bluuebunny/crossref_metadata_2025 huggingface dataset:
NERVE GRAFTING IN BRACHIAL PLEXUS INJURIES
Authors: Ochiai N. , Nagano A. , Sugioka H. , Hara T.
Published: February 2018

We have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor.

Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions.

It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential.
The prevalence and clinicopathological appearance of extension of osteonecrosis in the femoral head
Authors: Yamamoto T. , DiCarlo E. F. , Bullough P. G.
Published: February 2018

In about 50% of cases, osteonecrosis of the femoral head is known to occupy more than one site. There is controversy as to whether a single focus may increase in size. We have reviewed 606 consecutive femoral heads which had been surgically removed for osteonecrosis. Extension of osteonecrosis was observed in only two (0.3%) and was confirmed histopathologically by the enlargement of the necrotic segment beyond the repair zone formed for the primary necrosis into the adjacent, previously uninvolved bone. In both cases, the necrotic regions were wedge-shaped and occupied over 80% of the femoral head.

It appears that an increase in size is extremely rare and that osteonecrosis is due to a single event. Our findings may be of value in assessing the use of joint-salvage procedures for osteonecrosis of the femoral head.
Tuberculosis of the foot
Authors: Mittal R. , Gupta V. , Rastogi S.
Published: February 2018

In 44 patients with tuberculosis of the foot we identified five radiological patterns of lesions; cystic, rheumatoid, subperiosteal, kissing and spina ventosa. Cystic destruction had the best outcome and rheumatoid the poorest. All the patients were cured after antituberculous treatment for 18 months, and none required surgery.
A posterior approach to the elbow joint
Authors: Shahane S. A. , Stanley D.
Published: February 2018

We describe a posterior approach to the elbow which combines the advantages of both splitting and reflecting the triceps. It gives protection to the ulnar nerve and its blood supply during the operation while providing excellent exposure of the distal humerus. During closure, the triceps muscle can be tensioned, thereby improving stability of the elbow. This approach has particular relevance to unlinked total elbow arthroplasty allowing early rehabilitation of the joint.
Avascular necrosis and the Aberdeen splint in developmental dysplasia of the hip
Authors: Williams P. R. , Jones D. A. , Bishay M.
Published: February 2018

Between January 1987 and December 1988 there were 7575 births in the Swansea maternity unit. Of these 823 (10.9%) were considered to be at ‘high risk’ for developmental dysplasia of the hip (DDH). Static ultrasound examination was performed in each case and the results classified on the basis of the method of Graf. A total of 117 type III–IV hips in 83 infants was splinted using the Aberdeen splint.

Radiographs of these hips were taken at six and 12 months. Hilgenreiner’s measurements of the acetabular angle were made in all cases and the development of the femoral capital epiphysis was assessed by measuring the epiphyseal area. The effect of splintage on the acetabular angle and the epiphyseal area between the normal and abnormal splinted hips was compared. Radiographs of 16 normal infants (32 normal unsplinted hips) were used as a control group.

This cohort has now been followed up for a minimum of nine years. There have been no complications as a result of splintage. The failure rate was 1.7% or 0.25 per 1000 live births. No statistical difference was found when comparing the effect of splintage on the acetabular angle and epiphyseal area between normal and abnormal splinted hips and normal unsplinted hips.

Our study has shown that while the Aberdeen splint had a definite but small failure rate, it was safe in that it did not produce avascular necrosis. The current conventional view that a low rate of splintage is always best is therefore brought into question if the Aberdeen splint is chosen for the management of neonatal DDH.
The limping child: epidemiology, assessment and outcome
Authors: Fischer S. U. , Beattie T. F.
Published: February 2018

We investigated the epidemiology, assessment and outcome of acute atraumatic limp in 243 children under the age of 14 years presenting to a paediatric accident and emergency department (AED) over a period of six months. Data were collected at presentation and medical notes were re-examined after 18 to 21 months.

The incidence of limp was 1.8 per thousand. The male:female ratio was 1.7:1 and the median age 4.35 years. Limp was mainly right-sided (54%) and painful (80%); 33.7% of the children had localised pain in the hip. A preceding illness was found in 40%. The main diagnosis was ‘irritable hip’/transient synovitis (39.5%); Perthes’ disease accounted for 2%. Most patients (77%) were managed entirely in the AED.

Acute atraumatic limp is a common problem in children presenting to the AED. Most can be safely managed there if guidelines are followed and will have a benign outcome. Further studies are needed to identify the role of preceding illness in the aetiology of acute atraumatic limp.
Vascularised rib graft defects of the diaphysis of the humerus in children
Authors: Sundaresh D. C. , Gopalakrishnan D. , Shetty N.
Published: February 2018

In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail. Vascularised grafts with microvascular anastomosis are technically demanding with a high rate of failure. Transfer of the rib on its vascular pedicle to achieve anterior fusion in the thoracic spine is now well established and the length of the pedicle available is adequate to allow grafting of a diaphyseal defect in the humerus. We describe the successful use of this procedure in two patients.
Intraoperative heparin in addition to postoperative low-molecular-weight heparin for thromboprophylaxis in total knee replacement
Authors: Mant M. J. , Russell D. B. , Johnston D. W. C. , Donahue P. A.
Published: February 2018

The administration of heparin during operation has been reported to enhance the efficacy of thromboprophylaxis in patients undergoing total hip replacement. We have performed a small pilot study in which intraoperative doses of heparin were given in addition to the usual postoperative thromboprophylaxis with enoxaparin in 32 patients undergoing total knee replacement. The primary endpoint was deep-vein thrombosis (DVT) as demonstrated by bilateral venography on 6 ± 2 days after operation.

Sixteen patients developed DVT; in two the thrombosis was proximal as well as distal and in one the occurrence was bilateral. There was one major haemorrhage. These results are similar to those obtained with the use of postoperative thromboprophylaxis with enoxaparin alone. They do not provide support for the initiation of a larger randomised trial of this approach to management.
Impaction bone grafting in revision hip surgery
Authors: Pekkarinen J. , Alho A. , Lepistö J. , Ylikoski M. , Ylinen P. , Paavilainen T.
Published: February 2018

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification.

The Mayo hip score improved from a mean of 32 (sd ± 18) to 62 (sd ± 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united.

The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases.

In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.
The medium-term results of a cemented Freeman femoral neck-retaining prosthesis
Authors: Journeaux S. F. , Morgan D. A. F. , Donnelly W. J.
Published: February 2018

We have reviewed 202 consecutive primary hip replacements using a Freeman cemented femoral component after a mean period of follow-up of 64 months (23 to 113). There was only one revision for aseptic loosening. Retention of the femoral neck may act to reduce the torsional and shear forces at the implant-cement interface and may provide a seal against the migration of polyethylene-laden joint fluid in the potential joint space. The cemented Freeman femoral component with retention of the femoral neck was successful for up to nine years.
Displaced supracondylar fractures of the humerus in children
Authors: O’Hara L. J. , Barlow J. W. , Clarke N. M. P.
Published: February 2018

We performed an audit of 71 children with consecutive displaced, extension-type supracondylar fractures of the humerus over a period of 30 months. The fractures were classified according to the Wilkins modification of the Gartland system. There were 29 type IIA, 22 type IIB and 20 type III. We assessed the effectiveness of guidelines proposed after a previous four-year review of 83 supracondylar fractures. These recommended that: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type-IIB and type-III fractures must be supplemented by stabilisation with Kirschner (K-) wires; and 3) K-wires of adequate thickness (1.6 mm) must be used in a crossed configuration.

The guidelines were followed in 52 of the 71 cases. When they were observed there were no reoperations and no malunion. In 19 children in whom they had not been observed more than one-third required further operation and six had a varus deformity. Failure to institute treatment according to the guidelines led to an unsatisfactory result in 11 patients. When they were followed the result of treatment was much better. We have devised a protocol for the management of these difficult injuries.
The effect of the patellar tendon-bearing cast on loading
Authors: Tanaka H. , Nagata K. , Goto T. , Hoshiko H. , Inoue A.
Published: February 2018

We assessed the unloading effect of the patellar tendon-bearing (PTB) cast in five healthy volunteers using a new system for analysis of dynamic plantar pressure. We devised a method to improve the unloading effect of the PTB cast, and tested this using the same system.

Our findings showed that the conventional PTB cast only achieved unloading of 30% of the body-weight and that the part of the cast on the leg had a more important role in the unloading than that which was in contact with the patellar tendon. When the depth of the free space under the foot inside the PTB cast was 1, 2 and 3 cm, the unloading effect was 60%, 80% and 98%, respectively.

The unloading effect of the conventional PTB cast was disappointing at only 30% of body-weight. It was improved by producing a space between the sole of the foot and the cast, and was adjustable by altering the depth of this space.
Lengthening of congenital below-elbow amputation stumps by the Ilizarov technique
Authors: Alekberov C. , Karatosun V. , Baran Ö. , Günal I.
Published: February 2018

Patients with short congenital amputations below the elbow often function as if they have had a disarticulation of the elbow. We have reviewed the results in six patients who had lengthening of such stumps by the Ilizarov technique to improve the fitting of prostheses.

The mean lengthening was 5.6 cm (3.4 to 8.4), and in two patients flexion contractures of the elbows were corrected simultaneously. Additional lateral distraction was used in one patient to provide a better surface on the stump. There were no major complications. All six patients were able to use their prosthesis at the latest follow-up after 39 to 78 months.
Functional outcome of surgery for fractures of the ankle
Authors: Egol K. A. , Dolan R. , Koval K. J.
Published: February 2018

We randomised prospectively 60 consecutive patients who were undergoing internal fixation of similar fractures of the ankle into two groups, one of which was treated by immobilisation in a below-knee cast and the other by a functional brace with early movement. All were instructed to avoid weight-bearing on the affected side. They were seen at 6, 12, 26 and 52 weeks. The functional rating scale of Mazur et al was used to evaluate the patients at each follow-up and we recorded the time of return to work. After one year the patients completed the SF-36 questionnaire.

By then 55 patients remained in the study, 28 (mean age 45.5 years) in group 1 and 27 (mean age 39.5 years) in group 2. Those in group 2 had higher functional scores at each follow-up but only at six weeks was this difference significant (p = 0.02). They also had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated. For patients gainfully employed, not on workers’ compensation, the mean time from surgery to return to work was 53.3 days for group 2 and 106.5 days for group 1; this difference was significant (p = 0.01). No patient developed a problem with the wound or had loss of fixation.

Our findings support the use of a functional brace and early movement after surgery for fractures of the ankle.
Function after correction of a clawed great toe by a modified Robert Jones transfer
Authors: Breusch S. J. , Wenz W. , Döderlein L.
Published: February 2018

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically.

The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001).

The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.
Chondrosarcoma in a family with multiple hereditary exostoses
Authors: Kivioja A. , Ervasti H. , Kinnunen J. , Kaitila I. , Wolf M. , Böhling T.
Published: February 2018

Multiple hereditary exostoses is an autosomal dominant skeletal disorder in which there are numerous cartilage-capped excrescences in areas of actively growing bone. The condition is genetically heterogeneous, and at least three genes, ext1, ext2 and ext3 are involved. The reported risk for malignant transformation to chondrosarcoma has been from 0.6% to 2.8%. We have reviewed six generations of a family with 114 living adult members, 46 of them with multiple exostoses. Four have had operations for chondrosarcoma, giving the risk for malignant transformation as 8.3% in this family. Clinical and radiological examination revealed two additional patients with a suspicion of malignancy, but in whom the histological findings were benign. Reported elsewhere in detail, genetic linkage analysis mapped the causative gene to chromosome 11 and molecular studies revealed a guanine-to-thymine transversion in the ext2 gene. Patients with multiple hereditary exostoses carry a relatively high risk of malignant transformation. They should be informed of this possibility and regularly reviewed.
Intraoperative electroneurography in the assessment of the level of operation for cervical spondylotic myelopathy in the elderly
Authors: Tani T. , Ishida K. , Ushida T. , Yamamato H.
Published: February 2018

We treated 31 patients aged 65 years or more with cervical spondylotic myelopathy by microsurgical decompression and fusion at a single most appropriate level, in spite of MRI evidence of compression at several levels. Spinal cord potentials evoked at operation localised the level responsible for the principal lesion at C3-4 in 18 patients, C4-5 in 11 and at C5-6 in two. Despite the frequent coexistence of other age-related conditions, impairing ability to walk, the average Nurick grade improved from 3.5 before operation to 2.2 at a mean follow-up of 48 months. There was also good recovery of finger dexterity and sensitivity.

Operation at a single optimal level, as opposed to several, has the advantage of minimising complications, of particular importance in this age group.
Human osteoblast-like cells phagocytose metal particles and express the macrophage marker CD68 in vitro
Authors: Heinemann D. E. H. , Lohmann C. , Siggelkow H. , Alves F. , Engel I. , Köster G.
Published: February 2018

Periprosthetic osteolysis is a major cause of aseptic loosening in artificial joint replacement. It is assumed to occur in conjunction with the activation of macrophages. We have shown in vitro that human osteoblast-like cells, isolated from bone specimens obtained from patients undergoing hip replacement, phagocytose fine particles of titanium alloy (TiAlV).

The human osteoblast-like cells were identified immunocytochemically by the presence of bone-specific alkaline phosphatase (BAP). With increasing duration of culture, a variable number of the osteoblastic cells became positive for the macrophage marker CD68, independent of the phagocytosis of particles, with a fine granular cytoplasmic staining which was coexpressed with BAP as revealed by immunodoublestaining. The metal particles were not toxic to the osteoblastic cells since even in culture for up to four weeks massively laden cells were vital and had a characteristic morphology. Cells of the human osteosarcoma cell line (HOS 58) were also able to phagocytose metal particles but had only a low expression of the CD68 antigen. Fluorescence-activated cell scanning confirmed our immunocytochemical results. Additionally, the cells were found to be negative for the major histocompatibility complex-II (MHC-II) which is a marker for macrophages and other antigen-presenting cells. Negative results of histochemical tests for tartrate-resistant acid phosphatase excluded the contamination by osteoclasts or macrophages in culture.

Our observations suggest that the osteoblast can either change to a phagocytosing cell or that the phagocytosis is an underestimated property of the osteoblast. The detection of the CD68 antigen is insufficient to prove the monocytic lineage. In order to discriminate between macrophages and osteoblasts additional markers should be used. To our knowledge, this is the first demonstration of cells of an osteoblastic origin which have acquired a mixed phenotype of both osteoblasts and macrophages.
Osseointegration of Ti6Al4V alloy implants coated with titanium nitride by a new method
Authors: Sovak G. , Weiss A. , Gotman I.
Published: February 2018

Coating titanium alloy implants with titanium nitride (TiN) by the method of Powder Immersion Reaction Assisted Coating (PIRAC) produces a stable layer on their surface. We have examined the ability of the new TiN coating to undergo osseointegration. We implanted TiN-coated and uncoated Ti6Al4V alloy pins into the femora of six-month-old female Wistar rats.

SEM after two months showed a bone collar around both TiN-coated and uncoated implants. Morphometrical analysis revealed no significant differences between the percentage of the implant-bone contact and the area and volume of the bone around TiN-coated compared with uncoated implants. Electron-probe microanalysis indicated the presence of calcium and phosphorus at the implant-bone interface. Mineralisation around the implants was also confirmed by labelling with oxytetracycline. Strong activity of alkaline phosphatase and weak activity of tartrate-resistant acid phosphatase were shown histochemically. Very few macrophages were detected by the non-specific esterase reaction at the site of implantation.

Our findings indicate good biocompatibility and bone-bonding properties of the new PIRAC TiN coatings which are comparable to those of uncoated Ti6Al4V alloy implants.
The depressor function of biceps on the head of the humerus in shoulders with tears of the rotator cuff
Authors: Kido T. , Itoi E. , Konno N. , Sano A. , Urayama M. , Sato K.
Published: February 2018

We investigated the function of biceps in 18 patients (19 shoulders) with lesions of the rotator cuff. Their mean age was 59 years. Another series of 18 patients (19 shoulders) with normal rotator cuffs as seen on MRI acted as a control group. Their mean age was 55 years. A brace was used to maintain contraction of biceps during elevation. Anteroposterior radiographs were obtained with the arm elevated at 0°, 45° and 90° with and without contraction of biceps. The distance between the centre of the head of the humerus and the glenoid was compared in the two groups.

We found that in the group with tears there was significantly greater proximal migration of the head of the humerus at 0° and 45° of elevation without contraction of biceps but depression of the head of the humerus at 0°, 45° and 90° when biceps was functioning. We conclude that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff.
Magnetic resonance arthrography of the acetabular labrum
Authors: Plötz G. M. J. , Brossmann J. , Schünke M. , Heller M. , Kurz B. , Hassenpflug J.
Published: February 2018

We studied the sensitivity and specificity of magnetic resonance arthrography (MRa) for the diagnosis of lesions of the acetabular labrum in 20 cadaver hips. The MRa results were compared with macroscopic and histological findings.

We found that the labrum could be satisfactorily delineated by MRa and that large detachments could be identified satisfactorily. The diagnosis of small detachments and degeneration of the labrum was less reliable.
The effect of the position of the limb on venous impulse foot pumps
Authors: Fleming P. , Fitzgerald P. , Devitt A. , Rice J. , Murray P.
Published: February 2018

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions.

Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%.

The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect.
Autologous morsellised bone grafting restores uncontained femoral bone defects in knee arthroplasty
Authors: van Loon C. J. M. , de Waal Malefijt M. C. , Buma P. , Stolk P. W. Th. , Verdonschot N. , Tromp A. M. , Huiskes R. , Barneveld A.
Published: February 2018

The properties of impacted morsellised bone graft (MBG) in revision total knee arthroplasty (TKA) were studied in 12 horses. The left hind metatarsophalangeal joint was replaced by a human TKA. The horses were then randomly divided into graft and control groups. In the graft group, a unicondylar, lateral uncontained defect was created in the third metatarsal bone and reconstructed using autologous MBG before cementing the TKA. In the control group, a cemented TKA was implanted without the bone resection and grafting procedure. After four to eight months, the animals were killed and a biomechanical loading test was performed with a cyclic load equivalent to the horse’s body-weight to study mechanical stability. After removal of the prosthesis, the distal third metatarsal bone was studied radiologically, histologically and by quantitative and micro CT.

Biomechanical testing showed that the differences in deformation between the graft and the control condyles were not significant for either elastic or time-dependent deformations. The differences in bone mineral density (BMD) between the graft and the control condyles were not significant. The BMD of the MBG was significantly lower than that in the other regions in the same limb. Micro CT showed a significant difference in the degree of anisotropy between the graft and host bone, even although the structure of the area of the MBG had trabecular orientation in the direction of the axial load. Histological analysis revealed that all the grafts were revascularised and completely incorporated into a new trabecular structure with few or no remnants of graft. Our study provides a basis for the clinical application of this technique with MBG in revision TKA.
Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament
Authors: Fremerey R. W. , Lobenhoffer P. , Zeichen J. , Skutek M. , Bosch U. , Tscherne H.
Published: February 2018

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined.

Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 ± 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.
Osteoarticular allograft in surgery for high-grade malignant tumours of bone
Authors: Rödl R. W. , Ozaki T. , Hoffmann C. , Böttner F. , Lindner N. , Winkelmann W.
Published: February 2018

We assessed the results of 17 limb-salvage procedures using osteoarticular allografts after wide resection of high-grade malignant bone tumours. All patients received chemotherapy. At the five-year follow-up, three patients had died from metastases. The allografts survived for five years in only seven patients all of whom had good function, ranging from 73% to 90% of normal. The allografts were removed because of fracture in seven patients and infection in one, and in all of these a second limb-salvage procedure was undertaken.

With such a low rate of survival of osteoarticular allografts, we believe that their use in the management of high-grade malignant bone tumours should, at best, be considered a temporary solution.
Serrated W/M osteotomy
Authors: Hayek S. , Segev E. , Ezra E. , Lokiec F. , Wientroub S.
Published: February 2018

The conventional osteotomies used to treat infantile tibia vara (Blount’s disease) may require internal fixation and its subsequent removal. These techniques, which carry the risk of traction injury, and potential problems of stability and consolidation, do not always succeed in correcting the rotational deformity which accompanies the angular deformity.

We have used a new surgical approach, the serrated W/M osteotomy of the proximal tibia, to correct infantile tibia vara in 15 knees of 11 patients. We present the results in 13 knees of nine patients who have been followed up for a mean of eight years. The mean angular correction achieved after operation was 18 ± 5.8°. The mean femorotibial shaft angle was corrected from 14.2 ± 3.7° of varus to 4.6 ± 4.4° of valgus. At the last follow-up, the mean angular correction had reduced to 1.3 ± 4.9° of valgus without compromising the rotational correction and the overall good clinical results. All the patients and parents were satisfied, rating the result as excellent or good. There were no major postoperative complications and no reoperations. Eight patients were free from pain and able to perform physical activities suitable for their age. One complained of occasional pain. This procedure has the advantage of allowing both angular and rotational correction with a high degree of success without the need for internal fixation.
Hangman’s fracture: the relationship between asymmetry and instability
Authors: Samaha C. , Lazennec J. Y. , Laporte C. , Saillant G.
Published: February 2018

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable.

Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result.

Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis.
Modulation of the formation of adhesions during the healing of injured tendons
Authors: Khan U. , Kakar S. , Akali A. , Bentley G. , McGrouther D. A.
Published: February 2018

The formation of restrictive adhesions around the musculotendinous unit after injury is one of the most vexing processes faced by the surgeon. In flexor tendons it has been shown that the synovial tissue is the source of aggressive fibroblasts which contribute to this process. Using a rabbit model, we have examined the effects of treating the synovial sheath with the antimetabolite 5-fluorouracil (5-FU) for five minutes. Inflammatory, proliferative and molecular markers were compared in the response of the treated and control tendons to injury. Compared with a control group we found that the proliferative and inflammatory responses were significantly reduced (p < 0.001) in the treated tendons. Not only was there a reduction in the cellular and cytokine response, but there also was a significant (p < 0.001) reduction in the level of activity of the known pro-scarring agent, transforming growth factor beta 1 (TGF-β1). These pilot studies indicate that the formation of restrictive adhesions may be modulated using a simple single-touch technique in the hope of producing a better return of function.
The influence of avascularity on the mechanical properties of human bone-patellar-tendon-bone grafts
Authors: Rupp S. , Seil R. , Kohn D. , Müller B.
Published: February 2018

Our aim was to analyse the effect of avascularity on the morphology and mechanical properties (tensile strength, viscoelasticity) of human bone-patellar-tendon-bone (BPTB) grafts in vitro. These were harvested at postmortem and stored submerged in denaturated human plasma at a constant pH, pO2, pCO2, temperature and humidity under sterile conditions. Mechanical testing was performed two and four weeks after removal of the graft. The mean ultimate strength was 1085.7 ± 255.8 N (control), 1009.0 ± 314.9 N (two weeks cultured) and 1076.8 ± 414.8 N (four weeks cultured). There was no significant difference in linear stiffness or deformation to failure between the groups. There was a difference in viscoelasticity between the control group and the avascular grafts and the latter had significant lower peak load-to-load ratios after 15 minutes compared with the control group. After two and four weeks the graft contained viable fibroblasts. There was regular cellularity in the superficial layers and decreased cellularity in the midportion. The structure of the collagen including the crimp pattern appeared to be normal in polarised light.

We conclude that avascularity does not significantly affect ultimate failure loads or stiffness of BPTB grafts. Slight changes in viscoelasticity were induced, but the significance of the increased stress relaxation is not fully understood.
Precision of the measurements of periprosthetic bone mineral density in hips with a custom-made femoral stem
Authors: Martini F. , Lebherz C. , Mayer F. , Leichtle U. , Kremling E. , Sell S.
Published: February 2018

Our aim was to determine the precision of the measurements of bone mineral density (BMD) by dual-energy x-ray absorptiometry in the proximal femur before and after implantation of an uncemented implant, with particular regard to the significance of retro- and prospective studies.

We examined 60 patients to determine the difference in preoperative BMD between osteoarthritic and healthy hips. The results showed a preoperative BMD of the affected hip which was lower by a mean of 4% and by a maximum of 9% compared with the opposite side. In addition, measurements were made in the operated hip before and at ten days after operation to determine the effect of the implantation of an uncemented custom-made femoral stem. The mean increase in the BMD was 8% and the maximum was 24%. Previous retrospective studies have reported a marked loss of BMD on the operated side.

The precision of double measurements using a special foot jig showed a modified coefficient of variation of 0.6% for the non-operated side in 15 patients and of 0.6% for the operated femur in 20 patients.

The effect of rotation on the precision of the measurements after implantation of an uncemented femoral stem was determined in ten explanted femora and for the operated side in ten patients at 10° rotation and in 20 patients at 30° rotation. Rotation within 30° influenced the precision in studies in vivo and in vitro by a mean of 3% and in single cases in up to 60%.

Precise prediction of the degree of loss of BMD is thus only possible in prospective cross-sectional measurements, since the effect of the difference in preoperative BMD, as well as the apparent increase in BMD after implantation of an uncemented stem, is not known from retrospective studies. The DEXA method is a reliable procedure for determining periprosthetic BMD when positioning and rotation are strictly controlled.
Fractures of the odontoid process
Authors: Govender S. , Maharaj J. F. , Haffajee M. R.
Published: February 2018

We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.
The sulcus angle and malalignment of the extensor mechanism of the knee
Authors: Davies A. P. , Costa M. L. , Donnell S. T. , Glasgow M. M. , Shepstone L.
Published: February 2018

Anterior knee pain due to dysplasia of the extensor mechanism is common. We have studied 137 knees (103 patients) in order to identify a rapid and reproducible radiological feature which would indicate the need for further analysis.

Overall, 67 knees (49%) had at least one radiological abnormality; 70 (51%) were considered normal. There were five cases of Dejour type-3 dysplasia of the femoral trochlea, nine of type-2 and 12 of type-1. There were 49 cases of patella alta and five of patella infera. Four knees had an abnormal lateral patellofemoral angle (patellar tilt), and in 15 knees there was more than one abnormality. Classification of trochlear dysplasia was difficult and showed poor reproducibility. This was also true for the measurement of the lateral patellofemoral angle. Patellar height was more easily measured but took time. The sulcus angle is an easily and rapidly measurable feature which was reproducible and was closely related to other features of dysplasia of the extensor mechanism.

The finding of a normal sulcus angle suggested that seeking other radiological evidence of malalignment of the extensor mechanism was unlikely to reveal additional useful information. The severity of other features of dysplasia of the extensor mechanism correlated with increasing sulcus angle.
Tibiofemoral movement 1: the shapes and relative movements of the femur and tibia in the unloaded cadaver knee
Authors: Iwaki H. , Pinskerova V. , Freeman M. A. R.
Published: February 2018

In six unloaded cadaver knees we used MRI to determine the shapes of the articular surfaces and their relative movements. These were confirmed by dissection.

Medially, the femoral condyle in sagittal section is composed of the arcs of two circles and that of the tibia of two angled flats. The anterior facets articulate in extension. At about 20° the femur ‘rocks’ to articulate through the posterior facets. The medial femoral condyle does not move anteroposteriorly with flexion to 110°.

Laterally, the femoral condyle is composed entirely, or almost entirely, of a single circular facet similar in radius and arc to the posterior medial facet. The tibia is roughly flat. The femur tends to roll backwards with flexion.

The combination during flexion of no antero-posterior movement medially (i.e., sliding) and backward rolling (combined with sliding) laterally equates to internal rotation of the tibia around a medial axis with flexion. About 5° of this rotation may be obligatory from 0° to 10° flexion; thereafter little rotation occurs to at least 45°. Total rotation at 110° is about 20°, most if not all of which can be suppressed by applying external rotation to the tibia at 90°.
Tibiofemoral movement 4: changes of axial tibial rotation caused by forced rotation at the weight-bearing knee studied by RSA
Authors: Karrholm J. , Brandsson S. , Freeman M. A. R.
Published: February 2018

We studied the knees of 11 volunteers using RSA during a step-up exercise requiring extension while weight-bearing from 50° to 0°. The findings on weight-bearing flexion with and without external rotation of the tibia based on MRI were confirmed.
The treatment of scoliosis in muscular dystrophy using modified Luque and Harrington-Luque instrumentation
Authors: Bentley G. , Haddad F. , Bull T. M. , Seingry D.
Published: February 2018

We have treated 101 patients with scoliosis secondary to muscular dystrophy over a 13-year period; 64 had Duchenne’s muscular dystrophy, 33 spinal muscular atrophy and four congenital muscular dystrophy.

The patients underwent a modified Luque (87) or Harrington-Luque instrumentation (14) combined with a limited Moe fusion in all except 27 cases. A mean of 13 levels was instrumented. The mean preoperative sitting Cobb angle was 84° (10 to 150) and the mean postoperative angle 40° (52% correction). Most patients (96%) were able to discard their braces and there was a high level of patient satisfaction (89.6%).

Less correction was seen for severe curves, and there was a greater recurrence of postoperative pelvic tilt in those patients not instrumented to the sacrum. Although the incidence of minor or temporary complications was high, these occurred chiefly in the early high-risk patients with very severe curves and considerable pre-existing immobility.
Treatment of nonunion of the scaphoid by a limited combined approach
Authors: del Piñal F.
Published: February 2018

Seven patients with nonunion of the scaphoid were treated by a limited approach combining a palmar wedge graft with insertion of a dorsal (retrograde) Herbert screw through small incisions. All patients had palmar bone deficiency and a ‘difficult’ proximal fragment. They were followed up for a minimum of 12 months (12 to 38). Radiological union was achieved in all. In five patients correction of instability of the dorsal intercalary segment which was present before operation, was achieved. On a wrist-scoring chart, all patients had an excellent or good rating. The limited combined approach allows correction of the deformity with rigid fixation and has the advantage of preserving most of the palmar ligaments.
A histological study of the necrotic area after transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head
Authors: Yasunaga Y. , Hisatome T. , Ikuta Y. , Nakamura S.
Published: February 2018

We studied nine patients who had had a transtrochanteric anterior rotational osteotomy, as developed by Sugioka, for osteonecrosis of the femoral head. At a mean of 2.5 years after the initial operation we carried out a histological study of the previously necrotic femoral head which had not shown collapse of the new primary weight-bearing site. In seven joints, there was proliferation of fibrous tissue in the dead trabeculae with vascular ingrowth. New bone covering dead trabeculae created the characteristic appearance of ‘creeping substitution’. However, these changes were limited and did not extend over the entire necrotic area. Dead bone remained in all the cases. In the other two heads we did not observe proliferation of fibrous tissue or vascular ingrowth, only dead trabeculae and dead bone marrow.
Fluconazole-impregnated beads in the management of fungal infection of prosthetic joints
Authors: Bruce A. S. W. , Kerry R. M. , Norman P. , Stockley I.
Published: February 2018

We report two cases of fungal infection of prosthetic joints which were successfully treated by the incorporation of fluconazole into polymethylmethacrylate beads inserted at the time of debridement.
Oxford medial unicompartmental knee arthroplasty
Authors: Svärd U. C. G. , Price A. J.
Published: February 2018

We describe the outcome of a series of 124 Oxford meniscal-bearing unicompartmental arthroplasties carried out for osteoarthritis of the medial compartment. They had been undertaken more than ten years ago in a non-teaching hospital in Sweden by three surgeons. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and full-thickness cartilage in the lateral compartment. Thirty-seven patients had died; the mean time since operation for the remainder was 12.5 years (10.1 to 15.6).

Using the endpoint of revision for any cause, the outcome for every knee was established. Six had been revised (4.8%). At ten years there were 94 knees still at risk and the cumulative survival rate was 95.0% (95% confidence interval 90.8 to 99.3). This figure is similar to that reported by the designers of the prosthesis and to the best published results for independent series of total knee replacement. If patients are selected appropriately, this implant is a reliable treatment for anteromedial osteoarthritis of the knee.
‘Fat fracture’ – a physical sign mimicking tendon rupture
Authors: Thomas R. H. , Holt M. D. , James S. H. , White P. G.
Published: February 2018

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’.
Recurrent congenital haemangiopericytoma in a child
Authors: O’Donnell T. M. P. , Devitt A. T. , Kutty S. , Fogarty E. E.
Published: February 2018

A five-day-old boy was referred with a soft-tissue mass in his right upper arm. Plain radiographs and ultrasound demonstrated a lesion extending from the axilla to the elbow on the posterolateral aspect of the humerus. Open biopsy confirmed the diagnosis of congenital haemangiopericytoma. After MRI and selective angiography, excision biopsy was carried out, but no adjuvant therapy was administered. At further examination, four years and ten months later, he was noted to have three small nodules at the site of the original tumour. Excision biopsy confirmed this to be a local recurrence, although the lesion was less cellular with no appreciable mitotic activity. Congenital haemangiopericytoma is a rare cause of a soft-tissue mass in children. Most tumours are benign, and recurrence is uncommon. The treatment is controversial, but most centres recommend the use of adjuvant chemotherapy, combined with complete excision. We recommend treatment with doxorubicin. Orthopaedic surgeons should be familiar with this tumour since 30% to 50% of cases occur in the limbs.
Inflammatory responses of human primary macrophages to particulate bone cements in vitro
Authors: Wimhurst J. A. , Brooks R. A. , Rushton N.
Published: February 2018

We have investigated whether the particle-stimulated release of inflammatory cytokines from human primary macrophages in vitro was dependent upon the type of bone cement used. Particles of clinically relevant size were produced from Palacos R without radio-opacifier, Palacos R with BaSO4, Palacos R with ZrO2 and from CMW3 which contains BaSO4. All four preparations produced significantly greater release of tumour necrosis factor alpha, interleukin-6 and interleukin-1 beta than a negative control but there were no significant differences between them. The differences in the ability to stimulate bone resorption and in clinical performance between proprietary bone cements previously recorded are not explained by the release of the cytokines most commonly implicated in osteolysis.