Journal of Orthopaedic Surgery

Arthrogryposis multiplex congenita (AMC) is a rare syndrome with multiple joint contractures. It is commonly believed that bilaterally dislocated hips associated with joint contractures should not be reduced, because movement is satisfactory, while open reduction leads to poor results. This report presents our experience with surgical management of bilateral dislocation of hips in children with AMC.

During the period 1990 to 2000, we performed open reduction on 8 hips of 4 children with AMC. The mean age at surgery was 23 months (range, 5–48 months). Open reduction and capsular plication without any bony procedure were performed in 4 hips (2 patients). De-rotation and varus osteotomy of the femur was performed in 4 hips, and Salter osteotomy of the innominate bone in 2 hips. The average acetabular index was 44°, and the mean centre-edge angle was −41° preoperatively.

The average follow-up period was 4 years (range, 2–9 years). The average acetabular index and centre-edge angle were 19° and 18°, respectively at the time of last follow-up. All children could walk without support. One child required re-opening for redislocation of hip joint. The clinical results were good in 6 hips and fair in 2 hips, according to Severin's and McKay's classifications.

Our experience shows that open reduction for bilateral dislocation of hips in children with AMC is a suitable option with generally good results. Surgery performed at earlier age gives the best functional outcome.

To study the changing epidemiological pattern of micro-organisms as an aetiology of septic arthritis, and to correlate the pattern with the outcome of neonatal septic arthritis, in terms of joint function and morphology.

15 consecutive cases of neonatal septic arthritis of hip admitted between 1999 and 2002 were studied. Diagnosis of septic arthritis was made on the basis of Morrey's criteria. All patients were treated by arthrotomy after aspiration of purulent fluid from the joint. Patients were followed up for a mean period of 2.4 years. Clinical and radiological examinations were performed at follow-up.

The mean age of the 15 patients was 20.35 days. 13 (87%) patients had primary septic arthritis, while only 2 (13%) had associated osteomyelitis. Culture reports revealed that the spectrum consisted of 33% gram-negative organisms, 7% fungal, and only 20% gram-positive organisms—Staphylococcus aureus in 3 patients, Klebsiella in 2 patients, one each of Proteus, Candida, Escherichia coli, and Enterobactor. Six patients were pus-cell positive with negative culture. No organism was found in 6 (40%) cases. Investigations showed leukocytosis, raised C-reactive protein and erythrocyte sedimentation rate in all 15 patients. 12 patients had normal clinical and radiological parameters at follow-up. Three patients had delayed surgical drainage of more than 72 hours due to late presentation, and showed various radiological sequelae with terminal restriction of joint movements.

There are more cases of primary septic arthritis than secondary septic arthritis. Clinicians should be alert of the aetiology shift to gram-negative organisms, in addition to fungal and gram-positive ones. Arthrotomy to drain pus from the joint should not be delayed. Better long-term results can be achieved by early surgical drainage and immediate antibiotic coverage.

To assess the short-term outcome of cementless total hip arthroplasty involving an autograft of the femoral head in Japanese patients.

Cementless total hip arthroplasty with autogenous bone block grafting was performed on 18 hips in 15 patients with marked acetabular dysplasia. The resected femoral head was used as a graft for the superior-lateral region of the true acetabulum. Clinical outcome was correlated with the placement of the acetabular component, as revealed in radiographs.

The 13 women and 2 men had a mean age of 60.2 years (range, 37.0–73.0 years) at primary surgery and a mean follow-up duration of 3.3 years (range, 2.0–5.3 years). According to the classification of Crowe, 4 hips were in group I, 3 were in group II, one in group III, and 10 in group IV. The mean Harris Hip Score preoperatively was 45.7 (range, 19–69) and that at follow-up was 82.5 (range, 44–100). All 15 cases showed a good clinical outcome. There were no major intra-operative complications in this series. The grafted bones united in all patients. Two patients need surgical revision because the lateral insertion of the acetabular component resulted in loosening of it.

Medial insertion of the acetabular component provides satisfactory short-term outcomes. Lateral insertion of the acetabular component during total hip arthroplasty should be avoided in patients with marked acetabular dysplasia.

To compare the results of mini-incision total hip replacement (MITHR) to the standard posterior approach and evaluate the advantages and disadvantages of MITHR.

60 patients with osteoarthritis of the hip underwent total hip replacement utilising a mini-incision technique. They were compared to a matched cohort of patients who received the standard posterior approach. The average follow-up period was 14 months. The patients were compared with respect to the length of the incision, surgical time, intra-operative blood loss, narcotic requirements, length of hospital stay, requirement for walking aids, Harris hip score, and complications.

The length of the skin incision for MITHR, at an average of 9.2 cm, was half that of the standard approach. Statistically significant differences were found between the 2 groups in terms of intra-operative blood loss, length of hospital stay, and use of walking aids, all in favour of MITHR. There were no differences between the two approaches with regard to operating time, narcotic requirements, or Harris hip score. There were no cases of component malpositioning or major complications in the MITHR group.

Uncemented total hip replacement can be effectively performed through a smaller incision utilising MITHR without increased risk of complications. Significant benefits include less intra-operative blood loss, shorter hospitalisation, and cosmesis.

To report the outcome of revised total hip arthroplasty procedures involving an anterior cortical window, extensive strut allografts, and an Exeter impaction graft.

Eight patients (9 hips) with a mean age of 58 years underwent revision of total hip arthroplasty using the Exeter hip impaction graft system and strut allografts between 1995 and 1998. An extensile anterior approach was used, and an anterior cortical window was created in the femur, to remove the old implant. External strut allografts were attached by wires to provide cortical support. The mean follow-up duration was 74 months. Indications for surgery were aseptic loosening of previous implants in 8 hips and infection of one hip that had previously undergone total arthroplasty.

19 Dall Miles cables, 4 ordinary cerclage wires, and 8 cerclage wires tightened with the clincher knot technique were used to secure the allograft to the host bone. The strut grafts were found to be incorporated in all cases. No wires became loose. One patient developed 20° of angulation at the allograft-host bone junction. Using the method of Fowler and Gie, we found that one femoral implant had subsided 2 mm within the cement mantle. Two other implants had 1 mm of subsidence at the cement bone interface, and one patient had a major subsidence of 15 mm that required revision.

Using an anterior cortical window in the femur to remove the old implant does not predispose to failure of the allograft to incorporate into the host bone.

Vitamin D deficiency impairs bone mineralisation and can predispose individuals to fractures. This study aimed at testing whether measurement of plasma calcium, alkaline phosphatase, and phosphate levels could detect vitamin D insufficiency.

During a 10-week winter period from December 2000 to February 2001, all elderly patients presenting to a general hospital in Brighton—a British seaside town—with a fracture of the proximal femur and without known bone mineralisation problems were invited to participate in the study.

23 (63.9%) of the 36 eligible patients had insufficient levels of vitamin D, with a plasma concentration of less than 30 nmol/L. The mean parathyroid hormone level was 56 pg/mL (range, 12–193 pg/mL). 11 of the 36 patients had an elevated level of parathyroid hormone and were insufficient in vitamin D. The mean plasma concentration of calcium was 2.30 mmol/L (range, 2.05–2.98 mmol/L). The mean phosphate level was 0.98 mmol/L (range, 0.40–1.79 mmol/L), and the mean alkaline phosphatase level was 91 IU/L (range, 46–127 IU/L). There was poor correlation between vitamin D insufficiency and plasma calcium, alkaline phosphatase, or phosphate levels.

Plasma calcium, alkaline phosphatase, and phosphate testing cannot detect vitamin D insufficiency. We recommend that vitamin D and calcium supplementation be considered for patients with low-energy hip fractures.

To assess the effectiveness of sympathetic skin response in evaluating peripheral sympathetic nerve activity of patients with spinal cord injury, and to report on the basic properties of sympathetic skin response.

Sympathetic skin response evoked by electrical stimulation was recorded from the palms and soles of healthy volunteers and patients with spinal cord injury.

Sympathetic skin response was recorded in 17 healthy volunteers and 14 patients with spinal cord injury. Of the 4 waveforms, the shortest latency was obtained from the palm; the sympathetic skin response was 1.2 to 1.4 ms at all stimulated sites, 1.9 to 2.0 ms at the sole, with a difference of about 0.6 ms between the palm and the sole. None of the patients with spinal cord injury responded at either the upper or lower limbs. In patients with a thoracic cord injury, some responded at the upper limbs but none at the lower limbs; some responded at neither upper nor the lower limbs; and some responded at both upper and lower limbs. The conducting pathway of sympathetic skin response in the spinal cord for the upper limbs descends to the upper thoracic cord (T4–6), and the conducting pathway for the lower limbs departs from the spinal cord at the lower thoracic cord (T9–10).

It appears that sympathetic skin response should be used for the evaluation and morbid investigation of the functional abnormalities of the sympathetic nervous system in patients with spinal cord lesions such as spinal cord injuries, cervical spondylosis, and spinal canal stenosis.

In patients with blunt trauma, a cross-table lateral cervical (CTLC) film is followed by a focused computed tomographic (CT) scan of the cervical spine to assess an area inadequately delineated by common techniques and suspected injuries, based on recent guidelines in the United States. The purpose of this study was to calculate the frequency of such supplemental CT scans and to evaluate the efficacy of the recent guidelines describing the use of CTLC films as an indicator of supplemental focused CT scanning in Japan.

A review of CTLC films was performed. 100 initial CTLC films with injuries and another 100 films without injuries were evaluated for the lowest vertebra visualised on the CTLC film. The frequency of abnormal signs on the CTLC films was then examined.

Technically adequate CTLC films that showed the upper border of the T1 vertebra were not obtained from 70 patients with injuries and 63 patients without injuries. 88 patients with injuries and 28 patients without injuries had abnormal findings on CTLC films. Overall, 97 patients with injuries and 74 patients without injuries should have received supplemental CT scans.

CTLC films require frequent supplemental use of CT, even for patients without cervical spine injuries. Thus, the guidelines that consider CTLC film as an indicator of the necessity for CT scanning are not efficient and need revision.

Using Zucker fatty rats as an animal model, we evaluate the effectiveness of ethane-1-hydroxy-1, 1-diphosphonate on ossification of the posterior longitudinal ligament by histopathologically investigating the prodromal, early, and advanced stages of ossification of the spinal ligaments.

73 Zucker fatty rats were allocated to the ethane-1-hydroxy-1,1-diphosphonate group (n=33) and the control group (n=40). The former group was fed ethane-1-hydroxy-1,1-diphosphonate daily. The feed was given starting 2 months after birth and continued until the rats were killed at 3 to 18 months later. Chemical analysis of the blood, radiographic tests, and histopathological examination were then conducted for both groups.

The results showed that ossification of the spinal ligaments involved excessive cartilage cell proliferation around areas affected by enthesitis; enlargement of the fibrocartilage tissue layer; ligament thickening; calcification of the matrix around the cartilage cells; and ossification of the spinal ligaments through enchondral ossification. Radiographic examinations showed that osteoproliferation in vertebral bodies in rats receiving ethane-1-hydroxy-1, 1-diphosphonate was generally suppressed compared with controls, whereas histopathological examinations found no clear difference in cartilage cell proliferation in areas affected by enthesitis between the two groups, indicating the absence of calcification or osteoproliferation in areas affected by enthesitis for the rats receiving ethane-1-hydroxy-1,1-diphosphonate.

Ethane-1-hydroxy-1,1-diphosphonate is effective in suppressing progressive ligament ossification.

Giant cell tumour of bone with pulmonary metastases is rare. However, some patients die of pulmonary metastases, and histological examination cannot distinguish between benign tumour and malignant metastases. In this study, we present clinical and immunohistochemical findings associated with giant cell tumour of bone with pulmonary metastases.

Five patients with benign giant cell tumour of bone with pulmonary metastases (one man and 4 women) were studied. Patients' ages ranged between 20 and 23 years (mean age, 21.8 years). Tumours were in the distal femur in 2 cases, and in the proximal tibia, distal tibia, and lumbar spine in one case each. The tissue specimens from primary tumours, recurrent tumours, and pulmonary metastases were studied using immunohistochemical techniques.

Three of the 5 primary tumours were of the spontaneous regression or growth cessation type, or the continuously slow-growing type, showing 4.2% to 6.2% of positive cells for Ki-67 after immunohistochemical staining. However, 2 patients with the rapid-growing type of disease died of pulmonary metastases; their primary, recurrent, and metastatic tumour specimens contained 9.0% to 11.5% of positive cells for Ki-67.

Three of the 5 primary tumours had a benign clinical pattern and immunohistochemistry. Two of the 5 patients died of pulmonary metastases, which had an aggressive clinical pattern and a high prevalence of positive cells in Ki-67. Examination of Ki-67 should be carried out for aggressive type of giant cell tumour.

To determine the diagnostic utility of waveform analysis of compound muscle action potentials (CMAP) for carpal tunnel syndrome (CTS).

A total of 131 hands in 71 patients diagnosed with CTS (grouped according to severity) and 80 hands in 44 normal subjects were evaluated using nerve conduction test through the carpal tunnel combined with waveform analysis of CMAP.

Compared to normal subjects, the sensory nerve conduction velocity and mean frequency of the CMAP waveform were significantly reduced in patients with CTS. Compared with distal motor latency and sensory nerve conduction velocity, the mean frequency of the CMAP decreased significantly with increasing clinical severity.

This study suggests that waveform analysis of CMAP is of diagnostic value in CTS, and is also of value in objective evaluation of postoperative recovery of carpal median nerve dysfunction.

To assess an alternative technique for the treatment of midshaft non-unions of the clavicle.

Five patients with symptomatic non-unions of the clavicle were treated with open reduction and intramedullary fixation by using a Herbert cannulated bone screw. Autogenous bone grafting was applied in one case and decortication in the other 4 cases.

Review of the clinical and radiological documentation at a mean time of 13 months (range, 9–26 months) postoperatively shows that union was achieved in all 5 cases. There were no complications related to the operation, and no patient needed removal of the implant for protrusion, loosening, or any other cause.

Midshaft non-unions of the clavicle can be treated successfully using the Herbert cannulated bone screw, which avoids the need for a second operation to remove the implant after bone union.

To conduct a prospective randomised controlled study to compare the stability and risk of nerve injury between fractures treated by medial-lateral pin fixation and those treated by 2-lateral pin fixation.

Patients with displaced supracondylar fractures admitted between May 2000 and December 2001 were recruited into the study. They were randomised to treatment either with medial-lateral pin fixation (n=34) or with 2-lateral pin fixation (n=32).

66 children with the mean age of 5.78 years were admitted during the study period. 11 of them were lost to follow-up. The mean follow-up period of the remaining 55 patients was 8.93 months. The difference in the carrying angle between injured and normal elbows was 3.57° and 3.70° in medial-lateral pin fixation and 2-lateral pin fixation, respectively. The extension and flexion loss was 7.14° and 8.68° respectively in medial-lateral pin fixation, and 7.11° and 11.26° respectively in 2-lateral pin fixation. The Baumann angle difference was 5.96° in medial-lateral pin fixation, and 5.30° in 2-lateral pin fixation. The difference in the medial epicondylar epiphyseal angle was 6.07° in medial-lateral pin fixation and 6.92° in 2-lateral pin fixation. Statistical analyses show that these differences are not significant. Five iatrogenic ulnar nerve injuries developed in the group treated by medial-lateral pin fixation, while 2 ulnar nerve and one radial nerve injuries were seen after 2-lateral pin fixation. Again the differences were not statistically significant.

Both methods of fixation were comparable in terms of stability, duration of bone healing, and risks of injury to the nerve.

Radial tunnel syndrome refers to pain on the lateral aspect of the forearm as a result of compression of the posterior interosseous nerve within a tunnel with specific anatomical boundaries. Diagnosis of the condition is difficult because of its close association with lateral epicondylitis, which warrants different methods of treatment. Based on a cadaveric study, a new clinical test, the Rule-of-Nine test, is proposed to improve the diagnostic accuracy in radial tunnel syndrome. The test involves constructing 9 equal squares on the anterior aspect of the forearm and noting those squares where tenderness can be elicited.

19 upper limbs were dissected to delineate the path of the posterior interosseous nerve through the radial tunnel, and the relationship of the path of the nerve with the 9 squares.

A consistent mapping of the posterior interosseous nerve to the lateral column of 3 squares was observed.

The Rule-of-Nine test is proposed as a reliable method of diagnosing radial tunnel syndrome.

To evaluate the role of single photon emission computed tomography (SPECT) bone scan for the diagnosis of knee lesions in routine clinical practice.

40 consecutive case records were examined in patients who underwent a SPECT scan prior to knee arthroscopy in routine clinical practice. The accuracy of clinical examination, SPECT scan results, and arthroscopic findings (as the gold standard) in diagnosing knee lesions were compared.

The sensitivity of SPECT scans in detecting medial meniscal, lateral meniscal, anterior cruciate ligament lesions, osteochondral defects, and chondromalacia patellae was 77%, 14%, 33%, 50%, and 74%, respectively. The specificities for the same structural lesions were high at 89%, 94%, 97%, 94%, and 69%, respectively.

SPECT bone scan appears to be useful in the diagnosis of knee pathology in routine practice and in selecting patients for arthroscopy, especially most useful for the diagnosis of medial meniscal tears.

To evaluate treatment outcome following surgical repair of C3 distal femoral fractures using autogenous fibular strut, cortico-cancellous bone grafting, and Ilizarov ring fixation.

A total of 15 patients with type C3 fractures (supracondylar and intercondylar fractures, with multiplane articular injury) underwent surgical repair at St. John's Medical College Hospital between 1994 and 2001, using autogenous fibular strut, cortico-cancellous bone grafting, and Ilizarov ring fixation. 13 were seen for ongoing follow-up and assessment. Definitive surgery was undertaken at a mean of 3 weeks after admission. Postoperatively, weight-bearing and mobilisation exercise were begun in 2 to 4 weeks.

The mean follow-up period was 47 months. Union was achieved in all 13 cases by an average time of 19 weeks. At the last follow-up, the mean range of knee motion was 77°. Assessment of functional outcome (using Neer's scoring criteria) revealed 10 cases with good or satisfactory outcomes, and 3 cases with poor or unsatisfactory results.

Surgical repair with a fibular strut, cortico-cancellous bone graft and Ilizarov ring fixation appears a suitable treatment option for C3 distal femoral fractures.

To evaluate the operative findings and postoperative results of one-stage repair on patients with acromioclavicular joint dislocation complicated by rotator cuff tear.

Between 1992 and 1999, one-stage repair was performed on 5 patients with acromioclavicular joint dislocation complicated by rotator cuff tears. Modified Cadenat procedure for acromioclavicular joint dislocation, and McLaughlin procedure for rotator cuff tear, were performed on these patients. Postoperative results at the final examination were assessed according to the criteria for therapeutic effects on shoulder joint disorders of the Japanese Orthopaedic Association.

There was partial-thickness cuff tear in one patient, and full-thickness cuff tear in the remaining 4 patients. In all patients, tears were located only in the supraspinatus tendon, and were medium or small ones with maximal diameter of 3 cm or less. After a mean follow-up period of 56 months (range, 36–79 months), all patients were assessed to have excellent results. No patient showed a good reduction of the acromioclavicular joint.

For patients successfully treated by one-stage repair, satisfactory results were obtained without pain or disturbance in activities of daily living.

Major amputation of the lower limb is considered the last resort when limb salvage is impossible. The aim of this study is to determine the morbidity, mortality, and rehabilitation outcome of patients that underwent a lower-limb amputation.

A retrospective cohort study was conducted among 100 elderly patients who underwent a total of 120 lower-limb amputations in a regional hospital in Hong Kong from 1996 to 2001.

The mean age of the amputees was 77.9 years; 58 were female. 95% of the amputations were performed because of infection with or without vascular compromise; 55 transfemoral and 60 transtibial amputations contributed 96% of the case mix. Some 43% of patients experienced early complications and 12% required re-amputation. The early (30-day) mortality rate was 15%. Only 55% of the amputees survived after 4 years. A 44% return-home rate was achieved. However, only 11% of the amputees could walk without help from other people. Although prostheses were issued to 42% of the survivors, compliance was only 53%; 24% of the survivors lost their remaining leg within 2 years.

The outcome of major lower-extremity amputation remains poor. Efforts should be made to retain these limbs. When it is proven impossible, one should strive to preserve the knee joint whenever feasible.