Correcting deformity in total knee arthroplasty: Techniques to avoid the release of collateral ligaments in severely deformed knees.

Collateral ligament release is advocated in total knee arthroplasty (TKA) to deal with significant coronal plane deformities, but is also associated with significant disadvantages. We describe steps to avoid release of the collateral (superficial medial and lateral collateral) ligaments during TKA in severely deformed knees, while correcting deformity and balancing the knee.

Acetabular protrusio: surgical technique of dealing with a problem in depth.

There are few reports describing the technique of managing acetabular protrusio in primary total hip replacement. Most are small series with different methods of addressing the challenges of significant medial and proximal migration of the joint centre, deficient medial bone and reduced peripheral bony support to the acetabular component. We describe our technique and the clinical and radiological outcome of using impacted morsellised autograft with a porous-coated cementless cup in 30 primary THRs with mild (n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular protrusio. The mean Harris hip score had improved from 52 pre-operatively to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up, 27 hips (90%) had a good or excellent result, two (7%) had a fair result and one (3%) had a poor result. All bone grafts had united by the sixth post-operative month and none of the hips showed any radiological evidence of recurrence of protrusio, osteolysis or loosening. By using impacted morsellised autograft and cementless acetabular components it was possible to achieve restoration of hip mechanics, provide a biological solution to bone deficiency and ensure long-term fixation without recurrence in arthritic hips with protrusio undergoing THR.

Relation of spinal and thoracic cage deformities and their flexibilities with altered pulmonary functions in adolescent idiopathic scoliosis.

STUDY DESIGN: Seventy patients (average age, 13.8 years) with adolescent idiopathic right thoracic scoliosis had full assessment of pulmonary functions and radiographic evaluation of spinal and thoracic cage deformities and their flexibilities. OBJECTIVES: To determine how measurements of spinal and thoracic cage deformities related to pulmonary function. SUMMARY OF BACKGROUND DATA: Pulmonary functions have been evaluated in relation to lateral curvature of the spine in most of the published studies. Scoliosis is a three-dimensional deformity. There is a need to evaluate these changes in pulmonary functions, reflecting not only spinal curvature but also rotational deformity, thoracic cage deformity, and their flexibilities. METHODS: Radiographic measurements obtained from anteroposterior and lateral standing and anteroposterior supine bending radiographs included lateral curvature, vertebral rotation, kyphosis, maximum sternovertebral distance, and apical rib-vertebral angles. Using previous measurements, the flexibility of the curve, vertebral rotation, and rib-vertebral angle were calculated. A pulmonary function assessment was performed using a computerized pulmonary function system (5000V; Gould, Dayton, Ohio). We analyzed pulmonary functions in relation to deformity. RESULTS: Measurements reflecting spinal deformities obtained from anteroposterior radiographs, such as Cobb angle, vertebral rotation, and vertebral rotation flexibility, were significantly correlated with the percent of predicted values of vital capacity and forced vital capacity, whereas kyphosis measured from lateral radiographs was significantly correlated with absolute values of residual volume, total lung capacity, functional residual capacity, and forced expiratory flow from 25-75% of the forced vital capacity (FEF25-75). Of the measurements reflecting thoracic cage deformity obtained from anteroposterior radiographs, rib-vertebral angle asymmetry (measured from supine bending radiographs) showed significant correlation with the percent of predicted values of vital capacity, forced vital capacity, and functional residual capacity, whereas the sternovertebral distance that was measured from lateral radiographs correlated significantly with absolute values of vital capacity, total lung capacity, forced vital capacity, and FEF25-75. CONCLUSIONS: Deformities in coronal and transverse plane influence changes in pulmonary functions expressed as the percent of predicted values, whereas sagittal plane deformities influence mainly those absolute volumes in which residual volume is a component. It is suggested that rotational flexibility combined with other deformities could be evaluated in future studies on prediction of pulmonary function from the measurements of the deformity.

Evaluation of deformities and pulmonary function in adolescent idiopathic right thoracic scoliosis.

Seventy patients with adolescent idiopathic right thoracic scoliosis had full assessment of their pulmonary function using a computerised pulmonary function system. Their mean age at evaluation was 13.8 years. The following measurements were obtained from anteroposterior and lateral standing and antero-posterior supine bending radiographs: lateral curvature, vertebral rotation, kyphosis, maximum sterno-vertebral distance and apical rib-vertebral angles. Using the above measurements, the flexibility of curve, vertebral rotation and rib-vertebral angle asymmetry were calculated. Patients were classified into three groups on the basis of their predicted vital capacity, to determine whether radiological features of deformity can help identify patients with compromised pulmonary function. The mean Cobb angle and vertebral rotation for the 70 patients were 50 degrees (range 35-100 degrees) and 22 degrees (range 1-44 degrees) respectively. The mean flexibility of curve and vertebral rotation were 52% and 49% respectively. Mean thoracic kyphosis was 25 degrees, ranging from -7 to 55 degrees. Of the patients with Cobb angle less than 90 degrees, 71% had vital capacity less than 80% of predicted values, and of these, 18% had marked compromise of vital capacity (less than 60% of predicted values). Mean values of Cobb angle, vertebral rotational flexibility, kyphosis, rib-vertebral angle asymmetry (in standing as well as supine bending radiographs) differed significantly between patients with more than 80% of predicted vital capacity and those with 60% or less of predicted values. Radiological features indicative of better pulmonary function were: rotational flexibility exceeding 55%, rib-vertebral angle asymmetry (standing) less than 25 degrees and kyphosis greater than 15 degrees. Two deformity parameters--that give a better prediction of pulmonary function than the widely used Cobb angle, vertebral rotational flexibility and rib-vertebral angle asymmetry--were identified in this study.

Vertebral growth after posterior spinal fusion for idiopathic scoliosis in skeletally immature adolescents. The effect of growth on spinal deformity.

We studied 29 girls and one boy with adolescent idiopathic scoliosis who were at Risser grade 0 at the time of posterior spinal fusion and were followed until maturity (mean 7.8 years). We used serial radiographs to measure the ratio of disc to vertebral height in the fused segments and to detect differential anterior spinal growth and assess its effect on scoliosis, vertebral rotation, kyphosis, and rib-vertebral-angle difference (RVAD). From one year after surgery to the latest review, the percentage anterior disc height decreased by nearly one-half and the percentage posterior disc height by nearly one-third in the fused segments (p < 0.001). There was a 4 degree increase in mean Cobb angle (p < 0.001), 11 patients (37%) having an increase of between 6 degrees and 10 degrees. There was a significant increase in mean apical rotation by 2 degrees (p = 0.003), and four patients (13%) had an increase of between 6 degrees and 16 degrees. There was little change in kyphosis. There was an increase in mean RVAD by 4 degrees (p = 0.003), seven patients (23%) showing a reduction by 1 degree to 7 degrees, and 11 (37%) increases of between 6 degrees and 16 degrees. Spinal growth occurs after posterior fusion in adolescents who are skeletally immature, as a result of continued anterior vertebral growth. There is some progression of scoliosis, vertebral rotation, and RVAD, but little change in kyphosis. The increase in deformity is not enough to warrant the use of combined anterior and posterior fusion. The findings are relevant to the management of progressive curves, the timing and extent of surgery, and the prognosis for progression of deformity in this group of patients.

Arthroscopic excision of symptomatic medial plica. A study of 118 knees with 1-4 year follow-up.

We retrospectively reviewed 93 patients (118 knees) treated by arthroscopic excision of painful medial plica. A scoring scale 0-100 was used to evaluate the symptoms. After an average of 2 (1-4) years, 109 of 118 knees had little, if any, pain and the average improvement in the score was 41 points. Thus arthroscopic excision of a painful medial plica can provide lasting and satisfactory relief of symptoms.

Bone mineral density in ankylosing spondylitis. DEXA comparison of control subjects with mild and advanced cases.

We have used dual-energy X-ray absorptiometry to measure bone mineral density (BMD) in patients with ankylosing spondylitis comparing 41 healthy control subjects and 33 patients with either mild or advanced ankylosing spondylitis. A Norland XR-28 bone densitometer was used to measure the BMD of the lumbar spine and that of the head, trunk, arms, femoral neck, Ward's triangle, legs, pelvis, and total body. Mild ankylosing spondylitis was defined as that showing no or incipient syndesmophytes between L1 and L5 vertebrae: we studied 16 men of mean age 37 years and six women of mean age 37 years. Advanced ankylosing spondylitis, in 11 men of mean age 42 years, showed a bamboo spine with bridging syndesmophytes across all disc spaces between L1 and L5. The mean BMD of the lumbar spine was significantly different in the patients and control subjects of the same sex (0.01 < p < 0.05, analysis of variance), being significantly reduced compared with control subjects in mild disease (0.001 < p < 0.01, t-test) and significantly increased in advanced disease over control subjects (0.01 < p < 0.05; t-test) and over patients with mild disease (0.001 < p < 0.01; t-test). The relevance of these findings to the aetiology and pathogenesis of spinal deformities and other complications in ankylosing spondylitis is discussed.

Blade plate fixation of proximal humeral non-unions.

Non-union of fracture of the proximal humerus is unusual and can be difficult to treat. It is found more often than not in the elderly patient with weak bone, resorption at the fracture site, contracture of the glenohumeral joint and associated medical conditions. A blade plate, designed specifically for the treatment of these non-unions, was used in nine patients--seven females and two males (mean age 66 years)--who had painful non-union with a mean duration of 22.5 months. Autologous bone grafting was used in all cases. Eight non-unions followed displaced two-part proximal humeral fractures: five had been initially treated conservatively and four with medullary nails. Five patients had associated medical illness. After a mean of 6.5 months (range 4-28 months), union had been achieved in all but one patient. Functional evaluation revealed good results in five patients, fair results in three and one poor result. Use of the blade plate offered a successful method of stable internal fixation in these complex cases.

Quantitative bone scanning after asymptomatic Charnley arthroplasty.

To establish the normal pattern of postoperative tracer uptake we performed 73 99mtechnetium methylene diphosphonate scans following primary Charnley hip replacements for arthrosis in 68 patients without clinical, hematological and radiographic complications. The patients were divided into 7 subgroups according to the period, 6-24 months, between surgery and scan. There were 10-12 patients in each subgroup. A high-resolution gamma camera with a large field of view was used. Ratios of uptake in each of 10 peri-prosthetic zones to normal bone were calculated. Femoral uptake was found to decrease in linear fashion from 6 to 12 months after surgery. Thereafter the uptake remained unaltered at levels nearly twice the normal ones in the greater trochanter and nearly 1.5 times in the lesser trochanter, returning to almost normal levels in other zones. Acetabular uptake remained elevated throughout.

CT measurement of glenoid erosion in arthritis.

We studied serial CT scans of 45 arthritic shoulders (34 rheumatoid, 11 osteoarthritic) and 19 normal shoulders, making measurements at three levels on axial images. The maximum anteroposterior diameter of the glenoid was increased in rheumatoid glenoids at the upper and middle levels by 6 mm and in osteoarthritic glenoids at all levels by 5 to 8 mm as compared with normal. In rheumatoid cases, nearly half the available surface of the glenoid was of unsupported bone, mainly posteriorly at the upper and middle levels. In osteoarthritic glenoids, the best supported bone was anterior at the upper level and central at the middle and lower levels. The depth of the rheumatoid glenoid was reduced by a mean of 6 mm at the upper and middle levels and by 3 mm at the lower level. This inclined the surface of the glenoid superiorly. The depth at the middle level in osteoarthritis was reduced by a mean of 5 mm, suggesting central protrusion. Osteoarthritic glenoids were retroverted by a mean of 12.5 degrees, but of rheumatoid glenoids two-thirds were retroverted (mean 15.1 degrees) and one-third anteverted (mean 8.2 degrees). Our findings have important implications for the planning and placement of the glenoid component of total shoulder replacements; CT can provide useful information.

Ligamentotaxis with an internal spinal fixator for thoracolumbar fractures.

We assessed narrowing of the spinal canal in 39 burst fractures and fracture-dislocations of thoracolumbar vertebrae treated by the AO Internal Spinal Fixator, using CT preoperatively and at various stages postoperatively. Computer-aided planimetry was used to measure the narrowing, and its restoration shortly after instrumentation, or at 15 months. The mean initial reduction of canal area was to 63.7% +/- 18.8% of normal; this was restored to a mean of 95.4% +/- 21.2% of normal when measured either soon after surgery or at 15 months (p < 0.001 for both groups). There was more improvement in cases assessed later. For fractures from D12 to L3, the mean canal area was restored to 99.4% of normal; but at L4 or L5 the mean restitution was to only 60.9% (p < 0.05). We found no correlation between preoperative loss of area and amount of restoration, or severity of neurological deficit. Nor was there any correlation between the delay before surgery and the improvement achieved. The mechanism of fracture reduction appears to be a combination of distraction ligamentotaxis and forced hyperextension.

Low-contact dynamic compression plating of the clavicle.

Internal fixation of the clavicle is rarely necessary. When it is warranted, the clavicle's complex three-dimensional morphology and functional anatomy, proximity to vital structures, and the multidirectional biomechanical forces acting upon it place considerable demands on any implant used for skeletal fixation. We treated nine clavicles with the recently-introduced 3.5 mm low contact-dynamic compression plate (LC-DCP). Surgery was performed for symptomatic non-union in six patients, shoulder dysfunction following a malunited fracture in one, for an open fracture in one, and for an acute fracture associated with brachial plexus injury in one. After an average follow-up period of 17 months union was secured in each case. The advantages afforded by the 3.5 mm LC-DCP in internal fixation of the clavicle with its uniquely demanding anatomical and biomechanical characteristics are discussed.

Low-energy subtrochanteric fractures in elderly patients: results of fixation with the sliding screw plate.

Forty-two patients with subtrochanteric fractures were treated from 1987 through 1990. Of these, 31 patients above 70 years of age (average, 81.9) had nonpathologic low-energy fractures that were internally fixed with a sliding screw-plate device. Subtrochanteric fractures with an associated intertrochanteric component were the most common type. Interfragmentary compression was used in long oblique and spiral fractures and those with large butterfly fragments. Patients were mobilized early and allowed partial weightbearing for 6-8 weeks. There was a 29% mortality rate within 3 months of injury. Of the remaining cases, followed for a minimum of 6 months (average, 11.8 months), 20 (91%) united satisfactorily. There was loss of fixation in one case and one instance of plate fracture. We found, given the special circumstances in elderly patients, that the device was suitable not only for subtrochanteric fractures with an intertrochanteric element but also for four-part fractures and two-part spiral fractures. The sliding screw-plate permitted passage of interfragmentary screws and facilitated medial displacement and collapse, which are valuable in cases with medial comminution in reducing the bending moment on the plate. These factors may help reduce the incidence of plate failure and, coupled with familiarity with its use, make it a reliable implant for such difficult fractures in elderly patients.

Hip dislocation without fracture: traction or mobilization after reduction?

In all, 41 patients with traumatic dislocation of the hip, without associated acetabular or femoral fracture, were treated by two different methods after closed reduction, performed on average 2 h after injury. Patients in group A (N = 20) were subjected to skeletal traction for 2 weeks, followed by non-weight bearing for 3 months. Those in group B (N = 21) were mobilized a few days (average 9 days) after injury and allowed partial weight bearing. They were fully weight bearing at 3 months. The 31 patients were followed up for an average of 7.6 years and showed comparable long-term results in both groups. No early complications occurred in group B. There were no cases of avascular necrosis in either group. There were three cases of post-traumatic arthritis in group A and one in group B, and two cases each of heterotopic ossification. Early mobilization was concluded to be a safe and more comfortable method of after-treatment. Earlier return to work was a significant benefit in Group B.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

Glenohumeral joint instability in normal adolescents. Incidence and significance.

One hundred and fifty asymptomatic shoulders in 75 schoolchildren were studied. The shoulders were tested for instability and a hyperextensometer was used to assess joint laxity. Signs of instability were found in 57% of the shoulders in boys and 48% in girls; the commonest sign was a positive posterior drawer test which was found in 63 shoulders. A positive sulcus sign was found in 17 shoulders and 17 subjects had signs of multidirectional instability. General joint laxity was not a feature of subjects whose shoulders had positive instability signs.

Continuous passive motion for prevention and rehabilitation of knee stiffness--(a clinical evaluation).

This is a study of 43 knees in 42 patients, in whom a continuous passive motion was used to prevent stiffness of the knee and to assist restoration of a range of motion for a variety of disorders of the knee joint. CPM was given for an average of 6 hours daily in split sessions for a total duration of 3 weeks. Various clinical parameters were maintained and a scoring system was designed. It was observed that CPM caused little or no pain and elicited excellent patient compliance. There was a rapid subsidence of edema and effusion and a shorter hospital stay. 83% of cases had excellent or good results. There were no adverse effects, but there were a few minor complications. The study revealed that CPM is a valuable component of the therapeutic programme for preventing knee stiffness and aiding the speedy restoration of joint function without compromising healing of tissues.