The modified tibial tubercle osteotomy for anterior knee pain due to chondromalacia patellae in adults: A five-year prospective study.

OBJECTIVES: To assess the effectiveness of a modified tibial tubercle osteotomy as a treatment for arthroscopically diagnosed chondromalacia patellae. METHODS: A total of 47 consecutive patients (51 knees) with arthroscopically proven chondromalacia, who had failed conservative management, underwent a modified Fulkerson tibial tubercle osteotomy. The mean age was 34.4 years (19.6 to 52.2). Pre-operatively, none of the patients exhibited signs of patellar maltracking or instability in association with their anterior knee pain. The minimum follow-up for the study was five years (mean 72.6 months (62 to 118)), with only one patient lost to follow-up. RESULTS: A total of 50 knees were reviewed. At final follow-up, the Kujala knee score improved from 39.2 (12 to 63) pre-operatively to 57.7 (16 to 89) post-operatively (p < 0.001). The visual analogue pain score improved from 7.8 (4 to 10) pre-operatively to 5.0 (0 to 10) post-operatively. Overall patient satisfaction with good or excellent results was 72%. Patients with the lowest pre-operative Kujala score benefitted the most. Older patients benefited less than younger ones. The outcome was independent of the grade of chondromalacia. Six patients required screw removal. There were no major complications. CONCLUSIONS: We conclude that this modification of the Fulkerson procedure is a safe and useful operation to treat anterior knee pain in well aligned patellofemoral joints due to chondromalacia patellae in adults, when conservative measures have failed.

Bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia.

The gluteal compartment syndrome is uncommon and is discussed in only a few published case reports. The simultaneous bilateral gluteal compartment syndrome is exceptionally rare and is tackled in only 4 case reports to date. We report a case of bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia and discuss its management.

Observations of subchondral plate advancement during osteochondral repair: a histomorphometric and mechanical study in the rabbit femoral condyle.

OBJECTIVE: The subchondral plate and its reconstitution has been an under-researched aspect of articular cartilage repair. The extent to which the subchondral plate is restored by natural healing remains controversial. This study aimed to quantify advancement of subchondral bone during repair of an osteochondral defect, and to examine the effect of subchondral bone height on the quality of articular surface repair. DESIGN: Osteochondral defects, 3mm diameter by 3mm deep, were made by controlled drilling through the articular surface into the subchondral bone in femoral condyles of 33 rabbits. The repair response was examined at 8, 16 and 32 weeks (n=14, 12 and 7, respectively) post surgery. The specimens were subjected to mechanical testing, radiography, histology and histomorphometrology using an image analysis system. RESULTS: At 8 weeks, the level of reparative subchondral bone was 0.79+/-0.36 mm below the native tidemark. By 16 weeks, reformed subchondral plate was irregular, showing that 76.5% of the plate had extended beyond the native tidemark (0.13+/-0.05 mm) whilst 16.9% of the plate remained below (0.19+/-0.15 mm). The repaired surface non-osseous layer became thinner than the adjacent cartilage (0.23+/-0.08 vs 0.38+/-0.11 mm, P<0.05). This persisted up to 32 weeks. The repaired surface layers showed disappearance of safranin-O staining, increased separation splits at the boundary, and eventual degradation. General histological scores were similar across 8, 16 and 32 weeks although the scores of defect filling and restoration of osteochondral junction were decreased from 8 to 16 weeks. Mechanically, repaired defects had lower contact pressure and greater indentation than the normal controls at all time (P<0.05). Indentations of the cartilage adjacent to the defects were also greater than the normal at 8 and 32 weeks (P<0.05). CONCLUSION: The reparative subchondral bone advanced beyond the level of the native subchondral plate by 16 weeks in osteochondral defects of the rabbit femoral condyles. The presence of an advanced and irregular subchondral plate was associated with degradation of repaired articular surface. Abnormal subchondral plate is likely one of the major factors in influencing the long-term outcome of articular cartilage repair.

Evaluation of Gateshead carbon fibre rod as an implant material for repair of osteochondral defects: a morphological and mechanical study in the rabbit knee.

Use of the Gateshead carbon fibre rod system remains controversial. Although it has been shown to enhance the repair of lesions in load bearing areas of convex articular surfaces, there is a lack of evidence to support the claim that it provides an inert scaffold for ingrowth of organised fibrous tissue. and thereby increasing the rate and quality of articular surface regeneration. This study examined osteochondral repair following implantation of a Gateshead rod in the femoral condyles of 25 rabbits for up to 32 weeks. using radiology, histology, scanning electron microscopy and mechanical testing. The repaired fibrocartilaginous surface layer was found to be persistently softer than the normal control and some repaired surfaces were worn, exposing the rod at 32 weeks. Whilst fibrous tissue grew into the outer braided sheath of the rod, the core remained impervious. The rod appeared to act as a space occupier, initially providing better subsurface support than found in natural healing. In the long term, however, it prevented subchondral bone restoration and re-establishment of the normal osteochondral junction, resulting in a quality of repair which did not differ from that found in naturally healing defects.

Partridge osteosynthesis: a prospective clinical study on the use of nylon cerclage bands and plates in the treatment of periprosthetic femoral shaft fractures.

OBJECTIVE: To evaluate the clinical use of the Partridge osteosynthesis in periprosthetic femoral fractures. DESIGN AND SETTING: Prospective nonrandomized clinical study. PATIENTS: Over a ten-year period, 222 patients presenting with femoral fractures near the tip of a hip prosthesis were treated with the Partridge system, which employs elevated cerclage nylon bands and flexible elevated nylon plates. Sixty-five fractures were located cranial to the tip of the prosthesis (Whittaker Type I), 116 at the tip (type II), and forty-one distal to the tip of the prosthesis (Type III). The population consisted of 172 female and fifty male patients, with a mean age of 79.5 years. The mean duration between the index procedure and occurrence of the second fracture was 1.5 years. In 78 percent of the patients (173 out of 222), surgery was undertaken within forty-eight hours. Fracture reduction was open, and two nylon plates set at right angles to each other were secured to the femur with six to eight nylon bands. The mean operating time was fifty-five minutes, with an average blood loss of 550 milliliters. RESULTS: There were minor wound healing problems in eighteen patients (12.6 percent); there were no deep wound infections. Thirty-three elderly patients died within the first month from medical complications. Of the 189 remaining patients, 60 percent regained their prefracture functional level within six months postoperatively, whereas 25 percent required a higher level of care. The mean time of the in-hospital stay was thirty-three days. Ninety-three percent of the fractures consolidated with abundant callus during the follow-up period of one year. CONCLUSION: The indication for the use of this simple osteosynthesis method is swift convalescence by splinting the periprosthetic femoral fractures. Even with a loose prosthesis, the fracture often healed with abundant callus and the patient could be mobilized.

Measurement of coronal plane patellar mobility in normal subjects.

This study evaluated an instrument for measuring patellar mobility in the coronal plane in normal subjects, established baseline quantitative data and compared with methods of measurement described in the literature. This data can be used as a baseline for clinical assessment of patellar mobility. The findings suggest that 8-20 mm displacement is normal patellar mobility in the coronal plane. Displacement less than 8 mm may be considered as retinacular tightness and displacement greater than 20 mm considered as abnormal retinacular laxity.

Late functional deterioration following paralytic poliomyelitis.

Many patients with previous poliomyelitis develop 'post-polio syndrome' (PPS) in which late functional deterioration follows a period of relative stability. The frequency with which PPS can be attributed to clearly defined causes remains uncertain. We reviewed 283 newly-referred patients with previous poliomyelitis seen consecutively over a 4-year period; 239 patients developed symptoms of functional deterioration at a mean of 35 (5-65) years after the paralytic illness. Functional deterioration was associated with orthopaedic disorders in 170 cases, neurological disorders in 35, respiratory disorders in 19 and other disorders in 15. Progressive post-polio muscular atrophy was not observed. Functional deterioration following paralytic polio-myelitis is common, and associated with orthopaedic, neurological, respiratory and general medical factors which are potentially treatable.

The radiological anatomy of the scaphoid. Part 2: Radiology.

The complex shape of the scaphoid and its orientation within the carpus makes the radiological interpretation of scaphoid anatomy difficult. To improve our understanding of how the anatomy appears on plain X-ray, a study was performed using dry cadaver bones. Salient anatomical features were outlined using radiopaque markers, the bones set in wax blocks and the blocks X-rayed in the same axis as six "standard" scaphoid views. The pictures obtained were then compared with clinical X-rays.

Education and training opportunities in trauma and orthopaedics in SE Thames Region.

In preparation for the introduction of the specialist registrar grade the specialist advisory committee (SAC) in orthopaedics developed a six-year structured training programme leading to the award of the Certificate of Completion of Specialist Training (CCST). A team comprising the regional adviser in orthopaedics, the two regional programme directors and an associate dean of postgraduate medicine visited all the departments of orthopaedics in the South East Thames Region in order to evaluate the training opportunities they provided. This paper describes the methodology used during these visits, the lessons learned and the conclusions drawn.

In vivo corrosion of cobalt-chromium and titanium wear particles.

Tissue reaction to wear particles from metal implants may play a major role in the aseptic loosening of implants. We used electron microprobe elemental analysis to determine the chemical composition of wear particles embedded in the soft tissues around hip and knee implants from 11 patients at revision surgery for aseptic loosening. The implants were made of cobalt-chromium-molybdenum alloy or titanium-aluminium-vanadium alloy. Histological examination showed a widespread giant-cell reaction to the particles. Elemental analysis showed that the chemical composition of the particles was different from that of the implanted alloys: cobalt and titanium were reduced, often down to zero, whereas chromium and aluminium persisted. Our findings indicate that corrosion is continually changing the shape, size and chemical composition of the implanted alloy. This may alter the biochemical environment of the tissue surrounding an implant to favour bone resorption.

Sodium phosphate crystals in chondromalacic patellar cartilage.

We report the finding of sodium- and phosphorus-based crystallisation in abnormal human articular cartilage. We prepared five chondromalacic, five osteoarthritic and four macroscopically normal specimens of patellar cartilage by a cryofracturing technique and examined them in a scanning electron microscope. An energy-dispersive X-ray microanalysis system was used to identify the crystals, which were found in only three of the five chondromalacic specimens. Star-shaped crystals were seen either individually or in clusters in the matrix of the cartilage. They consisted of sodium and phosphorus, and we have found no previous reports of such findings. The calcified zone, the bone, and the articular surface were free from crystals.

Immediate strength after suture of a torn anterior cruciate ligament.

In an animal model we determined the strength of anterior cruciate ligaments (ACL) after section and repair by four different methods and compared it with that of the intact ligament. The standard suturing technique of multiple loops through the ligament stumps was used. Stronger suture material did not give a stronger repair. Wrapping a fine polyester mesh around the ligament or placing it between the bundles before suture increased the strength of the repair. This modification, allied to protective rehabilitation, may reduce the failure rate of acute ACL repairs.

The radiological anatomy of the scaphoid. Part 1: Osteology.

A review of the anatomical and clinical literature found that previous descriptions of the scaphoid were not detailed enough to match our present clinical knowledge or the requirements of modern imaging. With this in mind a revised and extended description has been produced following a study of 50 dry cadaver scaphoids. The incidence of the new features described were assessed in 90 pairs of Caucasian scaphoids.

Imaging the position of a screw within the scaphoid. A clinical, anatomical and radiological study.

In an audit of 68 scaphoid fractures with delayed and non-union that had been internally fixed using the Herbert bone screw, it was found that 39 had a significant fault in screw position. Poor intra-operative imaging was a major contributing factor. An anatomical and radiological study was therefore performed to evaluate which views were necessary in order to be confident about screw position. We recommend a minimum of four views. To display the proximal pole, an ulnar deviated postero-anterior (PA) view and true lateral; and to display the distal pole, a semi-pronated and semi-supinated view.

The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study.

We performed postoperative venography on 84 consecutive patients who had undergone upper tibial osteotomy for medial compartment osteoarthritis of the knee. Deep-vein thrombosis was demonstrated in 41%. Only 15% of the cases were diagnosed clinically, all in the calf veins. Cases of proximal thromboses (3) and mixed-vein thromboses (12) were only revealed by venography.

Effect of femoral component head size on movement of the two-component hemi-arthroplasty.

The movement of 75 two-component hemi-arthroplasties, implanted following displaced subcapital fracture of the femoral neck, were examined radiologically in equal numbers of Hastings hips (22 mm), 22-mm Bi-articular hips and 32-mm Bi-articular hips. A classification of the movement of the two-component hemi-arthroplasty was devised. The 22-mm Bi-articular hips showed predominantly intraprosthetic movement compared with the 32-mm Bi-articular hips, where movement was mainly extraprosthetic, thus confirming in vivo the Charnley low friction principle. True bipolar movement was found predominantly in the Hastings hips. In selecting a two-component hemi-arthroplasty, the prosthesis of choice is therefore one with a 22-mm rather than a 32-mm femoral head.

Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study.

We studied the arterial anatomy and the effect of four-part fractures on the vascularity of the humeral head, using barium sulphate perfusion of 16 cadaver shoulders. The main arterial supply to the humeral head was via the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There were significant intraosseous anastomoses between the arcuate artery and: 1) the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus; 2) metaphyseal vessels; and 3) the vessels of the greater and lesser tuberosities. Simulated four-part fractures prevented the perfusion of the humeral head in most cases. If, however, the head fragment extends distally below the articular surface medially, some perfusion of the head persists by the posteromedial vessels. These vessels are important in the management of comminuted fractures of the proximal humerus.

Measurement of tibial torsion--a new technique applicable to ultrasound and computed tomography.

A new method for measuring tibial torsion is described which can be applied to both ultrasound (US) and computed tomography (CT). The method has been validated in dry tibiae by comparison with direct measurements and with Jend's established CT method. In clinical practice a good statistical level of agreement has been demonstrated between the values obtained from US and CT scans. Both compared well with values obtained using Jend's CT technique. The use of US avoids exposure to radiation and is therefore suited to studying young subjects and controls and making repeat measurements.