There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively. The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high.
Limb lengthening and limb reconstruction using the Ilizarov system is a recognized treatment for children with congenital and acquired lower limb discrepancy and/or deformity. It is a complicated, costly, time consuming and challenging procedure for the multidisci-plinary team, the child and their family. Traditional outcome measures for this group of children tend to focus on X-ray appearances, lengthening indices and problems, obstacles and complications occurring during the treatment phase. At the present time there are unanswered questions as to their functional status as adults. The literature does not appear to have addressed this question as yet. For families considering this difficult treatment option, the potential function for their child as an adult may be valuable in the decision making process The aim of this study was to discover the physical, occupational and psychosocial function of a group of young adults who underwent Ilizarov procedures as children at Great Ormond Street Children’s Hospital. Forty young adults, aged 18 – 27 years (mean age 19.9 years), who had Ilizarov procedures between 1992 and 2000, were sent questionnaires. Items included in the questionnaire were taken from the Toronto Extremity Salvage Score (TESS) to assess function and the Pediatric Orthopaedic Society of North America (POSNA) Adolescent Musculoskeletal Functional Health Questionnaire to assess psychosocial and occupational domains. Questions were also included to gather demographic information. A total of 27 responses were received from 14 males and 13 females. Twenty four patients had Ilizarov procedures for limb lengthening or lengthening with deformity correction. Deformity correction only was carried out in three patients. Mean time since treatment was 5.6 years (range 9 – 2 years). A total of 24 tibial frames, 6 femoral, 4 whole leg and 2 foot frames were applied. Four patients had had repeat Ilizarov procedures. Six patients had had previous lengthenings using uniaxial fixators. Functional ability indicators were high but activities such as kneeling, walking up and down slopes or hills, walking long distances and running were significant problems reported by more than half. Assistive devices (crutches, shoe raises, AFO, knee brace) were needed full time by five, with crutches, sticks and wheelchair used occasionally by three others. Seven adults chose not to partake in sporting activity, with a further three finding it extremely hard and two impossible. Swimming was the most popular activity. Activity related pain was uncommon but pain in the limb requiring occasional analgesia was reported. All but one respondent worked full time or were students. Most occupations were office or shop based. Three men were manual workers. Time off work for problems related to their limb problem was minimal. Socialising with friends and family was high with only one respondent expressing extreme difficulty. Four men and five women identified scarring from the Ilizarov treatment as a cause of concern. Ten women and eight men raised body image issues. Twenty six adults said they would recommend Ilizarov treatment to others, if asked. Conclusions: We view this data as important to provide information for use when counselling It weill also help prospective patients and families of expectation for function in adult life.
Reflex sympathetic dystrophy is a syndrome characterised by pain and hyperaesthesia associated with swelling, vasomotor instability and dystrophic changes of the skin. It is rare in children, can occur without any previous history of significant trauma and may be recurrent and migratory. We reported 13 new cases of RSD in children and emphasised the role of a multidisciplinary team approach in management. A review of the literature was included. 13 children (3 boys and 10 girls) with reflex sympathetic dystrophy were presented. They were aged between 8 and 17 years. Mean age at onset was 13 years 4 months. All of them had RSD involving the lower limbs. Thermography was performed in 10 cases. The average time to correct diagnosis was 4 months. Five ankles, 4 knees and 5 hips were involved (14 joints in 13 cases). Psychological assessments revealed abnormalities in all cases. Pain (visual analogue score) and function were assessed before and after treatment. The most common therapy in children is progressive mobilisation supported by analgesic drugs, psychological and physical therapy. We individualised the therapy for each child. A team-care approach with the physiotherapist, psychologist and pain-care team co-ordinated by the Orthopaedic Consultant was the essence of our management. All children received physical therapy including a wide variety of non-standarised approaches involving analgesics and hydrotherapy. 5 patients received guanithidine blocks. Individual therapy was monitored with set achievable goals and weekly assessment of progression of mobility and joint motion. Time from the first RSD episode to resolution averaged 6 months in our series [it was mean 10 weeks in the non-adolescent cases (8 cases) and 7 months in the adolescent one (5 cases)]. The pain and function scores improved remarkably in all patients. RSD in children is not a widely recognised condition. There is often a delay in diagnosis in view of the rarity of the condition as well as the fact that specific diagnostic modalities are not readily available in all centres. Psychological factors should not be underestimated. Early diagnosis with an aggressive, multidisciplinary, monitored, ‘goal-oriented’ team approach should be the basis of management in these cases.
Humeral hemi arthroplasty has become widely used as a form of surgical management for severe fractures. However there is still no consensus as to the role for prosthetic replacement in displaced proximal humeral fractures. The aim was to assess shoulder hemi arthroplasty for un-reconstructable three and four part proximal humeral fractures at a minimum of twelve months and identify factors that guide to prognosis. Criteria for inclusion were patients with a fracture that went onto shoulder hemi arthroplasty with Constant scoring at a minimum follow up of one year. Patients were treated using a Neer or Osteonics prosthesis, with the decision for hemi arthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to comorbidities, and a radiological analysis were carried out. A survival analysis was performed for the one and five year results and data was analysed by linear regression to identify prognostic factors. Of 163 patients there were 138 fitting the criteria, 42 males and 96 females with an average age of 68.5 (range30–90) years and average follow up of 6.3 (range1–15) years. The fracture pattern was three or four part in 133 cases and 5 head split fractures; 58 were associated with a dislocation. Survival was 96.4% at 1 year and 93.6% at 5 years, with no significant difference between prostheses. There were 8 revisions, (1 deep infection, 4 dislocations and 3 peri-prosthetic fractures), most within 12 months. The average Constant score was 67.1 at one year. Prognostic factors on presentation were the age of the patient and their physiological index. Factors at 3 months were any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was gained by patients aged 55–60, with minimal comorbidities and an uncomplicated recovery.
Poor shoulder function may complicate the non-operative treatment of a humeral diaphyseal fracture. This has often been regarded as an unavoidable consequence of the relative immobility of the shoulder during brace treatment. Tears of the rotator cuff have not previously been recognised as an underlying cause of persistent shoulder pain and stiffness in this situation. In this report, we identified six patients, from a consecutive series of 294 patients with humeral fractures treated in our Institution over a five-year period, who were found to have symptomatic rotator cuff tears following non-operative treatment of their humeral diaphyseal fracture. All had normal pre-injury upper limb function, but had persistent pain and loss of active shoulder movement after their fracture had united. Large, retracted cuff tears, affecting the cuff muscles attached to the greater tuberosity, were identified pre-operatively from imaging of the rotator cuff and intra-operatively at open surgery. Surgical reconstruction of the cuff was carried out in all cases and yielded satisfactory return of shoulder function, on assessment at least eighteen months after injury.
We present the results of treatment for relapsed infantile Blounts disease using a technique of hemiplateau elevation with the Ilizarov frame. 7 patients with a mean age of 10 years 6 months were reviewed at 30 months following hemiplateau elevation with/without ipsilateral tibial lengthening. Preoperatively clinical photographs, long leg standing radiographs and 3D computed tomography images were acquired. The patients were evaluated clinically (presence of knee pain, range of knee motion, knee stability and leg length discrepancy) and radiologically. Schoeneckers objective assessment was undertaken. The results were analysed statistically. Clinically all the patients improved significantly. No patient had knee pain and the range of knee motion was from 0° to more than 100° of knee flexion. The radiological results and Schoeneckers grading are depicted below. The improvement in radiological measurements were statistically significant. Pin site infection was present in all but settled with antibiotics. The results of hemiplateau elevation for relapsed infantile Blounts disease are encouraging.
We report two cases of deformity of the ankle caused by physeal damage secondary to extravasation of an intravenous infusion in infancy. The possible mechanisms of injury to the physis are discussed.
We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.
Thirty-one patients with rheumatoid arthritis were reviewed after Shiers arthroplasty of the knee joint for which the main indication was intractable pain. Seven patients had the operation done to both knees. This review was done to assess the long-term results two to seven years later. All patients were clinically and radiologically assessed, and our results showed that pain and instability recurred within eighteen months. Thus it is likely that a prosthesis which allows rotation, and in which the bearing surfaces are metal on plastic, will replace the Shiers prosthesis.
