Arthroscopic triple and modified double hindfoot arthrodesis.

BACKGROUND: Arthroscopic arthrodesis is an accepted technique for the ankle but less commonly reported for multiple hindfoot joints. We present a case series review to establish the feasibility of this surgery. METHODS: In a consecutive series of 112 arthroscopic hindfoot arthrodeses, 18 involved decortication and fusion of 2 or 3 hindfoot joints. These were reviewed to identify complications, union rates and improvement over preoperative state. RESULTS: Mean age was 62 (45-78). Mean follow-up was 4.4 (1.75-7.5) years. There were no perioperative complications. The four patients with triple fusions united with good or excellent outcomes. Of 14 patients with subtalar and talonavicular arthrodeses there were three talonavicular non-unions. CONCLUSIONS: Arthroscopic double and triple arthrodeses appear feasible salvage options for pain and deformity. Decortication of all three joints and rotatory correction of deformity is possible whilst preserving the soft tissue envelope. Late adjacent joint pain and arthrosis can occur.

An improved cementing technique for revision hip surgery after peri-prosthetic fractures.

Replacement of the femoral component by a long-stemmed implant is one possible solution to the management of periprosthetic femoral shaft fractures. A problem often encountered, due to the extensive disruption of the femoral canal, is difficulty in achieving adequate cement pressurisation. We have overcome this by applying a split 60 ml syringe sleeve around the femoral shaft and holding it in position with clamps. This method has been used on five patients of mean age 87.7 (range 82-94) years with fractures that occurred at an average of 7.2 (range 4-17) years after the primary hip surgery. Two of the five patients achieved independent mobility and all of the patients were sufficiently independent to be discharged from the acute orthopaedic unit. We hope this cheap, effective method of supporting the bone fragments, maintaining alignment and achieving an acceptable level of pressurisation will lead to a decrease in the inevitable morbidity and mortality associated with a problem which as a result of an ageing population is likely to become increasingly common.

External fixation of unstable metacarpal and phalangeal fractures.

A prospective study of the management of 30 patients with 37 unstable or complex metacarpal or phalangeal fractures treated with the "Shearer" micro-external fixator was carried out over an 18-month period. The stability achieved, with minimal soft-tissue tethering, allowed early joint mobilisation with good or excellent function in 94% of metacarpal and 85% of phalangeal fractures by nine weeks. There were no cases of non-union and few complications.

Histology of a lengthened human tibia.

We describe the histology of a specimen taken from an amputated leg seven months after a 15 cm bone gap in the tibia had been closed by bone transport. Lengthening appeared to have occurred by repeated minor trauma to the bone, with the fractured trabeculae in sufficiently close contact for the repair process to proceed. Osteogenesis did not occur through a cartilage phase, but the fracture gaps were bridged by collagen fibres, around which new bone formed. Microfractures had repaired by primary healing with woven bone and with no microcallus. Small regions of bone were necrotic. Resorption of the necrotic bone and remodelling of the immature bundle and woven bone were still at an early stage, suggesting that complete remodelling in man may take years rather than months.

The management of dropfoot using the Lambrinudi arthrodesis.

The results of 12 Lambrinudi arthrodeses in 10 patients with spinal dysraphism were compared with 11 operations performed in patients with only motor nerve deficits performed over the same 10 year period. The early failure and complications were more common in these patients and the tendency to recurrence of dropfoot occurred earlier. Despite this, the operation was effective in the management of these patients, especially for the improvement of co-existent sores or the fitting of shoewear.

Elective splenectomy in haematological disorders.

We report on 106 elective splenectomies performed for haematological disorders between March 1979 and January 1986. The most common indications were immune thrombocytopenic purpura (30 patients) and Hodgkin's disease (19 patients). However, staging laparotomy is no longer performed routinely for patients with Hodgkin's disease and the reasons for this are discussed. Other indications for splenectomy included splenic pain (13 patients), autoimmune haemolytic anaemia (12 patients), hereditary spherocytosis (11 patients) and hypersplenism (9 patients). The overall morbidity and mortality was 48% and 5% respectively. The most common postoperative complication was thrombocytosis (defined as a platelet count greater than 800 X 10(9)/l) and occurred in 26 patients. This review confirms that splenectomy continues to have an important role in the management of certain haematological disorders.

Os calcis osteotomy in the management of deformities of the hindfoot in spinal dysraphism.

The results of 52 primary os calcis osteotomies in 44 patients with spinal dysraphism are reviewed. There were 42 varus hindfoot deformities and ten valgus hindfoot deformities. The results indicate that the operation is simple and uncomplicated, but over a mean 5.8 year follow-up for the varus feet and 6.5 years for the valgus feet, over 50% of the feet developed either a moderate or severe recurrence of deformity. Os calcis osteotomy appeared from this series to be a moderately successful interim operation for the equinus varus foot, delaying the need for premature triple arthrodesis, but the long-term results in cavo-varus feet with claw toes were uniformly poor. Furthermore, it appeared to be unsatisfactory in the mobile flail valgus foot unless the subtalar joint had been stabilised by fusion. Correction of proximal joint or bone deformity and muscle imbalance is considered necessary if satisfactory results are to be achieved from the osteotomy.

Solitary myeloma in chronic osteomyelitis presenting as a lower femoral fracture.

A 68-year-old man with chronic osteomyelitis of 40 years' duration, admitted through the Accident and Emergency Department with a fracture of the femur, required amputation through the left hip for the removal of a primitive solitary myeloma.