particular. The osmotic pressure of the matrix, in turn, is responsible for the resistance of cartilage to fluid loss and hence to compressive stresses. Together with the hydraulic permeability of the pore space, it is also an important determinant of the rate of fluid movement out of and into the tissue. In addition, the high ionic concentration and osmotic pressure in the immediate environment of the chondrocyte have been shown to affect their synthetic processes.
Endoscopic surgery has evolved tremendously in the past decades, especially the use of arthroscopy in orthopedics.
The knee is the joint most commonly treated, followed by the shoulder.
The arthroscopy of the elbow has developed slower than in the other joints mostly due to the close anatomic relationship to vital structures, that is, the risk of injuring the main blood vessels and nerves, as there are reports of as much as 10% of complications.
The purpose of our study is to summarize our experience of elbow arthroscopy in Kaplan Medical Center in the past years, and to show that sound technique, precision with details and expert use of this method may lead the elbow arthroscopy to be an excellent tool in the solution and treatment of many problems in clinical practice.
We present 18 subjects with the age ranging from 17 to 68. Our results were good in most of the cases. We had no major complications in long term follow up.
Our conclusion is that meticulous use of elbow arthroscopy has few complications and with good results, and may avoid open surgery.
Valgus High Tibial Osteotomy (H.T.O.) in a recent past has unfairly been compared to Total Knee Replacement (T.K.R.); H.T.O. was unduly discarded as n unreliable procedure due to its supposed high rate of failures and/or complication; the clinical material which led to these conclusions was, in fact, predominantly poorly done H.T.O.’s. If, however, Valgus H.T.O.
Is performed (and achieves union) with the same technical predictable accuracy as T.K.R. Is evaluated with comparable statistical methods as T.K.R. (on the basis of survivorship analysis of postoperative knee function). T.O. remains a very valuable procedure to treat knee osteoarthritis, especially in still very active patients.
Since 1989, 49 “A.C.C.W.I.F.” H.T.O. were performed and followed up for at least three years (Automatic Correction through Closing wedge Internal Fixation). Using full-length radiographs and pre-operative planning, the technical accuracy was assessed immediately after surgery, at the time of union and at the last follow-up. Negative marks were given either in case of inadequate correction (more than 3° degrees of error to the pre-op planning) or in case of complication. The knee function was rated according to the I.K.S. scoring system. Excellent results were observed in more than 90% of the operated knees, with very little deterioration of the results with time. Survivorship of knee function was assessed using revision by T.K.R>
or repeat H.T.O. as its end point.
A strict radiological and CT evaluation was done prior to and following the surgery and accompanied the clinical evaluation and follow up. A cohort of 32 patients is presented in details regarding the imaging pre-operative planning and the post-operative results.
The radiological data included: 1. Angle of frontal deformity; 2. Angle of instability; 3. Fi-Fc – distance from the tip of the fibular head to the distal part of the lateral femoral condyle; 4. Frontal inclination angle of tibial component; 5. Frontal inclination angle of femoral component; 6. Sagital posterior inclination of tibial component; 7. Sagital posterior inclination angle of the femoral component; 8. The distance from the patella to the knee center of motion.
The computed tomography data included: 1. The actual dimensions of the patella, tibia and femur; 2. The preoperative angle between the posterior condylar line and anterior condylar line; 3. The angle between the posterior condylar line and the trans-epicondylar line; 4. The angle of external rotation of the femoral component; 5. The angle of external rotation of the tibial component; 6. The distance of lateralization of the femoral and tibial components.
Measuring the angle of external rotation of the tibial component preop helped to determine the extent of external rotation of the tibial component intraoperatively.
A significant decrease of the postop Q angle was noticed in all patients.
The British Orthopaedic Association knee function score was used to access the clinical results and the Knee Society Radiographic evaluation was used for radiological evaluation.
Flexion was greater than 90 degrees in 97% of the patients.
Three knees required re-surgery, 1 for deep sepsis, 1 for patello femoral problems and 1 for a fractured polyethylene component.
No knee required revision for polyethylene were or loosening.
Approximately 700 TKRs (Total Knee Arthroplasty) were performed in our department from 1992–2000. In 13 cases, patellar dislocation occurred post-operation - 12 with no trauma and one following a fall and trauma to the medial aspect of the knee. Dislocation occurred from 2 months following the operation until 1 year postoperative (average 4.5 months). None of the patients had malalignment of the components. The average femorotibial angle was 5° (range 8° valgus to 3° varus). No patient had preoperative valgus deformity. Postoperative range of motion was 105° (range 90–125°). All dislocations were treated by operative lateral relapse and medial capsular implication followed by 6 weeks of immobilization with a brace in full extension and then physiotherapy, range of motion, patellar taping and Vastus medialis strengthening.
The patella stabilized in 11 cases following the operation. In 2 cases, dislocation recurred following the operation and they were operated on again where medialization of the tibial tubercle was performed. Both cases stabilized following the second operation. One case developed a stress fracture of the tibia at the end of the tubercle osteotomy which healed conservatively. All dislocations occurred in the IBII prosthesis.
During the past 3 years since using the PFC Sigma and Legacy prosthesis, we have had no dislocations of the patella, probably for the following reasons:
Use of the mid vastus exposure. Geometry of the prosthesis. In only 10% of the replacements, patellar resurfacing was performed.
We studied the influence of different femoral alignment systems on blood loss and the need for blood transfusion after total knee arthroplasty. We retrospectively recorded the blood loss in two groups of consecutive patients. The first group consisted of 46 patients in whom the total knee arthroplasty was performed using an intramedullary femoral alignment system and the second group consisted of 45 patients in whom the procedure was performed with the extramedullary system.
In the first group, the mean volume of drained blood was 758 milliliters, while in the second group it was 613 milliliters (p< 0.05). More patients in the first group required blood transfusions, but there was no significant difference in the number of blood units transfused per patient.
In conclusion, extramedullary femoral alignment instrumentation reduces the blood loss after the cementless total knee arthroplasty.
Between April 1999 and April 2001 we operated 233 ACL reconstructions. In 24 cases we used Bone Patellar Bone allografts for ACL reconstruction. All allografts came from the same tissue bank and prepared in the same manner. There were 10 Right knees and 14 Left knees. The average age of the patients was 46.8 years with the range between 26 and 55.
There were 6 females and 18 males. The average follow up was 8.2 months with the range between 3 and 24 months. All reconstructive surgery was done in the same technique by both authors. All graft donors were younger than 35 years.
The indications for using allografts were revision cases and patients over 40 years of age.
The width of the graft was increased by 20% to compensate for the decreased strength due to the preparation process. The outcome was assessed by clinical evaluation form, detailed physical examination of the knee by the examiners and structured interview. 21 had excellent and good results (full return to previous activity, no pain, stable knee with good range of motion). There were 19 primary cases and 5 revision cases. There was one poor result – spontaneous tear of the allograft (a revision case). One case had a partial tear of the graft falling from stairs (a revision case, that was treated with thermal shrinkage). One case who went for Genzyme treatment, had a stable knee, the arthroscopic examination showed a partial tear of the graft. We had no cases of infection or synovitis.
According to our short follow up data collected from the study, our conclusion is that using allografts for reconstruction of torn cruciate ligaments in the knee is a good method in the right indication. We find it suitable for the group of elderly patients and revision surgery. A larger study is recommended.
In all cases, revision was performed for mechanical loosening of one or several components. Using light microscopy, the articulating surface of each patella component was analyzed for six modes of damage: polishing, delaminating, surface deformation due to cold flow, scratching, pitting and abrasion.
To describe the damage, the surface of the patella component was divided into four sections. The contact stresses between the patellar and femoral components were calculated in relation to the areas of wear. Volumetric wear could not be accurately established.
Four modes of damage were observed: polishing in 13, delimitation in 12, cold flow in 6 and scratching in 3. The median total area of polyethylene damage was for polishing 76.5%, delimitation 70.6%, cold flow 35.3% and scratching 17.6%. The average contact stress on the nonconforming Total Condylar patella component was 12.9 Kgf/mm2. It was significantly higher (p< 0.002) than the average contact stress on the conforming Kinematic patellar component – 2.9 Kgf/mm2. The area of wear was smaller, 357.2 mm2 for the nonconforming Total Condylar, than for the conforming Kinematic patella 439.2 mm2. However, this difference was not statistically significant. The average weight of the patients with the Kinematic knee (74.5 kg) was higher as compared to the patients with Total Condylar knee (66 kg) but the difference was not significant.
Osteonecrosis (ON) around the knee joint can be spontaneous (primary), without comorbid medical conditions, or secondary. ON is characterized by sudden pain, usually self resolving after six months to a year, night pain, and involving mainly women older than 55 years of age.
Twenty seven patients with primary ON were retrospectively reviewed. The patients were evaluated clinically (physical examination and H.S.S. scoring) and radiographically (plain radiographs were done at the beginning and at the end of follow-up and MRI studies). The MRI study included calculations of the area and the volume of the lesion, osteoarthritic changes, bone collapse and meniscal pathologic findings.
The majority of the patients, 96% (26/27), complained of sudden pain. Night pain was observed in 46% of the patients. Osteoarthritic changes observed in 60% of the patients and further deterioration (37%) was noted at follow up radiographs. Osteoarthritic changes were more predominant in patients with tibial condyle involvement rather than those with femoral involvement, 61% vs. 43% (p=0.04), respectively. Diagnosis of osteonecrosis by the initial radiographs was more common in patients with femoral involvement (7 femurs vs. 1 tibia).
All ON lesions were diagnosed by MRI, from these, 17 meniscal tears (63%) were detected.
Several observations were noted in the volumetric analysis: Tibial lesions were larger than femoral lesions (8.1cm3 vs. 3.1cm3, respectively, p=0.026). Women had significantly larger lesions in volume and area than men (area – 5.09cm2 vs 2.05cm2, p=0.01; and volume – 6.6cm3 vs. 1.2cm3, p=0.001). Significant correlation was found between bone collapse and the need for total knee replacement (TKR): 40% collapse in the TKR patients versus 13.6% collapse without TKR (p=0.028). Patients that were diagnosed with collapse at the end of the follow up had a larger area (5.8cm2 vs 3.7cm2) and a lower HSS score (68.5 points vs. 83 points, p=0.02) than those without. A significant correlation was noted between a larger lesion area and lower HSS scoring (p=0.037) at the end of the follow-up. Patients with tibial lesions had more meniscal pathologies involvement, 56.3% vs. 43.8%, however it was not statistically significant (p=0.68).
We conclude that MRI study for patients with ON and calculating the area and the volumetric data particularly, is an accurate predictive tool for the natural history of knee ON. The findings presented here may guide us in determining the best possible treatment.
Topical treatment of infected wounds has a crucial role as an adjuvant to surgical debridement. Solutions currently used for local would treatment have either low antiseptic properties with low irritating effect, such as physiologically balanced solutions acting mostly by a mechanical irrigating effect, or antiseptic solutions which cause chemical irritation of the surrounding tissues. The use of topical substance with effective antiseptic properties, which is also not irritating to surrounding healthy tissues, should improve significantly the effectiveness of infected wound treatment.
Previous reports on the use of Hexamethylenebiguanide solution for local antiseptic treatment in infected wounds indicated on a good curative effect without any local or systemic side effects. Unfortunately none of these reports is based on well designed statistical data which is essential for the safe and skilled use of any pharmaceutical agent.
We present the results of controlled prospective double-blind study comparing the topical use of 0.1% Hexamethylenbiguanide solution with non lactated Ringer solution as agents for a topical treatment of infected wounds in extremities. The group of 104 patients with ischemic, combat, post surgical or due to open fracture wounds treated by either of these solutions following surgical debridement without additional systemic antibiotic use. According to the strict follow-up protocol, wounds’ healing was evaluated on a weekly basis. In the group of patients treated by the 0.1% Hexamethylenbiguanide solution, 75% rate of a complete wound healing was observed. In the control group the rate of healing was 52% [p=0.026, Chi square test, Figure 1]. These results indicate the high effectiveness of the Hexamethylenbiguanide as a topical agent for infected wound treatment.
A new fixating device was developed for fixation of the anterior cruciate ligament using hamstrings and allowing immediate full weight bearing and full range of movements as pain subsides. The surgical technique is simple, similar to the one described by L. Johnson: a femoral tunnel of 25 mm depth without exit on the lateral wall of the femur. The tibial tunnel is drilled in the usual manner. In order to achieve a straight line drill of the tibia and the femur an aimer is used. The hamstrings are harvested in the usual manner and used as free graft.
The new anchor is composed of 2 parts: a self tapping screw and an oval eyelet.
The harvested hamstrings are passed through the eyelet and doubled. The assembled system is passed through the tibia directly into the femur and screwed in place. For distal fixation 2 square staples are used.
The patients are discharged on the same operative day, and followed.
On follow up the clinical exam included assessment of range of movements, stability (Lachman, Pivot shift). The results of a subjective rating of patients’ satisfaction was also taken into consideration.
The anchor was used in 50 cases: 46 males and 4 females. In 4 cases semitendinosus alone was used as graft. Full range of movements and weight bearing were allowed as pain subsided. Short term follow-up (3 years) showed excellent results. No complication of any type (infection, loosening or vascular) were encountered. 48 of the 50 cases returned to their previous activity without any limitation. However, in 2 cases meniscal tears occurred:
1 medial meniscus and 1 lateral meniscus and were considered as failures because the stability achieved was insufficient for their activity. It has to be pointed out that none of our patients were professional athletes.
The importance of meniscal tears repair is discussed widely in the literature. The repair should be performed if the conditions promise some chance for healing. Due to technical difficulties many orthopaedic surgeons still prefer partial meniscectomy to meniscal repair.
We describe our techniques for meniscal repair. The described techniques could be used by any surgeon with basic skills in arthroscopic surgery. No special equipment is needed.
The basic equipment for this technique is a standard 18 gouge needle. The plastic cup of the needle is cut away in order to overcome the ridge between the plastic and the metal part of the needle, thus making the suture passage easier.
Following the arthroscopic identification of the meniscal tear and preparing the torn parts for repair, the place for the first suture is identified.
A 2–3 mm long skin incision is made. The subcutaneous tissue is bluntly developed to the capsule. The 18 gouge needle is past from outside-in in the desired point through the torn margins of the meniscus. The tip of the needle is emerged above or under the meniscal surface, depends on our decision of suture position.
1st step – Producing a loop outside the joint: Two ends of a nylon 2/0 suture are inserted through the needle into the joint cavity, and pulled out through one of the arthroscopic portals. The needle is removed. The result of this step is a nylon 2/0 suture passing through the torn parts of the meniscus with a loop outside the joint.
2nd step – Producing a double-loop inside the joint cavity: A second nylon 2/0 suture is passed through the first loop. The first suture is pulled into the joint. At this stage, both loops are inside the joint, holding each other. The free ends of the first loop are emerged through one of the arthroscopic portals, while the free ends of the second loop pass through the torn parts of the meniscus and emerge through the capsule.
3rd step – Producing the meniscal suture: A second 19 gouge needle is inserted close to the point of insertion of the first one, directed into the joint. The emerging point of this needle, on the meniscus, should be positioned according to the desired suture direction (transverse, vertical, or oblique). The tip of the needle is then directed into the “2nd” nylon loop (the “1st” nylon loop can assist at this stage). The loop is wrapped over the needle, and the 1st suture is removed.
PDS suture (1/0 or 2/0) is inserted through the needle until a 5 cm free end is positioned intra articular. The needle is removed with caution without pulling the PDS suture, leaving the
PDS free end inside the nylon loop. The nylon loop is used as a pooling tool for the PDS suture. Pulling the free end of the PDS suture out of the joint results in a PDS loop for the meniscal suture (in order to avoid iatrogenic tear of the meniscal tissue while pulling the sutures, a probe should be positioned under the PDS suture during the process). The PDS is tightened over the capsule. The technique is repeated as much as necessary for perfect repair of the meniscus.
The advantage of this method is that it does not necessitates unique equipment, but rather uses the ordinary arthroscopic tools and sutures. This method was used successfully upon large number of meniscal tears. We recommend its use routinely.
During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well.
The follow-up period was 6–18 months with an average follow-up period of 13 months.
All patients were treated with ESWT. One to three treatment sessions were provided to each patient with an interval of one week between the sessions. After all sessions were finished, pain and function were reassessed in the same method that was used before the beginning of the treatment.
The overall mean pain value was 1.96 before the treatment and 5.92 after the treatment.
8 patients (30.7%) reported no pain at all after the treatment and in 6 patients (23%) a significant improvement in pain was achieved. 7 patients (19%) reported of only slight relief of pain and 4 patients (15.4%) reported no change in pain level. Only in one patient (3.9%) worsening of the pain was observed.
The overall mean function capacity was 5.76 before the treatment and 8.65 after the treatment. 11 patients (42%) returned to full functional capacity and in 7 patients (27%) a significant improvement in functional capacity was observed. In 8 patients (30.7%) no change in the functional capacity was noticed.
Good results of improvement in pain severity and functional capacity were observed in cases of plantar fasciitis and tennis elbow.
In the study group only 1 patient needed prolonged high dose anticoagulant treatment while 6 patients in the enoxaparin group were treated (p=0.020).
The cumulative incidence of adverse events in the study group was significantly lower than that observed in the control group (p=0.000). Average postoperative hospital stay was 8.4 days in the study group and 11.7 days in the control group (p=0.002).
The CECT device was very well tolerated by the patients and facilitated early mobilization.
Low back pain is not a frequent complaint in adolescents and usually is a self-limited affliction without signs or significant findings in pertinent imaging studies. Adolescent athletes are in an increased risk of overuse injuries to the spine due to their relative ligamentous laxity and lack of proper technique in their chosen sport.
This is a prospective study of adolescent athletes referred to the spine clinic due to low back pain and significant findings on physical examination and/or the imaging studies.
Between 01.08.1998 and 31.03.2001 we have treated 7 athletes, 2 girls and 5 boys, average age 15.67 years (range 13–17). Sports involved were golf in 2, body building in 1, volleyball in 1, handball in 1, track and field in 1, and ballet in 1. Five were eventually diagnosed with L5 pars defects (2 unilateral and 3 with bilateral lesions); L2 spondylolysis was diagnosed in 1 and L5-S1 central disc protrusion in 1. All complained of pain located to the lower back, the patient with disc protrusion complained of pain radiating to her lower extremities. Plain films were diagnostic in 1 patient only with a unilateral L5 pars defect. Technetium bone scan showed increased uptake at the level of the lesion in all 6 patients with spondylolysis and was normal in the patient with L5-S1 disc protrusion. CT scans were performed in 4 patients and were diagnostic 2, MRI was performed in 2 patients and was diagnostic in both.
The six patients with spondylolysis were treated by analgesics, rest for 3 months and then gradual supervised return to sports with modification of the swing in both golfers, decrease of training volume in the body builder and limiting the track and field athlete to running only. Both volleyball and handball players withdrew from athletic activities. The volleyball player with L5-S1 herniation refused surgical treatment.
The evaluation of adolescent athletes with low back pain longer than few weeks, should be by bone scan first and CT and/or MRI later. MRI should be preferred to limit radiation exposure. After proper rest and supervised training they can safely resume their athletic interests.
Intraarticular injections of 25 mg Sodium-hyaluronate in 5 following weeks were administrated to 16 patients, 31–79 years old (average 43 years) suffering from pain in the ankle, 9 months to 27 years. 12 patients after operation, 4 with no trauma history.
Follow-up visits were performed 1,2,3,4,7 months post treatment and included clinical evaluation and score scale.
Global assessment of 2 patients did not show any significant improvement after the treatment. One patient dropped off the study due to other operation.
RMS in the ML direction increased from 0.57 to 0.68 cm. The EMG RMS in the TA increased from 4.15 to 5.58 and the MPF decreased from 107.6 to 96.7 Hz in the fatigued state.
Osteochondral lesions are frequent as a result of sport and daily activities.
The healing processes of these defects are prolonged and complicated and often leading to irreversible ostheo-arthritic changes. In this study, biotechanical and bioChemical approaches are being combined in an attempt to identify potential uses of biofabricated marine carbonate materials in biomedical applications, particularly as for remodeling cartilage and bone tissue. Biofabricated material was grafted into osteochondral induced defects in animals’ models during knee arthrotomy. Using histological sections, SEM, EDS studies it was revealed that the biofabricated, porous material is highly biocompatible. The graft was incorporated into the osteochondral defect area and followed by surface remodeling. After 4 months the interface and subchondral areas were been replaced by new cartilage and bone.
We believe that it is the first time that such biofabricated materials have been used for biomedical purposes. In face of the obvious environmental disadvantages of harvesting from limited natural resources, we propose the use of bio-engineered coralline and other materials such as those cultured by our group under field and laboratory conditions as a possible biomatrix for hard tissue remodeling.
Age ranged between 66 and 79 years (mean 71 years). A control group consisted of 6 cadaver knees (mean age 31 years) with no previous history of knee problems.
All the patients in the research group were graded functionally for their knee score by the system of Hospital for Special Surgery Functional Score.
Additional plain X-ray score on a three point scale was performed. During surgery macroscopic changes on the articular surface of all three compartments were recorded on a four point scale. Synovial specimens were taken from each compartment for microscopic examination.
A fifth control group did not receive any implant. Animals were followed for 3 months after transplantation and than sacrificed. The histological specimens were evaluated by image analysis after immuno-histochemical stains were performed (including the following antigens – collagen type II, collagen type I, collagen type III, collagen type X, S-100, alkaline phosphatase, osteocalcin, osteopontin, nitric oxide synthase).
The incidence of comminuted proximal femur fractures is increasing, due to the growing proportion of elderly people in the general population. Severely depleted cancellous bone in the femoral head and neck prevent stable proximal purchase, mandatory for intertrochanteric and subtrochanteric fractures. Osteoporotic bones are associated with high implant failure rates, evidenced by cutout and upward screw penetration of the hip joint.
A new method for femoral head fixation is described. The peg consists of a distal end that can expand in diameter from 7.8mm to 10.5mm by using pressurized saline, allowing good abutment into the femoral head. The peg may be connected to a side plate or an intramedullary device for inter or subtrochanteric fractures.
Preliminary positive results indicate that this new method may be suitable for inter or subtrochanteric femoral fracture fixation.
Mesenchymal Stem Cells (MSCs) are key regulators in senile osteoporosis and in bone formation and regeneration. MSCs are therefore suitable candidates for stem cells mediated gene therapy of bone. Recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) is a highly osteoinductive cytokine, promoting osteogenic differentiation of MSCs.
We hypothesized that genetically engineered MSCs, expressing rhBMP2, can be utilized for targeted cell mediated gene therapy for local and systemic bone disorders and for bone/cartilage tissue engineering. Engineered MSCs expressing rhBMP-2 have both autocrine and paracrine effects enabling the engineered cells to actively participate in bone formation.
We conditionally expressed rhBMP2 (tet-controlled gene expression, tet-off system) in mouse and human mesenchymal stem cells. RhBMP2 expressing clones (tet-off and adeno-BMP2 infected MSCs), spontaneously differentiated into osteogenic cells in vitro and in vivo.
Engineered MSCs were transplanted locally and tracked in vivo in radial segmental defects (regenerating site) and in ectopic muscular and subcutaneous sites (non-regenerating sites). In vitro and in vivo analysis revealed rhBMP2 expression and function, confirmed by RT-PCR, ELISA, western blot, immunohistochemistry and bioassays. Secretion of rhBMP2 in vitro was controlled by tetracycline and resulted in secretion of 1231 ng/24 hours/106 cells.
Quantitative Micro-CT 3-Dimentional reconstruction revealed complete bone regeneration regulated by tetracycline in vivo, indicating the potential of this platform for bone and cartilage tissue engineering. Angiogenesis, a crucial element in tissue engineering, was increased by 10-folds in transplants of rhBMP2 expressing MSCs (tet-off), shown by histomorphometry and MRI analysis (p< 0.05). In order to establish a gene therapy platform for systemic bone disorders, MSCs with tet-controlled rhBMP-2 expression, were injected systemically (iv).
These engineered MSCs were genetically modified in order to achieve homing to the bone marrow. Systemic non invasive tracking of engineered MSCs was achieved by recording topographical bioluminescence derived from luciferase expression detected by a coupled charged CCD imaging camera. For clinical situations that require immuno-isolation of transplanted cells, we developed an additional platform utilizing cell encapsulation technique. Immuno-isolated engineered MSCs, with tet-controlled rhBMP-2 expression, encapsulated with sodium alginate induced bone formation by paracrine effect of secreted rhBMP-2. Finally, we have characterized a novel tissue-engineering platform composed of engineered MSCs and biodegradable polymeric scaffolds, creating a 3D bone tissue in rotating Bioreactors. Our results indicate that engineered MSCs and polymeric scaffolds can be utilized for ex vivo bone tissue engineering. We therefore conclude that genetically engineered MSCs expressing rhBMP-2 under tetracycline control are applicable for: a) local and systemic gene therapy to bone, and b) bone tissue engineering. Our studies should lead to the creation of gene therapy platforms for systemic and local bone diseases in humans and bone/cartilage tissue engineering.
Osteoblastic cells response to mechanical forces by activating signal transduction cascades and altering gene expression patterns. We examined the responses of MC3T3E1 mouse osteoblasts to short term, low level (1000 microstrain, 1Hz) loads applied by cyclic deformation of the growth surface. At these load levels, daily short-term loading significantly retards the ascorbate induced differentiation of the cells as measured by alkaline phosphatase and osteopontin expression. This effect peaked at 5 minutes of loading per day; loads of 1 or more hours per day accelerated the differentiation process slightly as measured by the same criteria. C-fos is known to respond to mechanical loading of bones in vivo, we therefore examined the effect of brief loading bouts on c-fos promoter activity.
Stable lines of MC3T3E1 cells carrying the fos promoter driving a luciferase reporter gene were loaded for 0, 5 or 60 minutes. For these experiments cells were grown in MEM without ascorbate and were then either supplemented or not with 37.5mM ascorbate-2-phosphate at confluence. In cells which had not been pre-treated with ascorbate the c-fos promoter was essentially unresponsive to loads. Following 24 hours of ascorbate treatment (placing these cells at the earliest stages differentiation) a 5 minute loading bout resulted in a marked (~ 50%) decrease in luciferase activity with a trough at 6–8 hours. Loading for 60 minutes caused a similar, but accelerated inhibition of luciferase activity with a trough at 2–4 hours after loading. 24 hours after loading, fos promoter activity had returned to baseline in cells loaded for 60 minutes but remained depressed at 75% of baseline in cells loaded for 5 minutes.
Ets family transcription factors have been implicated in gene regulation in response to mechanical stimulation in several systems. The c-fos promoter contains a Serum Response Element which contains both a CarG motif responsible for binding the Serum Response Factor and an ets core motif CAGGT which can bind ets factors. We therefore repeated these experiments using a mutant c-fos promoter in which the ets binding site is destroyed. The response of this mutant to loading for 60 minutes was indistinguishable from that of the wt-promoter. However, in contrast to the wt-promoter, the ets-mutated promoter responded to a 5 minute loading with a rapid increase in activity (~150%) which peaked at 10 hours before returning to baseline at 24 hours.
These results suggest that although similar in magnitude, the inhibition of the c-fos promoter by 5 and 60 minute loading bouts are regulated by different mechanisms, and implicate the ets family of transcription factors in the response to the briefer loading events.
Severe bone loss in weight bearing bones is one of the main causes for morbidity in trauma victims. The use of guided bone regeneration in the treatment of such large defects has not yet been studied extensively. The aim of this study was to establish an accurate evaluation system, which will enable quantifying the compatibility of membranes to provide bone regeneration in a large middiaphyseal bone defect. In our longitudinal study on 16 rabbits we examined the new bone formation obtained in the vicinity of critical segmental defects (2.5 times the diameter of the bone) covered with tubular ethyl cellulose membranes. The contralateral limbs with the same bone defect served as the control group which was not treated by membranes. The healing process was followed up for eight weeks.
Bone analysis of the implanted and non-implanted bone defects and adjacent tissues was performed in order to evaluate the total area and the density of the regenerated new bone at the gap area. Computerized X-ray study showed newly formed bone as early as 14 days after membrane implantation within and around the radial defect compared with a typical creation of non-union in the contra-lateral non-implanted defects. The bone formation across the gap progressed until reconstruction of the defect occurred after 6–8 weeks. A slowdown in new bone formation was evident after 6 weeks according to the measurements of area size and density of the formed bone.
A parallel longitudinal histomorphological assessment of the process in the treated and non-treated bone defects was conducted. A characteristic process of osteogenic activity and new bone formation takes place inside the confined space and within the tissues around it. A typical modeling process with lytic changes in the different osteogenic fronts takes place from the second week post-implantation. These histological findings, corresponding with the radiological assessment, were summarized according to a scoring system which was constructed by the authors. The scoring was related to eight different zones which were defined within and around the osteotomy site.
This rabbit model clarifies the mechanism and provides quantification of guided bone regeneration. It can serve as a means to study the accelerated bone formation using different membranes in large segmental weight bearing bone defects.
Summary and background data: It appears that the inflammation produced by the herniated fragment is at least partially related to the sciatic pain. TNFα was found to be expressed by herniated nucleus polposus of rats and exogenous TNFα applied in vivo to rat nerve root produced neuropathologic changes and behavior deficit that mimicked experimental studies with herniated nucleus polposus (HNP) applied to nerve roots. Nitric oxide was shown to be involved in the mechanism that produce mechanical and thermal hyperalgesia in rats. Nitric oxide synthesis can be induced by different cytokines among them TNFα and is mediated by the enzyme Nitric oxide synthase. The current study was performed in order to evaluate the possible mechanism of action of TNFα in human herniated discs and define the relationship between nitric oxide and TNFα production by human discs.
The morphological structure of the collagen, namely, the architectural structure of the material and single fibers, as shown by the SEM in various magnifications (100, 1200, 2500 and 5000), was much more similar when comparing between the control group and the microwave group than in the autoclave processed group.
The ten-year survivorship figures were similar for both groups. Revision as the end point was 87.5% for the medial Sled and 89.6% for the Kinematic knees. When moderate and severe pain was considered in addition to revision ten-year survivorship was 79.4% in both groups. The worst case survivorship was also 74% in both groups.
There has been speculation as to whether the outcome of revision total knee arthroplasty (TKA) is as successful as primary TKA, this study was designed to compare the outcomes of primary and revision TKA in order to address this question.
The study collected data prospectively from patients operated upon by one surgeon using one prosthesis design in each group. All patients undergoing revision TKA between 1997 and 2000 were included in the study. 100 consecutive patients undergoing primary TKA between 1997 and 1999 were included in the study. All surgery was performed by the senior author.
Patients completed SF-12 and WOMAC questionnaires pre-operatively and at six and twelve months post-operatively. Mean scores were calculated for the different areas within both outcome measures (WOMAC pain, stiffness and function; SF-12 – physical constant score [PCS] and mental constant score [MCS])
The results were entered into a database and analysed using a combination of two way and simple repeated measures analysis of variance (ANOVA) and t-tests. Only if the result of the ANOVA was significant were post-hoc adjusted t-tests performed on the data values.
WOMAC scores did not differ between the two groups pre-operatively. Both patient groups showed a significant improvement in WOMAC scores at six months (P< 0.0005). In the primary group the pain and function scores improved significantly between six and twelve months (P=0.0258 and P=0.0019 respectively). This was not the case in revision patients.
SF-12 PCS scores were significantly better in the primary patients pre-operatively (P< 0.0005). Both groups showed a significant improvement at six months assessment (P< 0.0005). Neither group demonstrated an improvement between six and twelve months. SF-12 MCS scores did not show any difference between the two groups pre-operatively. No significant change in MCS score occurred during the study in either the primary or revision patients.
The SF-12 and WOMAC health questionnaires are valid, reliable and responsive outcome measures. The study has collected data prospectively from patients operated upon by one surgeon using one prosthesis design in each group. These findings support the concept that revision TKA leads to a comparable improvement in patient perceived outcomes of physical parameters as does primary TKA in both generic health outcome measures and disease specific outcome measures.
The aim of this study was to ascertain if a correlation exists between the indication for revision and the clinical outcome in revision total knee replacement.
Sixteen per cent of patients revised for aseptic loosening were non-committal or disappointed with the outcome in comparison with 33.3% revised for implant failure, 21.4% revised for instability, 62.5% revised for pain and 71.4% revised for infection.
It is usually assumed that there is a correlation between the number of previous operations and the clinical outcome of revision knee arthroplasty though it has not been studied and published. We reviewed our series of 81 revision knee arthroplasty patients to ascertain if a correlation exists. All patients had a semi-constrained prosthesis implanted.
The mean gapping across the repairs after 25 load cycles (with s.d.) in millimetres was: Sutures 3.3 (1.0), Arrows 2.2 (0.9), Fasteners 4.0 (0.6) and TFix 3.5 (0.7). The mean gapping was significantly less for the Arrows compared to the Sutures (p< 0.05), the Fasteners (p< 0.01), or the T-Fix (p< 0.05).
This is a prospective study analysing the accuracy of expected tunnel position (graft site) for anterior cruciate ligament reconstruction and to decide whether or not confirmation of the tunnel site using intraoperative imaging is required. 35 cases of anterior cruciate ligament reconstruction using bone patella bone tendon performed by three surgeons are studied. The surgeons use three different techniques. Immediately after the surgery, the surgeon marks the expected tunnel site (graft site) in a diagram (AP and LAT of femur and tibia) without seeing the x rays and a separate observer studies the actual position in the x-ray. Significance of the difference is studied using statistical tests. Best surgical outcome can be obtained using radiological confirmation of tunnel position intraoperatively with the guide wires.
In this experiment we induced posterolateral knee instability to cadaveric knees in vitro. We observed the changes in these knees to posterior displacement (PD), varus-valgus (V-V) rotation, external rotation (ER) and coupled external rotation (CER) and compared the effect of reconstructing, the popliteo-fibular ligament and the popliteus muscle in correcting posterolateral rotatory instability.
The purpose of this study was to evaluate the influence of trochlear design in total knee replacement with and without patellar resurfacing.
In July 1998 we began using the PFC Sigma. This incorporates a deeper trochlear groove with a 5° valgus angle.
We compared the results for the two types of prosthesis. In the PFC group there were 474 knees in 390 patients. Follow-up was from 2 to 9 years (mean 5.5 years). The overall prevalence of anterior knee pain) was 25.1% (58 knees) and 5.3% (13 knees) in the non-resurfaced group (n=231) versus the resurfaced group (n=243) respectively. Anterior knee pain became apparent in all cases within 18 months.
In the PFC sigma group there were 67 knees in 62 patients. Follow-up was from 18 months to 3 years (mean 2 years). The incidence of anterior knee pain was 0 in the resurfaced group (n=30) versus 37.8% (14 knees) in the non-resurfaced group (n=37). Knee scores were lower in the non-resurfaced groups for each prosthesis.
The function of the meniscofemoral ligaments is undetermined, although many hypotheses comment on a role in guiding the motion of the lateral meniscus during knee flexion. Other possibilities include a function as a secondary restraint supplementing the posterior cruciate ligament.
Chronic medial collateral ligament (MCL) instability is an unusual clinical problem. Due to the unsatisfactory results of advancement procedures or reconstruction using autologous techniques we have devised a new technique using a non-irradiated tendo achilles allograft construct.
Three patients are presented who had symptomatic MCL insufficiency. The laxity was demonstrated clinically (all grade 3) and radiologically using valgus stress views.
The tendo achilles was fashioned into a triangular composite graft consisting of a bone plug (30 x 10 mm) and the tendon. The bone plug was attached to the femur at the anatomical insertion of the MCL using an interference screw and the tendon on the tibia using a multiple suture anchor technique.
The rehabilitation programme consisted of immediate mobilisation and the use of a brace for twelve weeks.
At follow-up (average 12 months) all patients were asymptomatic, had a full range of movements, no increased clinical laxity and no increased radiological laxity to a valgus force at 25 degrees of flexion when compared to the other side.
We conclude that this is an effective technique in the treatment of chronic symptomatic MCL laxity.
At 10 years the cumulative survival rate was 83% and at 15 years 78% (10 knees at risk). The “worst case scenario” where knees with pain or lost to follow up are added to revisions shows a 10 year survivorship of 74%.
Race A., Amis A.A., 1996. Cross-sectional area measurement of soft tissue. A new casting method. RaceA., Amis A.A., 1994a. The mechanical properties of the two bundles of the human posterior cruciate ligament. Friederich N F., O’Brien W., 1990. Functional anatomy of the meniscofemoral ligaments. Fourth Congress of the European Society of Sports Traumatology Knee Surgery and Arthroscopy (ESSKA)
Predonation of autologous blood, administration of erythropoeitin alpha, postoperative blood recovery using cell saver or suction devices for reinfusion of whole blood have all been suggested to overcome this problem.
However whilst function appears to be as good the less successful objective criteria do suggest reservations for the long term results of the Leeds-keio graft.
Method: 66 revision procedures for failed uncemented porous coated anatomic (PCA) total knee replacement were performed in 60 patients. At review, four patients had died while two were lost to follow up, therefore 60 knees in 54 patients were included in this prospective study. The principal indications for primary revision were polyethylene wear and loosening of the tibial base plate. 14 patients had a well fixed femoral component and hence were retained while 46 patients had both the components revised. All patients were prospectively assessed prior to surgery, at three months, six months and yearly thereafter. Review comprised clinical and radiological assessment. The mean follow up was 8.4 yrs (7–12 yrs)
Arthrometric examination showed a mean side to side difference (SSD) of 1.66 mm ±1.5. The mean Lysholm score was 87.2 ±12.5 and 22 patients had a B rating (nearly normal) on IKDC scoring.
The Mark II Soffix group had a mean SSD of 1.23 mm ±1.3, a mean Lysholm score of 85.8 ±14.6 and IKDC B rating in 11/15. The lowest clinical scores were in 4 multiply operated knees but the SSDs were comparable with other groups. The Mark 1 Soffix group had a mean SSD of 2.0 mm ±1.6, Lysholm score of 84.6 ±14.3 and 13/16 had a B rating (IKDC). The smaller SSD in the Mark I Soffix was statistically significant (p< 0.05) when compared with the Mark I device. Multiply operated knees had worse IKDC and Lysholm scores (not statistically significant).
We present our methodology and some preliminary results.
Forty-one non-myelopathic individuals were obtained. There was good inter-and intra-observer reliability. Age matched with 41 patients referred to five neurosurgeons with spondylitic myelopathy were measured prior to surgery and at three, six, twelve, and twenty-four months postoperatively.
Significant improvement following surgery (p = 0.0018 and p = 5.87 x 10−6 respectively) and improvement maintained for at least two years after surgery.
The test is reproducible and reliable with good sensitivity and specificity. It shows validity and relevance when compared to other functional scales such as Myelopathy Disability and Nurick. Changes following surgery can be measured. A multi-centered trial is recommended.
The Oswestry Disability Index has become one of the major condition specific outcome measures for spinal problems. The original version has been in use since the late 1970’s. It was modified in 1985 by a MRC Working Group. Innumerable papers have cited the ODI and many of these have used the ODI as an outcome. It has been translated into at least five other languages.
The understanding of the validation and behaviour of outcome measures has expanded considerably in the 22 years since the ODI was first published. Many studies have been done on the ODI in conjunction with other spinal outcome measures. This material has now been brought together on a new website (
The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective in nature and have not used validated measures of outcome. They have rarely gathered any information regarding patient rated expectations of surgery and measures of satisfaction with surgery. The aim of this study was to prospectively investigate the short and long term outcome of lumbar decompression surgery in terms of function, disability, general health and psychological well being and to examine patient expectations of surgery and short and long term satisfaction with the outcome of decompressive surgery.
Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed using validated measures of outcome pre-operatively, and at six weeks, six months and one year postoperatively. On recruitment into the study patients were also asked to rate their expectations of improvement in pain, general health, function etc. In addition at each review stage patients were asked to rate their satisfaction in improvement of these key outcome measures.
A significant reduction in pain (p< 0.001) was observed at the six week post-operative stage, this did not change at the subsequent assessment stages. Only some of the SF~36 categories were sensitive to change. The sub-categories that were sensitive to change were; physical function (p< 0.05); bodily pain (p< 0.001); and social function (p< 0.05). Improvements were observed in these categories at the six week and six month reviews. A gradual reduction in the Oswestry Disability Index (ODI) was observed with time, with changes principally being observed between the six week and six month review, and six week and one year review stages (p< 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional or pain measures.
The results also demonstrated that patients had very high expectations of recovery particularly in terms of pain and function and that patients were confident of achieving this recovery (76.8%) confident of a good result. Levels of satisfaction however, varied considerably. 41% of subjects were 50% satisfied with the outcome, whilst 30% were dissatisfied. Most patients felt that they had made the right decision to have surgery although the surgery had only achieved 43.4% ± 37.8 of the outcome they had expected.
In conclusion, lumbar decompression surgery leads to a reduction in pain and some improvements in function. Examination of patient’s expectations of and satisfaction with surgery revealed that frequently patients had unrealistic expectations of their surgery and as a consequence tended to have lower levels of satisfaction.
Conclusion: The immediate advantages of a less invasive approach both to the patient and the hospital do not appear to be borne out by this study. Cosmesis was not assessed and long term functional outcome awaits later review.
Clinical governance encompasses audit. Audit is a requirement of our professional bodies and our hospital trusts. It is not usually resourced adequately and the ability to audit spinal surgical outcomes is haphazard nationally. This presentation describes the results that can be achieved in the absence of formal audit support.
A surgical database was started in 1993; its evolution involved the use of standard outcome measures in 1995. Between 1995 and 1999, four hundred and one major spine procedures were undertaken by a single surgeon. The outcome measures were the Oswestry disability index, the low back outcome, MSP MZD and a visual analogue pain scale.
Pre-operative data was collected on all 233 elective cases. Follow up was 59% at 6 months, 51% at one year and 57% at 2 years. At two years a Macnab score was available in 106 cases and the results were excellent/ good 81%, fair/poor 19%.
There were 56 recorded perioperative complications. 21 occurred in the 77 instrumented procedures and 35 in the 156 non instrumented procedures.
The results of this type of audit can only be cautiously compared to published data because of poor follow up. Quality outcome measures and audit probably require a funded resource to be of value.
Fourteen patients with neurofibromatosis presented with symptoms or radiological evidence of cervical spine involvement over a period of 27 years. The symptoms included neurological deficit in five, neck mass in two, deformity in eight, decrease in neck movement in two and two with neck pain. Patients’ age ranged from five to forty-two years. Twelve patients have had surgical procedures. Two patients have been followed up and treated non-operatively despite osteolysis of vertebral bodies with kyphosis of more than 100°.
Current literature presents few cases of neurofibromatosis of the cervical spine. The largest World Series is of eight cases (
Fixation was at one level in 14, two levels in 23, and three or four levels in 6 patients. Thirty-seven had Dyne-sys fixation alone and six had additional procedures at the same operation.
Complications included facet fracture (1), broken pedicle screw (1), apparent screw loosening (1) and discitis (1). At average follow-up of eight months (range 2–14 months), the average Oswestry disability score had fallen from 52 to 32 and the visual analogue pain score from 7.5 to 1.7. 65% of patients were pleased or better with their result.
Patients requiring posterior fixation of the cervical spine are often elderly and frequently suffer from concurrent connective tissue disease together with steroid therapy. These patients are at increased risk of wound infection and breakdown. The extensive tissue dissection required, and the bulk of the posterior spinal devices may lead to difficult wound closure and delayed wound healing.
Over a four-year period, 1997 – 2001, 54 patients underwent posterior cervical spine fixation. Of these, eleven patients required muscle cover, four at the time of initial surgery and seven as a delayed procedure for wound breakdown. All these patients underwent trapezius muscle flap reconstruction (ten unilateral, one bilateral) which resulted in successful wound healing.
We make several recommendations for prevention of wound breakdown in this patient population. These include modification of the screw and rod fixation system to reduce the bulk, and assessment of the wound at the end of the primary procedure with a view to primary trapezius muscle flap transposition in those patients who are at risk of wound breakdown.
Group1 detected by family and friends.
Group2 detected by GP or by another doctor incidentally.
Group3 detected at school.
Group 4 detected by teachers.
Surgical correction of spinal deformity in patients with neural axis abnormalities has established risks of causing further neurological injury. It is necessary to identify individuals with a predisposition for such abnormalities before treatment is instituted.
High stress, non- hydrostatic regions were consistently recorded in the concave annulus.
Average post-op scoliosis 19.4 degrees. Average correction 65%. One patient required second operation for long screws. Four self limiting rninor complications. Average time to discharge eight days
death data for further patients currently awaited from Cancer Registry.
*** consistent findings in multiple reports
** consensus based on balance of various findings
* limited information (single report)
Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.
This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period.
Serum samples taken at this time period were analysed for IGF-1 and TGF-β levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured.
Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p< 0.14, p< 0.18 respectively, Student’s t-test) but had lower TGF- (p< 0.05, p< 0.006) and osteoblast proliferation levels (p< 0.002, p< 0.001), despite having a significantly higher cell proliferation than a control group (p< 0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-. This trend is reversed in the osteoblast proliferation assay.
This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-β. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group.
The Synex cage is an expanding titanium implant designed for reconstruction of the anterior column in injury, post-traumatic kyphosis or tumour of the thoracolumbar spine. It is supplemented by a stabilizing implant. As it is expandable in situ it therefore can be inserted via a relatively small exposure. The design enables good purchase of the endplates and reduces the possibility of secondary displacement.
Surgery for anterior reconstruction is usually performed via an anterior approach, however, there are incidences were a posterolateral approach is indicated. The Synex cage is useful in these circumstances, as being expandable, posterolateral insertion with preservation of the nerve roots is possible. The Synex cage is then supplemented with a posterior construct. The cage can be inserted via a left or right posterolateral approach. A specially designed angled screwdriver is now available to release the ratchet mechanism and if necessary collapse the cage.
We present, what is, to the best of our knowledge and that of the manufacturer, the first two patients where a Synex cage has been inserted using the posterolateral approach.
Cervical orthoses are currently used in the pre-hospital stabilization of trauma patients and also as part of the definitive non-operative treatment of injuries of the cervical spine. The construct stability of orthoses is compromised by virtue of the fact that the cervical spine exhibits the greatest range of movement amongst the spinal segments and also because of the complex composite nature of neck movements.
To date, data has been difficult to attain comparing the various orthoses, in the various planes of movement of the cervical spine. Various methods including the use of inclinometers, goniometers, radiography, computerized tomography and cineroentgenography have been used in an attempt to measure these movements but none have provided satisfactory triplanar data.
This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested in a soft and hard collar, Philadelphia, Miami J and Minerva.
Results show that the Minerva is significantly the most stable construct for restriction of movement in all planes in both groups (p<
0.002 vs. all groups, Student’s t-test), but more impressively in the female group. In the male group, the standard hard collar performs second best in flexion, lateral bending and axial rotation. In the female group, the second most stable orthosis is the Philadelphia in flexion/extension and the hard collar in lateral bending and axial rotation (p<
0.05 vs. next most stable in all cases, Student’s t-test). The soft collar in both groups offered only minimal resistance to movement in any plane,
Looking at these results together allows the ranking of the measured orthoses in order of the three-dimensional stability they offer. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability.
In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses.
A study was undertaken to see the efficacy of backfilling the iliac crest post harvesting on postoperative pain levels and overall functional outcomes.
A randomized study was undertaken in which twenty patients were divided into two groups: one received backfilling of the iliac crest with corralline hydroxyapatite and the other did not.
All patients underwent posterior instrumented lumbar fusion’s with all evaluated for diagnosis, age, levels fused, and risk factors. Comparisions were made evaluating: postoperative pain, time to mobilization, rehabilitation levels, and incorporation of the corralline. Follow-up was a minimum of two years with patients still being followed.
Results revealed a reduction of pain on the analog pain scale in the corralline group compared to the non-backfilled group. This was seen at three days, two weeks, one month, three months, six months, one and two years. Pain levels were reported at one at three months and zero at six months, one and two years in the corralline group compared to five at three months and four at six months and three at one and two years. Time to mobilization was one day sooner in the corralline group. Functional outcomes were seen to be better in the corralline group as well. Incorporation of the corralline hydroxyapatite was seen in all patients.
Back-filling the iliac crest has shown to decrease pain, increase functional outcomes and produce a sooner time to mobilization and physical therapy than the non-filled iliac crest.
Since 1993, the author has performed over 400 posterior interbody fusions for a wide variety of degenerative, traumatic and neoplastic conditions. A review was undertaken of 362 consecutive patients who were managed with this technique between October 1993 and July 2001. The purpose of this review was to determine the efficacy and safety of the technique and in particular, to attempt to identify those factors, which have contributed to patient outcomes.
Patient pre-operative, operative and post-operative data and complications and follow-up Surgeon Subjective Outcome Assessments (SSOA’s) were acquired prospectively. Questionnaires were administered seeking patient generated follow-up data, including Patient Subjective Outcome Assessment (PSOA).
Overall, private patients did much better (very good or excellent outcomes) than compensation ones: 76% vs. 57% (p < 0.002). Patients who underwent surgery for conditions associated with deformity did significantly better than those without: 80% vs. 57% (p < 0.01). The outcomes since the introduction of interbody serrated spacers and additional posterior grafting have been significantly improved: for private patients, 86% now vs. 62% (p < 0.002).
The introduction of ramps improved the non-union rate from 16.3% in the first 86 patients to 8.3% in the next 84. The addition of posterior grafting improved the non-union rate to 1.0% in the next 198 patients. There have been no non-unions since the introduction of AGF.
Serious complications included three deaths, five deep infections, eight early returns to theatre for radiculopathy, four partial and one complete foot drop, four CSF leaks and one pulmonary embolus. Of the patients surveyed, 123/131 or 94% considered the surgery worthwhile and 88% said that they would have it again, if necessary.
The disc has been implanted in 39 patients in our clinic. This group includes 19 males and 20 females (mean age 39.8 years, range 26 to 54 years). The primary study inclusion criteria were single-level symptomatic disc degeneration, failure of at least six months of non-operative treatment, and no previous surgery at the operated segment. Outcome measures included neurological examination, radiographic assessment, Oswestry Low Back Pain Disability Questionnaire, visual analog scale (VAS) assessing pain, SF-36, and work status. Data were collected pre-operatively, and at six weeks, three, six, and 12 months post-operatively. To date, 22 patients have reached the 12 months follow-up point.
Up until now most spine surgery has been salvage (correcting the effects of trauma, stabilising correcting deformity, fusing degenerative segments) not restoration of normal function. As new alternatives to fusion come to fruition, we now have the ability to truly restore the spine to normal function. Spinal arthroplasty is a new concept and includes total disc replacement, nuclear replacement and there are efforts by investigators looking at posterior element reconstruction or facet replacement.
The results so far indicate good to excellent in 84% of cases. Complications have the potential to be catastrophic but attention to surgical detail results in minimal complications which will be discussed in the body of the presentation.
Pseudarthrosis – 3%–36% Graft collapse – 3%–14% Graft extrusion – 0.5%–4%
These figures are regardless of the graft source and are significant. Recent studies show that the combination of graft and anterior plate fixation virtually eliminates the complication of graft extrusion, and also decreases the risk of graft collapse and development of pseudarthrosis. There are also studies that contend that plate fixation can maintain proper lordotic alignment of the spine more effectively than can ACDF without plating. I contend that the use of contemporary cervical plates significantly decreases the rate of fusion failure and graft-related complications without imparting significant implant-related complications.
As a result, there is decreased overall risk to the patient.
The current type of plates which are available are unicortical with locking systems that substantially decrease the risk of screw loosening or hardware migration.
Pain management has remained a challenge for surgeons since the dawn of organised medicine. A massive influx of unproven techniques and alternative therapies has descended upon us with little regard to true efficacy and even safety. It is incumbent upon us as practitioners of medicine to finally begin to pay more attention to the tenets of evidenced based medicine while making therapeutic choices.
Johns Hopkins has had a long history of dealing with pain in many of its chameleon forms ranging from the management of acute post-operative pain to the more difficult management of chronic pain. To effectively manage pain in a surgical practice requires attention to first establishing the type of pain (ie. nociceptive or neuropathic). Once the type of pain is clear, specific algorithms can be worked out based on the principles of evidenced based medicine which can be carried out by a variety of paramedical personnel (ie. Physician Assistants or Nurses) without specific surgeon input. This maximises benefit to the patient and minimises problems for the surgeon. Specific algorithms for the management of acute LBP, chronic LBP, acute postoperative pain, chronic postoperative pain, cancer pain and sociopathic pain will be discussed.
This paper presents a review of 10 patients with severe thoracolumbar burst fracture or fracture dislocation managed since 1997, using a single stage posterior decompression, realignment and stabilisation/interbody fusion.
-Tracheal compression with laryngeal nerve palsy; -Esophageal compression with endoscopic implications. (
Dorsal syndromes: painful ankylosis, spinal stenosis &
myelopathy (
Lumbar syndromes: painful hyperlordotic ankylosis, spinal stenosis (
Sacroiliac fusion (
Extra spinal calcifications: peri articular at elbow, hips and in operative scars: Achilles’ repair; Post-laparatomy abdominal wall ossification (
Particular features: early onset (age 40); incidence in families with two brothers and another with three brothers.
Poly-axiality is a common feature to all the implants of this system; it greatly facilitates placement of the implants and allows to apply traction simultaneously to all the anchors, which results in progressive, gentle reduction. Simultaneous traction application ensures adequate correction of the thoracic kyphosis (gain of 18°). As a matter of fact, severe kyphosis can be bent into the rods, and translation of the vertebrae towards the rods is very easy. Adequate reduction of the main curve results in correction of the underlying lumbar curve and shifting of the first uninstrumented vertebra into a more horizontal position.
Technology has grown at a logarithmic pace during the last century. The ability to accommodate these challenges in today’s operating theatre has become problematic. A specific task force has been established at Johns Hopkins to deal with these issues proactively.
The operating room of the future must be able to integrate technology with continuous attention to modern day economics. Contributions from surgical staff must be combined with input from administrators, architects, and industry. Physician surgical administrators are perhaps the best compromise to spearhead such projects.
I will introduce the concepts of interstitial space, imaging track systems and surgical workstations to stimulate thought and discussion.
There is a very long way from diagnosis to treatment of the developmental dysplasia of the hip. Everything is complex: clinical examination is subtle and requires a long training. Treatment is not as simple as could be thought. The risks include approximate examinations and of standard, ready-made ones. The discussion has not been settled as to whether all children with hip instability can be clinically detected at birth. The complexity of the problem arises from the fact that only 10% of children who have instability at birth develop long-term problems if they are left untreated. It is well known, affirmed by several different studies that at birth the incidence of hip instability in approximately 1–4% of patients, with figure being higher in girls. There is also a consensus that a large majority of these unstable hips will become stable during the first few days of life, even without treatment.
Some children are at particular risk of hip instability. Those infants are labeled as “high risk”. They include children born in families with hip instability, those presented by breech, first born children or products of oligohydramniotic pregnancies, particularly girls, those with the generalized joint laxity, those with torticollis and scoliosis, those with foot deformities and increased birth-weight over 4000g. Whilst all children should be screened at birth by a doctor experienced in clinical examination with particular attention directed to those children, who are considered high risk.
It must be emphasized that
The D.D.H screening programme until the second half of ’80 was based on the clinical Ortolani-Barlow’s manoeuvre at newborn age and by xray examination of the pelvis at three – four month old to discover hip joint anomalies that could be address at a future dislocation. Never less the so-called Dislocation of the Hip was a quite common pathology around Europe. The close reduction of a dislocated hip has been the treatment of choice in order to attempt to reduce a dislocated hip without surgical operation. Close reduction was preferred to be obtained after a period of skin traction on bed, at which a special frame were added, to perform a progressive gentle reduction gaining, in an average of three weeks time, complete abduction before applying a spica cast. Two main methods were used: reduction with the hips extended, abducted and internal rotated according to Sommerville- Petit and reduction in over head position with the hips flexed, abducted and external rotated. These two systems were designed to decrease the Avascular Necrosis of the femoral head that often occurs if the reduction was obtained during a sudden manoeuvre under general anaesthesia.
Generally the correct position of the femoral head into the acetabular socket, at the moment to apply the plaster, was assessed by an arthrogram, to avoid the bad surprise of further dislocation due to false reduction after the traction period.
The child so treated had to be followed during her/his growth to assess the development of acetabular roof and the position of the femoral head linked at the antiversion of the femoral neck. Any hip joint, in which acetabular index do not improve during growth, needs acetabular and femoral osteotomies to overcome these anatomical defects as cause of a persisting genetic defect.
At the end of ’80, a deep change of the natural history of D.D.H. in Italy is related to the introduction of screening programme based on accurate clinical examination of the hip of the babies at the nursery, selection of babies with risk signs of D:D.H. such as clinical anomalies, instability of the hip at Ortolani-Barlow’s, familiarity for D.D.H. and breech delivery. The hips of those babies are immediately assessed by ultrasonographic examination according to Graf’s method. The general population, on the contrary, is examined by US between the second and the third months of age. The National Health Service encourages the US screening paying its cost. In this way the incidence of late-D.D.H. and late-dislocation is enormously decreased and the outcome of the pathology has been improved. The conservative treatment of the hip affected by different grade of anomalies early discovered trough US examination, in fact, are treated by simple harness in abduction for mild dyspalsia to plaster spica cast in human position if the hip is severely unstable and Ortolani positive. There are same rare cases of true Congenital Dislocation at birth that can not be conservatively reduced and it will be necessary to perform a open reduction generally when the ossified nucleus of femoral head appeares.
From 1975, when our Children Orthopaedic Department was created in the Medical School of “Federico II” University of Naples and the first authors become the Chief, we admitted 374 patients affected by dislocation of the hip (F=308 – M= 66 F:M= 5:1) with a mean age of 7 and half months (min.4 mths.– max 20 mths). All these patients were put in traction on the Morel’s bed in order to attempt a close reduction in extended, abducted and internal rotated position according to Sommerville- Petit method.
Average time of traction was 25 days (min. 7 max 38). 120 patients were undergone at an arthrographic examination in general anaesthesia. 46 patients did not achieve the reduction and were operated on.
A spica cast were applied for 60 days followed by an harness in abduction. Total amount of time of treatment was a mean of 7 months (min 110 days max. 12 months). Residual dysplasia was observed in 48 patients that needed a further surgical procedure.
The number of inpatient affected by D.D.H. were an average of 21 per year until 1990 to drop dramatically at 3 per year in the last decade. On the other hand the D.D.H. outpatient clinic increased. The selected babies examined were 6930 at an average age of 4 months old. All the babies were undergone to clinical and Us examination and classified according to Graf. Hip anomalies were seen in 630 babies. The treatment was related to clinical and Us observation. Simple abduction pillow or simple harness in abduction were used in hip clinically negative at Ortolani-Barlow’s manoeuvre and 2c or 2b type according to Graf.’s classification. Milgram harness or Coxaflex harness (Thamert –Burgwedel –Germany) or plaster spica cast in “human position” were applied in instable hip type D or worse and clinically positive at Ortolani-Barlow manoeuvre. 25 patients were hospitalised because affected by irreducible hip.
The experience that we have done over decades in treatment of D.D.H. confirms the assumption of Treadwell and Bell (1981) that claimed that D.D.H. screening deeply changed the natural history of D.D.H. The problem was to find a good screening test helpful to diagnose as soon as possible a pathological hip.
Graf’s method, after a decade of scientific criticism, can be elected at a worth method to screen an infant hip. Screening program based on ultrasound and clinical examination decreases hospitalisation, cost and sequels of D.D.H. in term of surgical operation and degenerative arthritis of hip joint at least at a medium follow up. The hip that need to be hospitalised are the true congenital dislocated hip for which early diagnosis probably should not effect their clinical history.
A danger is hidden in US screening. Ultrasonography has to be performed by a skill examiner and it has to be implemented by careful clinical examination with anamnestic recording of the data in order to obtain the best result of the D.D.H. screening program.
An additional pelvic osteotomy in cases of simple open reduction was performed on 17 hips (47%) and on 10 hips (31%) in cases of open reduction and derotation.
Aseptic necrosis developed in 5 cases (7.3%), but it is difficult to distinguish between pre-existing necrosis after conservative treatment and postoperative necrosis.
In the age group of 15 months to 36 months, there were 47 hip joints in 42 children. The surgery consisted of open reduction, varus and derotational osteotomy plus Salter (exceptionally Pemberton) osteotomy. The rate of necrosis was 12.8% (6 cases).
The open reduction in children older than the age of 3 was performed in 24 children (32 hip joints). The open reduction, varus and derotational osteotomy of the femur were performed in all cases. The Salter osteotomy was performed in 12 hips, Pemberton in 5, triple pelvic osteotomy in 6 cases, and Chiari was used in primary reduction in 9 cases.
The necrosis rate was 6.2% (2 cases).
In the targeted study regarding the effectivity of overhead traction, we had 90 hip joints in 76 patients. In the group of primary treatment in our institution (57 hip joints), successful reduction was reached in 80.1% of cases, but in the group of 33 hip joints where primary treatment had failed, conservative treatment was successful in only 30% and open reduction was performed in 23 cases.
We used the radiological classification according to Severin and clinical score according to Merle D’Aubigne: Severin I - excellent results − 12%, Severin II – good – 63%, Severin III – fair – 15%, Severin IV – poor – 6%, Severin V – re-dislocation, 6 cases – 4%. The necrosis rate was 9%.
In this paper operations are discussed that improve the dysplastic acetabular roof in developmental dislocation of the hip (DDH) of children up to 10 years. In the first year of life acetabular dysplasia can be treated successfully by flexion-abduction splints and plaster casts in „human position“. From the second year on, only slight dysplasias can heal spontaneously or be treated conservatively. Then the steep acetabular roof has to be osteotomized and levered down to a normal angle and coverage to avoid redislocation or residual dysplasia.
Different procedures have been described in the course of time. Two osteotomies are chiseling in the anterior to posterior direction. Salters innominate osteotomy levers the whole acetabulum with the lower part of the pelvis in an anterolateral direction around an axis passing through the pubic symphysis and the posterior part of the osteotomy. In Pembertons osteotomy the hinge for turning down the acetabular roof is the last, posterior, transverse cortical segment over the tri-radiate cartilage, short before the sciatic notch.
Osteotomies chiseling from lateral in medial direction have been described already by Albee (1915) and Jones (1920). Lance (1925) propagated this technique in Europe. Here the acetabular roof is partially osteotomized in a thickness of 5–7 mm. Only the lateral part of the acetabulum is brought into the horizontal position. Wiberg in 1939 used this technique, but in 1953 he was the first to publish a full osteotomy what Dega called 1973 a transiliac osteotomy. Dega had originally learned the technique of Lance, but in 1963 when he reduced high dislocations after the technique of Colonna, he performed also a full transiliac osteotomy. After the Symposium of Chapchal in Basel 1965 we started in Berlin also with the complete acetabular osteotomy. With the control of an image intensifier the blade of the osteotome is driven toward the posterior rim of the tri-radiate cartilage leaving only a small bony rim above. Anteriorly the blade passes through the ant. inf. iliac spine. Posteriorly it just enters the sciatic notch. Here we check the blade position by direct palpation. The acetabulum is bent down partly in the small rim of bone left and mainly in the triradiate cartilage. Angles up to 50° have been achieved, which you cannot reach by other techniques.
In the beginning we have combined after Mittelmeier and Witt this acetabuloplasty with a varus osteotomy of the femur. In our long-time follow-up (Brüning et al. 1988,1990) however, we found in almost 50% a subcapital coxa valga or a so-called head-in-neck-position of the femoral head. Then we avoided varusosteotomies and had good results without it (Pothmann).
To keep the acetabular roof in the new position we used first bone wedges from the varus osteotomy, then deproteinized bone wedges from animals, and today deep frozen wedges of human femoral heads of the bone bank, sterilized at 121 degrees C for 20 min. (Ekkernkamp, Katthagen). A firm layer of cortical bone laterally is necessary. Reinvestigations have proven the stability of this material too ( Pothmann). This type of acetabular osteotomy in our and other authors opinion is the best. Salters osteotomy is not as efficient in severe dysplasia. And in older children it produces a decrease in anteversion of the acetabulum, which may limit internal rotation of the hip and cause osteoarthritis if it does not improve. In Pembertons osteotomy one cannot use the image intensifier, which is of great help to perform the osteotomy exactly and also the levering of the acetabulum to the optimal coverage.
Our first long-time follow-up of children with additional varus-osteotomies (Brüning et al.) reviewed 90 hip joints in 67 children. The age at operation was in average 3.6 years, the age at follow-up 15 years.
In our study group of hip dysplasia we introduced a score of normal values of hip measurements and 3 grades of deviation from normal, slightly pathological, severely pathological and extremely. When we counted normal values and slightly pathological ones together as a good result, we found for the different measurements of the acetabulum percentages mainly between 82 and 93 %. Remarkable were two measurements of the femoral neck, the epiphyseal index with only 50 % of normal and slightly pathological angles and the head-neck index with 47.7% respectively. This was due to the head-in-neck position of the femoral neck after varus osteotomy as we have mentioned already.
Acetabular coverage is achieved best in transiliac osteotomies up to 10 years. Then, only by triple pelvic osteotomies the acetabulum in total can be redirected to a normal coverage. But this operation is more difficult. Residual dysplasias therefore should be treated as early as possible in the way demonstrated here.
In early secondary arthritis due to femoral dysplasia, varus osteotomy achieves a control of arthritis for two decades in 80 % of cases : it is therefore a very reliable conservative treatment. Moreover, in carefully selected cases of severe arthritis in young active patients, a valgus osteotomy can achieve pain relief for a decade in 70 % of cases.
A –
1) Four factors are mandatory to achieve long term improvement:
The arthritis must be the There must be a real The articular The possibility of articular
2) Therefore varus osteotomy is
in a non symptomatic dysplasia (as some of them may not lead to arthritis), or if the symptoms are those of a labrum syndrom, with suddent pain, instead of a progressive and mechanical arthritic pain. if the dysplasia is only acetabular : then only the acetabulum has to be treated. if the anatomic abnormality is not an increase of the inclinaison (neck-shaft) angle, but a modification of the head-neck angle, which causes impigement with the labrum, and which is not improved by inter-tro-chanteric osteotomy.
3) The
If there is a femoral hyperanteversion there are two different conditions in the adult : if the patient walks with internal rotation of knees (convergent strabismus of patella), realising a dynamic correction of hyperanteversion, the association an external rotation of the femur to the varisation is recommended. but if, despite hyperanteversion, walking is without abnormal rotations of the knees, this means that the optimum congruity of the hip is in that position. An ostotomy is no advocated as, instead of retroversing the femoral neck, it would rotate externally the femoral shaft. If there are both an acetabular and a femoral dysplasia, they both have to be treated : if an augmentation is recommended for an anterolateral defect, the shelf osteoplasty can be performed in the same operation that the varus osteotomy. if a medialisation is necessary (Chiari), both osteotomies can be assosciated in one stage. but if a complex reorientation osteotomy is necessary (either periacetabular –Giacometti-, or pelvic –Ganz-), it could be hazardous to perform a varus osteotomy at the same time.
B –
The importance of the varisation depends on that of the coxa valga. The final inclinaison angle must be 125°, as the lever of arm of the abductors is impaired for a lower angle. Moreover there is a post operative limping due to the ajustement of the glutei length, the duration of which is function of the varisation (one year per 10°). To reduce this limping, only the necessary varisation has to be made. The technic has several important points : non union is avoided by non dissection of the medial metaphysis or removal of a wedge : we use a subperiosteal osteotomy, leaving in contact the medial cortex, with a lateral opening, fixed by a nail plate as a tension band. This technique gives a minimum limb shortening (12 mm for 15° varisation). respect of the articulation and soft tissues. There is no arthrotomy as the nail plate is inserted on a guide pin. Later implantation of the THR will not be complicated by the previous osteotomy. precise, « automatic » correction, depends only on the nailplate angle. the resistance of the osteosynthesis allows immediate rehabilitation (this extra articular operation does not reduce ROM), and 10 to 20 kilos weight bearing. Full weight bearing is authorized at three months.
C –
There are less thant 5 % mechanical complications. An antalgic effect is obtained within some weeks. In 80 % of cases, painlessness and absence of radiological deterioration for two decades is achieved, a THR becoming necessary in the third decade. In 20 % of cases, only a temporary effect is obtained, leading to a THR after 5 to 10 years.
The femoral varus osteotomy remains one of the most reliable conservative operations in osteoarthritis due to DDH. However to achieve these good results, a clear understanding of the indications and biomechanical demands of this operation is required.
In seldom and selected cases of severe arthritis, a palliative valgus osteotomy can achieve a decade of pain relief.
DDH with or without previous treatment is the most frequent source of early hip OA in adolescents. Others are hip joint deformation following Legg-Calve-Perthes disease, slipped capital epiphysis or trauma. Secondary OA after rheumatoid arthritis, bacterial infection or as result of an hemophilic hip joint are relatively infrequent.
The choice of treatment depends on the type of the deformity and the severity of osteoarthritic changes. Osteotomies are favorably performed in adolescents. Arthrodesis is rarely accepted in this age group. In selected individuals THR is the matter of choice.
Pain, limping gait, restricted joint motion and sometimes clicking phemomena are the usual complains. Pain is usually aggravated by running and other sports activities.
Residual dysplasia of the hip with a spherical femoral head is best treated by a triple periacetabular osteotomy. The Bernese ostetomy of Ganz (
Chiari’s osteotomy is a supracetabular rotatory displacement osteotomy. Femoral head and joint capsule are medialised and covered by the osteomised iliac bone. The joint capsule in the weight bearing zone is transformed into fibrous cartilage by time. Congruent remodelling of the acetabular roof and fibrous tissue transformation into cartilage are biased by inproper height and orientation of the osteotomy (
In pathomorphologies with aspherical femoral heads femoral osteotomies, usually valgus osteotomies, are required additionally in order to optimize the joint congruency
A dysplastic hip in a high dislocation and moderate to severe OA are contraindications.
Radiographic work up includes pelvic ap view and faux profil view. Assessment of the anterior and posterior acetabular rim indicate orientation of the acetabulum in terms of anteversion / retroversion. Orientation of the subchondral sclerosis over the femoral head is an indicator of femoral head coverage as CE-angle and AC-angle. 20°–30° abduction view in neutral rotation mimikes the postoperative acetabulum / femoral head relation. From CT-scans acetabular orientation ( ante-version / retroversion ), degenerative bone cysts, posteroinferior joint space and femoral head deformities and femoral neck osteophytes are depicted. Labrum pathology is dedectable by MRT and MRT-arthrography.
After treatment of DDH deformation of the femoral head and neck due to ischaemic necrosis develop in an incidence up to 20 %, depending on the method. Premature closure of the epiphyseal plate can also follow trauma, septic arthritis and Legg-Calve-Perthes disease. Most often an combination of acetabular dysplasia and coxa magna with short femoral neck and a high-standing greater trochanter are typical deformities. Specchiulli’s classification (
If the abductor muscel deficit is dominant and only a minor leg length discrepancy is in slight deformities, e.g. some Specchiulli’s type B2, we do not always need such complex procedures. Isolated transfer of the greater trochanter also improves the lever arm of the abductor muscles and therefore joint function, but does not influence leg length discrepancy. Disappearance of the Tren-delenburg-type gait is the most visible improvement of this procedure (
Total hip replacement (=THR) is rarely indicated in adolescents, but sometimes necessary for restoration of a almost normal quality of life. Especially in severe symptomatic OA after septic arthritis or trauma in some individuals remain only two options : arthrodesis or arthroplasty. Arthrodesis is a permanent solution for many years or even life time. Gait function is compromised remarkable (
THR in young patients includes the risk of several revisions over life time , due to wear problems particularly in physically active individuals. A deficient acetabular bone stock as usual in severe acetabular dysplasia or poor bone quality after trauma or septic arthritis may compromize primary stability and secondary osteointegration. Nevertheless functional results and outcome (
There are numerous arthroscopic techniques available for the treatment of femorotibial osteoarthritis. Advances in arthroscopic technology have made arthroscopic treatment a widespread accepted treatment. Short-term pain relief after arthroscopic treatment in degenerative conditions of the knee has been well established, however this this not the case for the long-term results.
One of the reasons why arthroscopic procedures are well accepted is the favorable risk–benefit ratio, when compared to more invasive procedures like realignment osteotomies, unicompartmental or even total knee arthroplasty (15,16,17,18,19,21,26) Very often the arthroscopic procedure is offered to the patient as a temporizing or “time gaining” measures (11,23,24). However their efficacy is often unequal. Almost no prospective controlled studies are yet available. Arthroscopic mosaicplasty techniques as well as arthroscopically assisted autologous chondrocyte transplantations are – in this context – not regarded upon as treatment options for the
- (Partial) Meniscectomy - Chondral Shaving - Removal of osteophytes - Removal of loose bodies - Synovectomy - Subchondral drilling techniques (Pridie) - Abrasive chondroplasty - Microfracturing techniques
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Knee osteoarthritis (OA) is a major cause of pain and disability in elder people. The prevalence of radiographic OA in a population aged 35–74 years is 5–15% and about one third of involved people complain of symptoms. In the „Ulm Osteoarthritis Study“ patients undergoing total knee replacement reported a mean duration of knee pain of 10 years prior to surgery.
Multiple genetic, constitutional and environmental factors contribute to the development of OA. Initial cartilage degradation leads to joint space narrowing and early osteophyte formation which can be observed radiographically. Whether elevated subchondral bone mineral density is contributing to manifestation of the disease or just a secondary reaction process is still under debate. OA finally involves not only cartilage and subchondral bone but also soft tissues in and around the joint (synovial membrane, ligaments and muscles), which often results in painful effusions, muscular shortening and stiffness.
Many conservative treatment options have been developed in the past to relief these symptoms and to slow down or even stop the cartilage degradation process. Evidence to support the effectiveness of individual treatments, however, is variable. Recently the EULAR Committee for Clinical Trials determined an approach for the development of evidence based guidelines for conservative treatment of knee OA (
Treatment of knee OA must be tailored to individual patients, taking into account factors such as age, comorbidity and the presence of inflammation. Optimal management requires a combination of non-pharmacological treatment modalities (regular education, exercise, appliances and weight reduction) and pharmacological approaches. Paracetamol generally is the preferred analgesic and there is enough evidence to support its application, as the pain controlling effects are comparable to NSAIDS and long term application is safe enough. NSAIDS (oral or even topical) can be considered in patients with effusion. Although some studies found NSAIDS to have better efficacy than paracetamol in the treatment of painful knee OA, the gastrointestinal side effects limit their long-term application. Therefore most experts consider their application only in patients unresponsive to paracetamol and in major effusions. In such situations long-acting steroids can be injected intra-articularly as well. While the effects of steroids in knee OA have been assessed in a number of studies, the predictors of response are still somewhat unclear and further investigations are necessary.
Recent data seems to support the theory that some symptomatic slow acting drugs (glucosamine sulfate, chondroitin sulfate, diacerein and hyaluronic acid) may possess structure modifying properties. Further studies, however, are necessary to determine the pharmacoeconomic aspects of that treatment and to define the indications more precisely.
Education should be an integral part in the management of knee OA. Several large randomised controlled trials have shown benefits of different educational techniques in reducing pain and increasing coping skills. Function can reliably be improved by quadriceps strengthening exercises and there is enough evidence to show the positive effects of weight reduction on the progression of the disease process.
In conclusion, evidence based guidelines in the conservative management of knee OA exist. Orthopaedic Surgeons should have knowledge of the various approaches and be aware of the fact that certain clinical propositions are supported by substantial research based evidence, while others are not.
Osteoarthritis is the end stage of a gradual process of degradation of the cartilage and secondary responses in other tissues within a joint after many years of use. It is common in the knee joints in elderly. The surgical treatments for OA are often symptomatic, such as arthroplasty and HTO. Traumas to the knee, especially in combination with other injuries such as ACL rupture or meniscal tears, can lead to a speedy process and premature OA. The osteoarthritic patient often experiences a gradual on set of symptoms such as pain and swelling on weight bearing, catching and locking and in late stage nightly pains, leading to a very limited lifestyle. If it is possible to treat the OA at an early stage and thus hindering the destruction of the joint, much is won for the patient.
Autologous chondrocyte transplantation (ACT) is a treatment for focal chondral and osteochondral lesions in the knee joint. The technique has also been used on patients with early stages of OA in knee, including multiple lesions, kissing lesions, lesions in combination with malalignment, instability and total mensicectomy. When treating these patients it is important to not only focus on the cartilage lesions but also on other pathology. A high tibial osteotomy should be considered, especially if there is a malalignment, but also as an unloading procedure if the lesion is large or if there are bipolar kissing lesions. If the patient has had total or subtotal meniscectomy meniscal allograft transplantation may be indicated. Ligamentous instability from a ruptured ACL for example must also be treated. All these procedures can be done prior to or after the ACT, but mostly concomitant with the ACT. As the patients have often been symptomatic for a long time and the greater surgical trauma with a concomitant procedure, it is harder to regain knee function after the surgery. Close contact between the patient, the doctor and the physical therapist is imperative, so measures can be taken if the patient does not progress accordingly.
Young patients with early OA are hard cases. These patients often have a high demand on knee function and have had a high level of activity but are disabled by their symptoms. When treating these patients with ACT it is important to assess and treat all pathology that may jeopardize a good outcome.
Osteotomies around the knee are still utilized a lot in Europe and in Asia while in US unicompartmental and total arthroplasty for the same indications have more and more taken over, partially due to fear of complications. We think that with careful planning and technique the indications can be maintained. Furthermore with modern methods of cartilage repair it is of utmost importance to unload overloaded compartments. Also many young patients having suffered ligamentous tears of the knee and having been reconstructed are in need of OT’s later on.
Many of the poor results are due to absent or poor planning and to poor OT technique and fixation. Not every knee needs to be operated to an overcorrected position. While opening wedge OT has become trendy because of fewer neurological complications we think there are definite indications for closing wedge technique.
In this lecture we would like to summarize the principles and the steps which are very personal and that are based on 20 years of practice.
Indications for osteotomies around the knee
Varus Knee
Opening wedge osteotomy: Advantages: Rapid surgery, small incision, fast healing, precise correction. Indicated when:
Degree of OA moderate and angular correction of not >
8° Useful in associated MCL Instability Useful when open surgery on medial femoral condyle needed (Mosaicplasty) In case of associated ACL instability when tibial slope is not >
10° Patella alta
Has a tendency to increase the tibial slope. We use tricortical grafts from the iliac crest where the base of the wedges in mm corresponds to the degrees of correction. A cervical spine AO plate with for screws is used for fixation. Creates less deformity of the proximal tibia which is an advantage for a later total knee. Increases the intraarticular pressure even when the MCL is cut or detached distally, without us knowing the effect on the degree of OA, no long term studies being known to us.
Closing wedge osteotomy: Advantages: Allows higher degrees of correction
Degree of OA advanced, need for higher corrections Useful when open surgery on lateral femoral condyle needed In ACL instability when tibial slope must be corrected, because of need to break the medial cortical hinge a heavier implant is needed may be enforced by a sagital Ex.Fix. Patella baja
Corrections over 5 degrees need an OT of the proximal or distal fibula. We perform the resecting OT in the fibular neck, the proximal cut is incomplete removing only the anterior and lateral cortex, the distal cut is complete. This allows to shift the distal fragment proximally and in front of the proximal cortical shelf allowing nerve protection.
For fixation of the tibial OT we use the 90° angled cannulated AO osteotomy plate, that is inserted over a 2,0 K wire using a specific “transporteur” in relation to the amount of correction. The OT is done using the precise AO osteotomy jig, cutting along 2,5 mm K wires inserted through the jig. The two cuts meet 5–10 mm short of the opposite cortex.
The closing wedge OT creates more deformity, carries a certain risk of peroneal nerve injury and of compartment syndrome. Surgery must therefore been done very skilfully and demands expertise.
All the studies about long term effect of HTO have been done one using closing wedge technique.
Double Osteotomy
Indications:
For deformities of over 12° to avoid obliquity of the joint line otherwise created by tibial or femoral OT alone. When sagital deformity needs to be corrected together with frontal plane deformity, eg a flexum of 20° and a varus of 10°.
Valgus knee
Closing wedge Osteotomy of the distal femur: Advantages are the potent fixation using the same plate as on the tibia leading to rapid healing. Approach is rather extensive. Indicated:
When deformity of valgus and sagital plane ( flexion contracture) need to be addressed. When valgus is marked ( in small deformities the OT can also be performed in the tibia).
Opening wedge Osteotomy of the distal femur. Indicated:
When the deformity is small. When cartilage gestures need to be performed on the lateral femoral condyle.
Planning of Osteotomies:
We use one leg standing films in ap, pa 45° flexion, and lateral projection, varusvalgus stress films with 15 kp (Telos) and Orthoradiogramm (hip-ankle). A potential contralateral opening on the standing film is compensated on the drawing by a push orthoradiogram which virtually brings both compartments into contact.
For the varus knee the ideal crossing point of the mechanical xis sits at 30% in the lateral compartment, the centre between the tibial eminences being 0% the medial or lateral border of the tibia being 100%. This is the displacement corresponds to the classical 3° over-correction that is useful when the medial compartment is down to bone. This would be an overcorrection for the less damaged medial joint lines where however an OT may already be indicated.
We therefore have prospectively studied and validated a more balanced approach.
If the medial compartment in a varus knee has lost up to one third of his cartilage the axis is calculated to pass at 10% in the lateral compartment.
If is down by two thirds it is meant to pass at 20% laterally.
If it is totally worn it passes at 30%.
The drawing for the high tibial OT on the orthoradiogram is simple:
Connect the centre of the femoral head with the point at 10, rsp. 20, rsp. 30% in the lateral compartment and prolong this new axis of the leg distally to a point lateral of the ankle joint. Now select the hinge joint for the opening or closing wedge OT 2–3 cm distal to the joint line and connect this point with the old and the new centre of the ankle. Measure the angle between the t line which corresponds to the amount of correction and the angle to open or resect.
The planning for the varus OT of the distal femur in valgus deformity is somewhat more complicated but should aim at a correction which leaves a femorotibial valgus of 1–2°.
Using these rules one is able to reach adequate correction.
Osteotomy for medial gonarthrosis is most often done as a proximal tibial valgus osteotomy, either as a closing wedge osteotomy (HTO) or as an opening wedge osteotomy including hemicallostasis (HCO).
In case of lateral gonarthrosis the osteotomy is done as a proximal tibial varus osteotomy, closing or opening wedge or as a distal femoral varus osteotomy depending on the anatomy of the knee.
The early period after osteotomy is influenced by complications to osteotomy. Complications depend on the operative method and localisation of surgery.
Short- and long-term results are presented as knee scores or survivorship of high tibial osteotomy. Most often used scores are the HSS-score, NHP-score and the knee scores according to Lysholm and Tegner. Scores from the patient’s perspective are NHP, SF-36. KOOS (Knee Injury and Osteoarthritis Outcome Score) was introduced recently, and only short-term results are available.
Immediate postoperative results
The closing wedge osteotomy is the golden standard and reported complications are peroneal palsy in 0 – 8%, infection in 1 – 3%, fracture of the tibial plateau and delayed union in 3 – 5% and thromboembolism in 2 – 4%.
When the opening wedge method including HCO is used peroneal palsy is extremely seldom, delayed union is reported in 2%, major pin-tract infection in 2 – 20 % and thromboembolism in 2 – 4%.
Short-term results
The short-term results are generally good and one to two years after osteotomy excellent and good results are reported in 85 – 97 %. All five partial scales in KOOS with the exception of sports/ recreation function were significantly improved 3 – 4 months postoperatively.
Evaluations of osteotomies using survivorship of the osteotomy, with conversion to a total knee as the endpoint, show an expected rate of survival of 73–94% at 5 years, 51–85 % at ten years, 39–68 % at 15 years and 30% at 20 years. Analysis of risk factors show that age older than 50 years, presence of lateral tibial thrust and insufficient valgus correction were significantly associated with probability of early failure.
Evaluations using knee scores with a mean follow-up time of 5 – 10 years show excellent and good result in 64 – 80%. At follow-up 11– 15 years after surgery the fraction good and excellent knees is 55 – 60% and 16– 20 years after osteotomy a minority of the knees are good or excellent, at most 46%.
Stage of arthrosis: Good long-term results are reported for knees with early medial arthrosis with at most obliteration of the medial joint space or just minimal bone attrition. Results after HCO on knees with more advanced gonarthrosis are reported with a short follow-up and the change of osseous correction after osteotomy was less compared to HTO.
Only minimal progress of arthrosis after osteotomy is reported in most papers. The results of some studies indicate that the greater the surgical correction, the slower the progress of the medial joint arthrosis.
Alignment of the knee:
Most reports find better clinical results and less risk for failure when the osteotomy is corrected to a slight over-correction of the knee alignment. There is however no consensus on the smallest correction needed to change the load on the medial arthrotic compartment.
The condition is uncommon and a minority of the papers on osteotomy for gonarthrosis concern osteotomy for lateral gonarthrosis. The aim of osteotomy for lateral gonarthrosis is to achieve a varus alignment of the knee with a joint line obliquity, which after surgery is less than 10 degrees. That affects the method, which is either a proximal tibial osteotomy or a distal femoral osteotomy. Most often the aetiology of the deformity is posttraumatic.
Immediate postoperative results
When using the opening wedge osteotomy on tibia transient nerve palsy is reported in 9–50%. Infection is reported in 2% and thromboembolism in 2 – 4%. Pin tract infection when using HCO is reported in 2 – 20%.
In a multicenter follow-up distal femoral varus osteotomy 11 complications were recorded in 32 patients (five non unions, three deep infections and three cases with a stiff knee).
Short-term results
Short-term results one to two years after surgery are reported excellent and good in 85 – 95%.
Results 5 – 15 years
Five to ten years after surgery good and excellent results are reported in 75 − 77%, and in 11 – 15 years after surgery in 50 – 80%. Results are much better in recent reports because of better patient selection and operative technique. The tibial varus osteotomy can be used in knees with less than 12 degrees of valgus. Furthermore the tilting of the tibiofemoral joint line should postoperatively be less than 10 degrees. Otherwise a distal femoral osteotomy should be used. Persistent excessive obliquity of the tibiofemoral joint line predisposes instability with risk of compromising the result.
To summarize: Osteotomy is effective in a patient with a medial or a lateral gonarthrosis at most Stage II according to the classification of Ahlbäck, under the age of between 50 and 60 years and of high demands by reason of lifestyle and occupation.
Aim at an overcorrection so when the osteotomy is healed you should have a slight overcorrection in valgus in medial gonarthrosis and in varus when you have a lateral gonarthrosis. Furthermore the joint line obliquity should postoperatively be less than 10 degrees.
With this selection of patients and with a good surgical technique your patient can expect a probability of having a good knee in about 70 % after ten years. After ten years it is more difficult to make a prognosis for your patients knee.
There are now a number of controlled prospective trials comparing the advantages of unicompartmental arthroplasty versus total knee replacement (Rougraff 1991, Lawrencin 1991, Newman 1998, and Price 2000). These studies all favour unicompartmental arthroplasty over total knee replacement in terms of the following. The kinematics of uncompartmental arthroplasty are better and more normal for the surgery retains both cruciate ligaments with proprioceptive input. The range of motion tends to be greater in the unicompartmental group and the function better. This is especially true of demanding activities such as ascending and descending stairs, and has been shown using gait study analysis (O’Connor 1986).
The pain relief is as good, or better, with unicompartmental arthroplasty in these studies when compared to total knee replacement, and in particular there is “a better feel” with unicompartmental arthroplasty. The complications with the smaller procedure tend to be less frequent and severe and the recovery more rapid, with a potential benefit allowing for a lower cost.
There are however certain disadvantages encountered in using unicompartmental arthroplasty when compared to total knee replacement. In general there is a higher revision rate with the unicompartmental arthroplasty and this is particularly borne out in the Swedish Knee Arthroplasty Register. Using the strict criteria of Insal/Stern they suggest an incidence of 1:20 patients suitable for unicompartmental arthroplasty, and with such small numbers it is hardly surprising that there is a higher complication rate.
The advantages of unicompartmental arthroplasty in the young remains controversial. In particular there are few comparative studies (Broughton and Newman 1988).
In a small study from Oxford we have found that the pain relief and function in the unicompartmental arthroplasty group were substantially better with an age match comparison group using a patient based question score (The Oxford Knee Score 0–48). We sent the Oxford questionnaire to the HTO patients of the main proponent of osteotomy surgery in the UK, who has devoted a lifetime to perfecting the art of osteotomy surgery. These patients represent the “best case scenario” and his patients at five year follow up scored 27/48 on the Oxford Knee Score. Age match group of young uni-compartmental arthroplasty patients scored 38. Comparison of total knee replacement group would score 35, and it is of interest to note that those patients revised from a failed high tibial osteotomy to a total knee replacement raised their scores from 27 to 33. There are of course disadvantages comparing unicompartmental arthroplasty and high tibial osteotomy in the young. The main disadvantages that artificial material is implanted and there is the potential for infection. What remains debatable and controversial is the outcome of procedures when converting them to a total knee replacement. In terms of 10 year survivorship most of the published literature suggests that with high tibial osteotomy there is a two-thirds survivorship, one-third being converted to a total knee replacement by 10 years (range 51% to 80%) (Naudie 1999, Coventry 1993, Rudan 1991). The similar 10 year survivorship of unicompartmental arthroplasty in patients under 65 years is in the order of 80%. This is borne out in the Swedish Knee Registry.
In general the problem with unicompartmental arthroplasty seems to centre around a higher revision rate, and faced with this problem there are a number of solutions. One can accept this and abandon the procedure, which has happened until recently in the United States. One can suggest that a unicompartmental arthroplasty is used as a pre-knee replacement, which has been forwarded by Repicci in the States. Alternatively one can try to minimise the failure rate by employing an implant with very good wear characteristics, one can concentrate on appropriate indications and one can define an accurate reproducible technique. One can seek to achieve a survival rate that is similar to that of the best total knee replacement.
The Oxford unicompartmental knee replacement was deigned first by Goodfellow and O’Connor 25 years ago. It employs a spherical femoral component articulating on a flat tibial component. There is a fully mobile bearing, which is unconstrained. This bearing is fully congruent in all positions, which minimises wear.
In two published retrieval studies (Argenson and Psychoyios) 10 year wear rate was 0.03mm per year. In those cases with no impingement the rate was 0.01mm per year. There was no correlation with thickness and we now feel comfortable advising a 3.5mm bearing for long term survivorship.
The indications for unicompartmental arthroplasty in essence centre around medial compartment osteoarthritis with a functionally intact ACL. Some superficial damage to the ligament is acceptable, but in essence the structure needs to be intact to be functioning. There needs to be a correctable varus deformity with full thickness lateral compartment articular cartilage and this is best demonstrated on stress x-ray. A fixed flexion deformity of less than 15° is usual and employing the above indications we find that a unicompartmental arthroplasty is suitable for 1:4 knees presenting with osteoarthritis.
We do not feel that the state of the patellofemoral joint is a contraindication to unicompartmental arthroplasty. We have significant evidence to corroborate this statement. In Mr Goodfellow’s published series in 1998 the state of the patellofemoral joint and the clinical results did not correlate. The study by Weale (1999) there was no progression of patellofemoral osteoarthritis over 10 years. On the Swedish Registry there have been no cited revisions for progression of patellofemoral arthritis.
The age and the activity of the patient does not seem to be an obvious contraindication. In particular in the old and unfit using the minimal invasive approach there is a low morbidity, with all its attendant advantages. In the young patient (less than 50 years), the 10 year survivorship is 92% in two published series (Murray et al 1998 and Price 2000).
The published 10 year results of the designers patient (Murray et al 1998) details the follow up of 144 unicompartmental arthroplasties with a 10 year survivorship. At 10 years there were 34 knees at risk giving a 98% 10 year survivorship 95%, confidence levels 93–100%. There was one case lost to follow up giving a worse case scenario of 97%.
Of much more relevance concerns an independent series from Sweden (Svard et al 2001). These series is of 420 Oxford unicompartmental arthroplasties from a single centre performed by four surgeons. None lost to follow up. A 10+ year follow up involved 122 Oxford unis reviewed, with 92% good or excellent HSS scores.
The 15 year survivorship was 94% with confidence levels 86 to 100%, there were none lost to follow up so the 15 year worse case scenario was 94%. This is better than fixed bearing unis and as good as the best total.
The Swedish Knee Arthoplasty Register however gave a different picture, and was published in 1995 (Lewald et al), reported poor early results with no learning curve and advised that the difficult implant should not be used. We in fact have gained data from 944 rather than 699 from the register. It concluded that at these centres they had very reasonable results, but one or two centres had catastrophically poor results, in the order of 30% failure. We can only conclude that these poor results were due to inappropriate indications or technique. More recently in January 2001 Robertson et al have published an update of the Swedish Knee Arthroplasty Register citing good to excellent results in those centres performing more than 23 Oxford unicompartmental arthroplasties a year. Good results were possible, but there is a definite learning curve.
The phase 3 tradition of the Oxford was introduced in 1998. The aim of this introduction was to make the operation simpler and more consistent. We have consistently employed a minimally invasive approach, but we have sought to keep the advantages of phase 2 Oxford unicompartmental arthroplasty. In effect there has been minor modifications to the instruments with an increased range of sizes.
Our early phase 3 results, published in 1999 (Price et al) have compared the early recovery. This is the time taken to functional recovery, by which time the patient is ready for discharge. We compared the first 40 minimals with the last 20 opens and used 40 knee replacements taken as controls performed at the same time. We have shown that the minimally invasive unis recover three times faster than the totals (p< 0.001) and twice as fast as the open unis (p< 0.001).
Finally our one year follow up of the first 58 phase 3 Oxford unicompartmental arthroplasties reveal increase in the mean flexion from pre-operative 123° to postoperative 135°. A high proportion of the patients gained at least 130° of flexion and 50% were 140+. A mean AKS score rose from a pre of 37 to one year of 98. The AKS function score raised from a pre 53 to one year 94, with a very high proportion of patients scoring 95+ score out of 100 on the AKS.
In summary unicompartmental arthroplasties offer many potential advantages over TKR in terms of:
- Recovery, function. - The best long term results of uni (Oxford) are now as good as best TKR. - Unis in general are technically demanding and there is a definite learning curve.
Treatment by TKR of severe deformities : fixed varus or valgus knee, or flexion contracture, sometimes combined (valgus and flexed knee as for example in rheumatoid arthritis) is frequently a difficult challenge. Seldom a flessum, recurvatum or malrotation have also to be managed.
These deformations, articular, extra-articular or combined can be observed in knee arthritis associated with malalignement, malunion of diaphysis, malunion of lower part of the femur or upper tibia after fracture or osteotomy, chronic juvenile arthritis or rheumatoid arthritis, Paget’s or post-rachitism disease.
In 60′ and 70′ the most difficult cases have been frequently treated by hinge prosthesis with a high percentage of infection and loosening; many of the other cases treated with customary prosthesis had a poor follow-up because instability, luxation, patellar problems, pain or recurrence of the deformity.
Now to obtain the best prosthesis survival rate , the well trained orthopaedic surgeon has to make a good radiographical and clinical examination and the a good planification with the good choices:
- necessity or not to perform, as a first stage, an osteotomy of femur or tibia to correct a mal-union or a deformity in frontal, sagittal or horizontal plane - type of prosthesis ( constrained or not, PCL sparing or sacrificing, mobile bearing ), - medial or lateral approach, and then Keblish procedure or not; tibial tubercle osteotomy or quadricepsplasty in stiff knees; - sequence and level of tibial and femoral cuts; always perpendicular, for us, to the mechanical axis , - different steps of release of lateral, or medial and sometimes posterior ligamenteous and capsular elements, with many controversies for lateral compartment (iliotibial band, collateral lateral ligament, popliteus, posterolateral capsule, biceps tendon ) - necessity of medial ligament advancement or thightening when distension in severe valgus knee, - repair of bone loss by cement, or more usually by bone graft or metal wedge.
ARTICULAR OR PARA ARTICULAR DEFORMITIES
1) FIXED VARUS KNEE
Treatment of this deformation is usually not so difficult. In case of postero-stabilized prosthesis implantation, after removal of medial condylar and tibial plateau osteophytes resection of PCL and release of semi-membranosus tendon and postero- medial capsule are performed. Pes anserinus and collateral medial ligament release creating a subperiosteal elevation of the medial envelope is sometimes needed for good soft tissue balance; in such case a constrained plateau can be useful.
It is also possible to try PCL sparing but a good tightening of PCL is difficult and reconstruction by bone graft, metal wedge or cement or medial tibial plateau is in most cases necessary to protect tibial insertions of PCL.
2) FIXED VALGUS KNEE
We prefer the Keblish approach to have a direct look on the tightened formations (iliotibial band, lateral collateral ligament, popliteus.
We agree with the Krackow’s classification of valgus knee in 3 groups.
postero-stabilized prosthesis needs a release of lateral side; the tibial cut perpendicular to mechanical axis resecting bone to the bottom of the lateral defect takes off a too big amount of bone on the medial tibial plateau to have a safe support for metal back. If bone graft of lateral plateau is done to avoid this fact a constrained insert is potentially necessary.
implantation of a PCL sparing prosthesis with also release of lateral soft tissue, and reconstruction of medial tibial plateau and eventually condylar bone loss. For stability of the knee PCL acts as a collateral ligament. correction of the deformity by a new tibial osteotomy and after its consolidation implantation of the prosthesis some months later.
tibial osteotomy and prosthesis can be performed during the same operation, using a long tibial stem, cemented or not to stabilize the osteotomy site.
3) FLEXION CONTRACTURE
Correction of the deformity can be difficult when flexion is more than 30 or 40 degrees; PCL is not always an obstacle for correction. Sometimes initialy anterior bony deformity of the upper tibia has to be resected , especially in rheumatoid arthritis. After regular cut of the distal femur and removing of posterior osteophytes and loose bodies, elevation of posterior capsule from the distal femur is less dangerous than transverse incision of its middle part. If needed proximal attachements of gastrocnemius can also be stripped from the femur. Then if knee extension is not possible with trial component the tightened PCL has to be sacrified, or released or lengthened for some surgeons wanting to spare it. Finally a choice between lengthening of hamstrings and pes anserinus or a new cut of distal femur is necessary with use in some cases of a more constrained tibial plateau. For good tracking of patella lateral retinacular release is also mandatory.
4) FLESSUM, RECURVATUM, MALROTATION
Small flessum or recurvatum in metaphyseal area can be managed with the femoral anterior and posterior distal femoral cuts or tibial cut with sometimes incidence on prosthesis choice and biomechanical consequences.
Malrotation around 15 degrees can also be corrected by implants positioning, and perhaps a little more than 15° using a mobile bearing prosthesis.
EXTRA ARTICULAR OR COMBINED DEFORMITIES
In this type of deformity it can be necessary to perform in the same or in two separate operations its correction by a diaphyseal osteotomy preferably at the site of the deformity.
It is mandatory to have a good fixation of the bone to allow a quick and strong rehabilitation of the knee after prosthesis implantation. Plating, nailing or stabilization by the stem of prosthesis can be used.
At the present time the trend is to reach good correction of the deformity and implantation of the prosthesis at the same time even if the deformity is extra-articular; this challenge can be difficult.
Condylar knee prostheses were designed over 25 years ago, as it became evident that the hinge prostheses previously developed were unsatisfactory because of their marked potential for loosening and femoropatellar problems.
There are currently several hundreds of different types and subtypes of condylar prostheses available and more are being introduced on the market place every year. Continuous technical development has become a familiar feature with high technology products; does this also apply to knee prostheses?
The basic designs of condylar knee prostheses already existed 25 to 30 years ago, with the Freeman-Samuelson knee implanted in 1970, the Total Condylar in 1974 and the Insall-Burstein posterior stabilized knee in 1978. Long term results are now available for these prostheses as well as for others that came next: overall, survival rates between 84% and 98% have been reported with follow-up from 10 to 25 years. Will newer implants do any better? It will take that long to know, as it has been repeatedly demonstrated that theoretical studies or tests on knee simulators are not really predictive of the in vivo behavior of an implant.
The wide variety of current implants evidently reflects commercial interests. Each of the current prosthetic knees represents a more or less unique combination of a number of features related to the geometry of the articulating surfaces, including the trochlea and patella, the resection, preservation or substitution of the posterior cruciate ligament, the type of fixation to bone; most have a modular fixed tibial bearing, with various types of fixation to the underlying metal baseplate, and an increasing number of others have a mobile bearing with restrained or unrestrained mobility in rotation and/or in AP translation. The introduction of new knee prosthesis should hopefully provide some improvement in terms of function, range of motion, and implant survival as compared with the existing knees. Such improvements have proved very difficult to demonstrate on an objective basis, all the more as the results achieved with a specific implant do not only reflect its design, but also a number of manufacturing and processing features, and also the way it has been implanted.
We have learned a number of lessons from past failures such as
- the importance of selecting adequate materials - the importance of an optimal manufacturing of implants (surface macro- and microgeometry, rugosity, - the importance of an adequate sterilization technique for polyethylene - the importance of a good trochlear design - the dangers of resurfacing the patella using a metal-backed component.
Surgical technique has substantially improved over the years, not only because better instrumentations have been developed, but also because we have come to a better understanding of the anatomy and physiology of the arthritic knee before and after arthroplasty.
The rotational positioning of the femoral component has been extensively studied, and is now a regular feature of the operative technique. This, together with other technical factors such as improved design of the prosthetic trochlea, has to a large extent cleared the femoro-patellar complications which marred the results of some early designs. Techniques for ligament balancing in the varus or valgus knee have become systematized.
The issue of preservation or substitution of the posterior cruciate ligament is still a matter for debate, but we now know that it is unrealistic to expect restoring normal knee kinematics with prosthesis when both cruciate ligaments are not intact. Posterior stabilized prostheses have been shown to provide more predictable kinematics than others intended to be closer to normal physiology.
To summarize, advances have been made over the past 30 years regarding a number of elements among which implant design was probably of lesser importance than better understanding of the anatomy and physiology of the knee, better understanding of ligament balancing and operative technique in general, as well as improved manufacturing and processing of implants.
Despite of improved operative technique, ultra-clean air in the operating theater and systemically administered as well as in bone cement loaded antibiotics, septic complications after replacement arthroplasty of the knee still exist. Depending of the follow-up time in different reported series insidence vary from 0.5 to 5 per cent.
Classic clinical symptoms, painful, swollen knee joint, possibly fever, indicate to more accurate examinations.
Lesson to learn:
Prosthetic infection can be classified in many ways. The following classification is useful for the treatment purposes.
1. Early postoperative infection less than 4 weeks after surgery.
superficial deep extensive soft tissue defects due to skin necrosis
2. Originally patient is operated for aseptic loosening, but intraoperative cultures are positive.
3. Late chronic infection
4. Acute hematogenous infection
1. Clinical examination:
- symptoms can be suppressed by painkillers or immunomodulant drugs - wound healing problems - sinuses - swelling, redness - pain - temperature increased
2. Blood chemistry:
ESR, C-reactive protein and blood white cell count/ differentiation are helpful.
Be ware if the patient has such a general disease, which increases fex CRP
3. Routine x-rays. In early cases no significant signs, in late cases might appear erosions or cysts.
4. Isotope scintigraphy. Technetium- or indium labeled leucosytes are given intravenously
The patient is scanned 24 hours. Extended scintigraphy seems to be more sensitive than routine 6 to 8 hours‘ scintigraphy.
5. Joint aspiration.
One has to sure, that the patient is not on antibiotics. If she/he is, antibiotics has to be stopped for two to four weeks, and aspiration performed after that, unless infection is not clinically obvious or situation is not life-threatening
White cell count/differentiation can be for some help. When the cell count is less than 2000/ml, and majority of cells are mononuclear, the result is indicative negative for infection. White cell count over 10000/ml, and majority polymorphonuclear, speaks for infection.
When the aspiration has been carried in aseptic condition, positive culture is strong evidence for infection.
Adequate handling of sample is important: as little as possible air in the syringe and as short as possible time used for transportation to lab.
Treatment protocols can rather straight forward: if any sample culture is positive,
Two-stage revision arthroplasty is carried out. But also more conservative opinions are reported.
1.a. Early postoperative, superficial infection:
Surgical débridement of the wound.
Careful examination of retinaculum layer. Lavage and wound closure if possible. Systemic antibiotics. Joint puncture and aspiration through healthy skin area, never through open wound.
b. Early postoperative, deep infection:
Open débridement and careful lavage with retention of prosthesis. Additional peroperative samples for culture in order to confirm earlier pathogene definition.
Systemic antibiotics regarding sensitivity estimation. Arthroscopic debridement and lavage has not proved to be better or neither as good as open. New aspiration 4–6 days after. If white cell count clearly over 10000/ml and possibly culture positive, new debridement and lavage. If third debridement comes necessary, even without bony changes, removal of prosthesis and antibiotics- loaded spacer has to be considered.
c. Dehiscense of wound or soft tissue defect due to the necrosis:
Wound débridenent, antibiotics and depending on the extend of defect either partial closure, skin grafting or pedicled gastrocnemius muscle flap is performed.
2. In some cases there is no signs of infection, and the is operated as an aseptic loosening. In all revision, routineously 4 to 5 tissue samples should be taken for culture. If preoperatively there is any doubts about infection, histological examination of frozen sections should be carried out. If there are high count of polymorphonuclear cells, results of culture has to be waited. If later on in minimum two samples same pathogen is growing, the case has to be considered as infected. Two-stage revision protocol is recommended.
One positive sample cannot be regarded as a concluding proof. Long term antibiotics is recommended.
3. Late chronic infection has insidious , slowly progressing onset. Symptoms can be confusing mild, and can lead to misdiagnosis. Method of choice is débridement, removal of the prosthesis and all bone cement, and placement of an antibiotics-loaded cement spacer. No dead space is left , but has to be filled with antibiotic-loaded collagen or antibiotic-cement beads. The patient is put on systemic antibiotics, preferably combination of two. Antibiotic therapy is continued six- to eight weeks. Healing process is controlled with ESR and CRP tests. If the blood test normal and clinical situation is normal, delayed revision arthroplasty is performed. Antibiotic loaded-cement is always used.
4. Acute hematogenous infection. Onset is usually acute and symptoms dramatic.
Sometimes distant focus can be found. If the history is rather short( less than 14 days) open débridement, retainment of prosthesis, antibiotics-loaded collagen filling of the joint as well systemic antibiotics is recommended. Recovering is monitored by blood chemistry and repeated joint aspiration and cultures. If in aspiration sample there is high polymorphonueclear count and culture possibly positive, new débridemand is carried out. If signs of infection still continue, two-stage exchange to be considered.
Gram-positive
staphylococci are most frequent patogene in total knee replacement infections (95%).
Gram-negative
bacilli cover the rest (5%). Coagulase-negative staphylococci has grown up the most important bacteria, and it‘s resistance against antibiotics has turned frightening.
In cases with short history retainment of prosthesis can be considered. Many authors change of polyethylene bearing.
In two-stage revisions static antibiotic-loaded cement spacer was used during
The six to eight weeks‘ interval. Static spacer is connected with extensive bone loss as well as stiff causing problems in secondary revision. Molded cement spacer is used in order to avoid complications and to achieve better functional results.
In some cases treatment of infection is unsuccessful. Arthodesis with method of Ilizarov or intramedullary nail or sometimes above-knee amputation comes necessary.
The outcomes of any procedure in our clinical practice have to be looked upon in several ways:
a.The benefit the individual obtains from the procedure, in respect to the quality of life or well being.
b.All these gains, if they are produced, must have a cost inferior to the ones that had occurred if the operation had not been done: (medical and social costs).
c.The changes observed in pain, mobility and stability of the joint before and after the operation.
d.The changes in the individual functional state: what the patient can do in his normal life activities (walk, stairs, fasten shoes, personal wash-up, etc) and any needed help for a normal daily living.
e.Length of time the procedure will be holding the results, and the necessity of revision (survivorship), depending on the clinical state and the radiographic studies (migration, inclination, subsidence, lucent lines in the surfaces, etc).
The aspects on well-being and cost-benefit after the total knee replacement have changed for better in a parallel way to the improvement on the function of the knee joint and the function of the body as a whole. We have recently studied the first two (a and b) outcome measures with positive results, that compare well to the published ones.
In considering others aspects or measures of the outcomes, we agree with M. A. R. Freeman that the year 1980 could be the milestone for looking back and forth in the history of total knee replacement. Before 1980 the number of early failures was high, mainly due to sinkage and inclination of the tibial component, wear of the components, instability of the joint, and patelo-femoral pain.
We did work on the design of a new method of fixation for the tibial plateau from 1980 to 1988, because of the many publications on bad results due to tibial loosening; our method of fixation was based in an intramedullary elastic, press-fit, stem, trying to avoid the fixation on the tibial surface, mainly because the trabecular bone was weak to stand the weight pressures, and because it was very difficult to cover all the surface of the tibia cut (the tibial not only differs in size but also in shape).
Following the introduction of the ligament tensor by Freeman and the use of the “gaps” technique by Insall, in order obtain hte proper ligament tension and equal flexion and extension spaces and proper joint alignment, the short-term results published made us think that the tibial plateau problems were due more to bad surgical technique, that to other causes; we, therefore left aside our work.
The functional results since then have shown little changes; we have not obtained more flexion or stability, and the patello femoral problems have not improved much. The different new designs have more to do with early wear of the polyethylene and consequent osteolysis and instability, than with function.
The challenges of the future, in order to get better outcomes are:
1 and 2 should be addressed with a better geometry of the components. Practically every design and every technique change the geometric arrangement, specially, of the distal femur.
We change the troncoconical (medial bigger than lateral) shape of the condyles into a cylindrical one; we change the oblique hinge into a normal one; we do not allow space for the lateral condyle to run backwards and forwards on the lateral tibial plateau in flexion and extension. This last problem is made even worse by the tension of the lateral ligament in flexion of the knee.
If we had all this into consideration we could get more flexion and better patellar tracking. Actually, we are working on this subject.
The issue 3 on the radiolucent lines: the coating of Hydroxiapatite might finally give a better fixation than cement. Hydroxiapatite resists the micromovements better and its interface membrane dissapears in favour of bone.
Total knee arthroplasty is a predictable operation. Unfortunately, there is a subset of patients who do not well and require revision surgery. The surgical objective of revision total knee arthroplasty is the same as primary total knee arthroplasty: restore the original anatomy, restore function and provide a stable joint. The operation technique itself is a decisive for the success of arthroplasty as any type of malalignment may result in pain, instability or loosening of the implant.
1.
The most important reason for revision total knee arthroplasty include aseptic loosening of one or both components. Early loosenings occur frequently as failures of ingrowth of a porous coated implant, while late loosenings mainly concentrate on cemented components, predominantly the tibial part. Another major reason for knee arthroplasties to fail is instability between the femur and tibia, caused by incorrect alignment or laxacity of the ligaments. Wear and osteolysis are the result of abnormally increased abrasion and plastic deformation of the polyethylene inlay. Usually this is a sequela of overloading through subluxation or deformity. It generally happens when the weight-bearing contact surfaces are small.
Pain around the patella may occur due to anterior displacmenet of the patellofemoral joint and is not related whether the patella remains natural or is totally replaced.
Rare complications are fatigue fractures of metallic components, femoral or tibial fractures around the implant, extreme limitation of motion or hyperextension of the joint.
The most severe complication is periprosthetic infection, which in most of the cases requires a one or two-stage revision procedure to replace the implant.
Correct axial and rotational alignment including the restoration of the right joint line is mandatory for the success of a revision total knee arthroplasty. Especially joint line elevation can result in functional disorders, therefore the use of distal femoral augmentation in revision has given more attention.
Balance of soft tissues to create equal flexion and extension spaces is another mandatory goal for revisions. Soft tissue releases can usually correct fixed angular deformities. Concerning balance by additional cuts of femoral or tibial bone one has to remember that adjustments on the femoral side can effect the knee in flexion or extension, whereas any adjustment on the tibial side will effect both. Minimize bone resection and achieving stability by stable fixation of all components of the implant are further prerequisits for the success of revision surgery.
Another criteria for success is correct patella tracking, which can on the one hand be solved by soft tissue procedures or by revising the implant. Even one has to change the femoral and tibial component, retaining a well fixed patella component appears to be a suitable option.
One of the most important criteria in revision total knee arthroplasty is implant selection. Recent publications have demonstrated that the implant-related failure rate was 25% when using implants designed for primary total knee arthroplasty, the failure rate of modified primary components was 14% and if components were used specially designed for revision the implant-related failure rate dropped to 6%. It was evident that revision implants exhibited superior performance and durability despite their use in more difficult reconstructions.
Concerning wear and osteolysis one should consider that an isolated revision of an polyethylene insert should not be performed when there is accelerated wear of the insert with severe delamination and radiographically under surface osteolysis.
The major objectives of bone grafting or augmentation blocks are filling in bony defects with biomechanically stable components to allow weight bearing and functional motion, to create an equal flexion and extension space for ligamentous stability and to restore a nearly anatomic joint line.
The use of intramedullary stems at revision surgery provides fixation of components into diaphyseal bone leading to increased stability for reconstruction. It produces axial alignment, the stems also partially relieve stresses on the deficient metaphyseal bone or allograft.
The incidence of periprosthetic infections is rather low. In early infections antibiotic treatment combined with open arthrotomy including debridement and exchange of inlay are the treatments of choice.
Late infections are best treated combining antibiotics and two stage exchange arthroplasty. Arthrodeses or amputations are extremely rare to indicate.
Many of these procedures belong to the patella including the removal of osteophytes, secondary release of the lateral patella retinaculum, secondary replacing the patella with an implant, or patellectomy.
The replacement of a worn tibial inlay is often combined with secondary synovectomy, sometimes heterotopic ossifications need to be removed for the improvement of mobility. In infected knees the placement of an inflow/outflow drain in an attempt to manage an acute periprosthetic infection or to provide relief of pain in the presence of sepsis.
Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis).
Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks.
Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal.
Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate.
Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible.
Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term
Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique.
Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface.
My talk concentrates on the practical management of wrist fractures in adults. The management of complications of wrist fractures and the management of fractures in children are covered by other speakers.
Epidemiology
Fractures of the distal end of the radius have been estimated to account for upwards of 1/6 of all fractures seen and treated in emergency rooms. Distal radius fractures are more common in women. Above the age of 50 years, 86% of wrist fractures are in women. Fractures increase in incidence in both sexes with advancing age, and usually result from a fall from level ground rather than from high energy trauma. 10% of adults older than 35 years will suffer a distal radius fracture in a 30 year period.
Historical
Up until the early 18th century, it was thought that the injury that resulted from a fall on the outstretched hand was a dislocation and not a fracture. The first author to suggest that the injury was a fracture was probably JL Petit in 1783. Abraham Colles published his article in 1814 without having dissected a specimen showing a fractured wrist. Barton described the fracture associated with his name in 1838. RW Smith described extra-articular bending fractures of the distal end of the radius in 1847.
Classification
There are very many different classifications used to describe fractures of the distal radius. The Frykman classification (1967) has been widely used in the past. It concentrates on the involvement of the radioulnar joint. The classification system of AO is useful for documenting fractures that does produce 144 possible combinations. The classification by Fernandez (In: Fractures of the Distal Radius Fernandez and Jupiter, Springer 1995) concentrates on the mechanism of the fracture and enables correlation with the management of the fracture. It is the most useful classification when deciding exactly what to do.
Imaging
Plain radiographs are the mainstay of fracture management. Good quality AP and lateral views are essential. A lateral view with the forearm angled 20 degrees towards the tube gives a better view of the lunate fossa. Tomograms can be used to evaluate the joint surface in an intra-articular fracture but has been superseded by more sophisticated imaging. Uniplanar CT produced good images in 1 plain only. The reconstructed images in second plane were always of poor quality. Nowadays Spiral CT produces excellent images with rapid acquisition and low radiation dosage. MRI scanning has its use in evaluating soft tissue injuries and also injuries to the bone that have not caused a fracture, such as a “bone bruise”. Intraoperatively it is possible to arthroscope the wrist in order to guide fracture reduction. This should only be attempted by skilled wrist arthroscopists.
Anaesthesia
In the UK, haematoma blocks have become the standard method of anaesthesia in the emergency room when manipulating fractures of the wrist. The degree of anaesthesia is somewhat unpredictable and the failure to achieve a complete anaesthesia leads to poor reductions.
Intravenous regional anaesthetic (Biers block) used to being the main form of the anaesthesia in British emergency rooms. The technique requires two doctors and was going out of fashion even before the manufacturers of Prilocaine withdrew the preservative-free formulation generally used for Biers blocks.
Axillary block anaesthesia is commonly used in the operating room but is less so in the emergency room.
General Anaesthesia is my preference for patients undergoing more than just simple manipulation.
Operative techniques
Surgeons should not limit themselves to only performing one method of stabilisation. They should be able to perform all forms. They should plan surgery in advance and should have the facility to adopt an alternative technique intraoperatively should this prove necessary.
If a patient requires a manipulation in a proper operating theatre using anything other than a haematoma block anaesthetic, then K-wires should be inserted for most fractures. There are many ways of inserting K-wires but my preference is for Kapandji intrafocal pinning.
External fixation can be used for many types of intra-articular fractures using the principle of ligamentotaxis. Most fixators are applied bridging the joint. If not put on with excessive distraction, stiffness is not usually a problem. McQueen has published on the application of nonbridging fixators which certainly has some clinical indications. In the older patient, the use of bone graft should always be considered to fill the defect left the following elevation of a fracture. The alternative is to use synthetic bone graft substitutes such as Biobon®. Sometimes it is necessary to combine external fixation with supplementary K-wires.
Internal fixation
The volar approach through the terminal part of the Henry approach is relatively straightforward with low morbidity. This is used to apply volar buttress plates.
The distal radius is approached dorsally through incisions between the extensor compartments. The routine application of dorsal plates is favoured by some. However there is considerable morbidity associated with even the modern low profile plates such as the Pi plate. Tendon rupture is a particular problem. The plate usually has to be removed once the fracture has united. An approach between the fourth and fifth extensor compartment is useful in elevating the lunate facet prior to K-wire or screw fixation. Limited internal fixation using cannulated screws is useful in stabilising major fracture fragments such as the radial styloid.
As with any other fracture, the management of distal radius fractures is determined by the biology of the patient, the configuration of the fracture and the ability of the surgeon. The biggest errors come from considering all distal radius fractures as one, or applying one management protocol to all fractures.
The major aim of this presentation is to introduce the complex medical procedure concerning wrist fractures, luxations and wrist ligaments injuries based up-to date literature and author’s own experience. In scaphoid fractures the most common one – the diagnostic problems (proper X-ray projection, repete X-ray, CT, bone scan, e.t.c.) are presented as well as the right treatment based on the bone healing pathology (different vascular topography, fracture type e.t.c.). Also the medical procedure algorithm of the fresh scaphoid fractures (Herbert’s screw, Matti-Russe method), prolonged union or pseudoarthroses (bone transplant according to Matti-Russe or Fisk-Fernandes) is suggested.
The treatment ways concerning lunar fractures (blood supply disorders and Kienböck disease), capitatum fractures (unstable fractures - open reposition + bone graft), triquetrum fracture (a mirror Bennet or ridge fracture), trapezoideum fracture, hamatum fracture (most common one – the hook) and posiforme fracture (usually coexists with other fractures) one also discussed based on clinical examples.
Due to the wrist ligaments injuries author presents the most common luxations and instabilities; the treatment of perilunar luxations, either quicke hand reposition or open repositions with simultaneous tunnel decompression is described. The wrist instabilities are presented mainly due to diagnostic problems. According to static instabilities (dissociations) the author compares static X-ray and a healthy wrist X-ray (three arcs estimation, interbone space asymmetry) while dynamic instabilities require forced position X-ray scans. The most common instabilities – VISI and DISI – are also presented from wrist biomechanical point of view.
Non operative treatment of supracondylar fractures of the humerus has almost always resulted in failure. Closed reduction followed by prolonged immobilization until union, may be associated with an acceptable X-ray but with unacceptable function because of marked stiffness. Traction and early motion preserves movement but the incongruity of the joint leads to instability, early post-traumatic arthritis and pain. Traction also requires prolonged hospital admission which is not possible in modern health care settings. Attempts at early motion without reduction, the so called “bag of bones treatment” leads to gross malunions, non-unions and poor function.
In order to function normally an elbow requires stability, a congruent articulation, freedom from pain, and a functional range of motion. After fracture one can achieve a normal elbow only after anatomic reduction fracture which is combined with absolutely stable fixation and early motion.
These fractures are classified according to the Comprehensive Classification into Types: A, B, and C, with their respective groups and subgroups, all arranged in an ascending order of severity. Once a surgeon classifies a fracture he gains insight into the associated problems in treating it. Classification thus helps in proper decision making.
In young patients these fractures are usually the result of a high energy trauma. Although multifragmentary and at times open, these are fractures of normal bone and are therefore often amenable to secure fixation.
In the elderly the commonest mechanism is a slip and fall on to the point of the elbow. The olecranon is driven into the trochlea and splits the osteoporotic condyle of the humerus into a multitude of fragments. The resultant fractures are multifragmentary, displaced and often defy attempts at reduction and fixation.
When one is deciding on treatment the factors which must be considered are patient factors, the fracture factors, and the treatment factors. The most important factors are: the patients age and the degree of osteoporosis, the comminution and displacement of the fractures, the association of neurovascular injuries, and whether the fracture is open or closed.
An open reduction and internal fixation is best performed with the patient on the side with the injured elbow uppermost, or with the patient prone. The best surgical approach is posterior. Once the skin is incised one must isolate and protect the ulnar nerve. The facture is exposed by carrying out an osteotomy of the olecranon. In elderly patients in whom a prostheses might become the salvage, one should consider using a triceps splitting approach or a triceps peal as for an elbow arthroplasty.
Commence fixation with an anatomic reduction of the trochlear fragment to the capitellar fragment. If bone is missing than instead of lag screws one uses fully threaded screws to prevent the narrowing of the distal articulation. Once securely fixed, the articular complex is fixed to the metaphysis and shaft. The fixation is carried out with two plates which should be positioned at 90 degrees to each other to achieve the strongest biomechanical construct. The plates commonly used are the 3.5mm LCDCP plates or the 3.5mm reconstruction plates. The choice of one or the other plate depends on the fracture pattern and on the necessary contouring of the plates. The usual choice are two reconstruction plates one medially and one posteriorly contoured to fit the posterior aspect of the capitellum which is devoid of articular cartilage. Such fixation is particularly useful in distal fractures. If there is metaphyseal bone loss one should use at least one LCDCP since these are stronger than the reconstruction plates.
Post-operatively the elbow is immobilized in 120–150 degrees of extension and is elevated for 24–48 hours. Early active motion should commence no later than day three in order to regain a range of motion.
Delay in internal fixation beyond day 5 often leads to the formation of heterotopic bone with marked stiffness. If surgery is delayed the patient should receive Indocid to prevent heterotopic bone formation. If heterotopic bone develops and blocks motion it should be resected early. One should not delay until the alkaline phosphatase and the bone scans return to normal.
Supracondular fractures in the elderly present special problems since they defy attempts at reduction and stable fixation. As a result many elderly patients, whether operated or not, end up with poor and painful elbow function. To prevent these therapeutic disasters recently primary total elbow arthroplasty has been used as a primary form of treatment. Bernard Morrey published encouraging early results of elderly patients with supracondylar fractures treated primarily with the semi-constrained Coonrad Morrey prosthesis. Since then this rationale has been adopted by a number of trauma centers and there are numerous multicenter trials underway to evaluate this form of treatment and place it in its proper perspective.
Open supracondylar fractures present a special problem. If they occur in young patients with good bone and if they are reconstructible, then after a thorough irrigation and debridement a primary open reduction and internal fixation should be carried out. If stable fixation is not possible one should carry out an open reduction and fixation of the articular component, and span the elbow with an external fixator. Once a stable and closed soft tissue envelope has been achieved one can carry out a delayed reconstruction of the metaphyseal component. This greatly reduced risks of infection. In elderly patients with osteoporotic bone this may not be possible as indicated. Every open fracture must be irrigated and debrided. Stable internal fixation greatly lessens the risk of infection. Because of poor bone mobilization of the joint in these patients must be delayed and the internal fixation often supplemented with external fixation to prevent fixation failure. A primary arthroplasty should not be considered because of the risk of sepsis.
In young patients with good bone with Type C1 and C2 fractures 80–90% of good functional results are to be expected. C3 fractures particularly if open and fractures in the elderly, except those treated with primary arthroplsty, lead to unsatisfactory outcomes.
Proximal humeral fractures account for approximately 4–5% of all fractures seen in the emergency departments. Of all shoulder injuries they account for aproximatelly 53%. In 1970 Neer published his classic study, in which he described a new method of classification, and gave recommendations for treatment. Neer recommended ORIF for three-part fractures, and prosthetic replacement for four-part fractures and fracture-dislocations. However there is still disagreement on the management of the displaced humeral fractures.
Accurate radiographic evaluation, is essential in order to make a correct classification of the proximal humeral fractures. The radiographic examination consists of films from three different views. The anterio-posterior (AP), lateral (Y view of the scapula), and the axillary one. The AP view will assess the fracture position, and by centring it 30 degrees posteriorly and obliquely, clearly image the glenohumeral joint space. The lateral view is taken perpendicular to the scapular plain. The head overlaps the glenoid, and projects on the centre of a “Y“, formed by acromion, the coracoid superiorly, and the scapular body inferiorly. In this projection any large avulsed greater tuberosity fragments are usually easy to visualise posteriorly, and the lesser tuberosity is visualised medialy.
The axillary view is the most useful in assessing the relationship between the humeral head and the glenoid. Fracture dislocations, and true posterior dislocations can be easily distinguished in the axial view. Computer tomography, plain or with three dimensional reconstruction-views might also help the surgeon to make an accurate diagnosis and in preoperative planning.
A valid classification system can be useful as a tool to select the optimal treatment. The system should be comprehensive enough to reflect the complex fracture pattern, and specific enough to allow an accurate diagnosis. The classification should be useful as a tool for identifying those fractures which should be operated upon.
In 1935, Codman proposed a new classification system based on four different anatomical fragments of the proximal humerus. The anatomical head, the greater tuberosity, the lesser tuberosity and the humeral shaft. Codman stressed that the musculotendinous cuff attachment to each fragment was of major significance to the fracture pattern.
In 1970 Neer further developed Codmans classification, stressing the importance of the biomechanical forces, and the degree of displacement for more complex fractures. When any of the four major segments is displaced over 1 cm or angulated more than 45 degrees, the fracture is considered to be displaced:
In the 1970’s the AO group from Switzerland, emphasised the importance of the blood supply to the articular surface of the humeral head. Since the risk for avascular necrosis was high, they based their classification on the vascular anatomy of the proximal humerus. The system classified the fractures into three different categories:
Each group is sub-divided into three categories, from less to more serious lesions. This gave us 27 different sub-groups to analyse and interpret. The AO system is easy to use for the diaphyseal segments of the femur, tibia and humeral shaft, but applying it to the proximal humerus is confusing, and makes it more difficult to use than the Neer system. Consequently the AO classification system has not gained general acceptance among shoulder surgeons.
The reliability and the reproducibility of these classifications have been questioned Unfortunately, we do not have a better classification system on hand and therefore the Neer system is still widely used.
Many methods of treatment of proximal humeral fractures have been proposed during the past 50 years, creating a great deal of controversy and confusion. There are two main treatment options: Non-operative treatment and operative.
Approximately 80% of all proximal humeral fractures are non-displaced, or only minimally displaced, and the clinical outcome is satisfactory after conservative treatment. After some days of rest, early mobilisation with gentle physiotherapy is of great importance.
Various types of osteosynthesis have been suggested. Semitubular straight or angulated plates, screws, Rush pins, external fixators, cerclage wires, tension band technique or K-wires with bone grafting have been used. The results reported range from excellent to poor. In cases of three- and four- part fractures, most authors have used open reduction with internal fixation. Because of poor bone quality, and a torn cuff, especially in elderly patients, osteosynthesis is not always the best choice. Hemiarthroplasty is reported to give an excellent outcome in many studies. In fracture dislocations, when closed reduction is not possible, the only way to restore the dislocated shoulder joint is to perform an open reduction and stabilise the fracture with an osteosynthesis implant, or replace the humeral head with a hemiarthroplasty.
There are two rating systems generally used. The Neer system from 1970 has been widely used in a number of studies, all over the world, and the Constant-Murley system from 1987 has been recommended for use in Europe. Neer’s rating system from 1970 is used to assess shoulder function, after fractures, arthroplasty and dislocations. It is based on a 100 units scale, with points for pain (35), function (30), range of motion (25), and anatomy (10). In 1987 Constant and Murley designed a European scoring system, claiming it to be applicable for measuring shoulder function regardless of diagnosis. This system is also based on a 100 point scale. The degree of pain, activities of daily living, strength, and active range of movement are assessed. The results are then related to gender, age and activity level of the patient.
Both systems has recently been questioned because of its low reliability. Confusion remains because different authors from the USA and Europe continue to use their own criteria for evaluation. Consequently, it is not unusual that the reported results after fracture treatment vary, depending on which rating system was used.
This study is based on 286 consecutive fractures of the shaft of the humerus surgically treated in the Orthopaedic Department Spedali Civili, Brescia, from November 1996 to December 2001.
Fractures were classified accordingly to AO System.
A peculiar group was represented by 33 (11.5%) complex and multifragmental fractures, where the fracture involved either the shaft and the proximal metaphysis and epiphysis.
Fractures were always treated by plate and screws when a deficit of the radial nerve was present, in order to allow neurolysis or nervous graft.
Fractures without radial nerve lesion were treated either by plate or by endomedullary nail.
In the latter group two typed of nail were used:
rigid, reamed, Kuntscher nail inserted through the proximal epiphysis
elastic nail, type Marchetti-Vicenzi, inserted through a posterior, distal humeral approach.
Patients were evaluated with a follow-up of a least 1 year.
The rate of fracture consolidation, was similar in the group 1 rigid nail (96.5%) and plate (96.9%), while lower in the group of elastic nail (89.1%).
Also time of consolidation and functional recovery was similar in the first two groups.
Particular problems presented by the group of complex fractures required a differentiated post-surgical treatment, with plaster cast or orthopaedic devices used as adjuvant mode of immobilization. All except one of these cased consolidated in a larger lapse of time (mean 4.5 months) with the following functional results: 36.5% very good; 18.1% good; 9.1% fear; 36.3% poor. A selection of the technical solution adopted is presented.
Number one in frequency of all fractures in children is the distal forearm fracture. The most common
There is currently a prospective randomised study running organized by Mr Clarke from Southampton, to the advantages and disadvantages after use of pins or abstaining from them apparent risks.
For midshaft forearm fractures closed reduction and long arm cast immobilisation had been treatment of choice in the past. Remanipulation under anaesthesia because of lack of retention of both bone fractures have been common. Concerns came up mainly in the age group above 10 years with a high rate of unsatisfactory results (
J.L. Morote and the
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Intramedullary fixation with elastic stable nails even permits immediate motion (
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An unacceptable high
We recommend the intramedullary system for all displaced forearm fractures of children above 6 years until closure of the growth plate.(
Postoperative immobilisation is a plaster shell or brace is used for 2 weeks, this is not obligatory. Postoperative infections have not been observed after this minimal invasive method. Skin irritations can be avoided by complete bending of the K-wire ends.
In unacceptable
Acute
In late reconstruction of Monteggia lesions we prefer plate fixation of ulna osteotomy.
Undisplaced fractures: simple immobilisation e.g. collar and cuff
Incomplete displacement: in case of malrotation and/or age-related unacceptable extension (> 20° in patients older than 6 years) closed reduction and pinning otherwise conservative management
Complete displacement: Attempt for closed reduction and percutaneous pinning. Irreducibility is found in up to 22%. Open reduction is most widely as a last resort.
Infection
Occasionally, superficial infection after pinning occurs despite all preventive measure (wires left protruding through the skin should not be covered by plaster to prevent rubbing; pin care instruction for the parents; regular follow-up for pin site inspection)
Cubitus varus
Most common complication with an overall incidence of about 20%. As a malunion in the coronal plane it has no capacity for remodelling. Although this deformity is mainly a cosmetic problem and does not interfere with the range of motion, it may be a functional problem in some activities e.g. in apparatus gymnastics.
Malunion/Stiffness
Even after perfect reduction, lack of full extension is common and usually takes over 6 months to improve. Impaired range of motion may be prolonged or even persistent due to an underlying pathology. Malunion is the most common one. In the sagittal plane, antecurvation leads to hyperextension and reduced flexion of the elbow. Significant remodelling with growth can only be expected below the age of 6 and in antecurvations of less than 20°. Rotatory malunion with an anterior spur restrains flexion. Complete remodelling of the spur usually takes place even in older children. Volkmann’s contracture represents the most severe complication after supracondylar fractures. Fortunately, it has become a rarity.
The human factor, in view of the particular anatomy of the supracondylar region and the extreme fracture instability seems to be more decisive for the end result than any biomechanical differences of various pin configurations. Repeat instruction by an experienced surgeon for proper reduction technique, assessment of achieved reduction and technically correct pin placement is crucial to further improve the outcome of this challenging fracture.
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The Acetabular Dysplasia creates serious technical problems for the insertion of acetabular socket. In first, cup must have a good primary stable fixation in a shallow acetabulum. In second, smaller cups are usually required in dysplasia hip, but small sockets must have thick polyethylene wall. And in third, cup design must ensuring easy reconstruction of the anterolateral bone defect. In our opinion, all these problems can be achieved by using of cementless acetabular Robert Mathys (RM) cups.
In the period from 1996 to 2000 168 patients with ace-tabular dysplasia were operated with titanium powder coated RM cups. The patients age was from 18 to 75 years old (average 43,5). In 77 patients with type I dysplasia (AAOS classification) a primary stable fixation of the acetabular component in a good position without of filling bone defect was achieved. In 53 patient with type II dysplasia stable fixation was supplemented by closing of a cup by filler bone grafts in a place of bone defect. In case of type III dysplasia (38 patients) with very shallow acetabulum and extensive bone defects initial stabilization was achieved by the press-fit one or two anchoring pegs and insertion cancellous screws. In type III dysplasia the massive bone transplant was fixed by additional screws. The features of a design of a cup allowed to stop on the small socket sizes without danger of use implant with critically thin polyethylene wall. It considerably improved a covering of a cup.
In 166 patients (98,8 %) a good medium-term results (2–6 years) were obtained. The radiologic controls have shown that the prostheses underwent good osteointegration. 2 patients (1,2%) needed revision. Of them one patient had a infected complication, one other had an aceptic necrosis of acetabulum and secondary cup migration. In all other patients no osteolisis was observed. The good primary fixation of the RM cup decreased the risk of aseptic loosing of the autologous bone graft. The temporal partial (not more than 1/3) bone graft resorption was find in 33,9 % at the type II and 42,1 % at the type III dysplasia. After 2 years in all cases we observed improvement of the bone stock quality at the site of bone grafting.
The features of a design of RM cup allow to use implants of the small size. The application for cup fixation pegs and screws allows to receive its reliable primary stability even at expressed acetabular dysplasia. The good primary stability and ease of application of bone grafts allows to achieve with RM cup of an overall objective of operation - maximal restoration of anatomy and biomechanics of the dysplastic hip joint.
For the treatment of the acetabular dysplasia in the early childhood the spherical periacetabular osteotomy of the ilium is a well-recognized procedure.
52 hips of 35 patients treated with a periacetabular osteotomy between 1969 and 1985 we followed-up after 14 to 31 years. At the time of operation the average age was 2,8 years.
The measurement of the anterio-posterior radiographs showed a normalization of the acetabular roof obliquity in 79% of the cases. However, there were only 46% of the cases with a normal center-edge angle. 42% had a medium pathologic angle of 20 to 30 °. In 12 % we saw severe pathology with angles smaller than 20.
Fife cases (10%) presented radiologic signs of osteoarthritis and three a slight incongruence between head and acetabulum.
Rare cases of postoperative complications are presented.
The low incidence of radiographic osteoarthritis supports the view that the spherical periacetabular osteotomy is an appropriate surgical procedure to treat acetabular dysplasia in early childhood.
INTRODUCTION: The treatment of “congenital hip disease” by total hip arthroplasty is now well established, but the indications for this type of surgery, the preoperative planning, the selection of the stem and the technique to be followed are still open to debate.
AIM OF THE STUDY: The purpose of this study is to analyse the long-term follow up after use of the cementless-system (CLS) femoral component designed by Spotorno in dysplastic or congenitally dislocated hips.
MATERIAL AND METHODS: Our study includes 70 hips in 59 patients, 49 females and 10 males, 36 left hips and 34 right hips that treated with total hip arthroplasty from 1987 to 2000. The mean age of the patients was 48.5 years (range 34–74 years). Forty-one hips were congenitally dislocated and twenty-nine were severe dysplastic. Preoperative planning with CT and CAD-CAE system were used for selection of the stem. 11 patients had bilateral total hip arthroplasties with Spotorno CLS stem.
RESULTS: The mean follow up was 8.1 years (range 2–14 years). No patients were lost during the follow-up period. Patients were evaluated clinically with Merle d’ Aubigne and Postel hip score. There was a significant postoperative clinical improvement of the mean pain score by 3.7 points, of walking ability by 2.2 points and of motion by 2,6 points. Thigh pain was not reported. There were no deep infections or mechanical loosenings that required revision of the femoral component.
CONCLUSIONS: Although, the femoral component Spotorno CLS is used to every kind of hip diseases, had excellent long-term clinical results in adults, with dysplasia or congenital hip dislocation. Spotorno CLS uncemented femoral component represents an attractive option for adults with “congenital hip disease”.
Knee arthrodesis is a useful procedure in difficult cases such as failed total knee arthroplasty, bone tumors and infected knee joints. A review of 27 cases treated using a modular locked intramedullary nail “Wichita” in 4 hospitals was performed. This fusion nail is a device designed to provide simultaneous compression and intramedullary fixation. The device is implanted through a single knee incision using three main components after femoral and tibial reaming. The femoral components inserts retrograde and has two holes in its proximal end to accept transverse locking screws. The tibial component inserts anterograde into the proximal tibia and has some holes for transverse screw placement. The compression screw component is used to lock the femoral and tibial components together and simultaneusly compression is generated across the joint line. Teorical advantages are single incision, inmediate and solid stability, posibility of compression, adjust of length, high fusion rates and less risk of infection than other procedures. An individual study protocol was made and it includes previous primary or revision failed total knee replacement, severe articular trauma and infection. No bone tumors were includes. Protocol includes aspects such as operative time and blood loss,intraoperative complications, radiographic evaluation (tibiofemoral alignement, contact tibiofemoral surface area...) shortenning of extremity, time to union, posoperative complications and patient subjective evaluation.10 patients are being studied prospectively in our institution since january 2000 and the mean follow-up is 16 months. 17 patients were retrospectively studied in 3 differents hospitals using the same protocol and the mean follow-up is 26 months. Global results show a solid fusion in 26 (96 per cent) of the 27 patients at an average time of 15 weeks (range 12 to 22 weeks) after the operation. There were one mechanical failure of the implant (thecnical mistake during assembly of the compression screw component). There were 2 non desplaced fractures in the end of the nail. There was 1 desplaced fracture and removed of implant was required, osteosynthesis was performed with a long intramedullary nail. No infections were detected. These results and others are related. Although good results observed, with high fusion rates and minimal complications, a potential disadvantage is the difficult to remove the nail if this is necesary.
One of the advantage in using unicondylar prosthesis seems to be the preservation of the bone stock, which allows most often easily revision to a total knee replacement if required. The purpose of the study was to compare the patients outcome after revision of unicondylar prosthesis with a group of patients who have received total knee replacement primarily.
Displaced supracondylar fracture in adults often require internal fixation. Plate fixation, requires soft tissue stripping resulting in devitalisation of bony fragments and this predisposes to risk of non union, infection and nerve injuries. This is the first report of a new technique, locked intramedullary transolecranon fossa nailing.
In this technique the fracture is exposed through a limited posterior triceps splitting incision, keeping the soft tissue stripping to the minimum. The medullary canal is entered proximally through an anterior shoulder incision. A guide wire is inserted in an antegrade manner to enter the fracture site. The distal fragment is predrilled to create a tract with 3.2mm drill from proximal to distal, in such a way that the drill enters the olecranon fossa and then the proximal part of trochlea avoiding penetration of the elbow joint. The guide wire is then advanced into the tract in the distal segment. The medullary canal is reamed over the guide wire in anti-grade fashion with flexireamer. Utilising the standard antegrade technique, the nail is inserted and advanced under direct vision until tip of the nail is firmly seated in the trochlea. The proximal and distal locking are done in standard fashion. Postoperatively active mobilisation is encouraged. Four patients underwent this procedure. All the fractures healed in 3 months and at one year follow up the average arc of elbow motion is 120 degrees. There are no complications.
Transolecranon fossa locked nailing is an available option to treat the displaced supracondylar fracture of humerus in adults.
End results analysis of operative treatment in transcaphoid perilunate dislocations.
From 1/1/91 to 1/1/01 twenty transcaphoid perilunate dislocations were operative treated. Ligamentous lesions were repaired through a dorsal approach, either by directly suturing the ligaments (10cases), or by using mini Mitek anchors (8 cases). Simple approximation and stabilization with K-wires was performed in 2cases. Scaphoid fractures were treated by open reduction and internal osteosynthesis with Herbert screw (12 cases), cortical AO 2.0 screw (2cases) or K-wires (6 cases). The wrist remained immobilized in a slight flexed position with short arm plaster for 8 weeks. Physiotherapy was necessary for all patients to regain full range of motion. Clinical and radiological evaluation was possible for all patients. The end results were estimated according to Cooney’s evaluation system. Kinematics of the injured wrists was also tested by cineradiography in order to estimate the dynamic behaviour of the wrist. The Average follow-up time was 52 months (range 11–76).
Twelve patients had excellent result, 4 good, 1 fair, and 3 poor. Fourteen out of 16 cases returned to their previous work. Additional operations were required in two patients: 1) four corner arthrodesis because of aseptic necrosis of the proximal pole of the scaphoid with arthritic changes, 2) Scaphoid reoperation because of non-union by Matti-Russe procedure. The later was found in cineradiography to present a painless rotational instability.
Transcaphoid perilunate dislocation has a very good response to early operative treatment. Dorsal ligament repair with mite mini anchors seems to be a reliable easy made method. Scaphoid fracture stabilization requires a stable compressive fixation. Herbert screw is ideal and can be safely placed from proximal to distal via the dorsal incision. Cineradiography is the best way to evaluate normal wrist kinematics.
Varus deformity is found in 90% of patients with knee OA. Axis deviation of lower extremity influences joint biomechanics and produce alteration in bone mineral density. Structure and density of subchondral bone of the knee was previously examined by X-ray. Densitometry gives us a new method of bone mineral content measurement in the interesting regions of the skeleton.
The aim of this study was the assessment of effect of varus deformity on bone mineral density in tibial epiphysis.
Bone mineral densities (BMD) were estimated in 46 patients at a mean age of 62 years (15 to 78) who were operated on in Department of Orthopaedics. All of them represented osteoarthritis of the knee with varus deviation. BMD of the proximal tibia was evaluated on the Lunar DPX-IQ densitometer and analyzed in three regions of interest: medial, lateral and central. Lower extremity axis deviation was measured using the Metrecom devise (Faro). Results were compared to a control group of 20 patients without osteoarthritis of the knee and without deviation of lower extremity axis.
Increased BMD was found on the overweighed compartment of the knee in comparison to the underweight one. These differences were not observed in the control group. We developed a coefficient, which is the ratio of BMD in the overweighed compartment compared to BMD in underweight one. In our patients the mean value of this coefficient was 3.3, and it ranged from 1,2 to 24,5 (SD 5,7).
Significant correlation between varus axis deviation of the lower extremity and increased BMD coefficient was found.
The main aim of the report is to study the results of surgical treatment of distal radius nonunion, malunion, and pseudarthrosis in cases when different techniques of fixation were used.
INTRODUCTION AND OBJECTIVES
Classical treatment for supracondylar fractures of the femur has been osteosynthesis with plate and screws. This treatment is not free of complications as non-union, infection and material breakage. An alternative to this treatment is endomedullary osteosynthesis with retrograde interlocking nail.
MATERIALS AND METHODS
We have reviewed 7 supracongylar fractures of the femur in 6 patients, treated with SCN retrograde interlocking nail. The average age of patients was 73 years. Traffic accidents were responsible of 3 of the cases, and the other 4 were due to low energy traumatisms. None of the fracture was opened.
The average follow up was 20 months (17–27), and clinical results were evaluated according to the Hospital for Special Surgery (HSS) knee evaluation scale modified by Leung et al.
OPERATION TECHNIQUE
Patients were placed in the supine position, without any longitudinal traction. We performed an anterior access with parapatellar arthrotomy. All nails were locked both proximally and distally. Functional recovering of the limb in discharge began during postoperative period for an average of 12 weeks (6–20).
DISCUSSION AND CONCLUSIONS
The results were fully satisfactory. The use of intramed-ullary locking nail in these fractures provides several advantages over standard treatment with opened reduction and internal fixation with plates and screws Endomedullar nails have become the elective choice in shaft fractures of the femur, and with the use of interlocking nails, their indications have expanded to distal fractures of the femur. However, their use in supra and intercondylar fractures is not very expanded yet.
INTRODUCTION: To determine the bone mineral density (BMD), the osteoporosis risk factors and the wrist function after distal radius fractures, treated by non-operative methods at the Orthopaedic Department of Semmelweis University Budapest.
MATERIALS AND METHODS: 55 patients, between January 1999 and December 2000 (47 to 90, mean age: 69.4 years) were treated non-operatively after distal radius fracture following minor trauma. The osteoporosis risk factors were detected by an interview format and the BMD was measured in the proximal femur, in level LII.-LIV. vertebras and in the contralateral radius. An adapted interview format was filled in six months following fracture healing to detect the wrist function.
RESULTS: Of the wrist-fractured patients 78% are osteoporotic, 20% are osteopenic in one of the examined region. 72.5% are osteoporotic and 17.5% are osteopenic at the contralateral radius. The T score is below −1 in LII–LIV. and the hip region in 80.36% and 67.92% respectively. Some of the patients had earlier fractures. Those, who had previous fracture before the age of 70, are all osteoporotic, and those who had no fracture previously are 64.5% osteoporotic, 22.5% osteopenic at the contralateral radius. At the LII–LIV vertebras, those who had previous fracture, 60% are osteoporotic and 33.3% osteopenic and those who had no fracture previously are 27.7% osteoporotic, 44.4% osteopenic. At the proximal femur region, those who had previous fracture, 23% are osteoporotic and 53.8% osteopenic and those who had no fracture previously are 16.2% osteoporotic, 48.6% osteopenic. Patients with body mass index (BMI) under 25 are more osteoporotic in all of the measured region, than those with BMI over 25. We did not find significal difference in wrist function of those who had a redislocation of 5° to 20° after the reposition and those who had fracture healing in an anatomical reposition.
CONCLUSIONS: The examined patients with a distal radius fracture are a high risk population because of their high percentage of lower BMD. A wrist fracture resulted by minor trauma must be a warning sign: there is a higher probability of a following fracture due to osteoporosis. This might have a negative effect on life quality too. Therefore after a distal radius fracture there is a major importance of detecting the risk factors for osteoporosis, measuring the BMD in high-risk cases and starting the antiporotic therapy at the same time, to decrease the proximal femur and vertebral fractures rate.
The „Press Fit Condylar“ (P.F.C., DePuy Johnson& Johnson) knee implant was invented in 1984 as a cruciate-retaining endoprosthesis. 4 years later the cruciate substition was added. In 1991 this as „P.F.C. modular“ well known system was upgraded for extended revision surgery with stems and augmentations called „Total Condylar 3“(T.C.3). Last evolution was in 1997 the P.F.C. Sigma with improvement of contact areas in patellofemoral and tibiofemoral joint and improved PE. Instrumentation was also modified. Femoral implant is made from CoCr-alloy, tibial implant from TiAlV, PE inlays and onlay patellae complete the implant. Cemented or cementless versions are available.
Good result in condylar knee implantation depend strictly on using the techniques of planning/ templating, correct aligned bone cuts and especially on adequate soft-tissue-balancing. Different situations of ligament and/or capsule laxity or contracture associated with various deformities need stepwise release-procedures. The modularity helps also to manage the great variety of arthritic knees.
The P.F.C. is one of the worldwide most used implants, a lot of studies showed good results. Using revision due to loosening as an endpoint a 10years survivalrate from 97% or 15 until 21 years rate from 95-91% was published.
In future new technologies like navigation or robotics may help optimizing implants position and fit but a experienced surgeon will be absolutely necessary managing the operation and esp. the soft-tissue-part. Evolution of implantdesign and materials may in long term show new possibilities.
