Osteoarthritis of the costovertebral joints: the results of resection arthroplasty.

Thoracic back pain caused by osteoarthritis of a single costovertebral joint is a poorly recognised condition. We report a series of five patients who were successfully treated by resection arthroplasty of this joint. Each had received a preliminary image-guided injection of local anaesthetic and steroid into the joint to confirm it as the source of pain. The surgical technique is described. There were no complications. The pain improved from a mean of 7.0 (6 to 8) on a visual analogue scale to 2.0 (0 to 4) post-operatively. The final post-operative Oswestry disability index was a mean of 19.4 (9 to 38). Isolated osteoarthritis of a costovertebral joint is a rare but treatable cause of thoracic back pain. It is possible to obtain excellent short- and intermediate-term relief from pain with resection arthroplasty in appropriately selected patients.

Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening.

Results of surgery to correct fixed flexion contracture of the knee and improve voluntary knee extension in 39 knees in 20 children (11 females, 9 males; mean age 12 years 8 months, age range 5 to 20 years) with cerebral palsy were analyzed. All patients had neuromotor disease and 18 children had spastic diplegia or quadriplegia. All patients could initiate voluntary knee extension but lacked full passive extension. Five patients (10 knees) were free walkers with a mean motor severity index of 19 and mean fixed knee contracture of 20 degrees. Fifteen patients (29 knees) were not free walkers and 13 were wheelchair ambulators. They had a mean motor severity index of 8 and mean fixed knee contractures of 30 degrees. Surgical procedures included various combinations of hamstring lengthening and/or posterior capsulotomy to allow free passive knee extension, with or without quadriceps mechanism shortening, to enhance voluntary extension. The best results were in patients who had hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening.

The short clavicle syndrome.

Congenital or developmental shorting of the clavicle is an uncommon and isolated condition leading to a tangential position of the scapula. It presents in childhood as abnormal posture and may be familial. It causes minimal disability and affected patients do not require treatment.

Fractures of the femur after hip replacement: the Oregon experience.

The article provides an analysis of 102 interventions in 93 periprosthetic fractures of the femur contributed by multiple surgeons predominately in community practice. The authors find that treatment of periprosthetic fracture of the femur is problematic. Success in terms of arthroplasty function and fracture treatment is difficult to achieve. Specific treatment recommendations are made based upon the success and failures of this survey.

Total hip arthroplasty in patients with Down's syndrome.

Hip disease occurs in between 8% and 28% of patients with Down's syndrome, many of whom develop disabling pain. We have carried out total hip replacement in six adult patients (9 hips) with severe arthritis of the hip. The mean follow-up was 7.75 years (2 to 14). At the latest review, all had relief of pain and full hip function. Increasing longevity and a high incidence of hip disease in these patients suggest a greater role for total hip arthroplasty in the future.

Coxa vara in childhood: evaluation and management.

Coxa vara in childhood may be clinically classified as developmental, congenital, dysplastic, or traumatic and may occur at the physis or in the trochanteric or subtrochanteric area. Evaluation should include a search for a family history of similar deformity, a history of trauma or infection, and evidence of associated skeletal abnormality. Radiographs will illustrate whether the deformity is unilateral or bilateral and whether it occurs at or below the physis. With this information, coxa vara can be classified, and the optimal treatment can be selected. Surgical treatment of coxa vara in childhood is usually indicated when the disease is progressive, painful, unilateral, or associated with leg-length discrepancy.

Modified adductor muscle transfer in cerebral palsy.

Eighty-five patients with cerebral palsy had modified adductor muscle transfers. A study of associated patient characteristics suggests that comparing adductor transfer with adductor release using postoperative radiographs, need for subsequent surgery, or postoperative motor skills is flawed by multiple variables. Adductor release and adductor transfer are best compared by measuring the abduction obtained at surgery and maintained over time. A follow-up of 141 modified adductor transfers with no prior or concomitant hip surgery demonstrated an averaged initial improvement in abduction of 43 degrees and maintenance of abduction with a low incidence of recurrence.

Treatment of patellofemoral instability in childhood with creation of a femoral sulcus.

Four patients with six knees with patellofemoral instability and severe trochlear dysplasia were treated with creation of a femoral sulcus. None of the six knees have had recurrent dislocations at 3- to 11-year follow-up. All patients had chromosomal abnormalities and limited motor demands. We recommend this procedure for children with patellar instability refractory to standard treatment methods who have severe trochlear dysplasia and limited motor demands.

Sponastrime dysplasia: diagnostic criteria based on five new and six previously published cases.

Sponastrime dysplasia is a dwarfing autosomal recessive bone dysplasia, the diagnosis of which is based on a combination of clinical and radiological features. The radiological features are more specific than the clinical ones. We have developed diagnostic radiological criteria based on information from our five cases and from six previously published ones.

Saline load test for penetration of periarticular lacerations.

We used a saline load test in 50 consecutive patients with periarticular lacerations suggestive of joint penetration. The surgeon had predicted on clinical grounds whether or not the laceration penetrated the joint. Joint penetration was demonstrated in 14 and was absent in 36. A comparison of the prediction and the test results showed that there were false-positive clinical results in 39% and false-negative in 43%. There were no complications from the use of the test. Our findings support the use of a saline load test in evaluating periarticular lacerations.

Periprosthetic fractures of the femur. An analysis of 93 fractures.

A retrospective review of 93 periprosthetic fractures and 102 periprosthetic fracture treatments showed that the type of prosthesis (cemented, ingrowth, Austin-Moore) and the presence of preexisting stress risers play a role in determining where the fractures occur. The site of fracture and the prefracture interface influence treatment of periprosthetic fractures. This study suggests that fractures associated with a loose interface, cemented or cementless, are best treated by removal of the prosthesis, reduction of the fracture, and insertion of a long stemmed prosthesis with additional fixation as needed. Treatment of a periprosthetic fracture associated with a stable prosthesis depends on the site of fracture. Fractures proximal to the tip of a fixed prosthesis usually can be treated nonoperatively or with limited internal fixation. Fractures at the tip of the prosthesis may be managed by revision or internal fixation, and fractures below the prosthesis can be managed operatively or nonoperatively.

Sponastrime dysplasia: five new cases and review of nine previously published cases.

Sponastrime dysplasia (SD) is a dwarfing autosomal recessive short-limb bone dysplasia. The diagnosis is established by a combination of clinical and radiological findings of which the radiological are the more specific. The current diagnostic criteria are ambiguous as demonstrated by the fact that, in our opinion, three of the five patients reported since the original article do not have this condition. Comparison of our five patients and the 9 published patients has led to development of more specific diagnostic criteria. Previously undescribed complications of this condition are subglottic stenosis and tracheo-broncho-malacia, developmental coxa vara, and avascular necrosis of the capital femoral epiphyses.

Iliopsoas bursa imaging: efficacy in depicting abnormal iliopsoas tendon motion in patients with internal snapping hip syndrome.

PURPOSE: To evaluate the efficacy of both iliopsoas bursa imaging and therapeutic injections for determination of the cause of pain in patients with internal snapping hip syndrome. MATERIALS AND METHODS: Twelve patients underwent iliopsoas bursa imaging. One patient underwent the procedure bilaterally and five underwent repeated studies for a total of 21 studies. Eight patients also received therapeutic injections after bursa imaging. RESULTS: Abnormal motion of the iliopsoas musculotendinous unit that occurred synchronously with the snap was revealed in 15 of the 21 studies. Four studies revealed additional information that contributed to symptoms. Eight patients received therapeutic injections with relief of symptoms that ranged from 2 weeks to 2 years. CONCLUSION: Iliopsoas bursa imaging is a simple, rapid, and reproducible method with which abnormal iliopsoas tendon motion can be documented in patients with internal snapping hip syndrome and is also useful for diagnosis of other causes of atypical hip pain. Therapeutic injection into the iliopsoas bursa may delay or obviate surgery.

Craniofacial conodysplasia.

A family with dominant inheritance of a previously unreported syndrome of craniofacial dysplasia and cone-shaped physes of the hands and feet is described. Hydrocephalus and spinal cord compression at the craniocervical junction causes neurological complications and mimics cerebral palsy. Early diagnosis and treatment may prevent progression of neurological changes.

Osteoarticular allograft reconstruction for recurrent post-traumatic dislocation of the hip.

A patient with post-traumatic mechanical instability associated with a significant posterior acetabular deficiency in the presence of an otherwise good articular surface was treated with an allograft reconstruction. The short-term result was good; at 10-month follow-up there was full range of motion with no clinical evidence of instability. This procedure may be indicated in rare instances of post-traumatic mechanical instability where insufficiency of the posterior acetabular wall is felt to be a significant factor.

The results of treatment of posttraumatic avascular necrosis of the femoral head in young adults: report of 31 patients.

A series of 31 adult patients less than 42 years of age who were treated for avascular necrosis (AVN) following a healed femoral neck fracture were followed for an average of 14.6 years, and the results of their treatment were analyzed. The average age at fracture was 26.3 years (range: 12.2 to 41.4 years). The mechanism of injury was a motor vehicle accident in 18 and a fall in 13. Sixteen patients had multiple injuries. The average time from fracture to diagnosis of AVN was 19.1 months. The management of AVN included one or a combination of the following: non-weightbearing ambulation, decompression and bone grafting, electrical stimulation, femoral osteotomy, cup arthroplasty, resurface arthroplasty, arthrodesis, hemiarthroplasty, and total hip arthroplasty (THA). The average number of hip operations after initial fracture treatment was 2.9 per patient (range: 0-7). Current follow-up was possible in 97% (30 out of 31) of the patients. THA was performed either primarily or following other treatment in 23 patients at an average age of 31.9 years (range: 16.9-55.3 years). The survivorship of these THAs was 89% at five years and 49% at ten years. Revisions have been done for aseptic loosening of cemented components with the exception of two infections and one loose metal-on-metal press-fit THA. The results of this study indicate that total hip arthroplasty has a high long-term failure rate in this population, and alternate treatment should be considered in order to improve the long-term results.

Painful snapping hip in young adults.

The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in orthopedics. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of these items of progress in orthopedics that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Orthopedics of the California Medical Association, and the summaries were prepared under its direction.

Anomalies associated with vertebral malformations.

A review of 218 patients with congenital vertebral anomalies demonstrates that 61% of patients had associated abnormalities affecting seven systems. The type of vertebral anomaly did not predict the location or type of associated abnormality. The site of vertebral anomaly did correlate with the occurrence of some associated diagnoses. The most common abnormalities associated with vertebral malformation were cranial nerve palsy, radial hypoplasia, club feet, dislocated hip, Sprengel's deformity, imperforate anus, hemifacial microsomia, and renal and cardiac anomalies. Comprehensive evaluation of patients with vertebral anomalies will be enhanced by knowledge of the type and frequency of associated anomalies.