Trimalleolar fracture and associated Achilles tendon rupture: Ten year follow up of an unusual water-skiing injury.

A 49 year old professional fitness instructor sustained a high velocity rotational injury to his right ankle while waterski-ing. The ski bindings did not release, exacerbating the injury. This resulted in a trimalleolar fracture and a rupture of his Achilles tendon. A trimalleolar fracture in association with a rupture of the Achilles tendon has not been previously reported. This combination of injuries posed a dilemma in treatment options and postoperative management. The authors felt that ensuring that the Achilles tendon healed with no shortening was the priority for future function in this professional athlete. It was decided to treat the Achilles tendon rupture by open repair and to place the ankle in equinus postoperatively. It was also decided to openly reduce and internally fix the medial and lateral malleolar fractures before immobilising the ankle in equinus. Any residual stiffness in the ankle, subtalar and midtarsal joints would be treated with aggressive physiotherapy. It was felt that the rotational forces may have resulted in a degree of degloving around the ankle. Care was therefore taken in the choice and placement of the surgical incisions. In spite of this, the lateral surgical wound broke down postoperatively, needing treatment with a fasciocutaneous flap. When reviewed at ten years following the injury, the patient was continuing to work as a fitness instructor with a view to continuing to retirement in five years at the age of 65. There was a slight decrease in dorsiflexion of the right ankle but flexion was full and movement of the subtalar and midtarsal joints were also full. There remained 1 cm of wasting of the right calf. Radiology of the ankle showed no joint space narrowing or evidence of degenerative change at ten years following the injury.

Children's surgery cancelled due to malaria and anaemia.

At our hospital 461 children were admitted for elective orthopaedic and reconstructivesurgery between January and December 2003; 90 of these (19.5%) were positive for malaria, and 37 (8%) had haemoglobin levels below 8 g/dL. The mean delay between admission and operation was five days for patients without anaemia or malaria, 7.17 days for patients with malaria,11.05 days for patients with anaemia and 13 days for patients with both anaemia and malaria.

Technical note: a technique for measuring the surface area of articular cartilage in acetabular fractures.

The aim of this study was to develop a reliable technique for measuring the area of a curved surface from an axial computed tomography (CT) scan and to apply this clinically in the measurement of articular cartilage surface area in acetabular fractures. The method used was a triangulation algorithm. In order to determine the accuracy of the technique, areas of hemispheres of known size were measured to give the percentage error in area measurement. Seven such hemispheres were machined into a Perspex block and their area measured geometrically, and also from CT scans by means of the triangulation algorithm. Scans of 1, 2 and 4 mm slice thickness and separation were used. The error varied with slice thickness and hemisphere diameter. It was shown that the 2 mm slice thickness provides the most accurate area measurement, while 1 mm cuts overestimate and 4 mm cuts underestimate the area. For a hemisphere diameter of 5 cm, which is of similar size to the acetabulum, the error was -11.2% for 4 mm cuts, +4.2% for 2 mm cuts and +5.1% for 1 mm cuts. As expected, area measurement was more accurate for larger hemispheres. This method can be applied clinically to quantify acetabular fractures by measuring the percentage area of intact articular cartilage. In the case of both column fractures, the percentage area of secondary congruence can be determined. This technique of quantifying acetabular fractures has a potential clinical application as a prognostic factor and an indication for surgery in the long term.

The role of 3D CT in the assessment of acetabular fractures.

A total of 16 patients with acetabular fractures were evaluated by plain radiography, axial computed tomography (CT) and three dimensional (3D) CT. It was possible to classify the fracture type in each case from the plain radiographs alone. Axial CT gave additional detail in certain areas, notably the region of the teardrop, the obturator foramen and the acetabular roof. Intra-articular and impacted roof fragments and associated soft tissue injuries were also shown. 3D CT provided the best and most easily interpreted overall assessment of the fractures. In addition to projections equivalent to the plain radiographs, two other views were of particular clinical value in demonstrating surgically inaccessible areas, namely the view of the pelvis from above and the view of the inner aspect of the fractured hemipelvis. However, fracture lines demonstrated on plain radiographs and axial CT were not always apparent on the 3D CT scans. Although 3D CT is a valuable addition to the imaging of acetabular fractures, it is not a substitute for good quality plain radiography and analysis of the axial CT images.

A review of 40 acetabular fractures: the importance of early surgery.

This study demonstrates the importance of early surgery in the management of acetabular fractures. A total of 40 acetabular fractures in 39 patients was treated by open reduction and internal fixation over a 5-year period. Of these, 26 fractures were assessed at over 1 year and up to 4.25 years postoperatively by the Merle D'Aubigné/Postel hip score. Sixteen patients (61.5 per cent) had a good result (16-18), five patients (19.25 per cent) a moderate result (11-15) and five (19.25 per cent) a poor result (0-10). The quality of the clinical result correlated closely with the quality of the reduction of the fracture. The timing of surgery was found to be directly related to the quality of the clinical result. Patients with poor results had been operated on at an average of 17 days after injury, while those with good results had undergone an operation at an average of 11 days. Rapid referral to a regional centre with the necessary facilities and expertise to manage these fractures is recommended in those patients where an operation may be indicated.

Painful bipartite patella following injury.

We report nine rare cases of painful bipartite patella following injury to the knee, in seven non-athletic adults. Patients suffered with persistent anterior knee pain and localized tenderness over the superolateral aspect of the patella for an average of 2 years following injury. The clinical, radiographic and arthroscopic findings are described. Excision of the accessory bipartite fragment resulted in satisfactory relief of pain and complete restoration of the knee function in all patients at a mean follow-up of 10 months (range 3-36 months). Although painful bipartite patella may be considered rare it should be recognized as a cause of post-traumatic anterior pain in the adult.

The vascular repair of an experimental osteotomy held in an external fixator.

The vascular repair of a lower tibial transverse osteotomy in the New Zealand white rabbit held in an external fixator was studied in three groups. In the first group, composed of 18 animals, the osteotomy gap was maintained throughout repair. Three animals were killed every two weeks up to 12 weeks postoperatively. In the second group, composed of three animals killed at six weeks, the fragments were brought into contact. In a third and similar group, the osteotomy was compressed. Plain roentgenograms were taken weekly, and intraarterial perfusion with Micropaque was performed when the animals were killed. Roentgenography using fine-grain film, microradiography, and histology were carried out on a midsagittal tibial slice. The results showed that following transverse osteotomy in which the gap was maintained, vascular union of the proximal and distal cortices and associated external callus masses had usually occurred by ten weeks postoperatively. However, an occasional hypovascular zone at the osteotomy site at 12 weeks was associated with fibrous delayed union. In contrast, when apposition or compression of the fragments was used, repair was accelerated, and cortical bone union was established at six weeks. Vascular union of the fragments occurred predominantly through the medullary vessels. The results emphasize the overriding clinical importance of abolition of a fracture gap to achieve rapid revascularization of a fracture and its union by bone.

Knee pathology among seafarers: a review of 299 patients.

A retrospective study was carried out on 1,250 patients who were referred to the orthopaedic clinic of the Dreadnought Unit during 1989 and 1990. These included 299 actively serving or retired seafarers (24%) with knee pathology, who form the basis of this study. Fifty-one per cent of these patients had a diagnosis of knee osteoarthritis, with a predominance of medial compartment degenerative change (34%). Genu varus or bow legs was present in 31% of seafarers studied. Osteoarthritis of the knee, particularly genu varus, among seafarers may result from acute minor trauma to the medial compartment upon which is superimposed a lifetime of working and living in the vertical environment of a moving ship. It is proposed that improvement in ship design, such as the installation of a two lift system, together with sound working practices would be effective in reducing the incidence of osteoarthritis of the knee among seafarers.

Bone-scintigraphy in painful bipartite patella.

We report the scintigraphic-appearances of painful bipartite patella in 25-year-old man a 2 1/2 years history of unexplained patellar pain. Painful bipartite patella is a rare cause of chronic post-traumatic patellar pain. Bone scintigraphy, by demonstrating increased uptake by the painful accessory bipartite fragment, appears to be an imaging method of choice in the diagnosis of this condition.

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.