Total hip replacement in children with juvenile chronic arthritis.

The results of 75 total hip replacements in 42 children with juvenile chronic arthritis are reported after a mean follow-up of 5.4 years. Their ages ranged from 11 to nearly 17 years at operation and many had active disease. Severe pain and marked stiffness of the hips were limiting their independence. At least half of the children were still growing and continued to grow after operation. The patients were carefully selected and gratifying results were obtained, but pre-operative assessment and overall supervision by a rheumatologist are important. Technical difficulties related to the size and maldevelopment of the hip are discussed. There was no infection and the single case of loosening of a femoral component after nine years has been successfully revised.

Surgical treatment of juvenile rheumatoid arthritis.

Juvenile rheumatoid arthritis is rare and only affects a small number of children but can lead to severe crippling of adolescents or adults unless they are treated early. In this review the problems encountered in the surgical treatment, particularly those caused by skeletal stunting are discussed. The results of synovectomy of the knee and elbow are valuable procedures in suitably selected patients. Stapling of the knee in young children with genu valgum gave good correction in the majority. Soft tissue operation on the hip and knee in young children with severe deformities have given encouraging results. Complications and the results of reconstructive surgery for the hip and knee are discussed, and it was found that total joint replacement in these young patients with badly damaged hips is fully justified before they become chairbound.

Computer aided analysis of total knee replacement in rheumatoid arthritis.

A computer-aided analysis has been carried out on 176 knee replacements performed on 129 patients during the last 12 years. Owing to the variety of knee replacements used, the number of complications seen, and the large quantity of survey data a computer was very helpful in storing this amount of data with facilities for rapid recall of information. The results of the early Shiers knee hinged arthroplasties have been less than 50% good results, and these were followed by many complications. A smaller number of other knee replacements have been analysed, namely, Freeman-Swanson, Gunston, Sheehan, and Attenborough. The best results were obtained using 60 Attenborough knee prostheses, with a low infection rate of 3.3%, a loosening rate of 5%, and good prospects of salvage by fusion of the knee if required.

Surgical treatment of Still's disease (juvenile chronic arthritis).

We have carried out 433 operations on 268 patients suffering from Still's disease during the period 1959-1979, the average age of the patients being 21 years. A synovectomy of the knee was performed on 76 knees with a good result in 68%, while a similar operation on the elbows of 16 patients was more successful and 90% did well. Stapling of the knee in young children with genu valgum was carried out on 33 knees with a good correction in the great majority. Soft tissue operations were carried out with encouraging results on 24 hips and 9 knees, the patients having severe deformities of these joints. Reconstructive surgery was necessary in some patients with severe damage to their hips and knees, and we obtained good results in the great majority. Two hundred and forty eight total hip replacements have been carried out on 132 patients during the last 14 years and 84% have had a good result, but owing to the skeletal stunting frequently present a special small sized hip prosthesis had to be used. Knee replacement has been less satisfactory but was carried out on 40 knees in 28 patients and 55% had a good result. The main complications seen with these joint replacements have been due to infection or loosening. Multiple joint replacement has been carried out on 42 patients, 13 of which had both hips and knees replaced with 54% good results. Difficulties were experienced in anaesthetizing some patients owing to a stiff neck and jaw, but this was overcome by the use of Ketamine anaesthesia.

Traumatic rupture of the spleen.

Sixty-three cases of traumatic rupture of the spleen were analyzed. The patients were admitted to our hospitals during the last 24 years and there has been a steady increase in the numbers seen. The great majority of these cases resulted from road traffic accidents, and 33% of the patients had multiple injuries. Most were in the second and fourth decades; males outnumbered females by nearly four to one. Associated injuries, which occurred in 33% of cases, significantly raised the mortality. The mortality was also higher in the older age group and in those patients who had multiple injuries and were severely shocked on admission. Difficulty and delay in diagnosis occurred particularly in the unconscious patients and also in those in whom shock was not apparent, particularly when abdominal signs were late in developing. Treatment by resuscitation and splenectomy was used routinely and our overall mortality was 17.5%. Complications were frequent, the most serious being gastrointestinal and respiratory. A long-term follow-up showed that the great majority of patients have done well. There has been no evidence of an increased infection risk following splenectomy, and all but a few patients were able to return to their former sporting activities.

Deep infection after total hip replacement.

Sixty-eight patients suffering deep infection from a consecutive series of 1746 total hip replacement operations are reviewed. The infection rate has been reduced considerably by improved technique and multiple antibiotic prophylaxis without the use of a special operation enclosure. Factors affecting deep infection are analysed and discussed.

A review of 100 Attenborough stabilised gliding knee prostheses.

We have reviewed 100 Attenborough total knee replacements in eighty-two patients with a follow-up of one to four years and conclude that this prosthesis has a valuable place in the surgical management of patients suffering from rheumatoid arthritis and osteoarthritis with severe involvement of the knee. In 85 per cent of these knees a good result was obtained with relief from pain, and in 77 per cent a useful range of movement with a stable knee. Only two patients with loosening and three with deep infection were seen in this series.

The treatment of arthritis of the shoulder joint by double osteotomy.

This paper presents the new operations of double osteotomy of the shoulder for the treatment of painful arthritis. The procedure consists of osteotomy without displacement of the necks of both the scapula and the humerus. Sixteen patients who have had this operation have been followed for one to nine years (average 2 years 11 months). The results show good or excellent pain relief in 13 patients and a substantial increase in active abduction in 13 patients. Complications were few and none were serious. A possible reason for the reduction of pain is suggested and the advantages of this operation over arthrodesis and total shoulder replacement are discussed.

Shoulder problems in juvenile chronic polyarthritis.

A high incidence of shoulder involvement was seen in severely disabled young people suffering from juvenile chronic polyarthritis who were undergoing surgical procedures on the lower limbs. The progressive nature of the radiological changes is described. Possible lines of surgical management are considered.

Arthroplasty of the hip in ankylosing spondylitis.

In fifty-six patients with ankylosing spondylitis three types of arthroplasty had been performed in ninety-nine hips. Forty-one of the patients were men and fifteen were women, their average age at operation being forty-two years. Primary pseudarthrosis produced well-satisfied patients, but only a fair result in five hips, whereas cup arthroplasty resulted in a poor outcome for eight hips, all of which needed revision. Total replacement of eighty-six hips, however, led to 73 per cent being graded as good or excellent up to ten years later. The main complications were deep infection of five hips, para-articular ossification around nine hips (six leading to bony ankylosis), and fibrous ankylosis of six hips.

The operative management of the difficult supracondylar fracture of the humerus in the child.

A series of supracondylar fractures of the humerus in children is presented. The majority was reduced by closed manipulation. The difficult fractures were defined as those in which adequate reduction either could not be achieved by manipulation or was not maintained, or those in which neurological or vascular complications occurred. Such cases were treated by open reduction and internal fixation. The results were assessed with regard to loss of elbow movement, deformity and symptoms. The results of the operative series were comparable with those achieved by closed manipulation in the easier cases. No secondary corrective procedures were necessary. It is concluded that closed manipulation should be used routinely as the method of treatment for supracondylar fractures of the humerus in children, except in the difficult case, for which operative treatment should be undertaken. Stiffness or deformity does not follow open reduction and internal fixation.

A comparison of the treatment of trochanteric fractures of the femur by internal fixation with a nail plate and the Ender technique.

In our experience, trochanteric fractures fixed with Ender nails achieved a degree of success similar to those treated by nail plating, but the risk of wound infection was much less with the former method. The results of 78 trochanteric fractures of the femur internally fixed with Ender nails have been analysed and compared with the results in 100 similar patients treated by nail plate fixation. The Ender method has advantages over existing operative methods, in that in our series the infection rate was zero and we found that the operation produced less shock. We consider that this method, although technically more difficult, can be used for most intertrochanteric fractures and merits further trial.

A comparison of the stability of proplast-coated and cemented Thompson prostheses in the treatment of subcapital femoral fractures.

Twenty randomly selected patients with displaced subcapital fractures of the femur, were treated with prosthetic replacement of the femoral head using a Thompson prosthesis of which the intramedullary portion was coated with Proplast. The results were compared with a control group of 20 similar patients in whom the standard Thompson prosthesis was used with acrylic cement. At follow-up, which ranged from 3 to 17 months, there was substantial X-ray evidence of prosthetic loosening in the Proplast series.

Ketamine and juvenile chronic polyarthritis (Still's disease). Anaesthetic problems in Still's disease and allied disorders.

The rationale for the use of ketamine anaesthesia in patients with juvenile chronic polyarthritis is presented. The method was used successfully in 70 patients. There were no deaths but one refused to have ketamine again.