bluuebunny/crossref_metadata_2025 huggingface dataset:
TUBERCULOUS OSTEOMYELITIS
Authors: Vohra R. , Kang H. S. , Dogra S. , Saggar R. R. , Sharma R.
Published: February 2018

Tuberculous osteomyelitis which does not involve a joint is uncommon and may fail to be diagnosed by an orthopaedic surgeon. We treated 28 lesions of tuberculous osteomyelitis in 25 patients between 1988 and 1995. The duration of symptoms was from two to 39 months, and most of our patients had been treated initially with non-steroidal anti-inflammatory drugs which failed to provide relief. Bone pain which does not promptly respond to analgesic medication is often due to infection or neoplasia.

In the early stages, when plain radiographs are normal, MRI or CT may help to localise lesions. On plain radiographs, more advanced lesions may mimic chronic pyogenic osteomyelitis, Brodie’s abscess, tumours or granulomatous lesions. Biopsy is mandatory to confirm the diagnosis, and antituberculous drugs are the mainstay of treatment. When operative findings at biopsy have the features of skeletal tuberculosis curettage of the affected bone may promote earlier healing.
MRI CAN PREVENT UNNECESSARY ARTHROSCOPY
Authors: Carmichael I. W. , MacLeod A. M. , Travlos J.
Published: February 2018

We compared the practice of four orthopaedic consultants as regards the use of MRI and arthroscopy to diagnose problems of the knee. In one year 324 arthroscopies and 66 MR scans were performed for this purpose.

We found that MRI is a reliable and cheaper alternative to ‘diagnostic arthroscopy’. We consider that patients with definite clinical signs merit an early ‘therapeutic arthroscopy’, but that all other knees should be investigated by MRI. This policy spares patients from unnecessary and expensive surgery.

Arthroscopy for diagnostic purposes should be used only with a specific purpose. Modern MRI can and should replace “having a look”.
GENETIC INFLUENCES IN END-STAGE OSTEOARTHRITIS
Authors: Chitnavis J. , Sinsheimer J. S. , Clipsham K. , Loughlin J. , Sykes B. , Burge P. D. , Carr A. J.
Published: February 2018

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95% CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%.

The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.
REGENERATION OF BONE AFTER LOSS OF THE DISTAL HALF OF THE HUMERUS
Authors: Ülkü Ö , Karatosun V.
Published: February 2018

A 16-year-old boy was involved in an agricultural accident in which he sustained a large wound to the right arm and forearm. Radiological examination showed loss of the distal half of the humerus. A posterior splint was applied and after two months there was regeneration of the distal humerus including the articular portion. He was able to use his arm at five months. Twenty years later, he had a painless elbow and a 70° range of movement.
FRACTURES OF THE BASE OF THE MIDDLE PHALANX OF THE FINGER
Authors: Seno N. , Hashizume H. , Inoue H. , Imatani J. , Morito Y.
Published: February 2018

We classified fractures of the base of the middle phalanx into five types: 1) single palmar fragment; 2) single dorsal fragment; 3) two main fragments; 4) not involving the articular surface, including epiphyseal separation in children; and 5) all others. Types 1 and 2 were subclassified into avulsion, split and split-depression.

Surgery is recommended for unstable type-1 avulsion fractures, type-2 avulsions which may develop buttonhole deformities, and all fractures which displace articular cartilage surfaces. Long-term follow-up showed that surgical treatment which produced good stability and congruity gave good results. These should be the primary aims of treatment.
SYMPTOMATIC VENOUS THROMBOEMBOLISM AFTER TOTAL KNEE REPLACEMENT
Authors: Warwick D. J. , Whitehouse S.
Published: February 2018

Chemical prophylaxis is known to reduce the venographic prevalence of deep-vein thrombosis (DVT) after total knee replacement (TKR), but it is uncertain whether this affects the incidence of symptoms. Further analysis depends on the basic epidemiology of thromboembolic symptoms. We therefore studied the pattern of such symptoms in a consecutive series of 1000 patients with primary TKR, with particular reference to risk factors and prophylaxis.

We reviewed all the clinical records and contacted all the patients individually, noting risk factors, prophylaxis, symptomatic pulmonary embolus (PE) or DVT and its timing, death and its causes, and all complications. All the patients wore antiembolism stockings, 83% had regional anaesthesia and 33.9% had chemical prophylaxis.

One patient died from PE on the day of surgery, having had no prophylaxis giving a rate of 0.1% (95% CI 0.003% to 0.56%). Symptomatic, radiologically confirmed thromboembolism (VTE) was common with a rate of 10.6% (95% CI 8.7% to 12.5%). There was a similar incidence of VTE in those with and without chemical prophylaxis (10.1% v 10.5%, RR 0.96, NS). VTE was more common in patients with risk factors (15.1% v 9.5%, RR 1.59, p = 0.02) and tended to occur earlier in this group (median day of onset 5 v 7, p = 0.01). Chemical prophylaxis did not reduce the frequency of symptomatic thromboembolism in either those with risk factors (RR 0.81, p = 0.5) or those without them (RR 0.94, p = 0.8). Haematoma or wound dehiscence was more common in those having chemical prophylaxis (11.9% v 6.9%; RR 1.73 95% CI 1.16 to 2.60). Readmission for symptomatic, radio-logically confirmed thromboembolism involved 1.1% of patients (95% CI 0.55% to 2.1%). Four patients were readmitted with proven non-fatal PE and six with proven DVT (the latest on day 40).

Our results show that the main risk factor for thromboembolism was TKR itself; chemical prophylaxis did not reduce the incidence of symptomatic thromboembolism but gave an increased perception of side-effects. New prophylactic methods or combinations of methods are needed, with their efficacy compared by randomised controlled studies of both the clinical and the radiological effect.
THE SUPERFICIAL PERONEAL TUNNEL SYNDROME
Authors: Styf J. , Morberg P.
Published: February 2018

We diagnosed entrapment of the superficial peroneal nerve in 17 patients (19 legs) with a mean age of 41 years. In all cases, plain radiographs of the leg, nerve-conduction studies of the superficial peroneal nerve and measurement of the intramuscular pressure at rest after exercise were normal. Diagnostic tests for nerve compression during rest after exercise produced pain and clinical signs in all.

We performed decompression of the superficial peroneal tunnel in 14 patients and local fasciectomy in three. Fourteen patients (80%) were free from symptoms or satisfied with the result.
FORAMINAL INJECTION FOR LATERAL LUMBAR DISC HERNIATION
Authors: Weiner B. K. , Fraser R. D.
Published: February 2018

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW).

Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61.

Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc.
THE CEMENT MANTLE IN FEMORAL IMPACTION ALLOGRAFTING
Authors: Masterson E. L. , Masri B. A. , Duncan C. P. , Rosenberg A. , Cabanela M. , Gross M.
Published: February 2018

An analysis of the cement mantle obtained with the Exeter impaction allografting system at one centre showed that it was either deficient or absent in almost 47% of Gruen zones. We therefore examined the mantle obtained using this system at another hospital and compared the results with those from the CPT and Harris Precoat Systems at other centres.

The surgical indications for the procedure and the patient details were broadly similar in all four hospitals. There was some variation in the frequency of use of cortical strut allografts, cerclage wires and wire mesh to supplement the impaction allograft. Analysis of the cement mantles showed that when uncertain Gruen zones were excluded, the incidence of zones with areas of absence or deficiency of the cement was 47% and 50%, respectively, for the two centres using the Exeter system, 21% for the CPT system and 18% for the Harris Precoat system.

We measured the difference in size between the proximal allograft impactors and the definitive prosthesis for each system. The Exeter system impactors are shorter than the definitive prosthesis and taper sharply so that the cavity created is inadequate, especially distally. The CPT proximal impactors are considerably longer than the definitive prosthesis and are designed to give a mantle of approximately 2 mm medially and laterally and 1.5 mm anteriorly and posteriorly. The Harris Precoat proximal impactors allow for a mantle with a circumference of 0.75 mm in the smaller sizes and 1 mm in the larger.

Many reports link the longevity of a cemented implant to the adequacy of the cement mantle. For this reason, femoral impaction systems require careful design to achieve a cement mantle which is uninterrupted in its length and adequate in its thickness. Our results suggest that some current systems require modification.
SYNOVECTOMY OF THE ELBOW AND RADIAL HEAD EXCISION IN RHEUMATOID ARTHRITIS
Authors: Gendi N. S. T. , Axon J. M. C. , Carr A. J. , Pile K. D. , Burge P. D. , Mowat A. G.
Published: February 2018

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain.

The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04).

At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder.

Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.
STANMORE CUSTOM-MADE EXTENDIBLE DISTAL FEMORAL REPLACEMENTS
Authors: Schindler O. S. , Cannon S. R. , Briggs T. W. R. , Blunn G. W.
Published: February 2018

The use of extendible distal femoral replacements is a relatively new treatment alternative for malignant bone tumours in growing individuals. Although their appearance was widely appreciated, questions about functional practicality and longevity remain unclear. With longer follow-up, advantages of immediate functional restoration and beneficial psychological aspects seem to be overshadowed by an increase in complications such as aseptic loosening, infection or prosthetic failure.

We have reviewed 18 children with such tumours who were treated between 1983 and 1990 by custom-made Stanmore extendible distal femoral replacements. Four died from metastatic disease within 2.5 years of operation and two required amputation for local recurrence or chronic infection.

The remaining 12 patients were followed for a mean of 8.7 years (6 to 13.2). A mean total lengthening of 5.2 cm was achieved, requiring, on average, 4.3 operations. Using the Musculoskeletal Tumor Society rating score the functional result at review was, on average, 77% of the expected normal function, with seven patients achieving ≥ 80%. Revision of the prosthesis was required in ten patients, in six for aseptic loosening, at a mean of 6.2 years after the initial procedure.
DOES INDOMETHACIN REDUCE HETEROTOPIC BONE FORMATION AFTER OPERATIONS FOR ACETABULAR FRACTURES?
Authors: Matta J. M. , Siebenrock K. A.
Published: February 2018

We have studied prospectively the effect of indomethacin on the development of heterotopic ossification (HO) after the internal fixation of acetabular fractures. After operation 107 patients randomly received either a six-week course of indomethacin or no treatment against HO. Plain radiographs of 101 patients at a mean of 7.9 months after surgery showed HO in 47.4% of the 57 patients who received indomethacin and in 56.8% of the 44 who did not. This difference was not statistically significant. Heterotopic ossification of Brooker class II or more was seen in four patients (7%) with prophylaxis and in one without (p = 0.51).

Measurements of the volume of HO on 3-D CT reconstructions showed a median value of 1.5 cm3 in patients with indomethacin and 4.0 cm3 in those without (p = 0.28). When only the 57 patients in whom the operation was carried out through either a Kocher-Langenbeck or an extended iliofemoral approach were included the indomethacin group showed a median volume of 1.7 cm3 compared with 3.6 cm3. On plain radiographs Brooker class II or above was seen in 9.4% of the patients receiving indomethacin and in 4.8% of those who did not.

Indomethacin was therefore not effective in preventing ectopic bone formation after surgery for acetabular fractures. There was a significant association of male gender with volume of HO using a non-parametric analysis of variance.
AWARENESS OF TIP-APEX DISTANCE REDUCES FAILURE OF FIXATION OF TROCHANTERIC FRACTURES OF THE HIP
Authors: Baumgaertner M. R. , Solberg B. D.
Published: February 2018

We compared the results of the surgical treatment of trochanteric hip fractures before and after surgeons had been introduced to the tip-apex distance (TAD) as a method of evaluating screw position. There were 198 fractures evaluated retrospectively and 118 after instruction.

The TAD is the sum of the distance from the tip of the screw to the apex of the femoral head on antero-posterior and lateral views. This decreased from a mean of 25 mm in the control group to 20 mm in the study group (p = 0.0001). The number of mechanical failures by cut-out of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of eight months (p = 0.0015). There were significantly fewer poor reductions in the study group.

Our study confirms the importance of good surgical technique in the treatment of trochanteric fractures and supports the concept of the TAD as a clinically useful way of describing the position of the screw.
LENGTH AND TORSION OF THE LOWER LIMB
Authors: Strecker W. , Keppler P. , Gebhard F. , Kinzl L.
Published: February 2018

Corrective osteotomies are often planned and performed on the basis of normal anatomical proportions. We have evaluated the length and torsion of the segments of the lower limb in normal individuals, to analyse the differences between left and right sides, and to provide tolerance figures for both length and torsion.

We used CT on 355 adult patients and measured length and torsion by the Ulm method. We excluded all patients with evidence of trauma, infection, tumour or any congenital disorder.

The mean length of 511 femora was 46.3 ± 6.4 cm (±2sd) and of 513 tibiae 36.9 ± 5.6 cm; the mean total length of 378 lower limbs was 83.2 ± 11.4 cm with a tibiofemoral ratio of 1 to 1.26 ± 0.1. The 99th percentile level for length difference in 178 paired femora was 1.2 cm, in 171 paired tibiae 1.0 cm and in 60 paired lower limbs 1.4 cm.

In 505 femora the mean internal torsion was 24.1 ± 17.4°, and in 504 tibiae the mean external torsion was 34.9 ± 15.9°. For 352 lower limbs the mean external torsion was 9.8 ± 11.4°. The mean torsion angle of right and left femora in individuals did not differ significantly, but mean tibial torsion showed a significant difference between right (36.46° of external torsion) and left sides (33.07° of external torsion). For the whole legs torsion on the left was 7.5 ± 18.2° and 11.8 ± 18.8°, respectively (p < 0.001). There was a trend to greater internal torsion in femora in association with an increased external torsion in tibiae, but we found no correlation. The 99th percentile value for the difference in 172 paired femora was 13°; in 176 pairs of tibiae it was 14.3° and for 60 paired lower limbs 15.6°.

These results will help to plan corrective osteotomies in the lower limbs, and we have re-evaluated the mathematical limits of differences in length and torsion.
Long-term results of late non-operative reduction of developmental dysplasia of the hip
Authors: Kerry R. M. , Simonds G. W.
Published: February 2018

Over a 20-year period we treated 29 patients (31 dislocated hips) by non-operative reduction after nine months of age, using horizontal traction. They were followed up for a mean of 11.7 years, and 12 hips required secondary extra-articular surgery.

The clinical result was excellent in 25 hips, good in four and fair in two. Of the 29 hips for which detailed radiographs were available, 18 achieved Severin grade I, nine grade II and two grade III. There were no major complications and, in particular, no cases of avascular necrosis.

The non-operative reduction of late-presenting developmental dysplasia of the hip is still a viable option. It has a potential for excellent results and a very low complication rate.
The extended lateral approach to the hindfoot
Authors: Freeman B. J. C. , Duff S. , Allen P. E. , Nicholson H. D. , Atkins R. M.
Published: February 2018

We have recently described an extended lateral approach to the hindfoot for the operative treatment of displaced intra-articular fractures of the calcaneum. It has the advantage of avoiding damage to the sural nerve and preserving blood supply to allow prompt healing.

We dissected 15 formalin-preserved cadavers, taking photographs to show the structures of the posterolateral aspect of the hindfoot and ankle. We describe a superficial and a deep triangle: the deep triangle contains a constant posterior peroneal artery which supplies the skin of the posterolateral heel. An approach designed to expose the sural nerve will divide this important artery and cause ischaemia of the posterior skin. The extended lateral approach elevates the sural nerve in a thick flap and preserves the blood supply of the skin.

We have reviewed 150 consecutive patients after the use of this approach to study the indications for operation, the quality of wound healing, any damage to the sural nerve and other complications. We recommend the careful use of this approach. Our understanding of its anatomical basis has allowed us to widen the indications for its use.
Sensory nerves in the interface membrane of aseptic loose hip prostheses
Authors: Ahmed M. , Bergström J. , Lundblad H. , Gillespie W. J. , Kreicbergs A.
Published: February 2018

We studied the presence of sensory nerves by immunohistochemistry in the interface membranes of hip prostheses after aseptic loosening. Substance P (SP), neurokinin A (NKA) and calcitonin gene-related peptide (CGRP) were analysed as was protein gene product (PGP) 9.5, a general marker for nerve fibres.

We identified nerve fibres in all samples but differences in their density were found. SP- and NKA-positive fibres were predominantly non-vascular, forming varicose nerve terminals. CGRP-immunoreactive nerve fibres with varicose terminals were seen mostly close to blood vessels, but also as free nerve endings.

Sensory neuropeptides participate not only in nociception but also stimulate immune cells to release cytokines. The presence of sensory nerves in the interface membrane may reflect a pathophysiological response contributing to the aseptic loosening of hip prostheses.
PCL reconstruction
Authors: Race A. , Amis A. A.
Published: February 2018

We compared the ability of three different posterior cruciate ligament (PCL) reconstructions to restore normal anteroposterior laxity to the knee from 0 to 130° of knee flexion.

Cadaver knees were tested intact, after PCL rupture or after bone-patellar tendon-bone grafting. Grafts were performed isometrically or with a single bundle representing the anatomical anterior PCL fibre bulk (aPC) or with a double bundle that added the posterior PCL fibre bulk (pPC). The grafts were tensioned to restore normal knee laxity at 60° of flexion, except for the pPC which was tensioned at 130°.

The isometric graft led to overconstraint as the knee extended resulting in high graft tension in extension and excess laxity in flexion. The aPC graft matched normal laxity from 0 to 60° of flexion but was lax from 90 to 130° of flexion. Only the double-bundled graft could restore normal knee laxity across the full range of flexion.
External fixation for phalangeal and metacarpal fractures
Authors: Drenth D. J. , Klasen H. J.
Published: February 2018

From 1987 to 1993 we treated 33 patients with 29 phalangeal and seven metacarpal fractures by external fixation using a mini-Hoffmann device. There were 27 open and 25 comminuted fractures. In 12 patients one or more tendons was involved.

The mean follow-up was 4.4 years. Complications occurred in ten fractures; two required repositioning of the fixator. All the fractures healed. The functional results after metacarpal fractures were better than those after phalangeal fractures and fractures of the middle phalanx had better recovery than those of the proximal phalanx. Twenty-eight of the 33 patients were satisfied with their result.

External fixation proved to be a suitable technique for stabilising unstable, open fractures with severe soft-tissue injuries.
Development of the hip in diastrophic dysplasia
Authors: Vaara P. , Peltonen J. , Poussa M. , Merikanto J. , Nurminen M. , Kaitila I. , Ryöppy S.
Published: February 2018

We examined 50 patients with diastrophic dysplasia both clinically and radiologically. Two legally aborted fetuses were dissected. The mean age of the patients was 16.2 years (newborn to 38) and the mean follow-up was 11.4 years (3 months to 34 years).

The fetal hips and MRI of newborn infants showed congruity and no significant joint deformity. Flexion contracture of the hip became evident later in 93% and was progressive. The radiological appearance of the proximal femoral ossific nuclei was delayed and in 17% of males and 28% of females the ossific nuclei had not appeared by the age of 12 years.

Radiological measurements differed considerably from reference values and were related to the rapid and progressive restriction of rotational movement and the increase in flexion contracture. The typical findings were flattening and inferomedial bulking of the femoral head and a double-hump deformation. The changes in the hip led to secondary osteoarthritis before early middle age. We describe the clinical and radiological measurements which define the early degeneration of the joint.
The Singapore operation for recurrent dislocation of peroneal tendons
Authors: Hui J. H. P. , De S. Das , Balasubramaniam P.
Published: February 2018

Recurrent dislocation of peroneal tendons is uncommon and there are few reports of the long-term results after repair. The Singapore operation, first described in 1985, is an anatomical repair based on the Bankart-like lesion seen in the superior peroneal retinaculum.

We reviewed 21 patients after a mean follow-up of 9.3 years, and found no recurrence. Eighteen had good functional results and had returned to their previous levels of vocational and sports activities. The three fair results were due to painful scars or neuromas.
Acetabular reconstruction with impacted morsellised cancellous bone graft and cement
Authors: Schreurs B. W. , Slooff T. J. J. H. , Buma P. , Gardeniers J. W. M. , Huiskes R.
Published: February 2018

We report a long-term review of 60 acetabular components revised using impacted, morsellised bone allografts and a cemented polyethylene cup. The acetabular defects were cavitary (37) or combined (23). Follow-up was for a mean 11.8 years (10 to 15).

Further revision was needed in five hips, two for septic and three for aseptic loosening. The overall survival rate at 11.8 years was 90%; excluding the septic cases it was 94%.

Acetabular reconstruction with impacted morsellised cancellous grafts and cement gives satisfactory long-term results.
Hydroxyapatite augmentation of the porous coating improves fixation of tibial components
Authors: Önsten I. , Nordqvist A. , Carlsson å. S. , Besjakov J. , Shott S.
Published: February 2018

In a single-blind, randomised series of knee replacements in 116 patients, we used radiostereometric analysis (RSA) to measure micromotion in three types of tibial implant fixation for two years after knee replacement. We compared hydroxyapatite-augmented porous coating, porous coating, and cemented fixation of the same design of tibial component.

At one to two years, porous-coated implants migrated at a statistically significantly higher rate than hydroxyapatite-augmented or cemented implants. There was no significant difference between hydroxyapatite-coated and cemented implants.

We conclude that hydroxyapatite augmentation may offer a clinically relevant advantage over a simple porous coating for tibial component fixation, but is no better than cemented fixation.
The influence of osteoporosis on varus osteoarthritis of the knee
Authors: Terauchi M. , Shirakura K. , Katayama M. , Higuchi H. , Takagishi K.
Published: February 2018

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1–L4 spinal region using dual X-ray absorptiometry.

In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men.

Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee.
Evaluation of fluorodeoxyglucose positron emission tomography in the management of soft-tissue sarcomas
Authors: Lucas J. D. , O’Doherty M. J. , Wong J. C. H. , Bingham J. B. , McKee P. H. , Fletcher C. D. M. , Smith M. A.
Published: February 2018

We performed a retrospective analysis to evaluate the ability of whole-body 18F-fluorodeoxyglucose positron emission tomography (FDG PET) to identify local recurrence and pulmonary metastases in patients with soft-tissue tumours after treatment. We compared the results of FDG PET with those of MRI for the detection of local recurrence, and with CT of the chest for pulmonary metastases.

We assessed 62 patients of mean age 51 years, who had 15 types of soft-tissue sarcoma, after a mean follow-up of 3 years 2 months. For the detection of local disease, 71 comparisons showed that the sensitivity and specificity of FDG PET were 73.7% and 94.3%, respectively; there were 14 true-positive and five false-negative results. MRI had a sensitivity and specificity of 88.2% and 96.0% respectively. For the identification of lung metastases, 70 comparisons showed that the sensitivity and specificity of FDG PET were 86.7% and 100%, with 13 true-positive results and two false-negative results. CT of the chest had a sensitivity and specificity of 100% and 96.4%. Thirteen other sites of metastases were identified by FDG PET.

FDG PET can identify both local and distant recurrence of tumour as a one-step procedure and will detect other metastases. It seems that all three methods of imaging are needed to define accurately the extent of disease, both at initial staging and during follow-up.
Neuropathic arthropathy of the knee associated with an intra-articular neurofibroma in a child
Authors: Lokiec F. , Arbel R. , Isakov J. , Wientroub S.
Published: February 2018

We describe a five-year-old child with neurofibromatosis type I who developed a Charcot knee. Infiltration of the joint by tissue associated with the disease caused damage to the proprioceptive mechanism and resulted in severe joint instability, accelerated destruction and development of neuropathic arthropathy.
A new provocative test for carpal tunnel syndrome
Authors: Tetro A. M. , Evanoff B. A. , Hollstien S. B. , Gelberman R. H.
Published: February 2018

To establish the value of median nerve compression with wrist flexion as a provocative test for carpal tunnel syndrome (CTS), we performed a prospective study of 64 patients (95 hands) with CTS confirmed by electrodiagnostic studies and 50 normal subjects (96 hands). We recorded results for the common provocative tests (Tinel’s percussion test, Phalen’s wrist flexion test and the carpal compression test) and the new test which combines wrist flexion with median nerve compression.

Using a receiver operator characteristic curve (ROC) technique, we found that the optimal cut-off time for the wrist-flexion and median-nerve compression test was 20 s, giving a sensitivity of 82% and a specificity of 99%. These results were significantly better than for Phalen’s wrist flexion test (61% and 83%, respectively) and for the sensitivity of Tinel’s test (74%). The positive predictive values of the wrist flexion and median-nerve compression test, which is more important clinically, were 99%, 95% and 81% at population prevalences of 50%, 20% and 5%, respectively. These were significantly better than those of the three other provocative tests at each prevalence.

Electrodiagnostic studies have significant false-positive and false-negative rates in CTS, and therefore provocative tests remain important in its diagnosis. We have shown that wrist flexion combined with the median-nerve compression test at 20 s, is significantly better than the other methods, and may thus be clinically useful.
Dose-related effects of shock waves on rabbit tendo Achillis
Authors: Rompe J. D. , Kirkpatrick C. J. , Küllmer K. , Schwitalle M. , Krischek O.
Published: February 2018

We aimed to determine whether extracorporeal shock waves of varying intensity would damage the intact tendo Achillis and paratenon in a rabbit model. We used 42 female New Zealand white rabbits randomly divided into four groups as follows: group a received 1000 shock-wave impulses of an energy flux density of 0.08 mJ/mm2, group b 1000 impulses of 0.28 mJ/mm2, group c 1000 impulses of 0.60 mJ/mm2, and group d was a control group.

Sonographic and histological evaluation showed no changes in group a, and transient swelling of the tendon with a minor inflammatory reaction in group b. Group c had formation of paratendinous fluid with a significant increase in the anteroposterior diameter of the tendon. In this group there were marked histological changes with increased eosin staining, fibrinoid necrosis, fibrosis in the paratenon and infiltration of inflammatory cells.

We conclude that there are dose-dependent changes in the tendon and paratenon after extracorporeal shock-wave therapy and that energy flux densities of over 0.28 mJ/mm2 should not be used clinically in the treatment of tendon disorders.
Macrodactyly
Authors: Kotwal P. P. , Farooque M.
Published: February 2018

We report the results of the treatment of 23 patients with macrodactyly. Eighteen had a two-stage bulk-reducing (defatting) procedure; phalangectomy was used to shorten the digits.

At a mean follow-up of nine years (2 to 12), two patients had been lost to follow-up, and three await a second-stage procedure. Good cosmetic correction was achieved in 12 patients, with satisfactory results in seven; two patients had poor results and required amputation.
Soft-tissue amyloidoma
Authors: Flores M. , Nadarajan P. , Mangham D. C.
Published: February 2018

Amyloidoma of soft tissue is rare and there have been no previously published reports of limb involvement. We describe a case in which the tumour was present in the popliteal fossa. There was no evidence of systemic amyloid disease or of malignant neoplasm one year after the diagnosis.
Multiple schwannomas in the peripheral nerves
Authors: Ogose A. , Hotta T. , Morita T. , Otsuka H. , Hirata Y.
Published: February 2018

Multiple tumours of peripheral nerves are often seen in patients with neurofibromatosis of type 1 or 2. Multiple schwannomas may occur without other manifestations of neurofibromatosis.

We have reviewed 12 patients with multiple schwannomas arising from peripheral lesions who did not fulfil the criteria for either type of neurofibromatosis. Four had spinal and one an intracranial lesion in addition to the peripheral tumours. Two patients had one and three café-au-lait spots, respectively, and another had a probable family history. The largest tumours were 45 to 250 mm in size. Three patients had been referred as having von Recklinghausen’s disease.

The large size of tumours, the difficulties of histological diagnosis on biopsy, and the confusion with neurofibromatosis can lead to overtreatment. Malignant change seldom, if ever, occurs in patients with multiple schwannomas.
Poor interobserver reliability of AO classification of fractures of the distal radius
Authors: Flinkkilä T. , Nikkola-Sihto A. , Kaarela O. , Päakkö E. , Raatikainen T.
Published: February 2018

Interobserver reliability of the AO system of classification of fractures of the distal radius was assessed using plain radiographs and CT. Five observers classified 30 Colles’-type fractures using only plain radiographs; two months later they were reclassified using CT in addition.

Interobserver reliability was poor in both series when detailed classification was used. By reducing the categories to five, interobserver reliability was slightly improved, but was still poor. When only two AO types were used, the reliability was moderate using plain radiographs and good to excellent with the addition of CT.

The use of CT as well as plain radiographs brings interobserver reliability to a good level in assessment of the presence or absence of articular involvement, but is otherwise of minor value in improving the interobserver reliability of the AO system of classification of fractures of the distal radius.
Assessment of the AO classification of intracapsular fractures of the proximal femur
Authors: Blundell C. M. , Parker M. J. , Pryor G. A. , Hopkinson-Woolley J. , Bhonsle S. S.
Published: February 2018

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra-and interobserver accuracy and its value in predicting treatment and outcome.

We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used.
The morphology of the femur in developmental dysplasia of the hip
Authors: Sugano N. , Noble P. C. , Kamaric E. , Salama J. K. , Ochi T. , Tullos H. S.
Published: February 2018

We studied the morphometry of 35 femora from 31 female patients with developmental dysplasia of the hip (DDH) and another 15 from 15 age- and sex-matched control patients using CT and three-dimensional computer reconstruction models. According to the classification of Crowe et al 15 of the dysplastic hips were graded as class I (less than 50% subluxation), ten as class II/III (50% to 100% subluxation) and ten as class IV (more than 100% subluxation).

The femora with DDH had 10 to 14° more anteversion than the control group independent of the degree of subluxation of the hip. In even the most mildly dysplastic joints, the femur had a smaller and more anteverted canal than the normal control. With increased subluxation, additional abnormalities were observed in the size and position of the femoral head. Femora from dislocated joints had a short, anteverted neck associated with a smaller, narrower, and straighter canal than femora of classes I and II/III or the normal control group.

We suggest that when total hip replacement is performed in the patient with DDH, the femoral prosthesis should be chosen on the basis of the severity of the subluxation and the degree of anteversion of each individual femur.
Structural disorders at the insertion of the supraspinatus tendon
Authors: Sano H. , Uhthoff H. K. , Backman D. S. , Brunet J. A. , Trudel G. , Pham B. , Ishii H.
Published: February 2018

We examined macroscopically and microscopically 55 cadaver rotator-cuff tendons attached to their humeral heads to determine the distance between the edge of the articular cartilage and the tendon insertion of the supraspinatus (the width of the sulcus) and the score of regressive changes at the sulcus. In 33 specimens we measured the tensile strength. The width of the sulcus was correlated with the score of regressive changes and with the ultimate tensile strength of the supraspinatus tendon.

The width of the sulcus correlated positively with the score of regressive changes (r = 0.66, p < 0.0001), but there was a negative correlation between the latter and the ultimate tensile strength (r = −0.81, p = 0.001) and between the width of the sulcus and the ultimate tensile strength (r = −0.74, p = 0.004).

We believe that the width of the sulcus is a simple and useful clinical indicator of the integrity and the tensile strength of the supraspinatus tendon.
Residual deformity in congenital radial club hands after previous centralisation of the wrist
Authors: Kawabata H. , Shibata T. , Masatomi T. , Yasui N.
Published: February 2018

We used the Ilizarov method in seven patients with severe congenital radial club hands who had had previous wrist surgery, to correct residual shortening and bowing of the ulna together with recurrent wrist deformity.

The mean age at operation was 6.5 years. The mean ulnar shortening was 5.3 cm and the mean angular deformity 42°.

The mean length gained was 51% of the original ulna. The mean healing index was 46.9 days (29.8 to 64.0). The ratio of the length of the lengthened ulna to the normal side improved on average from 64% to 95%. The angular deformity was initially completely corrected in six out of seven patients. The length ratio, however, decreased to 83% at the final follow-up. In four patients, the angular deformity partially recurred.

We recommend correction of congenital radial club hand by staged procedures. The first is centralisation and stabilisation of the wrist and the second lengthening of the ulna and correction of the angular deformity using the Ilizarov method.
Second fracture of the distal humerus after varus malunion of a supracondylar fracture in children
Authors: Takahara M. , Sasaki I. , Kimura T. , Kato H. , Minami A. , Ogino T.
Published: February 2018

Nine children sustained a second fracture of the distal humerus after union of an ipsilateral supracondylar fracture which had healed with cubitus varus. There were eight boys and one girl with a mean age of five years (1 to 8) at the time of the second fracture which occurred at a mean of 1.5 years after the first. In all patients, the second fracture was an epiphyseal injury of the distal humerus, either associated with a fracture of the lateral metaphysis below the site of the previous supracondylar fracture, or a fracture-separation of the entire distal humeral epiphysis. This suggests that the physis and epiphysis tend to be more subject to injury than the metaphysis of the distal humerus in children who have had a previous supracondylar fracture with varus malunion.
Open acromioplasty does not prevent the progression of an impingement syndrome to a tear
Authors: Hyvönen P. , Lohi S. , Jalovaara P.
Published: February 2018

We performed open acromioplasty for intractable impingement syndrome on 96 shoulders (93 patients) with an intact rotator cuff. All the shoulders were examined by ultrasound after a mean interval of nine years. Those showing pathological findings, a poor or fair subjective result, or deterioration of the primary excellent outcome had MRI and/or arthrography.

The mean Constant score for the affected shoulders was 70 points and that for 48 non-involved, symptom-free shoulders, 84 points. The subjective outcome was excellent in 45, good in 24, fair in 18 and poor in 9 shoulders. Complete tears were found in 12 shoulders and partial tears in seven. A total of 14 shoulders was symptom-free after acromioplasty, but after an average of five years became painful again and showed deterioration. Of these, six had complete tears and four partial tears of the cuff. The tear rate was 4% in shoulders initially judged to be excellent, 25% in good, 33% in fair and 55% in poor shoulders. The tear rate was 71% in shoulders which subsequently deteriorated. The incidence was higher in men (25%) than in women (11%).

We conclude that a tear of the rotator cuff may appear after acromioplasty, although there was no evidence of a tear at the time of operation. This is usually the reason for deterioration in a shoulder with an initially good operative outcome.
Changes in the disc space after fractures of the thoracolumbar spine
Authors: Oner F. C. , van der Rijt R. R. , Ramos L. M. P. , Dhert W. J. A. , Verbout A. J.
Published: February 2018

We have studied the intervertebral discs adjacent to fractured vertebral bodies using MRI in 63 patients at a minimum of 18 months after injury. There were 75 thoracolumbar fractures of which 26 were treated conservatively and 37 by posterior reduction and fusion with an AO internal fixator. We identified six different types of disc using criteria based on the morphology and the intensity of the MRI signal. The inter- and intraobserver variability of this system was good. Most of the discs showed predominantly morphological changes with no variation in signal intensity. Some disc types were associated with progressive kyphosis in patients treated conservatively. In those managed by operation, recurrent kyphosis appeared to result from creeping of the disc in the central depression of the bony endplate rather than from disc degeneration. Changes in the disc space after posterior fixation should not be seen as a form of chronic instability but as a redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate.
Acute compartment syndrome of the thigh after joint replacement with anticoagulation
Authors: Nadeem R. D. , Clift B. A. , Martindale J. P. , Hadden W. A. , Ritchie I. K.
Published: February 2018

We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated.

A compartment syndrome of the thigh is a rare, but important complication of joint replacement surgery if patients are receiving anticoagulants. Close observation is needed and when indicated monitoring of the intracompartmental pressure should be done. Early recognition of the signs and symptoms of an acute compartment syndrome and knowledge of the anatomy of the compartments of the thigh will help in the diagnosis and treatment of this potentially devastating complication.
Anti-inflammatory properties of titanium in the joint environment
Authors: Overgaard L. , Danielsen N. , Bjursten L. M.
Published: February 2018

Little is known about the tissue reactions to various implant materials which coincide with an inflammatory reaction. We used the avridine arthritis rat model to evaluate the tissue response in the synovial, interstitial and subcutaneous tissues after implant insertion.

Quantitative immunohistochemistry showed that normal joint synovial tissue is dominated by ED2-positive resident macrophages. Polyethylene implants induced a much stronger foreign-body reaction than titanium implants, as measured by the number of interfacial ED1-positive macrophages. The tissue response to titanium and polyethylene was also vastly different in arthritic synovial tissue compared with control tissue.

It is likely that these biomaterials interact differently with inflammatory cells or intermediary compounds. It may be that arthritic synovial tissue produces reactive oxygen intermediates (free radicals) with which titanium has a unique anti-inflammatory interaction in vitro.
Treatment of painful articular cartilage defects of the patella by carbon-fibre implants
Authors: Meister K. , Cobb A. , Bentley G.
Published: February 2018

Between 1989 and 1993 we implanted a matrix support prosthesis made of carbon fibre for the treatment of chronic painful articular defects of the patella in 27 patients. The mean period of follow-up was 33 months (11 to 54) with clinical and arthroscopic evaluation of the implant.

Overall, there were four excellent, three good, seven fair and 13 poor results. Nine patients subsequently had a patellectomy for persistent pain at a mean of 27 months after surgery (14 to 47). The mean visual analogue pain scores in those who retained their patella were 7.6 before operation and 5.5 at the time of the latest follow-up. Patient satisfaction for the entire group was 41%.

There appeared to be good incorporation of the prosthesis and a satisfactory ingrowth of fibrocartilage, but the poor results in 48% and low patient satisfaction discourage us from recommending the procedure for lesions of the articular cartilage of the patella. The consistent seeding of the joint with carbon-fibre debris and a histiocytic giant-cell reaction in the synovium are also a cause for concern.
A new method of stabilising the elevated laminae in open-door laminoplasty using an anchor system
Authors: Wang J.-M. , Roh K.-J. , Kim D.-J. , Kim D.-W.
Published: February 2018

We treated 12 patients with multilevel stenosis of the cervical canal after spondylosis or ossification of the posterior longitudinal ligament by an expansive open-door laminoplasty, stabilised by using an anchor system.

The preoperative sagittal diameter of the canal was 9.8 mm(±2.2) which was increased to 16.1 mm (±2.9) after surgery. The mean expansion ratio of the canal was 64% (42 to 100). The anchoring systems did not fail during the follow-up period (mean 29.5 months), and the decompression was maintained. The use of anchor systems to stabilise the posterior elements after laminoplasty is a simple and effective technique for maintaining the increased sagittal diameter of the canal.