Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures.

The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68).

The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94).

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Cite this article: Bone Joint J 2013;95-B:1250–4.

Mutual interaction of special phytoestrogenic compounds, their synthetic carboxy-derivatives and the less-calcemic vitamin D analog activities in human derived female cultured osteoblasts

Cultured female-derived human bone cells (hObs) responded by different parameters to different phytoestrogenic and vitamin D compounds. Pre- and post-menopausal hObs express ERα and ERβ mRNA with higher abundance of ERα. Pre-treatment with the less-calcemic vitamin D analog JKF 1624F(2)-2 (JKF) upregulated responsiveness to estrogens via modulation of ERs expression. These estrogenic compounds induce the expression and activity of 25 hydroxy-vitamin D(3)-1α hydroxylase (1OHase). We now analyzed the effects of carboxy-genistein (cG), carboxy-biocainin A (cBA) and carboxy-daidzein (cD), of BA, D or G and of licorice derived compounds glabridin (Glb) and glabrene (Gla) and estradiol-17β (E(2)) on DNA synthesis, creatine kinase specific activity (CK), intracellular and membranal E(2) binding and their modulations by JKF in hObs. We also analyzed modulation by phytoestrogenic compounds of 1OHase mRNA expression and activity. We showed that: (1) all compounds stimulated DNA synthesis and CK. (2) JKF and all estrogenic compounds modulated ERα and ERβ mRNA expression. (3) Pre-treatment with JKF increased DNA synthesis and CK responses only to E(2), D, G and Gla. (4) JKF increased the intracellular competitive binding only of E(2), D and G. (5) JKF abolished the membranal binding of all protein-bound estrogens. (6) JKF and all estrogenic compounds except the protein-bound ones up-regulated 1OHase expression and activity. In conclusion phytoestrogens and their analogs increase DNA synthesis and CK, and lead to increased production of 1,25(OH)(2)D(3) in hObs, while pre-treatment with JKF modulates the effect of estrogenic compounds via regulation of ERs mRNA expression in a yet unclear mechanism.

DT56a (Femarelle), contrary to estradiol-17β, is effective in human derived female osteoblasts in hyperglycemic condition

We have reported previously, that female-derived cultured osteoblasts (hObs) responded to DT56a (Femarelle) measured by the stimulation of creatine kinase specific activity (CK), which is a marker for hormone responsiveness and (3)[H] thymidine incorporation into DNA (DNA synthesis). Since the skeletal protective effects of estrogens are not discernable in hyperglycemic diabetic women, we sought to analyze the effect of estrogenic compounds on CK and DNA synthesis in hObs when grown in high glucose concentration (HG). Cells were grown either in normal glucose (NG) (4.5g/L; 22mM) or HG (9.0g/L; 44mM) for 7 days. HG increased constitutive CK but, the response of CK activity and DNA synthesis to estradiol-17β (E(2)) treatment was reduced. In contrary, DT56a was found to be active (as measured by CK activity and DNA synthesis) in both NG and HG. HG decreases the hormonal responsiveness and might block important effects of estrogenic compounds, most likely contributing to their decreased skeletal preserving properties in hyperglycemic women. In hObs from post-menopausal women grown in HG, ERs mRNA expressions were unchanged. On the other hand, in hObs from pre-menopausal women HG increased ERs mRNA expressions. Since DT56a unlike E(2) is active in HG environment as well as in normal glucose, it may be an effective bone restoring agent in diabetic post-menopausal women.

[Stupor due to sleep apnea syndrome after total knee replacement]

Obstructive sleep apnea syndrome is defined as a condition of repeated episodes of apnea and hypopnea during sleep, accompanied by excessive daytime sleepiness. This syndrome is common among the adult population, and is related to an increased risk for significant complications, during and immediately after surgery. Often, this condition is undiagnosed, and is not considered in the pre-operative evaluation. Therefore, it is highly important to recognize this syndrome in patients who are scheduled for elective surgery, and provide appropriate management, in order to avoid life-threatening exacerbation in the perioperative period. Although this syndrome is common, there is low awareness of its expression in elective surgery in-patients. We present a case report of a patient who suffered from obstructive sleep apnea related respiratory distress following total knee replacement surgery.

Degenerative disease in lumbar spine of military parachuting instructors

Parachuting, be it static line or skydiving, places enormous stresses on the human spine. It is, therefore, important to determine the prevalence and severity of degenerative changes in the lumbar spine of subjects who practice this sport activity. Seventy four parachuting instructors, mean age 33 years and with an average of 410 static line and skydiving jumps, were included in the study. Past radiographs were examined and compared to current anterolateral and lateral views of the lumbar spine, in order to determine the prevalence of degenerative changes and document possible progression. Doubtful radiographic changes in the lumbar spine were identified in 47.4 percent of the parachuting instructors, mild degeneration in 9.6 percent, moderate degenerative disease in 10.9 percent and severe radiographic changes in 5.5 percent. Schmorll nodes were found in 8.1 percent of the subjects. Traction spurs--osteophytes were identified in 6.8 percent. The degenerative changes correlated with age and the number of jumps. Spondylolysis of L5-S1 and L3-L4 segments were observed in 12.2 and 1.4 percent respectively. Progressive spondylolisthesis was found in 2 subjects. No correlation was found between the severity of radiographic changes and either the prevalence and the severity of low back pain. The present findings provide a rational for considering repeated sheer stress as an etiology of degenerative changes in the spinal cord, and as a possible contributing factor to the pathogenesis of spondylolysis. Further study has to be done comparing parachuting instructors to a non-parachuting group, or equivalent physically active individuals, in order to assess the effect of sport-background on the development of degenerative changes.

Medial unicompartmental replacement for tricompartmental disease in the elderly

Between 1993 and 1998, we performed 18 unicompartmental arthroplasties of the knee, all on the medial side, in a selected group consisting of 18 elderly patients aged 74-81 (mean 77.2), with severe arthrosis mainly in the medial compartment and mild arthrosis in the lateral compartment and the patellar articular surface mostly covered with articular cartilage. The patients were mainly housebound due to relatively advanced age and severe pain. Unicompartmental arthroplasty was chosen for this group because of a quicker and easier rehabilitation. Two patients had had a high tibial osteotomy 7 and 10 years ago. The average follow up was 5.5 years ranging in age from 5 to 8 years. The average initial American Knee Society Knee Score was 52, ranging from 28 to 70 which improved at follow up to 83 (range 60-92). All prostheses used were Allegretto (Sulzer). The operation was done through short medial arthrotomy. The purpose of this study is to report our results in these low demand patients and although the follow-up was only 5-8 years, the results are promising.

Serum and synovial vancomycin concentrations following prophylactic administration in knee arthroplasty

A single preoperative dose of 15 mg/kg of total body weight, to a maximum of 1 g of vancomycin, was administered intravenously to patients undergoing knee arthroplasty prior to anesthesia. Vancomycin concentration levels were examined in 39 patients. Vancomycin levels were analyzed preoperatively, intraoperatively, and postoperatively. Results confirmed effective serum and synovial vancomycin levels during surgery. Effective therapeutic levels of vancomycin remained in the knee >20 hours postoperatively. Although vancomycin is not commonly used as a prophylactic antibiotic in arthroplasty, it should be considered in patients with known hypersensitivity to penicillin, or when methicillin-resistant Staphylococcus aureus in present.

Increased median nerve latency at the carpal tunnel of patients with "trigger finger": comparison of 62 patients and 13 controls

An association between symptomatic compression neuropathy of the median nerve at the carpal tunnel and "trigger finger" has been reported in endocrine and metabolic disorders. We assessed the incidence of increased median nerve latency in subjects with "trigger finger". 62 consecutive patients with "trigger finger" and no signs or symptoms of median nerve compression underwent nerve conduction studies of the median nerve. 13 healthy adults served as controls. 39/62 patients had increased distal motor latency in the median nerve. Only 1 of 13 subjects in the control group had a borderline value of distal motor latency.

[Local necrosis of finger following stab with needle used to pump terbutaline sulfate (Bricalin)]

Terbutaline sulfate (Bricalin) is a widely used medication for asthma. It works mostly, but not only, on beta-adrenergic receptors. In this case study we describe a 50-year-old nurse referred to the emergency department after she was stabbed by needle that was used to draw bricalin for inhalation. She arrived at the emergency room with an inflamed necrotic area at the point of the stab. Later, she developed acute infection that was treated with antibiotics. Following the acute phase there was still a necrotic area, that required surgical debridement. It seems that this is the result of the vasoconstrictive influence of terbutaline sulfate via alpha adrenergic receptors. In the medical literature there is scarce data regarding this side effect.

Dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture

Fifty-three elderly patients with intracapsular hip fracture were hospitalized in the Department of Orthopaedics. Forty-two underwent operations: 38 hemiarthroplasty; 2 total hip replacements and 2 closed reduction interior fixation. They were followed up and assessed prospectively five times for 6 months post-fracture. Cognition was evaluated by the Mini-Mental State Examination. Pre-fracture functioning was determined by the Functional Independence Measure (FIM) and the Katz index of activities of daily living (ADL). The functional outcome was assessed by the FIM gain defined as the difference between FIM scores at 6 months and just prior to discharge. FIM gain, length of stay, complications and mortality rates were not significantly different between three cognitive groups: normal, moderately and severely demented patients. The majority of patients were independent and partially dependent in their ADL. We conclude that dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture if they were mobile before the fracture.

Recombinant human erythropoietin reduces allogeneic blood transfusion requirements in patients undergoing major orthopedic surgery

Blood loss is a significant problem encountered in patients undergoing total joint arthroplasty, and is considered to be one of the factors affecting the outcome of the operation. Traditionally these patients have been treated with blood transfusions. The introduction of recombinant human erythropoietin (rHuEpo) into clinical practice enabled assessment of its effectiveness to decrease the allogeneic blood transfusion requirement (BTR), thus avoiding or minimizing transfusion-related complications. Fifteen patients undergoing total hip replacement (THR, 10 patients) and total knee replacement (TKR, 5 patients) in our institute (from January-April 1997), were studied. After signing an informed consent they received daily s.c. rHuEpo (100 IU/kg for those with hemoglobin (Hb) > 13 g/dl, 300 IU/kg for Hb < 13) during the 10 days prior to surgery and the 4 days following the operation. Allogeneic red blood cell (RBC) transfusions were given as needed. Hb levels were measured on days -10, 0, +1.3 and 7 of the procedure and the BTR was recorded. The results were compared with those of previous patients operated on from January-December 1996. Patients who were eligible for the study but refused to participate served as controls. The mean Hb level in the study group prior to rHuEpo administration (day -10) was 13.41 g/dl, similar to those of the control group (13.47 g/dl on day 0). However, the mean Hb levels in the rHuEpo treated patients on days 0, 1, 3 and 7 were 14.37, 11.09, 10.99, and 11.2 g/dl, respectively. This way compared with the levels of 13.47 (p = 0.016), 9.88 (p = 0.024), 9.60 (p = 0.004) and 9.97 g/dl (p = 0.007) in the control patients. The difference between the rHuEpo treated patients and the control patients was more significant among the THR patients than among the TKR patients. Of the 10 rHuEpo-treated THR patients, only a single patient required one allogeneic blood unit, as compared with 23 units transfused to the 30 control patients. None of the rHuEpo-treated TKR patients required blood transfusion as opposed to 4 units needed by the 11 control patients. In total, only one allogeneic blood unit was required by the study group which way calculated to an average consumption of 0.066 blood unit per person, compared with 27 blood units used by the 41 controls, i.e. 0.66 blood units per person (p < 0.001). In the patients treated, rHuEpo was very well tolerated with no adverse effects.

Outcome of medically unstable elderly patients admitted to a geriatric ward after hip fracture

Outcome of surgical treatment is superior to that of conservative treatment for hip fractures. Nevertheless, for a number of patients, the operation is either delayed or unfit due to their unstable medical conditions. We retrospectively reviewed patients admitted to a geriatric ward after hip fracture, and investigated complications, functional outcome and survival in different cognitive, pre-fracture functional and treatment groups. Patients hospitalized (N=78) from January 1993 to June 1999 were included (1/2 demented, 1/3 fully dependent in Basic Activities of Daily Living, and 2/5 high operative risk patients). Following stabilization, 14 subjects (17. 9%) were operated. The mean and range of surgical delay was 9+/-7.2, and 3 to 30 days, respectively. Comparison between surgical and conservative treatment groups, and cognitive and pre-fracture functional groups showed no differences in age, gender, chronic medical conditions, fracture type, reasons for surgical delay or conservative approach, complications, survival curves and laboratory results. Thirteen operated patients were in ASA I + II grades, only 1 in ASA grades III + IV (low and high operative risk, American Society of Anesthesiologists grading system) (p=0.004). Functional outcome was similar in the surgical vs the conservative group, and intracapsular vs extracapsular fractures. ASA I + II patients had a higher survival rate compared to ASA III + IV patients (p=0. 02). We conclude that after stabilization of acute medical conditions, the most important preoperative consideration is the anesthetic risk, and surgical and conservative approaches may be equally considered in selected groups of elderly, frail patients with hip fracture who are medically unstable for more than a few days.

Age and gender specific stimulation of creatine kinase specific activity by gonadal steroids in human bone-derived cells in culture

We previously reported a non-enzymatic method for isolation of human bone cells in culture that display osteoblastic features and respond to 1,25 dihydroxy vitamin D (1,25) and to parathyroid hormone (PTH). The present study was undertaken to analyze the response of cultured human bone cells to 17beta-estradiol (E2) and to dihydrotestosterone (DHT) as a function of gender and age. Cultured human bone cells, obtained from biopsies during orthopedic surgery, were divided into four groups defined by gender and age: pre- and post-menopausal healthy non-osteoporotic women that were not under hormone replacement therapy (HRT) and mature (<55-year-old) and older (>60-year-old) men. We found gender specific responses to gonadal steroids using the specific activity of the brain type (BB) isozyme of creatine kinase (CK) as a response marker. Constitutive levels of CK activity did not change with age or gender and the enzyme extracted from cells from the different sexes and ages did not respond to either progesterone (P) or to 1,25. CK from the different cells responded to gonadal steroids in a gender specific manner, i.e. CK from female derived cells responded to E2 only and the enzyme from male derived cells responded to DHT only. In female derived cells the response to E2 declined significantly with age, while the response to DHT in CK from male derived cells did not vary with age. This may be due to either decreased proportion of mature osteoblasts and/or their differentiation state and/or changes in the levels of estrogen receptor(s), coactivators or corepressors in these cells. These results extend our knowledge of human osteoblast biology (beyond murine cells) and are therefore more relevant for developing models for treatment of human metabolic bone diseases such as post-menopausal osteoporosis.

Sonographic features of dialysis-related amyloidosis of the shoulder

This study evaluated the diagnostic role of ultrasonography in dialysis-related amyloidosis in shoulders of chronically hemodialyzed patients. Fourteen shoulders of 12 long-term hemodialysis patients were examined. All patients had been on dialysis for at least 10 years. All patients had varying degrees of pain and limitations of movement in the studied shoulders. Dialysis-related amyloidosis was the presumed diagnosis in all patients. Any patient with a history of any disease, other than dialysis-related amyloidosis, capable of producing a pathologic shoulder condition was excluded. The following parameters were studied: supraspinatus and biceps tendon thickness, tendon tears, synovial thickening, and the presence of hypoechoic material around tendons and within bursae. All shoulders had a nonhomogeneous thickening, greater than 7 mm, of the supraspinatus tendon. Seven shoulders (50%) had abnormal thickening of the biceps tendon (4 mm or greater), and two shoulders had abnormal thickening of the subscapularis tendon. Hypoechoic deposits were seen in the subdeltoid bursae and biceps sheaths in five and six shoulders, respectively. Three shoulders showed partial tears of the supraspinatus tendon, one shoulder showed a tear in the biceps tendon, and one shoulder had a tear in the subscapularis tendon. Ultrasonography is an excellent imaging modality in diagnosing the presence of dialysis-related amyloidosis in symptomatic shoulders of long-term hemodialysis patients, without having to resort to invasive procedures. The results of previous studies have been confirmed and new ultrasonographic findings described. Of particular interest is the involvement of the subscapularis tendon in dialysis-related amyloidosis. Repeat ultrasonography can become an important way to follow-up progression of shoulder dialysis-related amyloidosis in hemodialyzed patients.

Musculoskeletal problems in Down Syndrome European Paediatric Orthopaedic Society Survey: the Israeli sample

An Israeli sample of 475 individuals representing the full spectrum of those with Down syndrome in the Jewish population is presented. The sample is part of a European multicenter study evaluating musculoskeletal disorders. Generalized joint laxity was found to have significant relationships with a number of medical conditions (knee problems, patello-femoral instability, genu valgus, pes planus, heart defects, and gastrointestinal problems). Body mass index was also related to feet problems, vertical talus, spinal problems, genu valgum, pes planus, and heart problems. Yearly multidisciplinary clinical follow-up is recommended in persons with Down syndrome.

Isolation and hormonal responsiveness of primary cultures of human bone-derived cells: gender and age differences

We present a model for isolating human cell culture derived from biopsies obtained during orthopedic surgery. Four donor groups were defined by gender and age: pre- and postmenopausal women (<50 and >55 years, respectively), and younger (30-55 years) and older (>60 years) men. Bone-derived cells were identified as osteoblasts by major osteoblastic characteristics; that is, high alkaline phosphatase (ALP) activity, dose-dependent increase of ALP by 1,25(OH)2D3, high levels of parathyroid hormone (PTH)-induced cyclic AMP, and 1,25-(OH)2D3-induced osteocalcin. In all cells, levels of osteocalcin were significantly elevated (p < 0.05 and 0.01). In cells derived from men, no significant age differences were found in ALP and osteocalcin values of basal activity and in fold stimulation 1,25(OH)2D3. Cells from postmenopausal women showed a nonsignificant lower basal ALP activity than premenopausal cells. In postmenopausal cells, ALP responded less to 1,25(OH)2D3 (33% increase, p < 0.05) than the premenopausal cells (100% increase, p < 0.05). In cells from either age group, ALP did not respond to the gonadal steroids 17beta-estradiol (E2) and dihydrotestosterone (DHT) or progesterone. Basal levels of osteocalcin were higher in cells of premenopausal origin as compared with postmenopausal cells (p = 0.05), but response to 1,25(OH)2D3 was the same. PTH significantly stimulated cAMP (p = 0.001) in all age and gender groups analyzed. In all groups, no differences were found in either basal activity or in PTH response. Unlike men, cells derived from the bone of women were more susceptible to age changes. We postulate that the postmenopausal cell population had a decreased number of osteoblasts, or cells in a lower differentiation stage. These results extend our knowledge of bone biology found in animal models and reveal that human osteoblasts from men do not show the same age-dependent differences observed in women.

Sequential foot compression reduces lower limb swelling and pain after total knee arthroplasty

Two common prophylactic measures to prevent deep vein thrombosis (DVT) in patients after orthopedic lower limb surgeries are pneumatic foot and calf compression and antithrombotic treatment. These preventive measures differ in their mechanisms of operation. Antithrombotic agents are aimed to minimize the risk of clot formation, whereas pneumatic foot and calf compression therapy prevents venous stasis, which is a primary factor leading to thrombus formation in patients with leg trauma. DVT, however, is not the only consequence of patient immobility and venous stasis. Additional sequelae of venous stasis include lower limb swelling and pain resulting from the increase in venous pressures and change of normal compartmental circulatory pressures. We therefore hypothesized in the present study that antithrombotic treatment alone is not as effective as combined with pneumatic foot compression in reducing limb swelling and pain. Forty-eight patients after total knee arthroplasty participated in this randomized, controlled study. Low-molecular-weight heparin was the prophylactic measure used for the control group, whereas the pneumatic compression group received low-molecular-weight heparin and foot compression therapy for approximately 7 days after surgery. Lower limb swelling and pain were significantly reduced for the foot compression group in relation to the control group. Ultrasound and venography demonstrated no significant DVT in either group. We conclude that foot compression therapy is an important prophylactic addition to antithrombotic treatment in overcoming the hazardous clinical implications of venous stasis.

[Ilizarov reconstructive surgery--a solution for complex problems of the musculoskeletal system]

The Ilizarov technique is an important modality of reconstructive surgery for limb deformities, such as malunion and nonunion of fractures, persistent osteomyelitis, and bone loss following complex limb injuries, as well as in limb-lengthening procedures. It has received wide recognition in the Western world over the past decade. In MEDLINE we found 537 articles published between 1971-1995 that describe the use of this technique. Of these, only 18 were published between 1971-1975, while 261 were published between 1991-1995. The present paper describes the developments and updates in this method, as a result of the large experience gained by the authors in a number of centers in Israel using this technique. The Ilizarov apparatus is a circular frame that allows accurate control, much more than any other external fixator, during correction of limb deformities and limb-lengthening. It is minimally invasive, and open techniques and use of internal hardware and bone grafts are not needed. Based on our experience, we suggest that this method requires careful preoperative planning and meticulous surgical technique. More important, cooperation between surgeon and patient throughout the lengthy treatment is a prerequisite to ensure complete success, even in the most complicated cases.

[Rupture of pectoralis major muscle: operative treatment of an uncommon sport injury]

Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.

Intra-articular tibial plateau stress fracture associated with osteoarthrosis and valgus knee deformity

Severe valgus deformity of the knee secondary to osteoarthritis can predispose to stress fracture of the lateral tibial plateau. Described herein is a case of severe valgus knee deformity that was complicated by an intra-articular tibial plateau stress fracture and treated by a fully constrained Guepar hinge prosthesis with a satisfactory end result. The etiology and mechanism of this complication are discussed, with emphasis on the diagnostic process.

[Recurrent late hemarthrosis after total knee replacement]

A patient who had a successful total knee replacement for severe degenerative osteoarthritis of the right knee had an excellent functional result. 2 years after the operation there was spontaneous intra-articular bleeding that was treated successfully conservatively. Recurrent hemarthrosis 2 months later was treated similarly and also resolved without residual functional impairment after a follow-up of over 1 year. Recurrent late hemarthrosis in the knee is a fairly rare complication following total knee arthroplasty, but is amenable to conservative measures. Frequently, persistent recurrent hemarthrosis requires debridement of the bleeding synovium of the knee.

Changes in femur dimensions in asymptomatic non-cemented hip arthroplasties. 20 cases followed for 5-8 years

We assessed changes in proximal femur diameter during 5-8 years follow-up of 20 clinically successful press-fit cementless isoelastic implants. Total bone diameter, medullary diameter and cortical thickness were measured over the distal half of the prosthesis and just beyond the prosthesis tip. During the follow-up period total bone diameter did not change. However, cortical thickness declined by an average of 1 mm, while the size of the medullary canal increased by the same amount. As the patients remained asymptomatic during this period, the phenomenon observed did not appear to be related to loosening. We concluded that age-related changes in bone diameter can lead to widening of the tight interface between the stem and the femur.

The use of the transpillar posterolateral approach to resect cervical osteoid osteomas: operative technique and results

Osteoid osteomas located in the cervical spine are a rare cause of cervical and shoulder pain. However, successful diagnosis of these tumors has become more frequent in the recent years. This is due to more available diagnostic modalities as well as to physician awareness of the possibility that such lesions can cause cervical pain syndrome. Resection of osteoid osteomas located close to the vertebral artery is often technically difficult, and poses significant risk to the patient. We describe resection of such tumors using a posterolateral transpillar approach in three patients. The advantage of this approach is the direct and relatively easy visualization of the tumor, without the need for an extensive dissection. The stability of the cervical spine is not compromised by this approach. However, extension of the operative field is difficult, should the need arise.

An overlapping pubic dislocation treated by closed reduction: case report and review of the literature

An overlapping dislocation of the symphysis pubis is a rare injury caused by either side-to-side compression or hyperextension. We hereby describe a case of such injury sustained during parachuting and reduced by closed means. This case appears to be the first described in the literature where no damage to the urogenital tract was observed. The patient is asymptomatic 1 year later.

Multicentric giant-cell reparative granuloma. A case in the foot

A case of multicentric giant-cell reparative granuloma in the foot of a 17-year-old boy is reported. Initially, there was a calcaneal lesion and 6 months later, three additional lesions in the forefoot. The calcaneal lesion was treated by curettage and bone grafting, and those in the forefoot by wide excision. The patient has now been free of disease for 18 months.

Traumatic anterior dislocation of the hip joint with fracture of the acetabulum: a case report

A 67-year-old woman sustained a pubic-type anterior dislocation of the hip associated with a comminuted fracture of the anterosuperior part of the acetabulum and the anteroinferior iliac spine following a fall on the knee. Because of interposition of the iliopsoas tendon, closed reduction followed by skeletal traction failed to achieve reduction of the acetabular fragment. An abnormally high degree of anteversion of the femoral neck is suggested as a possible predisposing factor in this injury.

An unusual loose body hidden in a sealed suprapatellar pouch

A 20-year-old soldier presented with pain and swelling in his right knee, both of which became aggravated with activity. An unusual loose body was found in a sealed suprapatellar pouch in the knee. All symptoms disappeared following removal of the loose body.

Anterior interosseous nerve palsy following closed fracture of the proximal ulna. A case report and review of the literature

Complete paralysis of the anterior interosseous nerve was seen in 32-year-old army officer 5 weeks after he sustained a minimally displaced fracture of the proximal ulna. The fracture was immobilized in an arm cast. Thirteen weeks after injury, the cast was removed following evidence of bone union. Complete recovery of the flexor pollicis longus was noted 17 weeks after the injury, while recovery of the flexor profundus to the index finger to grade four lasted 10 months. To the best of our knowledge, this is the first case reported in the English language literature in which anterior interosseous nerve palsy follows isolated fracture of the proximal ulna.

Semimembranosus tenosynovitis: operative results

Semimembranosus tenosynovitis is a common knee problem in the over-50 age-group, occurring mainly in women. It affects the reflected portion of the tendon of the semimembranosus muscle as well as the bursa below it. The tendon becomes inflamed as a result of friction at the entrance to the bony canal (semimembranosus groove), especially if osteophytes are present on the edges of the groove. Conservative treatment includes anti-inflammatory drugs, ultrasound, and friction massage. If necessary, nonresponders may be given local injection of 40-80 mg methylprednisolone acetate with 1% Xylocaine. Between 1979 and 1983 we operated on 16 patients who had not obtained relief even after three or four injections. The approach in each case was through a posterior medial oblique incision. The semimembranosus osteofibrotic tunnel was revealed and the fibrous sheath surrounding the tendon was excised. Good results were obtained in eight patients in whom the inflammatory process had been localized to only the semimembranosus insertion area: eight patients in whom the knee joint or the pes anserinus insertion was also involved achieved fair or poor results. The operation is not advised for young athletes because of the important function of the reflected head of the semimembranosus muscle.

Unusual fracture dislocation of the elbow joint

A rare case of posterior dislocation of the elbow joint with an avulsion fracture of the medial humeral epicondyle and fracture of the capitulum humeri is presented. Closed reduction was insufficient. Excision of the comminuted segments of the fractured capitulum was imperative to allow an optimal return of elbow function.

Residual shortening after osteotomy for Perthes' disease. A comparative study

The residual shortening of the affected limbs in 55 patients treated by subtrochanteric varus derotation osteotomy was compared with that in 71 patients treated with weight-relieving calipers. When last examined, 43 of the former group and 47 of the latter had reached complete or near-complete skeletal maturity. The average follow-up was 9.1 years in the osteotomised patients and 5.25 years in the conservatively treated group. The average residual shortening (0.9 cm) was identical in both groups. In most patients the initial shortening caused by the osteotomy gradually corrected as, over a period of several years, the postosteotomy angle gradually became less varus. Any residual shortening depended principally on the severity of inhibition of endochondral ossification at the proximal femoral growth plate. Less residual shortening was seen in children who were under seven years of age at the onset of symptoms (under eight at operation) in whom the open-wedge technique of osteotomy was employed and who had good anatomical results.

Abduction-traction injury of the knee

Disruption of the major ligaments of the knee was seen in six young men, five parachutists and a house painter, after what we have termed abduction-traction injury. This unusual complaint results from the application of a sudden block to the ankle while falling head first, leading to traction and abduction of the knee. All the patients underwent operations, generally with unsatisfactory results. At operation tears of the anterior cruciate ligament, medial collateral ligament and posterior oblique ligament were seen in each case; in four patients the posterior capsule and in three the posterior cruciate ligament also were torn. In one patient the lateral collateral ligament was torn and the lateral meniscotibial ligament was avulsed. The compression component is absent in this type of injury and consequently the menisci and the osteochondral surfaces of the tibia and femur remained intact in each case.

Anterior cruciate ligament insufficiency syndrome

Corrective surgery for anterior cruciate ligament (ACL) lesions was performed in 64 patients. Approximately two-thirds of the patients who presented with anteromedial instability were approached through the medial aspect of the knee. In all cases the instability was improved but not entirely eliminated. This was not in itself a disabling problem, as 44% of these patients had good subjective results. However, pivot-shift tests at follow-up examination clearly indicated the presence of anterolateral instability in most, if not all, of these patients. This did not necessarily preclude a self-evaluation of "good"; conversely, a self-evaluation of "fair" (33% of patients) was always related to a positive pivot-shift phenomenon. The authors' current surgical policy is, therefore, to regard the two types of instability as related aspects of a single ACL insufficiency syndrome, and to correct both the anterolateral instability (by the MacIntosh procedure) and the anteromedial instability (by suturing the posterior medial capsule to the semimembranosus tendon together with pes transfer). Poor subjective results (22% of patients) were always associated with the patellofemoral pain syndrome, which could be traced to rotational instability leading to patellar malalignment.

A simple operation for correction of chronic lateral instability of the ankle

Twenty-two patients underwent a simple operation for correction of chronic lateral instability of the ankle. During the procedure the function of the peroneus brevis was preserved and the anterior talofibular ligament was reconstructed. At follow-up only one patient reported that the ankle still felt unstable.