The use of hydroxyapatite-coated CAD-CAM femoral components in adolescents and young adults with inflammatory polyarthropathy: ten-year results.

Between June 1991 and January 1995, 42 hydroxyapatite-coated CAD-CAM femoral components were inserted in 25 patients with inflammatory polyarthropathy, 21 of whom had juvenile idiopathic arthritis. Their mean age was 21 years (11 to 35). All the patients were reviewed clinically and radiologically at one, three and five years. At the final review at a mean of 11.2 years (8 to 13) 37 hips in 23 patients were available for assessment. A total of four femoral components (9.5%) had failed, of which two were radiologically loose and two were revised. The four failed components were in patients aged 16 years or less at the time of surgery. Hydroxyapatite-coated customized femoral components give excellent medium- to long-term results in skeletally-mature young adults with inflammatory polyarthropathy. Patients aged less than 16 years at the time of surgery have a risk of 28.5% of failure of the femoral component at approximately ten years.

Wrist arthrodesis following ulnar bar excision in Fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva is a rare disorder characterized by the progressive development of heterotopic bone in the connective tissues of skeletal muscle, ligaments and tendons. Surgical trauma is one of the most potent stimuli for ossification and surgical treatment is generally considered to be contraindicated in this condition. We report a good functional result in a patient with severe hand disability secondary to an ulna-carpal bar in fibrodysplasia ossificans progressiva.

An accessory extensor tendon of the thumb as a cause of dorsal wrist pain.

An accessory extensor pollicis longus muscle within the third extensor compartment resulted in dorsal wrist pain that resolved following excision of the accessory muscle.

Trigger wrist and flexor tenosynovitis.

We report a case of a profundus tendon sheath fibroma which initially presented as triggering on wrist movements but rapidly caused a flexor tenosynovitis limiting both finger and wrist movements. Surgical excision was curative.

Anterior soft-tissue release of the hip in juvenile chronic arthritis.

We report the results of anterior soft-tissue release of the hip for fixed flexion deformity in 17 patients (31 hips) with juvenile chronic arthritis. The mean age at operation was 8 years 6 months. All the patients were reviewed at one and three years and 11 (21 hips) were available for review at five years. The results were good as regards early pain relief and improved mobility. At one year, the average fixed flexion deformity was reduced from 35 degrees to 9.5 degrees, and at three years it was 18 degrees. This degree of improvement was maintained in the hips followed for five years. At 5 to 12 years' follow-up (mean 6.7) seven patients (14 hips) have required no further surgery and have maintained an acceptable range of motion. We discuss the influence of surgery on radiographic changes and on femoral neck anteversion.

Surgical management of the hip in juvenile chronic arthritis.

The hip joint is the most important joint as far as surgical management of JCA is concerned. Approximately a third of children will develop hip involvement, leading to pain and deformity. A wide spectrum of hip joint abnormalities may occur, being the result of either under-development or over-development of the bones and erosive change secondary to the synovitis. For the acutely irritable hip with no fixed deformity an intra-articular injection of Triamcinolone Hexacetonide may be beneficial. For those hips with a fixed deformity, resulting in functional impairment in children prior to the closure of the proximal femoral capital epiphysis, a soft tissue release of selected muscles around the hip joint can correct deformity and improve function. For the painful destroyed hip joint, total joint replacement is indicated. Cemented hip replacements have been shown to have a high incidence of loosening in this patient group and consideration is being given to the use of customized uncemented femoral components.

Results of cemented total hip replacement in juvenile chronic arthritis. A radiological review.

We assessed 57 total hip arthroplasties in 34 adolescents with juvenile chronic arthritis using standard radiological techniques at an average of 4.7 years (20 months to 9 years) after surgery. The incidence of overall loosening was 24.6% (14 hips), but hips with a follow-up of more than five years had a loosening rate of 43.5% (10 hips; p < 0.01).

Bilateral spontaneous scapho-lunate subluxation treated by limited carpal fusion.

The case of a 19 year-old-girl who developed spontaneous bilateral snapping scapho-lunate subluxation is described. Her symptoms were successfully treated by bilateral triscaphoid fusion.

Tendon implantation into bone: an experimental study.

We report the results of an experimental study to investigate the mechanical properties and histological structure of the tendon-bone junction following surgical implantation of tendon into bone in the rabbit. The results following tendon transfer and tendon grafting were compared. The normal four-zone tendon junction was not reproduced histologically, in either group. After 20 weeks, the mechanical strength of the tendon transfers had reached 60% of the controls and that of the tendon grafts 20% of the controls. Microangiography demonstrated that these differences were not related to the vascularisation of the tendon bone junction. The mechanical properties of the tendon-bone junction may be dependent more on the functional state of the implanted tendon than on its structure.

Axon regeneration and vascularisation of nerve grafts. An experimental study.

An experimental model has been designed to assess the effect of vascularisation on axon regeneration in nerve grafts. The vascular status of the grafts has been demonstrated by microangiography and histology. Rat sciatic nerve grafts in which the vascular pedicles were left intact retained a normal vascular pattern which was not adversely affected by wrapping the graft in a polythene sleeve. In devascularised grafts, revascularisation commenced at three days and was complete at nine days. If the devascularised grafts were wrapped in a polythene sleeve, revascularisation was impeded and at fifteen days the middle segment of the graft was avascular and infarcted. The rate of axon regeneration was measured electrophysiologically in the above four groups of nerve grafts. There was a linear relationship between the rate of axon regeneration with time post-graft, axon growth proceeding at a mean rate of 1.150mm/day (S.E. +/- 0.084) after a mean delay of 4.85 days. There was no significant difference in the rate of axon regeneration in the four groups.

Malunited fractures of the forearm in children.

Malunion of fractures of the forearm in children can lead to permanent disability. The capacity of the radius and ulna to remodel spontaneously after malunion has been assessed in this study. Forty-nine children who had malunited fractures of the forearm were examined when the remodelling process was complete. It was noted that fractures of the distal third of the radius and ulna led to fewer problems than those of the diaphysis. It was concluded that malunion of the distal third of the radius and the ulna will remodel satisfactorily providing the child is less than 14 years of age. Gross malunion of the midshaft of the radius and ulna will spontaneously correct in an infant but little useful correction of deformity can be anticipated in diaphysial fractures when the child is aged eight years or more.

Rotatory stability of the load-bearing ankle. An experimental study.

The range of rotation of the talus in the horizontal plane was studied in the cadaveric ankle under conditions which simulated normal load-bearing. In the unloaded state there was 25 degrees of rotation, approximately half of which resulted from movement of the inferior tibiofibular joint. Rotation was load-dependent in both the intact ankle and in the ankle rendered unstable by division of the ligaments. Experimental division of the ligaments increased the range of rotation. The malleoli were contact areas during flexion and extension but excision of their articular surfaces caused only a moderate increase in rotation. The factors which limit talar rotation in intact and injured ankles are discussed.

Eosinophilic granuloma of bone.

Forty-three patients with histologically proven Histiocytosis X localized to bone at presentation have been reviewed. Thirty-six patients presented with solitary bone lesions and 31 have healed without complication with a mean follow-up of 10 years. The remaining five patients developed polyostotic disease, three exhibiting either pulmonary lesions or diabetes insipidus. Seven patients presented with multiple bone lesions and six of them developed other bone lesions. Four of these patients also showed some of the features of Hand-Schüller-Christian disease. An increase in size of the presenting bone lesion within a few months of biopsy heralded the subsequent development of further bone or soft tissue lesions and was the only feature of prognostic value.

Healing of osteochondritis dissecans following congenital dislocation of the hip: report of a case.

An 18-month-old boy treated for congenital dislocation of the hip, developed osteochondritis dissecans of the femoral head. Serial roentgenograms demonstrated that the lesion had healed by the time he was 15 years of age. There have been no previous reports of healing of osteochondritis dissecans complicating congenital dislocation of the hip, or Legg-Calvé-Perthes disease, although healing in idiopathic cases has been described.

Acute nerve injury as a complication of closed fractures or dislocations of the elbow.

Twenty-one patients with acute injury of either the median, ulnar, radial, anterior interosseous or posterior interosseous nerves associated with 1540 closed fractures or dislocations of the elbow have been reviewed. The mean time of follow-up was three years and nine months. Nine patients, 6 of whom had ulnar nerve lesions, had persistent evidence of nerve damage. Five patients sustained median nerve lesions complicating supracondylar fractures of the humerus. One patient, in whom there was no evidence of nerve recovery at five months, made a full recovery following neurolysis. Of the 9 patients who sustained ulnar nerve lesions, 2 required neurolysis and anterior transposition of the nerve, at two months and five months respectively, to facilitate recovery. Except for one patient with persistent radial paraesthesiae, full spontaneous recovery occurred in 7 patients who had sustained either anterior interosseous, posterior interosseous or radial nerve lesions.