Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients.

BACKGROUND: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. PATIENTS AND METHODS: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. RESULTS: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. CONCLUSION: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly.

AIDS-related ankle arthropathy: Mycobacterium avium-intracellulare infection.

We present a case of Mycobacterium avium-intracellulare (MAI) infection of the ankle joint in a patient with HIV infection. The patient presented with a painful, destructive arthropathy of the ankle. Initial microbiological studies were negative but infection with MAI was later identified from biopsies taken during hindfoot fusion. Antibiotic triple therapy was given and the patient remains pain-free without evidence of active infection. To our knowledge, this is the first case of MAI infection of the ankle reported in the literature. A high index of suspicion of (atypical) Mycobacterial infection should be maintained in patients with HIV infection presenting with an indolent but destructive arthropathy of the ankle joint.

Synovial impingement in the ankle. A new physical sign.

Inversion injuries of the ankle are common and most are managed adequately by functional treatment. A significant number will, however, remain symptomatic. Synovial impingement is one cause of continuing pain. This condition is often difficult to diagnose because the physical signs and investigations are non-specific. If the diagnosis is made, treatment by arthroscopic debridement has been shown to be highly effective. Our aim was to describe a new physical sign to help in the diagnosis of anterolateral synovial impingement in the ankle. A cadaver dissection demonstrated the anatomical basis for the physical sign and a prospective clinical study involving 73 patients showed that the lateral synovial impingement test had a sensitivity of 94.8% and a specificity of 88%. We describe the test and conclude that this physical sign will be of use to practitioners treating patients with chronic pain in the ankle after injury.

Manipulation and injection for hallux rigidus. Is it worthwhile?

Manipulation of the metatarsophalangeal joint and injection with steroid and local anaesthetic are widely practised in the treatment of hallux rigidus, but there is little information on the outcome. We report the results of this procedure carried out on 37 joints, with a minimum follow-up of one year (mean, 41.2 months). Patients with mild (grade-1) changes gained symptomatic relief for a median of six months and only one-third required surgery. Two-thirds of patients with moderate (grade-2) disease proceeded to open surgery. In advanced (grade-III) hallux rigidus, little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are graded before treatment and that manipulation under anaesthetic and injection be used only in early (grades I and II) hallux rigidus.

The surgical anatomy of the dorsomedial cutaneous nerve of the hallux.

Most techniques described for the correction of hallux valgus require exposure of the distal aspect of the first metatarsal. A dorsomedial incision is often recommended. Texts counsel against damaging the dorsal digital nerve, as a painful neuroma is an unwelcome surgical complication. Our study on cadavers aimed to investigate the anatomy of the dorsomedial cutaneous nerve in the metatarsophalangeal region, with special reference to surgical incisions. A constant, previously unrecognised branch of the nerve was identified. This branch is likely to be damaged if a dorsomedial approach is used. It is recommended that a mid-medial incision be used instead, i.e. at the junction of the plantar and dorsal skin.

Nonunion of tibial stress fractures in patients with deformed arthritic knees. Treatment using modular total knee arthroplasty.

In two years we treated four women with ununited stress fractures of their proximal tibial diaphyses. They all had arthritis and valgus deformity. The stress fractures had been treated elsewhere by non-operative means in three patients and by open reduction and internal fixation in one, but had failed to unite. After treatment with a modular total knee prosthesis with a long tibial stem extension, all the fractures united. A modular total knee prosthesis is suitable for the rare and difficult problem of ununited tibial stress fractures in patients with deformed arthritic knees since it corrects the deformity and the adverse biomechanics at the fracture site, stabilises the fracture and treats the arthritis.

Effect of particulate bioactive glass on human synoviocyte cultures.

Bioglass is a resorbable glass material that has been shown to induce osteoblast proliferation as well as bone matrix production in vitro. Its physico-chemical properties have been reported to be suitable for use as an implant coating for arthroplasty. However, Bioglass is a ceramic material that can fragment into particulate debris in vivo. The effect of particulate Bioglass on tissue cells has not been defined. In order to determine the biologic response to particulate Bioglass, we tested its effect on human synoviocytes in a cell culture model. At the concentrations of 1.0 and 10, micrograms/mL, particulate Bioglass (sizes ranging from approximately 0.5 to 80 microns) had a low cytotoxic effect. However, these concentrations induced secretion of TNF alpha. The observation that particulate Bioglass elicits release of inflammatory cytokines suggests that the development of this bioceramic implant coating should address techniques that would minimize the generation of particulates.

Human osteoblast-like cells (MG63) proliferate on a bioactive glass surface.

Bioglass, a resorbable glass, previously has been evaluated as a bone graft substitute using cells of animal origin. Limited information is available on its effect on human cells. The objective of this study was to test the hypothesis that Bioglass supports viability and proliferation of human bone cells. As a prototype of human bone cells, the osteoblast cell line MG63 was used and propagated on Bioglass disks. MG63 cells also were seeded onto disks made of titanium (Ti-6Al-4V) and of cobalt chrome (Co-Cr-Mo) alloys. The number of viable cells recovered was similar for Bioglass, titanium, and polystyrene control surfaces. Significantly fewer cells were recovered from CoCr (P < 0.05) compared to Bioglass, Ti-6 Al-4v, and polystyrene surfaces. The proportion of cells undergoing DNA synthesis, estimated by thymidine uptake, was significantly greater on Bioglass and titanium surfaces (P < 0.05) than on the CoCr surface. There were detectable differences in cell morphology on these biomaterials. Functional capacity was tested by assay of osteocalcin production and no differences were detectable among the different biomaterials. This study supports the hypothesis that 45S5 Bioglass provides a favorable environment for human osteoblast proliferation and function. Bioglass may have clinical potential as a bone graft substitute, a bioactive grout, or an implant coating for promoting bony ingrowth in uncemented prostheses.

Local symptoms after open carpal tunnel release. A randomized prospective trial of two incisions.

We report a randomized trial of two skin incisions for carpal tunnel decompression, namely a standard incision and an ulnar L incision. We looked particularly at the resolution of local symptoms namely pillar pain and scar sensitivity. There were 47 patients in the trial. No difference was found in pillar pain between the two incisions, but one had a lower incidence of scar sensitivity. These results give a baseline for comparison of local postoperative symptoms following open release with those following endoscopic release.