Knee arthrodesis--a review.

Knee arthrodesis as a primary treatment method for knee arthritis has re-emerged as a salvage procedure for failed knee arthroplasty. This article is an overview of indications, contraindications, principles, preoperative preparation and surgical techniques of knee arthrodesis. Their advantages and disadvantages are discussed together with results and complications. An attempt has also been made to incorporate technical considerations, the author's preferred surgical techniques and indications for the various methods of arthrodesis.

An alternative to fixation of displaced fractures of the anterior intercondylar eminence in children.

Fractures of the anterior intercondylar eminence in children are relatively uncommon. There is considerable debate as to the best treatment of displaced fractures, but most methods described in the literature involve an open procedure combined with some form of fixation. Using human anatomical dissections, we have shown that the transverse meniscal ligament can become incarcerated within the fracture and act as a block to reduction. We describe an arthroscopic technique which requires no fixation device and report the results of its use in eight displaced fractures. This method gives reliable results and offers the advantage of less potential morbidity.

The Mennen plate: unsuitable for elderly femoral peri-prosthetic fractures.

The Mennen plate has been advocated for femoral shaft and femoral peri-prosthetic fractures. We utilised this fixation system in five patients with peri-prosthetic femoral shaft fractures. The operative technique was that described by the CMW laboratories. The postoperative regimen deviated from that recommended, i.e. prolonged bed-rest, since the patients were elderly and complicated by chest problems and pressure sores. Once the surgical wounds had healed, at an average of 11 days (range 10-14 days), one patient achieved non-weight-bearing mobilisation. Four patients were managed with bed-to-chair transfer only. All five plates failed at an average of 32 days (range 15-42 days). Only one patient had an identifiable accident to account for the failure. Two patients underwent revision hip arthroplasty and two had revision fixation with Dall-Miles (Howmedica), and Cable Ready (Zimmer) plate and cables. Femoral shaft peri-prosthetic fractures are not adequately stabilised with the Mennen plate system, and prolonged recumbency in such an elderly population often worsens pre-existing medical problems. We advocate the use of one of the many available plate and cable fixation systems for such fractures in the elderly and in those in whom revision arthroplasty may not be possible.

Peri-prosthetic femoral shaft fractures treated with plate and cable fixation.

Management of post-operative peri-prosthetic femoral shaft fractures remains difficult and controversial, with no widely accepted form of treatment. Fractures at the tip of a femoral component are associated with poor union rates. We present a series of 15 fractures at the component tip extending proximally in association with a loose cement mantle. All 15 patients were treated with open reduction and internal fixation using a plate and cable system. They were followed to clinical and radiological union, at an average of 3.5 months (range 3-5 months). At final review examination, 13 patients had achieved pre-fracture mobility, with one patient requiring a single walking stick, and one requiring a Zimmer frame. Three patients under-went revision surgery after successful fracture union and rehabilitation, with long stemmed femoral components. The plate and cable procedure is not technically demanding and avoids hip exposure. This form of internal fixation provides immediate fracture stability, allowing early ambulation, hence avoiding the complications and difficulties of other methods of treatment. Such fractures should be acutely treated to achieve fracture union with a plate, cable, and screw internal fixation technique. The loose components can be revised electively, preferably by a revision hip surgeon.

Revision of failed open reduction of congenital dislocation of the hip.

We report a review of 33 hips (32 patients) which had required repeat open reduction for congenital dislocation of the hip. They were followed up for a mean of 76 months (36 to 132). Factors predisposing to failure of the initial open reduction were simultaneous femoral or pelvic osteotomy, inadequate inferior capsular release, and inadequate capsulorrhaphy. Avascular necrosis had developed in more than half the hips, usually before the final open reduction. At review, 11 of the hips (one-third) were in Severin grade 3 or worse; five had significant symptoms and only ten were asymptomatic and radiographically normal. Once redisplacement has occurred after primary open reduction, attempts to reduce the head by closed means or by pelvic or femoral osteotomy are usually unsuccessful and a further open reduction is necessary.

Repair of the ruptured distal tendon of the biceps brachii.

The biceps brachii is the main supinator of the forearm. Unless the ruptured distal tendon is reattached to its correct anatomical site on the radial tuberosity, its action cannot be restored. We report four cases treated surgically, who all regained full forearm function, and on the basis of our experience suggest a simple method of reattaching the tendon.

Sickle cell disease and silent avascular necrosis of the hip.

We reviewed the prevalence of avascular necrosis (AVN) in a series of patients with sickle cell disease, using radiography and magnetic resonance imaging. We found AVN of at least one hip in 11 of 27 patients (41%). This is a significantly greater prevalence than reported. MRI was not as helpful in patients with sickle cell disease as it is in patients with AVN from other causes; it detected no more cases than radiography.