Appliances and surgery for poliomyelitis in developing countries.

Death before maturity is the usual fate of the untreated crawling crippled child in developing countries. Most children with poliomyelitis, however, when upright and walking with supports or following surgery, are accepted by the community, educated by parents and relatives, and employable when they reach maturity. It is more economical to prevent 100 polio cases than to treat one hopelessly crippled child. It is often quicker to straighten 100 deformed limbs by simple subcutaneous surgeries than to treat a single patient with complicated procedures. It costs less for 100 crawling paralyzed children to walk in simple, locally made braces and clogs, than for 1 patient to be mobile in expensive imported appliances and boots. It is essential to educate or rehabilitate patients in addition to making them mobile. The final aim should be patients returned to their own village or town, accepted and integrated into their own communities, and earning their own living among their own friends. This chapter is discussed in further detail in both English and French in my Website, . This site also includes comprehensive information on both the manufacture of the simple appliances described and various surgical details. This information is also available on CD-ROM.

Replacement of the proximal humerus in primary bone tumours.

BACKGROUND: Primary bone tumours have traditionally been treated by forequarter amputation. However, recent limb salvage techniques have become available which are comparable for tumour control and preserve a useful distal limb. This report describes the use of the Huckstep ceramic shoulder with ceramic spacers, non-vascularized fibular grafts and Huckstep nail with ceramic spacers. METHODS: Three techniques are described for the reconstruction of the humerus following primary tumour excision. The seven primary bone tumours in this series included three patients with osteosarcoma, two with chondrosarcoma, one with fibrosarcoma and one with an aneurysmal bone cyst. The mean age of the four males and three females was 27 years (range 18-57). Mean follow up was 8.8 years (range 1-18). The techniques used were the Huckstep ceramic shoulder prosthesis with spacers (three cases), non-vascularized fibular grafts (three cases) and the Huckstep nail with ceramic spacers (one case). RESULTS: One fibular graft required supplementary bone grafting and one patient with a shoulder prosthesis died of metastatic disease. The other five patients are well with a good range of shoulder abduction and external rotation. CONCLUSIONS: Limb salvage surgery of the upper limb is possible. Deltoid, rotator cuff and radial nerve functions can be preserved.

Management of chondrosarcoma including modular ceramic and alumina prosthetic replacement.

Forty-one cases of chondrosarcoma from varying sites throughout the body, and treated exclusively by one of the authors (R.L.H.) from 1972 to 1990 were reviewed. The symptoms, signs, location of tumours, treatment and progress are presented. Particular attention was paid to modular bone replacement techniques. Excision and reconstruction of the bone or joint were carried out in 17 femora, five tibia and six humeri. Comparison between this method of management and other techniques is discussed. Titanium and alumina prostheses for the hip, femur, tibia, shoulder and humerus have been designed by the senior author. These are both inert and modular, and have been found to be superior to other methods of treatment in both function and cosmesis. They do not possess the same potential donor infection risks and other disadvantages of allograft replacement. Immediate postoperative weight bearing and mobilization are possible with these systems. The Huckstep prostheses allow for bony ingrowth into their porous coated alumina sleeves, spacers and stems. In addition, the titanium alloy locking component for the femoral stems has an elasticity half that of other metal alloys and this was found to minimize stress shielding.

Titanium staple and screw fixation for recurrent dislocation of the shoulder.

A small titanium staple with a locking screw was designed in 1979 to hold the anterior capsule of the shoulder firmly to the front of the scapula just medial to the glenoid. The posterior or inferior capsule can also be stabilized. Two indentations on the staple diminish capsular compression, while a central hole for a 4.5-mm titanium alloy cortical screw allows firm fixation of the staple. A small deltopectoral or axillary approach is used and the subscapularis and capsule are incised on the line of the muscle fibres. The operation is relatively simple and combines the advantages of a Bankart, bone block and capsular plication in a single small operative procedure. Full movement, including external rotation, can be started 3 days postoperatively, and most patients can return to manual labour or contact sport in 4 to 6 weeks. A total of 47 anterior dislocations and two posterior dislocations have been treated since 1981, including six failed Putti-Platt operations and one Helfet operation. Full shoulder movement is usually achieved within 3 weeks of operation.

The role of thallium scintigraphy in excluding malignancy in bone.

Scintigraphy with thallium-201 was performed on 22 patients in whom a solitary abnormality in bone was suspected of being malignant. In three patients, an additional lesion was subsequently identified. Preferential TI-201 uptake was found in 7 of 8 malignant lesions, but was absent in 16 of 17 abnormalities that proved to be benign. The use of TI-201 scanning is considered to offer high negative predictive value in the assessment of possible malignant change in bone.

Ewing's sarcoma: long-term follow-up in 49 patients treated from 1967 to 1989.

PURPOSE: Review of long-term results of therapy for Ewing's sarcoma in terms of survival, local tumor control, distant failure and complications rates. METHODS AND MATERIALS: Retrospective review of the records of patients with Ewing's sarcoma of bone and soft tissues treated at The Prince of Wales Children's and Prince of Wales Hospitals, Sydney, between 1967 and 1989 and followed-up to July 1991. RESULTS: There were 49 patients with median age 16 years (range 3-33 years) and average potential follow-up time 12.3 years (range 2-24 years). Forty patients presented with localized disease (three with regional lymph node involvement) and nine with distant metastases. Local therapy for the primary was by amputation in three patients, by resection and postoperative radiotherapy in five, and by definitive radiotherapy in 41 (median dose 50 Gy). Forty-four patients received adjuvant multi-agent chemotherapy. The overall actuarial survival rate was 33% (SE = 7%) at 5 years and 30% (SE = 7%) at 10, 15, and 20 years. The factors predictive of shorter survival were distant metastases at diagnosis (p = 0.036) and older age (p = 0.025). The actuarial local control rate for all 49 patients was 75% (SE = 8%) at 5, 10, 15, and 20 years. The only factor predictive of local failure was an inadequate target volume irradiated (p = 0.003). In 40 patients who presented with localized disease only, the actuarial rate of freedom from distant failure at 5 years was 44% (SE = 8%) and at 10, 15, and 20 years was 40% (SE = 8%). Seven patients experienced severe or fatal complications (defined as requiring investigation and treatment in hospital), namely stress fracture in two, fatal osteogenic sarcoma in one, fatal cardiotoxicity in one and severe hemorrhagic cystitis in three. The rate for severe or fatal complications at 5 years was 19% (SE = 8%), at 10 years was 29% (SE = 12%) and at 15 and 20 years was 53% (SE = 21%). CONCLUSION: Survival to 5 years appears to confer probable cure and one third of our patients have achieved this. Long-term follow-up also reveals that an increasing number of patients experience treatment-related complications, the majority of which, however, can be corrected.

Stabilization and prosthetic replacement in difficult fractures and bone tumors.

Comminuted fractures of the femoral shaft, especially when combined with fractures of the hip, may be difficult to treat. A four-sided titanium alloy locking nail with transfixing screws was designed in 1967 and allows compression of the fracture site. If necessary, the nail may be inserted without intraoperative roentgenograms, and permits early weight-bearing in most cases. One hundred seventy-one difficult fractures in femora, humeri, tibiae, and ulnae have been treated with this nail since 1974. Many cemented total hip arthroplasties are failing. A cementless, modular titanium alloy and alumina hip, based on the nail with a modular alumina or titanium head, will allow cementless hemi- or total hip arthroplasty. Porous, 200-microns ceramic coating on the stem allows bone ingrowth while transfixing screws allow full and immediate postoperative weight-bearing. A ceramic sleeve and spacers also allow modular replacement of the upper three-quarters of the femur for tumors and trauma. A similar shoulder and humerus is also available. Fifty-four hips and two shoulders have been successfully replaced since January 1983. In addition, 285 bones with pathologic or potential pathologic fractures caused by secondary tumors have been stabilized by the author between August 1972 and August 1986, with a variety of implants.

Intraluminal allograft restoration of the upper femur in failed total hip arthroplasty.

Deep-frozen cancellous allografts have been used to restore the proximal femur of 23 hips following failed total hip arthroplasty. The canal is cleared and reaming is performed under direct vision through a cortical window. A modified Huckstep prosthesis permits early weight-bearing on the distal femur regardless of the state of proximal bone, but retains the option for later restoration of proximal loading once grafts appear mature. This transfer has been performed on four occasions. All 23 patients have had relief of pain with early ambulation. The follow-up periods ranged from six to 30 months. With the exception of one deep infection, the grafts have not undergone resorption in this period of follow-up study. Consolidation appears slower when the defect has followed multiple operations than following an initial revision for prosthetic loosening. The basic bone bank facilities are required for the supply of frozen allografts.

Effect of a static magnetic field on fracture healing in a rabbit radius. Preliminary results.

To ascertain what effect a static magnetic force has on a healing fracture, samarium cobalt magnets were implanted adjacent to induced radial fractures in adult rabbits. A magnetic field of 220-260 G was generated at the fracture site. The radii were allowed to heal for four weeks and the contralateral fractured bones acted as controls. Healing bone units were assessed microscopically and mechanically. Significantly greater forces (p less than 0.01) were required to break those bone units exposed to magnetic fields. However, no significant difference was found when comparing the longitudinal midcallus areas from magnetized and nonmagnetized limbs.

Proximal femoral fractures. A perspective from developing countries.

The approach to hip fractures in the developing world has been reviewed to give perspective to the problem on a larger scale. Hip fracture treatment in the developing world is a paradigm for treatment of other orthopedic problems as well as for medical care in general. The most successful approach has been to use the resources as sparingly as possible so as to provide care for the greatest number of people. Reliance on simpler, more basic techniques of nonoperative treatment reduces the complication rate and seems to provide a safer, more cost-effective approach, but the nonunion rate may be 30%-70%. The situation in which technical development exceeds resources is not unique to the developing world, although it is perhaps more apparent there because of a lower resource level. The "developed" world faces the same dilemma, the only real difference perhaps being a higher minimum. Probably no society today can provide the medical care it is technically capable of producing for all of its members. When viewed from a world-wide scale, the task of providing high-technology medical care seems daunting indeed. Development of more sophisticated, expensive technology may not be the appropriate direction; a more fundamental or preventive approach might in the long run be the most effective.

The Huckstep intramedullary compression nail. Indications, technique, and results.

A four-sided, intramedullary compression nail of solid titanium alloy has been developed since 1967. This nail is 12.5 mm in diameter with 4.5-mm transverse holes at 15-mm intervals, for 4-mm fine threaded screws. It has four oblique holes in the proximal end to allow 4.5-mm lag screws to be inserted up the femoral neck. A compressor over the trochanter can be used for compression in transverse fractures. Advantages include inert titanium alloy, which is stronger than the average femoral shaft, a recessed end of the nail, reaming to only 13 mm, and a quadrilateral shape. No operative roentgenograms are usually required. Comminuted, oblique, and infected fractures of the entire length of the femoral shaft down to the supracondylar region can be held rigidly, usually allowing for immediate weight-bearing. The femur can be lengthened or shortened with compression and the knee can be arthrodesed with a 60-cm nail. One hundred twenty-two nails inserted since 1974 included 32 comminuted or oblique acute femoral fractures. Forty-two patients had had failure of other implants. Among these, 34 had nonunion for one year and 17 nonunion for more than three years. Fifty-one bones in 47 patients were stabilized for pathologic fractures and other conditions. Complications were minimal.

Simulation of injuries in disaster exercises.

It is essential that hospitals, doctors, nurses, ambulances, helicopters, police, fire services and all others involved in major accidents or disasters should have adequate training in the assessment, management and transport of casualties by the means of regular disaster exercises. These practices, whether small or large, are much more realistic if casualties are properly made up to simulate the injury that they are supposed to represent, and if the 'patients' can act the part. The illustrations in this article show how real the make-up can be and how seriously the doctors, nurses, ambulance officers, fire and police officers and others take these exercises which often have between 100-200 'victims'.

Simple guidelines to disasters.

Good organization and communications are essential in the management of disasters and major accidents. A quick method of assessment of patients and simple guidelines to resuscitation, splinting and emergency care are given in this illustrated paper on the optimum procedures to be followed by doctors and other who may be asked to assist.

Early mobilization and rehabilitation in fractures and orthopaedic conditions.

Many advances have taken place during the past decade in the early mobilization of orthopaedic patients and those with injuries. Light-weight scientific splinting, early rigid fixation with compression plates and nails, and the early mobilization of patients with pathological fractures in neoplastic disease, have meant that these patients can often be mobile in days, and home in a fortnight, instead of spending months languishing in hospital. Scientific treatment of patients with neck and low back pain may similarly minimize chronic disability, while early rehabilitation can enable their early return to employment. It is the purpose of this paper to underline some of the important advances in treatment which have made this possible.