Second carpometacarpal joint dislocation: an impossible situation?

We report a case of a seemingly anatomically impossible dislocation of the second carpometacarpal joint treated by closed manipulation, and a review the literature. Isolated second carpometacarpal joint dislocation is rare, whereas dislocations of the first, fourth and fifth joints are more common. A true lateral X-ray is necessary if the injury is suspected clinically. We recommend that closed reduction under local anaesthetic is attempted, although the patient should be warned that subsequent open reduction may be necessary if closed reduction fails. Chronic unreduced dislocations do not produce serious disabilities in the hand.

Rotaflex total knee arthroplasty: a report of two prosthetic failures at the hinge mechanism.

We present two cases of Rotaflex hinged total knee arthroplasties in which the components forming the hinge mechanism have fractured. In one case this was the high density polyethelene sleeve bush of the tibial bearing, the other case being the titanium retaining peg of the tibial component. Component failure in this design of prosthesis is previously unreported.

Closed intramedullary biopsy for metastatic disease.

The surgical stabilization of metastatic fractures or impending fractures of long bones is recommended with the use of intramedullary nails. While the primary tumour has often been diagnosed previously, there are occasions when the fracture may be the presenting feature of malignancy. In both circumstances surgical oncologists require a histological diagnosis from around the fracture site so that any adjuvant therapy can be planned. Open biopsy is often employed although a closed method has been used by percutaneous puncture. Although intramedullary specimens have been obtained before with long bronchial type biopsy forceps, we report a simple and reliable technique for closed biopsy taken from intramedullary reamings at the time of fracture fixation. Lesions from both the femur and the humerus are amenable to this technique.

Closed intramedullary osteotomy for the correction of deformities of the femur.

Over the period 1986-1990, an intramedullary saw was used to correct length inequality, rotational and axial deformities and malunions of 17 femora in 15 patients. Interlocking intramedullary nails were inserted after the osteotomies were performed. No postoperative complications were encountered. Quadriceps function returned within 2-8 days and all osteotomies healed radiographically within 3 months. All deformities were satisfactorily corrected and all patients were pleased with the outcome. The intramedullary nails were removed in the majority one year following surgery. The authors conclude that closed intramedullary osteotomy of the femur is a safe and effective technique to correct deformities of the femur, although demanding in terms of experience and equipment.

Osteotomy and intramedullary nailing for the correction of progressive deformity in vitamin D-resistant hypophosphataemic rickets.

We have reviewed the results of surgical treatment of vitamin D-resistant hypophosphataemic rickets (VDRR) and describe a technique of corrective osteotomy and intramedullary nailing. From 1978 to 1986, epiphysiodesis (n = 4) and osteotomy (n = 8) was performed in 6 children (mean age 13, range 10-16 years) for the correction of progressive lower limb deformity. Realignment and internal fixation of a pathological fracture of the femur was performed in an adult (aged 24). Epiphysiodesis resulted in recurrent deformity in all patients and reapplication of staples for loosening was required in three. Corrective osteotomies were secured with staples (n = 3), plates (n = 4), or plaster alone (n = 1) and were complicated by non-union in one patient, and recurrent deformity in two patients. Double-plating of the femoral fracture resulted in union but recurrent deformity. Compliance to treatment with phosphate and vitamin D was variable. In order to manage progressive recurrent deformity, we have performed corrective osteotomy and closed intramedullary nailing of the tibia (n = 2) and femur (n = 3) in 4 skeletally mature patients (mean age 31). All osteotomies united and no complications were encountered. Deformity has been corrected in all cases and all patients are satisfied with the outcome at least 2 years after surgery. We conclude that rigid methods of fixation spanning the whole length of the bone are required to maintain limb alignment in skeletally mature patients with VDRR. Since the quality of bone in VDRR is variable, experience with intramedullary techniques is essential. We stress the importance of appropriate medical therapy throughout the treatment of these patients.

Spontaneous fractures in a patient treated with low doses of etidronic acid (disodium etidronate).

The recommended regimen of etidronic acid (disodium etidronate) for the treatment of Paget's disease of bone is 5mg/kg/day for a period of less than six months. There have, however, been reports of impaired mineralisation of bone and concern that the risk of fracture is increased with this dosage. We report a patient with Paget's disease in whom fractures occurred through pagetic and non-pagetic bone which appeared to be causally related to treatment with lose doses of etidronic acid. The osteomalacia resolved when etidronic acid was discontinued.

Risk of deep infection with intramedullary nailing following the use of external fixators.

A retrospective review was carried out to assess the incidence of deep infection occurring when intramedullary nailing was performed following the use of an external fixator. Three groups of patients were identified: group 1 in which the external fixator was used in initial fracture management (ten cases, nine patients), group 2 in which the external fixator was used in the management of established non-union (seven cases, seven patients), and group 3 in which the external fixator was used in limb lengthening procedures (eight cases, eight patients). All the 25 cases reviewed had clinical evidence of pin track infection before removal of the external fixator. After removal of the fixator it is our normal policy to wait for the pin sites to become dry before performing intramedullary nailing. In only one case, where there was a history of preceding recrudescent osteomyelitis, was there evidence of deep infection being reactivated following intramedullary nailing. We therefore conclude that pin track infection does not seem to be a contraindication to the subsequent use of an intramedullary nail, providing that underlying active osteomyelitis is not present. A delay of 7 to 14 days after removal of the fixator is recommended. Some problems experienced during nailing are highlighted, and solutions proposed.

Fatal pulmonary fat embolism during total hip replacement due to high-pressure cementing techniques in an osteoporotic femur.

High-pressure cementing techniques, involving the use of a cement gun and cement restrictor, placed within the femoral medullary cavity, are commonly used to secure the femoral component of hip arthroplasties. Such techniques have been shown to be important in maintaining the integrity of the bone-cement interface and also the integrity of the cement itself. This case report illustrates that such techniques are not without complications.

Bicondylar St. Georg sledge knee arthroplasty.

Fifty-three bicondylar St. Georg sledge knee arthroplasties in 44 patients were reviewed. These patients had a mean follow-up period of 5.9 years (range, three to ten years). Function was assessed using the d'Aubigné scale coupled with measurement of range of motion (ROM) and stability. Pain relief was substantial (75%), and functional ability improved commensurately. ROM improved from a preoperative average of 83 to a postoperative 123. Three (5.7%) arthroplasties failed and were subsequently revised, while three (6.8%) of the knees examined at review have static radiolucent lines at the tibial bone-cement interface. The remaining 44 knees examined (93.2%) showed no signs of impending failure and have sustained their functional result. The polyethylene tibial components are not metal backed, and it is of interest that bone-cement interface failure has been unusual. This operation is a somewhat exacting procedure, but with the correct choice of patient and technique, a predictable result can be expected.

Improvement in the deformity of the face in Paget's disease treated with diphosphonates.

We studied nine patients with Paget's disease affecting the skull or facial bones, who were subsequently treated with either dichloromethylene diphosphonate (clodronate) or ethylene-1-hydroxy-1,1-diphosphonate (etidronate). Long-term treatment induced a clinical and biochemical improvement in eight, and this was associated with a reduction in maxillary or skull volume as assessed by quantitative stereophotogrammetry. The one patient whose disease was resistant to treatment with diphosphonate, showed no change in maxillary shape. These studies suggest that the long-term control of disease activity attained with diphosphonates, results in the improvement of skeletal deformity.

The long-term results of the surgical management of paralytic pes cavus by soft tissue release and tendon transfer.

Twenty-six patients with paralytic pes cavus were managed by early soft tissue correction and tendon transfer. Eighteen had spina bifida, 6 had peroneal muscular atrophy and two had cerebral palsy. The most frequent operations were flexor hallucis longus tenodesis, Girdlestone's flexor to extensor tendon transfer and plantar release. The indications for these procedures are discussed and the results presented, with particular reference to static and dynamic foot pressure studies performed at review. Follow-up averaged 5.2 years. Toe correction was found to be successful in most cases but plantar release failed in 55% of feet, with many progressing to fusion. Many failed feet had presented at an earlier age and it was felt that the initial procedures had delayed the need for bony correction thus minimising growth disturbance.

Treatment of malignant hypercalcaemia with clodronate.

We have assessed the effects of clodronate (dichloromethylene diphosphonate; Cl2MDP 0.8-3.2g daily by mouth for up to 3 months) in 17 episodes of hypercalcaemia and osteolysis due to carcinoma. Clodronate reduced serum calcium in 14 episodes and bone resorption in all patients. These remained suppressed for the duration of treatment, but recurred promptly when treatment was stopped. Clodronate may be a useful measure for controlling hypercalcaemia and osteolysis in patients with carcinoma.

Abnormal vitamin D metabolism in Paget's disease of bone.

We have studied several biochemical indices of bone turnover and vitamin D metabolism in 32 untreated patients with Paget's disease and in 32 age-matched control subjects. patients with Paget's disease, as expected, were characterized by high bone turnover, as judged by alkaline phosphatase and urinary excretion of hydorxyproline. Serum values of 24,25-dihydroxyvitamin D3 (24,25(OH)2D3) and the ratio of 24,25(OH)2D3 to 25-OHD were significantly lower in patients than in control subjects. Serum concentrations of 1,25(OH)2D3 were normal in Paget's disease. The distribution of values for 24,25(OH)2D3 was log normal. On the basis of the normal range computed from control subjects, patients were divided into those with low or normal values for 24,25(OH)2D3. Disease activity, as judged by biochemical indices was significantly higher in the patients with the lower values of 24,25(OH)2D3. We conclude that Paget's disease is characterized by low circulating concentrations of 24,25(OH)2D3, particularly in patients with more extensive or severe disease.

Keller's arthroplasty: is distraction useful? A prospective trial.

There are many operations for hallux valgus and hallux rigidus, but Keller's operation remains one of the most popular, particularly for the older patient. A prospective trial was carried out to compare the results of Keller's operation modified by Kirschner-wire distraction with those of the standard operation. The results suggest that there is no advantage in using temporary Kirschner-wire distraction; indeed, degenerative changes in the interphalangeal joint and a subjectively worse result may result from its use.