Diaphyseal tibial fractures are common and generally heal well. However, non-union is a frequent consequence, can require prolonged treatment with unpredictable results and lead to chronic disability. This article describes the management of non-unions and provides an algorithm for current management techniques including the challenges of bone loss, deformity and infection and an overview of the role of biological augments in non-union surgery.
Elbow arthroplasty has an important rote in the treatment of many conditions affecting the elbow, including inflammatory arthritis, osteoarthritis, fracture and instability. The types of implant differ in the degree of constraint they provide. Some are linked and highly constrained implants, whereas others have a "sloppy hinge" which allows some varus/valgus play. Yet others are completely unlinked and provide the least constraint, relying on Ligament and muscle balance for stability. A variety of implants have achieved good results in terms of pain relief and range of movement, which usually leads to significant functional benefit to the patient.However, this surgery is not without risk and the main complications include loosening, infection, instability, dislocation and nerve dysfunction. As with other forms of arthroplasty, but particularly the elbow, it is important to scrutinise the indication for surgery when considering the results of elbow arthroplasty; the majority of procedures are performed for inflammatory arthritis. The precise difference in outcome between unlinked, linked and sloppy articulations appears to be small and the exact rote for each implant type is yet to be precisely defined. (C) 2008 Elsevier Ltd. All rights reserved.
Traditional surgical correction of spinal deformity has involved relatively long instrumentation and fusion techniques, producing a straighter but stiffer spine. In the infant this approach leads to a shorter trunk. Current surgical techniques may also have an adverse effect on pulmonary function. In order to minimize the tatter, strategies have been devised to limit exposure related morbidity. These have largely focused on minimally invasive and thoracoscopic techniques, and endoscopic techniques of spinal instrumentation and scoliosis correction are now well established.Non-fusion techniques in the growing spine, to maximize or modulate future growth potential, are being explored. Their potential advantages are obviation of the need for early fusion and countering of the resultant relative axial. shortening from spinal. arthrodesis. (c) 2007 Published by Elsevier Ltd.
There is a wealth of data published on the biomechanical properties of intra-articular tissues. However, much of this information is not intuitively applicable to clinical practice due to both methodological disparity between studies and the relevance of the methodology used to test the biomaterial. This inevitably results in comparison difficulties with other experimental data produced for the same tissue, or indeed different tissues.Therefore, this review highlights the salient issues that need to be considered when trying to interpret biomechanical testing scenarios and how they influence clinical practice. As such, different testing protocols and their clinical relevance are scrutinised. The importance of recreating the physiological loading conditions and the interpretation of the functional anatomy are highlighted. (C) 2008 Elsevier Ltd. All rights reserved.
This article reviews the management of neonatal brachial plexus injuries, including assessment and indications for surgical exploration and nerve repair, as well as the most common later sequelae, shoulder subluxation and dislocation.
The management of osteonecrosis of the hip is evolving but remains challenging. As the patients are typically younger, it remains imperative to preserve the femoral. head for as Long as is possible. When arthroplasty is indicated, the need for longevity of implants and bearing surfaces is paramount. Developments in bone biology, the use of appropriate pharmacology, improved implant design, better bearing surfaces and appropriate choice of implant fixation should all improve the historically poorer results seen with arthroplasty in osteonecrosis patients. (C) 2008 Etsevier Ltd. All rights reserved.
This review looks at the history of replantation in the upper limb, and how both survival of the amputated part and functional outcomes have improved with increasing microsurgical experience. We discuss the relevant considerations when part of an upper limb is amputated, and the indications and contraindications to microsurgical replantation. The practicalities of managing this injury that threatens limb, and sometimes life, are highlighted, together with key points from our suggested operative management plan. Finally, we review the current literature with regard to prognosis and functional outcomes that can be achieved when replanting an amputated part of an upper Limb. (c) 2008 Elsevier Ltd. All rights reserved.
The occurrence of total hip impingement, whether or not accompanied by frank dislocation, holds substantial untoward clinical consequences, especially as less-forgiving advanced bearing implant designs come into ever more widespread use. Biomechanical aspects of impingement and dislocation have historically received relatively little scientific attention, although that situation is now rapidly changing. The present article reviews contemporary laboratory and clinical research on the impingement/dislocation phenomena, focusing particularly on how implant design variables, surgical implantation factors and patient activity each act individually and in concert to pose impingement and dislocation challenges. In recent years, several powerful new research methodologies have emerged that have greatly expanded the scope for clinical translation of systematic laboratory study. Transferring the findings from such research into yet better implant designs, and even better surgical procedures, offers encouragement that the clinical impact of this troublesome complication can be further reduced.
Fragility fractures in older people lead to significant morbidity and mortality. An initial fracture is a clear indicator for further fractures and therefore it is imperative that services should focus on secondary prevention for this vulnerable group of people. Despite shortfalls in current provision it should be possible to focus on effective interventions that will reduce future fracture risk through fracture liaison, specialist orthogeriatric care and falls services. Within Primary Care, case finding and medicines management offer proven opportunities that will contribute and impact on successful service delivery. All aspects need to be founded on the identification of priorities and standards and require a coordinated multidisciplinary approach with clear pathways of communication across the relevant health care system.
Fractures of the elbow comprise 5% of fractures. Most are minimally displaced and can be managed conservatively. Displaced fractures or those associated with elbow dislocation are likely to require operative intervention. Displaced distal humeral fractures present a particular clinical challenge. Elbow stiffness is the most common complication and can follow seemingly innocuous/minimally displaced fractures.
Total hip replacement is a very successful operation which relieves pain of an arthritic hip. Increasingly patients are demanding more than just pain relief from their replaced joints and challenging the surgeons and the implants used to deliver high function as well as longevity. This challenge can be achieved by using modern implants and perhaps more importantly by restoring the normal anatomy, biomechanics and kinematics of the hip during implantation.
The menisci of the knee are complex structures with various important functions within the knee. Loss of the menisci leads to a significantly increased risk of developing degenerative changes in the long term. To fully understand the role of the menisci it is necessary to have an appropriate understanding of their anatomy, microstructure, material/mechanical properties and biomechanical function. This review will give a brief outline of both the underlying principles involved as well as giving some detail explaining the behaviour in-vivo of these complex and important structures.
Osteoporotic fractures cause excess mortality, substantial morbidity and health and social service expenditure in older people. The risk of these fractures is determined by skeletal factors, including bone mineral density (BMD), bone turnover, architecture, bone size, and skeletal geometry, together with non-skeletal factors associated with falling. With the advent of treatments which decrease the incidence of fractures and the development of strategies for preventing falls, there is growing interest in identifying people at high risk of fragility fractures, in whom to target therapeutic intervention. The World Health Organization (WHO) has recently developed a Fracture Risk Assessment Tool (FRAX™). This uses clinical risk factors, including prior fracture after age of 50 years, parental hip fracture, current smoking, oral steroid therapy, alcohol intake >2units/day and chronic conditions such as rheumatoid arthritis, with or without femoral neck BMDt, to estimate the ten year probability of hip and other major osteoporotic fractures.
Compression neuropathies around the elbow are a common clinical problem. Any of the three major nerves can be involved (ulnar, radial, median). The pathology in compression neuropathy goes through stages that reflect the clinical presentation and prognosis following treatment. The diagnosis is not always clear and electrophysiological studies can be helpful to confirm the diagnosis. Treatment of compression neuropathies can be conservative or surgical. Surgery usually means decompression of the nerve and this allows return of the nerve physiology and functions and relief of symptoms. This article includes the main types of compression neuropathies around the elbow and clarifies the diagnostic process and the treatment options.
Femoral head size remains one of the most controversial and oft debated aspects of hip replacement surgery. Sir John Charnley set the debate in motion in his paper on Low Friction Arthroplasty with the emphasis on finding the ideal head size to reduce friction and therefore, it was thought, wear. As our understanding of tribology improved and with the development of more wear-resistant materials, the emphasis has shifted towards finding the ideal size to improve joint stability. The ability to use large diameter heads has provided an opportunity to expand the indications for total hip arthroplasty to include trauma and younger patients.
Because of its improved wear-resistance, crosslinked polyethylene is now regarded as a desirable technology for hip articulations. In the present review, we focus specifically on applications of crosslinked polyethylene in the hip. We begin with an overview of the basic science concepts and terminology surrounding crosslinked polyethylene and the two main thermal processing techniques, which involve either annealing or remelting the polymer after irradiative crosslinking. The second part of the review is a critical assessment of the peer-reviewed literature on the subject of femoral head penetration and wear in crosslinked polyethylenes measured in clinical studies.
Posterior Lumbar Interbody Fusion (PLIF) may be indicated for intractable back pain, as it maintains adequate distraction of the intervertebral space thus relieving pressure on the nerve root. Iliac crest autografts, allografts and porous metallic cages are used.Success rates of above 90% have been reported, but complications due to the operative approach have been described. White biomechanically PLIF is superior to simple disc excision in relieving intractable back pain, the procedure is technically difficult in the presence of scar tissue from previous surgery. A proper understanding of operative principles and appropriate patient selection is essential to achieve good results. As an alternative technique, Anterior Lumbar Interbody Fusion (ALIF) has advocates. (C) 2008 Elsevier Ltd. All rights reserved.
Clubfoot or congenital talipes equinovarus is a common congenital abnormality of uncertain aetiology. It presents with fixed cavus, adductus, varus and equinus of the foot. Serial manipulation and casting using the Ponseti technique can produce a plantigrade, pain-free, functional foot in the majority of cases in the long term. Most patients treated this way will require only minimal surgery, such as Achilles tenotomy, dramatically reducing the need for extensive, open releases. Recurrent and complex clubfoot can also be treated by the Ponseti technique but some challenging cases still require surgical correction. Those that resist primary or revision operations can be salvaged by arthrodesis but the long term results are less predictable. This review will summarise the current theories on aetiology and pathogenesis, assessment and management according to the Ponseti regime, surgical options for primary clubfoot and recurrences and possible future directions.
Total knee arthroplasty (TKA) surgery is a widely used treatment and has a high success rate. Despite its success, the patello-femoral articulation has been overlooked as a contributor to the successful outcome of TKA. Patello-femoral complications remain the leading cause of failed knee replacement, accounting for up to 10% of complications. To understand the concept of patellar mal-tracking, we explore the normal anatomy and biomechanics of the patello-femoral articulation, and review the surgical factors and complications related to patellar tracking, with an aim to discussing the concepts on how to avoid such complications. Surgeons should be aware of the frequent occurrence of abnormal patellar tracking, and should pay particular attention to the patello-femoral component of knee replacement surgery.
