Hip resurfacing with femoral osteotomy for painful subluxed or dislocated hips in patients with cerebral palsy.

The painful subluxed or dislocated hip in adults with cerebral palsy presents a challenging problem. Prosthetic dislocation and heterotopic ossification are particular concerns. We present the first reported series of 19 such patients (20 hips) treated with hip resurfacing and proximal femoral osteotomy. The pre-operative Gross Motor Function Classification System (GMFCS) was level V in 13 (68%) patients, level IV in three (16%), level III in one (5%) and level II in two (11%). The mean age at operation was 37 years (13 to 57). The mean follow-up was 8.0 years (2.7 to 11.6), and 16 of the 18 (89%) contactable patients or their carers felt that the surgery had been worthwhile. Pain was relieved in 16 of the 18 surviving hips (89%) at the last follow-up, and the GMFCS level had improved in seven (37%) patients. There were two (10%) early dislocations; three hips (15%) required revision of femoral fixation, and two hips (10%) required revision, for late traumatic fracture of the femoral neck and extra-articular impingement, respectively. Hence there were significant surgical complications in a total of seven hips (35%). No hips required revision for instability, and there were no cases of heterotopic ossification. We recommend hip resurfacing with proximal femoral osteotomy for the treatment of the painful subluxed or dislocated hip in patients with cerebral palsy.

Does curettage without adjuvant therapy provide low recurrence rates in giant-cell tumors of bone?

UNLABELLED: Adjuvant treatment or filling agents have been recommended for reducing recurrence rates of giant-cell tumors of bone. However, reports of low recurrence rates without either caused us to question this concept. We retrospectively reviewed 193 patients treated during a 27-year period, comparing our results with historic controls. One hundred thirty-seven patients had curettage as a primary treatment, and of these, 26 (19%) had local recurrences. The local recurrence rate of giant-cell tumors confined to bone (Campanacci Grades I and II) was only 7% compared with 29% in tumors with extraosseous extension (Campanacci Grade III). Six patients (4%) had a fracture after curettage. Twenty-nine patients who were referred to us with local recurrences after treatment elsewhere had curettage, and 10 (34%) of these patients had local recurrences develop. Twenty-seven patients had excision as their primary treatment, and two (7%) of these patients had local recurrence develop. We recommend primary curettage for intraosseous giant-cell tumors without adjuvant treatment or filling agents, but tumors with soft tissue extension or with local recurrence require more aggressive treatment. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The presentation of scaphoid non-union.

A retrospective study of 30 patients presenting with scaphoid non-union was performed. The results showed that eight had been treated in plaster for a mean of 6 weeks and discharged from follow-up. They presented with established non-union at a mean of 60.3 months after the original fracture. Three of these cases have resulted in litigation against the surgeon. A total of 27 patients underwent bone grafting and Herbert's screw fixation achieving in union in 24. The natural history of scaphoid non-union has been examined in some detail in the literature. These studies have shown that scaphoid non-union is inevitably associated with arthritic changes that become worse with time and that freedom from symptoms is not protective from these changes. Therefore, prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future. Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome and even litigation against the surgeon. It is the authors' advice that all scaphoid fractures treated in a plaster cast are reassessed clinically and radiologically 6 months post-injury.

Intratendinous rupture of flexor digitorum profundus caused by non-specific synovitis.

Closed ruptures of flexor tendons in the hands of patients without rheumatoid arthritis are rare. We report a case of closed rupture of the flexor digitorum profundus of the middle finger in zone II, secondary to acute florid synovitis forming a tumour-like mass. No similar case has been reported to our knowledge. The management of this unexpected finding at surgical exploration is discussed.