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Comparing Groups 1 & 2, girls in Group 1 were younger and smaller at diagnosis with lower Cobb angles. They were older at menarche, but this was inevitable from the selection criteria, and more likely to progress (p< 0.001), to receive a brace (p=0.047) and to undergo surgery (p=0.043). Age, final Cobb angle and height at discharge were not significantly different.
A transverse force system, consisting of an anterior progression force counteracted by a posterior force and torque, acts on the vertebrae of a scoliotic spine. The aim of the newly introduced TriaC brace is to reverse this transverse force pattern by externally applied and constantly present orthotic forces. In the frontal plane the force system is in accordance with the conventional braces. However, in the sagittal plane the force system acts only in the thoracic region. As a result, there is no pelvic tilt, and it provides flexibility without affecting the correction forces during body motion.
The new brace prevented further progression of the scoliotic curves, except for seven patients, who required surgery. The initial mean Cobb angle before brace treatment, was 26,5 degrees, the mean lateral displacement at the apex 18,5 millimetres, and the initial axial rotation of the apex was 12,3 degrees. Analysis of differences between each successive visit showed that the difference was not statistically significant for the Cobb angle (p=0,71), nor for the other parameters.
Rib asymmetry is confirmed as a negative prognostic sign. Early treatment gives better results.
There was no relationship between repeatability and the measurement size.
The operation was not responsible for the development of a new spondylolisthesis. A minimal increase in an existing degenerative listhesis was seen in two patients only without compromise of their good results. There was no revision surgery at any of the operated levels.
Patient outcome was assessed by means of a visual analogue scale (VAS) for pain, SF36 health assessment questionnaire, a patient subjective outcome assessment, employment status and analgesic usage.
The mean VAS reduced by 3.2 points from 8.3 to 5.1 (p=0.0001). There was a significant improvement in all the physical component scores of the SF36. The subjective outcome was either excellent or good in 24 (71%) patients. Of the 26 patients working prior to surgery, 20 (77%) returned to work. Analgesia usage reduced in 21 (61%) patients.
One patient died in the post operative period.
Patient outcome was assessed by means of a visual analogue scale (VAS) for pain, SF36 health assessment questionnaire, a patient subjective outcome assessment, employment status and analgesic usage.
The mean VAS reduced by 2.2 points from 8.2 to 5.9 (p=0.007). There was a significant improvement in all the physical component scores of the SF36. The subjective outcome was either excellent or good in 65% of patients. Analgesia usage reduced in 71% of patients. 4 patients underwent further surgery. One patient died in the post operative period. There was no significant difference in the fusion rate in smokers compared to non smokers, or those that had undergone previous spinal surgery. The subjective outcome was either excellent or good in 59% of smokers, but only 37% in those that had undergone previous surgery.
Outcome Measures: The incidence of post-traumatic syrinx in both groups and its relationship with level and type of skeletal injury, severity of spinal cord injury, sagittal angle at the injury level were assessed.
The aims of this study were to determine the incidence of significant SSEP changes in patients undergoing anterior spinal deformity surgery; to ascertain whether the ‘at risk’ cord was more likely to demonstrate significant intraoperative SSEP changes and what proportion of these changes yielded post operative neurological deficit.
Heart rate variance was highest in the Consultant with the most recent appointment. Heart rate variance in the Trainee was the lowest. The highest heart rate was achieved when scrubbed supervising the surgical trainee. The surgeons with the highest deformity work load had the lowest intra-operative heart rate
Lifting and turning with the trunk in the flexed position is the commonest cause of an acute disc prolapse. Flexion and rotation of the lumbar spine, under load, may also give rise to unilateral fractures in the lumbar spine in fast bowlers in cricket and in eighty percent of these cases the fracture occurs on the opposite side to the bowling arm (ref
Ninety two of the one hundred and twenty six patients contacted about their hand dominance responded: eighty three patients (90.2%) were right handed, eight (8.7%) were left handed and one patient (1.1%) was ambidextrous. Of the eighty three right handed patients, forty (48.2%) had a left sided disc prolapse and forty three (51.8%) had a right sided disc prolapse.
Conclusion: This study revealed no difference in the side incidence of lumbar disc prolapse. There was no correlation either with the side of the prolapse and hand dominance.
The findings are considered to support the view that a disc prolapse, and the side on which it occurs, is not a consequence of a single unilateral action but an end product of pre-existing disc degeneration in a midline structure.
Definitive spinal fusion was required in thirteen cases at a mean age of 14.5 years (range 12–23 years), due to progression of scoliosis in 9 cases (mean Cobb angle 55°), and the development of junctional kyphosis in 4 cases. In ten cases the correction obtained was maintained through skeletal maturity (mean Cobb angle at final follow-up 33°). These cases did not require definitive spinal fusion.
The mean growth within the instrumented segment was 3.2 cm (42% of the expected growth). Progression of scoliosis was predicted by pre-operative apical convex rib-vertebra angle (RVA) (p=0.002). Excessive growth within the instrumented segment was predictive of junctional kyphosis but not of scoliosis progression. Age at operation and initial curve magnitude were not found to be significant predictive factors. 72% of overlapped ‘L’ rod construct (10 cases), and 33% of overlapped ‘U’ rod construct (3 cases) had documented curve progression within the adolescent growth spurt and required definitive spinal fusion.
In spite of preventive treatment, particularly in young paraplegics with transverse lesions above T9, a high rate of neurogenic scoliosis must be expected. Due to the loss of sitting balance in the wheelchair, to increased risks of pressure sores, and to progressive restriction to the patient’s ventilatory function, surgical intervention often becomes necessary. A surgical method for successful application in SCI patients should meet specific demands:
High primary stability: External immobilisation in braces or casts would pose problems, long-lasting bed rest must be avoided and no muscular support is possible. Conversely, the instrumentation must resist against often very strong spinal spasticity. High corrective capacity in all planes: Wheelchair dependent patients have fewer facilities for compensation of a remaining spinal deformity than ambulating patients. In sub-optimal correction, the sacrum has to be included into the fusion more frequently, with serious impact on the patient’s independence in ADL. Avoidance of precedent procedures for anterior release: The ventilatory function in patients with mainly high thoracic or cervical transverse lesions is already impaired, let alone the effect of the scoliosis. Additional impacts by thoracotomy should be avoided if possible. The same aspect should also be considered, looking at the following. Posterior procedure: Because neurogenic scoliosis deformities usually need long instrumentations, exclusively anterior procedures can rarely be used. Compared with the combination of anterior (e.g. thoracic VDS) procedures together with a posterior method, a purely posterior procedure would be beneficial, as long as it can achieve equal correction.
Since 1991 the author has worked on a concept using pedicle screws as cantilevers for 3-D correction, de-rotation being the core manoeuvre. The evolutive development of suitable, outrigged instruments for the reduction has now been finalised, allowing the presentation of the method.
Although more than 20 cases have demonstrated the method’s superior potential in 3-D correction of the deformity, and although the primary stability provided by the method meets the requirements of this patient group, neurogenic scoliosis in para- and tetraplegics still poses inherent problems:
• Insertion of pedicle screws in scoliosis is difficult, at least in the upper thoracic region. It will take time before sufficiently accurate and available modern navigation systems can resolve this.
• Once the lumbosacral junction is included in the fusion, negative impacts on the patient’s ADL, as well as on the fusion rate, must be anticipated.
In conclusion, a promising and effective method for surgical correction of neurogenic scoliosis is available.
The use of this method will become easier by further developments in computer assisted surgery. Having a tool at hand, which, by it’s corrective abilities, allows the sparing of the lumbosacral junction from fusion, as long as pelvic obliquity is not fixed, the detection of initial fixation by thorough follow up of the patients at risk becomes paramount.
Anterior instrumentation for thoracic AIS has advanced to a point where it can be widely adopted, particularly if the patient expresses concerns regarding the rib hump or is hypokyphotic.
ISIS showed the mean pre-operative Standing Angle of Trunk Inclination (sATI) of 15 degrees (range 7 to 25) was reduced to 5 degrees (range 0 to 15) post-operatively with a further mean improvement of 2 degrees during the follow-up period. The final sATI was within the range of normality for 21 patients (87 percent). Spinal balance in the coronal plane improved from a mean of 24mm to 11mm. Spinal balance in the sagittal plane was unchanged.
15% of the CDI patients and 24% of the HRI patients reported frequent low back pain episodes. Group differences were significant (p=0.008). A high correlation between incidence of low back pain and low degrees of lumbar lordosis below the fusion was revealed in HRI patients (p=0.02).
We studied the correction achieved and the maintenance of the correction at a minimum 15 months follow up using the Paediatric USS.
Sciatic Nerve Palsy (SNP) is a recognised complication in Primary Total Hip Replacement after a transtrochanteric or a posterior approach (5). It is considered to be caused by direct trauma to the nerve during surgery. In our unit this complication was rare with an incidence of < 0.2% over the past ten years. However we know describe six cases of sciatic nerve palsy occurring in 355 consecutive primary THRs (incidence 1.60%) performed in our unit from June 2000 to June 2001. Each of these sciatic nerve palsies we believe was due to postoperative haematoma in the region of the sciatic nerve.
To our knowledge there are only five reported cases in the literature of sciatic nerve palsy secondary to postoperative haematoma (1). (Each of the six patients who developed SNP was receiving prophylactic anticoagulation).
Cases recognized early and drained promptly showed earlier and more complete recovery. Those in whom diagnosis was delayed and were therefore managed expectantly showed no or poor recovery. More than usual pain the buttock, significant swelling in the buttock region and sciatic nerve tenderness associated with signs of sciatic nerve irritation may suggest the presence of haematoma in the region of the sciatic nerve. It is therefore of prime importance to be vigilant for the signs and symptoms of sciatic nerve palsy in the early post operative period because if recognized and treated early the potential injury to the sciatic nerve may be reversible.
Patients over 65years at time of injury
Minor trauma e.g. minor fall
No neurological deficit
Patients over 65 years who were involved in major trauma.
Non-Irish residents
The Extensor Digitorum Brevis is an easily visualised superficial muscle present on the dorsolateral aspect of the foot. It is innervated by the terminal branches of L5. Wasting of this muscle has been described as a sign of L5 radiculopathy, however its specificity and sensitivity as a clinical sign in patients with disc disease has never been assessed to the best of our knowledge.
The purpose of our study was to determine the effectiveness of this sign in patients with a know L5 radiculopathy. We included three groups of patients, which were prospectively assessed by a blinded single examiner. Group A were patients with a clinical L5 radiculopathy confirmed on MRI, Group B were patients with a clinical a S1 radiculopathy confirmed on MRI and Group C were a control group. There were 20 patients in each group, 10 male and 10 female, mean age 38 years (range 19 – 57 years). Our inclusion criteria were leg pain greater than 6 weeks, we excluded and patient with a history of previous disc disease or foot surgery. A positive sign was defined as a gross clinical wasting of the extensor digitorum brevis compared to the opposite foot.
The sign was negative in all 20 patients in the control group. The sign was positive in 12 patients (60%) with L5 radiculopathy and only one patient (5%) with S1 radiculopathy. Fishers exact test confirmed statistical significance between the two groups with a p value of < 0.05.
We conclude that this easily performed objective clinical sign, when used inpatients with leg pain, is highly specific in determining the pressure of an L5 root involvement.
The conservative management if isolated humeral shaft fractures is a long, drawn out, painful process for the patient. For the clinician, it involves multiple clinic attendances and repeated radiographic assessment and brace alteration.
The primary reason for conservative management is the excellent results, but a very definite secondary consideration is the high incidence of shoulder pathology after I.M. nailing. This is thought to be due to rotator cuff pathology at the time of surgery. We question the validity of this second argument.
Ten consecutive humeral shaft fractures attending our unit had an MRI of both shoulders carried out during the initial stages of their injury. Two of the ten had retrograde nailing and the remainder was managed conservatively. While there was no patient with an occult coracoid fracture in association with the shaft fracture. We found eight out of ten to have significant signal changes in the subacromial space on the side of the fracture only.
We conclude that there is a significant occult injury to the shoulder at the time of humeral shaft fracture and this may in fact represent a cause for the high incidence of shoulder pain post fracture.
Ulna Styloid Fractures have been historically dismissed as a relatively benign injury. However recent clinical and biomechanical research has suggested that primary repair of displaced ulna styloid avulsion fractures is advised as a means of stabilizing the radioulnar joint and preventing the disability associated with chronic radioulnar joint instability.
Optimum fixation method was examined in this study using a human cadaveric model. A custom jig was designed to allow testing in radial/ulna deviation in varying degrees of wrist flexion and extension. Universal materials testing device was used to apply a maximum load of 150 N. Eight pairs of cadaveric wrists were tested. Constructs tested were 1.6mm K-wire fixation, Tension Band wiring and Screw Fixation. Fracture displacement was measured using a venire micrometer.
There have been multiple approaches described for internal fixation of acetabular fractures. We discuss the results of acetabular fractures treated in our institution via a Stoppa intrapelvic approach. Between July 1997 to October 2002, the senior author surgically treated 14 acetabular fractures using this approach. Indications for utilizing this approach include displaced anterior column fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemi transverse component. The fractures were classified according to Letournel and Judet. There were 10 males, 4 females with a mean age of 34 years (20–57 years).
Patients were followed up for an average of 26 months (8–60 months). All fractures went on to union at an average of 12 weeks. There was one superficial wound infection, which was successfully treated with antibiotics. No patients suffered loss of fixation. There were no nerve or visceral injury in our series.
Clinical results evaluated were based on the Harris Hip Score (out of 100). Our results show 13 patients had good to excellent results (Score 80–100), whereas one patient had a fair result.
The Stoppa intrapelvic approach offers improved reduction and fixation techniques with a decrease in complications associated with extensile approaches.
Spinal injuries are among the most devastating injuries related to recreational sport. There are few studies specifically on spinal injuries in horseback riding. The purpose of our study was to determine the factors contributing to horse-riding accidents and to assess the usefulness of wearing protectors while horse riding.
All patients with spinal injuries admitted to our unit over a six-year period (1993–1998) were reviewed. Of 957 patients admitted to the National Spinal Injuries Unit from 1993–1998, 25 patients incurred spinal injury while horse riding. Age, sex, occupation and injury details were collected for all patients. All 25 patients were also contacted retrospectively to collect further details in relation to the specifics of the horse-riding event.
There were 16 male and 9 female patients with a mean age of 35 years (range 17–61). There were nine cervical fractures/dislocations, eleven thoracic fractures, and eight lumbar fractures. Four patient sustained injuries at more than one level. In relation to spinal cord injury, two patients had complete neurological deficit, a further ten had incomplete lesions. Thirteen patients had no neurological deficit. Surgical intervention was required in eleven patients.
Only six riders, all of who were either jockeys or horse trainers, wore back protectors. Of the 19 patients without a back protector there were 5 cervical, 10 thoracic and 6 lumbar injuries. Two patients sustained injuries at more than one level. However, of the six riders wearing a protective jacket there was a completely different fracture pattern level with 4 cervical injuries, only one thoracic injury and on e lumber injury.
The variation in injury level between the group wearing protective back supports and those without is noteworthy. While the numbers are too small to draw a significant conclusion it would appear that there is a trend for riders wearing a back protector to suffer less thoracic and lumbar injuries relative to cervical injuries.
The management of three or four-part fractures of proximal Humerus remains difficult. Controversy still persists concerning the preferred treatment of these fractures. The aim of our study was to review the functional outcome and factors influencing the outcome after shoulder hemi arthroplasty in acute fractures of proximal humerus.
The aim of the study was to determine the effects of 0 Ticron suture soaked in polyhydroxybutyrate (PHB) on the histological and mechanical properties of healing meniscal tears in the red-white zone in an established animal model.
The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur.
Between February 2nd 1995 and March 21st 2001, 1249 patients were admitted to our spinal tertiary referral unit. Of these, 77 had suffered fractures to some part of their upper thoracic spine (T1–T6), of which, 32 required surgical procedures. Using patient case notes, we retrospectively studied this series.
Twenty-six of the 32 patients were male, with an average age of the group of 24.4 +/− 11.3 years and an average impatient stay of 17.5 +/− 10.5 days. 29 patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. 90.7% sustained their injuries in road traffic accidents, with 53.9% of the male group being involved in motorcycle accidents. Multiple imaging (in addition to plain film radiography) was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest injuries. Cardiothoracic surgical consultants were required in 56.3% of cases, and from the general surgeons in 37.5% of patients. 59.4% of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit.
Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. This series would suggest that patients suffering from these injuries are best treated in a multi-disciplinary approach within a general setting, rather that in a specialist orthopaedic unit, where other medical and surgical services may not be readily available.
We report the result of 46 patients (30 female, 16 male) with periprosthetic femoral fractures who underwent insertion of the Kent Hip Prosthesis. Average age was 73 years (range 43–96years) and follow-up ranged from one to seven years (average, 4 years). The primary implants involved were as follows: Charnley (26), Austin Moore (6), Howse (5), Custom (4), Exeter (1), DHS (1), Thompson (1) and Richards (1). Average time to fracture from insertion of the primary implant ranged from 3 weeks to 20 years (average, 8 years). Forty cases were post-primary implant fractures (38 traumatic, 2 atraumatic) and 6 occurred intraoperatively. Using the Johanssen classification there were 12 type I, 30 type II and two type III fractures. Of the 46 cases, prior to fracture, 42 were living in their own home, 24 were mobile unaided and 20 had thigh and/or groin pain. Thirty-two had a loose stem and/or cup assessed at the time of surgery. Operating time was on average 143 mins (65–235mins). At latest follow-up, 43 were living in their own home, 5 were walking unaided and 10 had ongoing pain. In 34 cases complete union was achieved. There were no cases on non-union. Three patients required revision surgery for broken stems. Three patients sustained wound infections and there were six posterior dislocations. All of the complications were treated satisfactorily. We conclude that the Kent Hip Prosthesis is a useful option in the management of periprosthetic femoral fractures.
Leg-length inequality is not uncommon following primary total hip arthroplasty and can be distressing to the patient. An excellent clinical result with respect to pain relief, function, component fixation, range of motion and radiographic appearance can be transformed into a surgical failure because of patient dissatisfaction due to leg-length inequality.
Postoperative leg-length discrepancy was determined radiographically for 200 patients who had had a primary custom total hip arthroplasty. In all cases the opposite hip was considered to have a normal joint center.
The femoral component was designed and manufactured individually for each patient using screened marker x-rays. A graduated calliper was used at the time of surgery to control depth of femoral component insertion. The transverse acetabular ligament was used to control placement of the acetabular component and therefore restore acetabular joint center.
Using this method 94% of subjects had a postoperative leg-length discrepancy that was 6mm or less when compared to the normal side (average, +0.38mm). The maximum value measured for leg-length discrepancy was +/−8mm.
We describe a simple technique for controlling leg length during primary total hip arthroplasty and propose an alternative radiographic method for measuring leg-length discrepancy.
Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the gold standard treatment of a wide range of pathologies involving the 1st MTPJ. Numerous methods of internal fixation and bone end preparation have been reported to perform this procedure, however there is no universal technique. Therefore in an effort to bring together the best features of the different surgical techniques, a low profile contoured titanium plate (Hallu-S plate), with a compression screw, with a ball and socket bone end preparation were designed. A prospective study was carried out to determine the efficacy of using the Hallu-S plate for 1st MTPJ arthrodesis.
1st MTPJ arthrodesis, using the Hallu-S plate, was carried out in 11 consecutive patients. The procedure was performed in isolation and with other forefoot procedures. Cast immobilization was not used in patients with an isolated 1st MTPJ arthrodesis and the patients were allowed to mobilize (heel walking – full weight bearing) between 2 and 6 weeks postoperatively. The changes in the level of pain and activities of daily living using the AOFAS Hallux score, pre-operatively and at the last assessment, and the time to bone union were assessed.
The mean follow-up time was 10 months (STD 6 months) and there was statistically significant increase in the AOFAS Hallux score. All radiographs at 6 weeks showed bone union and an appropriate degree of dorsiflexion in relation to 1st metatarsal (20–25). The combination of the Hallu-S plate and a ball and socket preparation has both operative and biomechanical advantages over previously described techniques. This combination ensures the biomechanics of the 1st ray are maintained and a better functional result is achieved.
The surgical treatment of chronic Achilles tendon ruptures is essential to restore the normal gait pattern. There are a variety of surgical techniques described, including primary repair, augmentation with tendon transfers, augmentation with aponeurosis flaps and bridging techniques. In recent times augmentation with tendon transfers or aponeurosis flaps are the most commonly performed procedures. Our study examined the biomechanical effect of using the flexor hallicus longus in an augmented chronic Achilles tendon repair on gait pattern and forefoot loading distribution using pedobaragraphical analysis.
We, pedobarographically examined the gait patterns of 10 patients who had undergone augmented chronic Achilles tendon repair using the flexor hallicus longus tendon. The mean age at the time of injury was 59 years of age (range 46–70). The mean follow-up time was 38 months. All patients reported good to excellent results. The mean AOFAS ankle score was 96.25 (range 90–100). There was no statistically significant difference between the loading distributions of the operated foot relative to the contralateral side.
While there is no comparative study examining the outcomes of the varying surgical techniques for chronic Achilles tendon repair, the use of the flexor hallicus longus tendon in augmented chronic Achilles tendon repair has been proven as an effective repair to restore normal function while not compromising the biomechanics of the 1st ray or the loading distribution of the forefoot.
Apert’s syndrome (or acrocephalosyndactyly type 1) is a rare condition characterized by anomalies of the skull (craniosynostosis) in conjunction with complex syndactyly of the hands and feet. There are many studies involving the description and management of hand deformities in Apert’s syndrome. The study of foot anomalies however in children with Apert’s syndrome has been limited to individual case reports and small series. Plain radiographic studies have shown that during childhood, progressive fusion of the bones of the feet occurs. The management of these children’s feet has never been addressed in the literature.
Seven patients with Apert’s syndrome were included in our study. The study group consisted of 2 girls and 5 boys, age range 4–16 years. We performed plain radiography, 3-D computed tomography and paedobarographic studies on all seven children based on our observation that some children with Apert’s had prominent metatarsal heads with symptomatic callosities under the first and second metatarsal heads. Five of the seven children studied demonstrated a specific pattern both on paedobarographic studies and 3D computed tomography of an excessively plantar flexed, fused first and second rays.
A corrective extension osteotomy of the fused first and second rays were then carried out in one patient with an excellent post-operative result. We propose that by early recognition and correction of the pattern of an excessively plantar flexed first and second ray would improve both function and footwear.
Plantar faciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the valvaneus. Several aetiological factors have been implicated in the development of plantar faciitis, however the role of hamstring tightness has not previously been assessed.
Increasing the angle of flexion from 0–20° at the knee joint led to statistically significant increase in pressure in the forefoot phase by an average of 0.08K/cm2s (p, 0.05,t-test). An increase from 20 – 40° led to increased forefoot phase pressure of 0.15 kg/cm2s (p0.05, t-test). The percentage time spent in contact phase reduced from 30 to 26.5 to 16 with increasing flexion (P< 0.05). However there was an inverse increase in the time spent in the forefoot phase 51–58–69 with increasing degrees of flexion (P< 0.05). Thus the authors feel that an increase in hamstring tightness may induce prolonged fore foot loading.
Percutaneous wiring is a successful technique for the management of distal radial fractures. Practice differs according to surgeon preference as to whether the wires used are buried or protruding. To assess patient satisfaction with wither technique, we prospectively randomised 52 consecutive patients undergoing percutaneous wiring for distal radius fractures with regard to whether the wires were buried or not.
Patients with a distal radial fracture managed with percutaneous wire fixation and casting only were randomly allocated to have the wires buried or protruding. The fractures were classified according to Frykmn’s classification of fractures of the distal radius, and there were no differences between the groups (p=0.9).
The total number of patients studied was 52, with a mean age of 56.6 years (range 19–84). The female: male ratio was 38:13. Twenty-five (48%) patients had percutaneous wiring of their fracture with the Kirschner wires buried and 27 (52%) had the wires protruding. Cast and wire fixation were removed at a mean duration of 5.8 weeks in an outpatient setting. Patients recorded whether they experienced pain during the period of wire fixation or pain during the removal of wires on a visual analogue scale. Fifteen patients reported pain during the period of fixation (55.5%), the severity ranged between 2–8 (mean 3.8) with no significant difference between the groups (p=0.8). All patients with buried wires compared with 10% of those protruding wires required local anaesthesia in the operating theatre for removal (p=0.03). Superficial infection was diagnosed in 4 patients with no significant difference between groups (p=0.14).
Buried wires are typically advocated to prevent pin site infections and to improve patient comfort and satisfaction. However, we found no difference between the study groups with regard to patient satisfaction, pain during the period of fixation or pin-site infections. Furthermore, all patients in the buried wire group required local anaesthesia for removal with some of these necessitating a visit to the operating theatre. We therefore feel that burying these wires confers no advantage while adding to the complexity, time and cost of removal and recommend leaving wires protruding through the skin.
Clinical and radiographic data on 47 hips in 45 patients with Developmental Hip Dysplasia who underwent either a Salters Innominate Osteotomy or a Femoral Derotation Varus Osteotomy by a single operator were reviewed. The average age of patients at the time of osteotomy was 21 months (range 12–108 months). Clinical evaluation was performed with use of the lowa hip rating score and the Harris hip score. Radiographs were evaluated pre=operatively, post-operatively and at final review.
The mean duration of follow-up was 15 years 9 months (range 10–21 years). Thirty-five patients had a Salter innominate osteotomy, 11 a derotation varus osteotomies and one a Klisic.
Al last follow-up examination the Iowa hip rating averaged 96.6 (range 62 to 100) and the modified Harris Hip Score averaged 96.8 (range 48 to 100). Forty seven percent of patients reported abductor fatigue after sport. Forty-one patients had excellent result with a Severin class I hip on radiographic evaluation. All of these patients had an Iowa index > 95 and a mean Centre-Edge angle of 35.5 (range 25–40).
Six patients had a poor radiological outcome with 5 Severin class IV hips and one class V. Clinical outcome scores did not correlate with poor radiological outcome; Iowa hip score 92 (range 62–100). One patient required a Ganz periactabular osteotomy. The age at which primary osteotomy was performed was significantly higher in the poor outcome group with a mean of 50.8 months.
When the anatomy of the hip is restored to normality at an early age with out the development of avascular necrosis excellent long-term results can be expected.
Open tibial fractures have traditionally been treated as surgical emergencies. However, the “golden eight hour rule” for emergent treatment of these injuries is based more on historic principles and in-vitro data.
A substantial number of open tibial fractures referred to our hospital from the peripheral referral units have transport times in excess of eight hours. These circumstances provide the source for the present study of the effect of delay in initial treatment on the final outcome in terms of infection, delayed union, non-union, malalignment and failure of fixation.
Between January 1998 and June 2001, 53 open tibial fractures were treated at our institution. The fractures were classified using the Gustilo classification. All patient had a minimum of one year’s follow-up. Patients were categorized into 4 groups based on the time delay from injury to surgery, namely those treated within 6 hours of injury, 6 to 12 hours, 12 to 18 hours and > 18 hours following injury. Following recognized methods of surgical toilet and wound debridement, treatment modalities included intramedullar nailing, external fixation and cast application.
There were 22 Grade 1, 22 Grade II and 9 Grade 3 open fractures. Twenty-three received treatment within 6 hours of injury, 10 between 6 to 12 hours, 6 between 12 to 18 hours and 14 at more than 18 hours following injury.
Forty three percent of cases with complications were in the group of patients treated within 6 hours of injury, 29% were in those treated between 6 to 12 hours, 7% were in those treated between 12 to 18 hours and 21% were in those treated at > 18 hours following injury.
27% of Grade I open fractures, 14% of Grade II fractures and 55% of Grade III fractures developed complications.
Our experience indicates that the incidence of complications correlates more with the severity of the injury rather than with time from injury to treatment. In spite of early treatment, fractures treated within 6 hours of injury developed more complications in our series. Delays of 6 to 18 hours did not reflect a proportional increase in incidence of complications.
Limb length discrepancy (LLD) is a complication of total hip arthroplasty (THR). We reviewed the x-rays of patients who underwent THR in our unit to establish the incidence and magnitude of LLD, and try to identify reasons why a length discrepancy arose. Patients with abnormalities of the opposite hip (previous THR, significant osteoarthritis) were excluded, to allow comparison with a normal contralateral side.
100 consecutive patients who fulfilled these criteria were included. There were 38 male and 62 female patients. The implants used were Charnley (89 cases), Elite (4 cases), and Exeter (7 cases). The following measurements were made on pre-and post-operative films on the hospital PACS system: centre of lesser trochanter to ischial tuberosity; tip of greater trochanter to centre of femoral head; centre of head to base of teardrop. The distance from the osteotomy in the femoral neck to the centre of the lesser trochanter was also measured. The interval from the greater trochanter to the closest margin of the pelvis, and the interval from the lesser trochanter to the base of the teardrop (compared to the normal side) were recorded as indices on adduction. Surgery was performed via a direct lateral (Hardinge) approach (95 cases) or through transtrochanteric approach (5 cases).
There was a radiographic difference between limbs of > 1cm in 43 cases; in 9 of these, the operated limb was longer, and in 34 cases it was shortened. In those cases where the operated side was lengthened, the cause was on the acetabular side in 2 patients, and on the femoral side in 25 cases, and on the femoral side in 9 cases. The shortened limb was noted to be adducted relative to the opposite side in 29 patients. There was difference noted in the incidence of discrepancy between different implants. The transtrochanteric approach was associated with significantly (p< 0.01) less length discrepancy.
Our findings suggest that shortening is much more common than lengthening following THR, and that incorrect positioning of the acetabulum is the more likely cause. Persistence of an adduction contracture may also contribute to an apparent shortening postoperatively. The transtrochanteric approach appeared to make LLD less likely. Surgeons should be aware of these findings when performing THR. The clinical effect of differing degrees of LLD is till debatable.
We have developed a system of assessment and reassessment and for the patients who are on the waiting list for hi p and knee arthroplasty. We have evaluated the changes in hip and knee scores in cohort of patients while waiting for surgery.
Aseptic loosening of the acetabular component is the major long-term complication of cemented total hip arthroplasty (THA). Failure of the acetabular cup occurs two to three times more frequently than failure of the femoral component. Third generation cementing techniques have improved the longevity of cemented components in THA. Although suction venting of the femoral shaft is a well-recognised practice, venting of the acetabulum during the cementing process has been little studied. This prospective study sets out to evaluate the effect of iliac wing vacuum aspiration on cement penetration of the acetabulum. Forty patients (Male 18, Female 22) aged 19–82 years (average 67+12 years) undergoing primary THA were entered consecutively into two study groups (20 hips per group). Reasons for THA included osteoarthritis (35) acetabular Dysplasia (2), rheumatoid arthritis (1), perthes (1) and conversion THA post dynamic screw (1)> A single consultant surgeon performed all procedures in a standard operating room with laminar flow. A posterior approach was used in all hips. Third generation cementing techniques were used for acetabular component insertion. Twenty-six millimetres internal diameter Charnley ogee LPW polyethylene cups (Depuy) with varying external diameters [43 mm (9), 47 mm (24), 50 mm (5) and 53 mm (3)] were used and implanted with “Simplex” polymethylmethacrylate cement (Howmedica). Group 1 underwent acetabular cement pressurisation for sixty seconds prior to insertion of cup. Group 2 underwent pressurisation with simultaneous vacuum suction of the ipsilateral ilium using an Exeter iliac wing aspirator. Pre-and post-operative haemoglobin values were recorded for all patients. Standard post-operative radiographs were reviewed blindly to assess penetration of cement. A custom-made template facilitated measurement of depth (mm) of cement penetration in three areas corresponding with Delee-Charnley acetabular zones. Cement penetration was enhanced in all zones following iliac wing vacuum aspiration. The effect of venting was statistically significant (zone I 21.1+6.4mm v 12.8+2.8mm. zone II 7.0+2.4mm v 5.5+2.0mm, zone III 5.3+2.4mm v 4.2+1.4mm). The bone cement mantle interface was also completely obliterated following iliac wing aspiration.
Patients were matched for age, gender, pathology, weight, implant type, pre operative haemoglobin and senior operator in all three groups. We assessed intra-operative and total blood loss, transfusions requirements, postoperative wound complication, regaining of the range of motion, incidence of systemic effects of tourniquet and duration of hospital stay. We also looked at the effects of NSAIDS on blood loss and compared the validity of various factors reported in the literature to be predictive of future transfusion after the surgery. Statistical analysis used were, student’s t-test, univariate and multivariate analysis and regression statistical analysis.
Pathological conditions of the hip joint may present with variable patterns of pain referral in the lower limb. Literature reports suggest that up to 35% of total hip arthroplasties are performed on patients whose primary compliant is obturator nerve referred “knee pain”. However the effect of varied pain patterns on patient outcome and satisfaction has not previously been examined. This prospective study was undertaken to determine the most common referral patterns of hip pain in patients scheduled to undergo primary total hip replacement and to examine whether initial pain referral pattern predicted ultimate patient outcome. Patients were assessed using the Harris Hip score, SF 36 and WOMAC scoring systems measured preoperatively, at 6 months, 1 and 2 years post operatively.
236 patients were identified with isolated single hip joint disease. Patients who demonstrated multi joint disease, and particularly ipsilateral knee pathology were excluded. Forty-five percent of patients with primary hip disease had pain primarily at or about the knee. There was no difference in preoperative demographics, physical function, social function, perceived general health, Harris Hip score (p=0.74), SF 36 (p=0.66) or WOMAC scores (p=0.81) between the pain pattern groups. Operator status and operative techniques were comparable. At 1 and 2 years postoperatively the groin and thigh pain groups were similar in all respects. However at 6 months, 12 months and 2 years, Harris hip scores (p=0.04, p=0.037, p=0.021) and SF 36 scores (p=0.035, p=0.027, p=0.01) were significantly lower in those patients presenting initially with knee pain. Multivariate regression analysis confirmed that no other confounding variables could account for the observed differences between the groups. These results indicate that, using current outcome measures, patients with “knee pain” who undergo total hip arthroplasty, and in whom ipsilateral knee disease has been excluded, have poorer long-term physical and social function and perceived general health. We believe this is the first report of its kind and suggest that patient and surgeon expectations of the results of total hip arthroplasty should be tailored according to the individual initial pain referral pattern.
In late presenting developmental Dysplasia of hip there is controversy as to the most appropriate method of treatment. The purpose of study was to determine the outcome following the non-operative and operative treatment for late presenting developmental dysplasia of hip.
Retrospective study. Inclusion criteria – (1) Unilateral DH (2) Diagnosed 6 months or more after birth (3) Minimum follow up of 2 years after treatment. 41 patients matched the inclusion criteria. 32 patients attended the follow-up clinic. Patients were divided into non-operative and operative group. Outcome instruments used include activities scale for kids (ASK), physical component of SF36 v2, centre edge angle and severin classification system, all validated scoring systems.
32 patients with mean follow-up of 7 (2–12_ years. Mean age at the time of follow-up was 9 (range 2.7 – 15) years. In our series, 15 patients received non-operative and 17 patients received operative treatment. On ASK, conservatively treated hips scored 72% and surgically treated hips scored 69%. (P-Value = > 0.05). On SF36 v2, mean value of physical function score (PFS) for both non-operative and operative group were 57.58 respectively (P Value > 0.05). Centre edge angle (CEA) of non-operative and operative group were compared with their contra-lateral normal sides (P Value > 0.05). According to Severin classification system, 7 hips were grade I, 8 were grade II in the non operative group and in operative group, 10 were grade II, 5 were grade III and 2 were grade IV. There were no major complications and only one (3%) hip developed avascular necrosis of hip.
On a medium term follow-up, despite some radiological abnormalities, most of the patients achieved good functional results following both non-operative treatments for late presenting DDH. There was no statistically significant difference in the development of hips either treated conservatively or surgically. Long term follow up studies are required in order to establish the true outcome of late presenting DDH treated either conservatively or surgically.
Only one patient (2.5%) from Group 1 was cancelled pre-operatively; this for treatment of a chronic comorbidity. Five patients (10%) in Group 2 were cancelled on admission for surgery. Four of these patients were cancelled for acute illness that had developed following in-patient assessment, with one being discharged for treatment of a chronic illness.
The diagnosis and subsequent treatment of patients with “Anterior Knee Pain” remains a challenge and an enigma at times.
The 4 main parameters, which need to be assessed, are:
Bony anatomy of the PFJ Cartilage structure within the PFJ Tracking of the patella with active knee extension Structure of the soft tissues in the extensor mechanism
While plain radiographs, CT scans and static MRI sans and arthroscopic assessments highlight some of the parameters none of them are comprehensive. The type of MRI scanning used in this study assesses all 4 parameters. The equipment required for resisted quadriceps contraction is inexpensive and readily available.
Radiological diagnosis and grading of subluxation if present. Clinical scoring of 26 patients who returned the questionnaires. Oxford, Lysholm and Tegner scores were used and correlated with the radiological scores. Development of a Treatment Algorithm based o the scan results.
Breech presentation is historically associated with an increased incidence of hip Dysplasia (6.6%–9.6%), but the effect of vaginal breech delivery on the development of hip dysplasia is unknown. In the Irish Republic, the proportion of breech presentations delivered by caesarean section is now over 90%. If the mechanical trauma of vaginal delivery is a significant event in the aetiology of DDH in breech presenters, caesarean section should be protective. We tested this hypothesis by a prospective study in infants presenting in the breech position who were delivered by caesarean section, during the 2002 calendar year.
There were 108 infants in the breech position at the time of delivery during this period; all but two of these (excluded from the study) were delivered by caesarean section. 50 were male and 56 were female. The mean duration of pregnancy at delivery was 37 weeks. An initial examination was performed in all cases within the first 48 hours postpartum, and treatment in a Pavlik harness commenced where there was clinical instability. Standardised AP and BIR views of the pelvis were taken at 4 months after birth, in all 106 cases. The acetabular index (AI) was measured on both sides.
There was only one case of hip dislocation at birth (bilateral dislocation in a first-born female infant). In 7 cases the initial examination was suspicious for instability, and patients were treated in Pavlik harness; in five of these cases another recognised risk factor (first-born female, family history) was also present. Two of these cases were found to have evidence of instability at 4 months, and underwent treatment by closed reduction and spica casting. For the entire group, the mean acetabular index (212 hips) was 23 degrees (range 17 to 36 degrees). Among those with signs suggestive of instability, the mean AI was 28 degrees. Only one patient had an AI > 30 degrees. Among those with no other risk factors, the mean AI was 22 degrees (range 17 to 28).
Our prospective study suggests that the incidence of DDH is markedly lower in breech presenters delivered by caesarean section (< 3%) that that reported for breech presenters as a whole. The three patients in our group with DDH had other risk factors present. We conclude that caesarean section may be protective for the development of DDH in infants who present in the breech position.
Hip fracture in the elderly is associated with significant morbidity and mortality. Significant intra-operative blood loss and the subsequent need for transfusion significantly contribute to patient morbidity. Making a surgical incision with diathermy reduces wound related blood loss, by coagulating small vessels as tissue is incised, however no study to date has looked at the use of diathermy in making surgical incisions around the hip. In addition, the increasing prevalence of blood borne infections makes the exclusion of sharps from the operative field an attractive option. The aim of this study was to compare diathermy incision with traditional wound opening using a scalpel to incise all layers. 50 patient undergoing hemiarthroplasty for fractured neck of femur were recruited prospectively. Patients on warfarin were excluded from the study while those on aspirin were not. After informed consent was obtained patients were randomized to scalpel or diathermy incision by coin toss.
In the diathermy group the dermis was incised with the scalpel and all further layers with the diathermy, while in both groups diathermy as used for haemostasis. All patients received prophylactic antibiotics at induction and for 24 hours post-op. Wounds were closed in a standard fashion using absorbable sutures for closing fascia and fat layers and surgical staples for skin. Intra-operative parameters measured included: 1) Time to open wound – defined as time taken to open wound from skin incision to complete opening of the fascia lata and achieve haemostasis. 2) Wound length and depth. 3) Wound related blood loss – swabs used while creating and closing the wound were weighed separately. 4) Total operative blood loss. Post-operatively all wound related complications were recorded. Statistical analysis was performed using the un-paired Student t-test parametric data.
Both groups were similar in relation to age, sex and pre-operative aspirin use. Intra-operatively neither wound sizes nor time taken to create the wound were statistically significantly different. In the scalpel group wound related blood loss represented over 30% of the total operative blood loss as compared with only 18.5% in the diathermy group. Post-operatively there were no wound infections or dehiscences in either group, however 4 patients in the scalpel group developed significant wound ooze that responded to conservative treatment. There were no significant wound problems in the diathermy incision group.
This prospective study has shown that the use of diathermy incision for hip hemiarthroplasty significantly reduces wound related blood loss and the incidence of post-operative wound ooze. We conclude that the routine use of diathermy to make incisions around the hip is effective in reducing wound related bleeding without adverse effects on wound healing or infection rate.
Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of > 12g/dl. When combined with intraoperative cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz peri-acetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two-surgeon approach is invaluable to the management of these difficult cases.
Langerhans-cell histiocytosis (LCH) is a reactive proliferative disease characterized by the accumulation of abnormal histiocytes. The disease is broadly divided into two groups, unisystem and multisystem disease. The aetiology of LCH is unknown; the disease is currently accepted to be a reactive process rather than a malignancy. Localized LCH of bone is a benign tumour-like condition, which is characterized by a clonal proliferation of Langerhan’s-type histocytes, which infiltrate bone and cause osteolytic lesions. The common bones involved include – skull, pelvis, and diaphysis of long bones.
We wanted to determine whether patient demographics at the time of presentation could help determine the clinical course and eventual outcome of the disease. We prospectively reviewed 68 patients with a primary diagnosis of LCH.
Forty-six patients had unisystem disease, 22 had multisystem disease. There was a statistically significant difference in the age of presentation between the two groups. There were 6 deaths, all had multisystem disease. Of the 46 patients with unisystem disease, 31 (67.3%) underwent orthopaedic surgical intervention, 26 open biopsies and 5 curettage and bone grafting of lesions of the humeras (2), skin, clavicle and skull (1 each). There was a statistically significant difference in the average length of follow-up, between the 2 groups.
We recommend closed and prolonged multidisciplinary follow-up of patient initially presenting with multisystem disease. Patients with unisystem disease can safely be discharged after a short follow-up period.
Nosocomial infection with methicillin-resistant Staphylococcus aureus (MRSA) is on the increase and is expensive to treat. MRSA surgical wound infection may have disastrous consequences, particularly in an orthopaedic setting. We studied the rate of MRSA colonization in an important subgroup of orthopaedic patients. 50 nursing home residents were retrospectively reviewed with regard to their MRSA status on admission to an orthopaedic ward with fractured neck of femur. As is policy in our institution, all patients from nursing homes or other institutions are screened for MRSA on admission.
Of the 50 nursing home patients requiring a hemi-arthroplasty, 16%(8) were MRSA positive. 2%(1/50) acquired MRSA infection while I hospital, while the remaining 14%(7/50) were carriers on admission. 4%(2/50) developed sepsis postoperatively, followed by multiorgan failure and death. 4% had their MRSA cleared prior to discharge, while 8% remained positive on discharge. All patients undergoing hemiarthroplasty received cefuroxime, unless allergic, as prophylaxis at induction. These findings of considerable MRSA carriage in nursing home patients is particularly relevant today, as the number of patients in nursing homes continues to grow as the population ages. The patient population in nursing homes is susceptible to infection because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live.
Nursing home residents presenting to orthopaedic units for surgery are a unique group in repairing careful consideration.
The management of long bone infected non-unions; posttraumatic chronic osteomyelitis and primary segmental bone defects constitute some of the most difficult reconstructive challenges encountered by orthopaedic surgeons. Measures employed to treat these conditions are tantamount to limb salvage with amputation a likely outcome if reconstructive endeavors prove unsuccessful. The Ilizarov method of distraction osteogenesis and bone transport, following radical debridement in the case of infection, is one potential management option in such cases.
*Association for the Study and Application of the Methods of Ilizarov
We retrospectively reviewed medical records and radiographs of 82 children who presented within 12 months of their birth, with unilateral dislocated/subluxed hips and required treatment in from of traction, closed/open reduction, pelvic osteotomy and maintenance. The purpose of the study was to assess if HE angle could be utilized as a prognostic indicator fro assessing reduction of the affected hip. Hilgenreiner epiphyseal angle was measured by two observers for the normal as well as the abnormal side and differences noted. The measurements of the primary presentation and follow-up films were then correlated. Two groups of patients emerged, those in who the difference between the normal and abnormal hips was less than 10 degrees and those in whom was greater than or equal to 10 degrees, on initial presentation. Their management transpired to be quite different (p=0.000), with open reduction/pelvic osteotomy being required in all cases in the latter group.
Fractures of the mid-shaft of the clavicle have been treated conservatively with excellent results regarding functional outcome. Indeed some studies have indicated that open reduction and internal fixation of mid-shaft clavicle fractures by plating have superior union rates. Recent studies have indicated that early plating of the mid-shaft clavicle fractures is a stable and reliable procedure well tolerated by the patient and results in a rapid rehabilitation and better functional outcome of the shoulder. This study aims to examine the results at retrospective cases of mid-shaft clavicle fractures that underwent acute open reduction and internal fixation.
Case records and x-rays have been recorded for all the 60 patients. All patients have been informed for clinical and radiological examination. Up-to date 50% patients have attended. This gives us a mean follow-up of 9.5 years. Parameters assessed at clinical and radiological examination were Union/non-union rates, time to union, Shoulder function, time back to work and complications.
The shoulder function was assesses by using the Constant-Murley score, which has been recommended by the European Orthopaedic Association. All of the 60m mid-shaft clavicle fractures have plated with one-third tubular plate within 48 hours of the injury. All of them were immobilized in a sling for 72 hours and were the commenced physiotherapy. Skin sutures were removed on the 10th postoperative day. The mean time to radiographic union was 10 weeks. No non-union occurred. Four cases has superficial infection. Six patients had skin numbness over the incision. Average Constant-Murley score was 97% as compared to the contralateral shoulder.
In this study we analyzed our results with osteosynthesis of mid-shaft clavicle fractures using one-third tubular plate.
* Pain: Average score 11.3 *Daily-life activities: Average score 14.7 points out of a maximum 20 points; 80% of patients achieved activity similar to pre-fracture levels. * Mobility: Average score was 24.6 out of 40. * Strength: Average score was 17 points. Overall average score for all patients out of 100 points on Constant’s scale was 67.7. Complications included local infection of the wound at the screw site in 4 cases, all of which were proximal screws. Algodystrophy was present in 3 patients. Three patients presented subacromial conflict after consolidation. No surgical iatrogenic injuries to vascular or nervous tissues were noted. Subjective results: Patients showed good acceptance of the external fixator due to the fact that it caused them little incapacity during treatment.
There was no statistically significant difference in baseline lesion volume between decreasing lesions and unchanged lesions.