Transient Peroneal Nerve Palsy Research Articles

Autologous Nonvascularized Fibula Graft and Locking Compression Plating for Failed Fixation of Humeral Shaft With Atrophic Gap Nonunion.

IntroductionThe surgical treatment of humeral shaft atrophic, gap nonunion following failed surgical fixation is challenging. We intended to evaluate the surgical outcome of failed fixation of humeral shaft atrophic, gap nonunions using locking compression plate (LCP) and autologous nonvascularized fibular graft (ANVFG) and autologous iliac crest bone graft (AICBG). MethodsThrough our database search between 2015 and 2018, we identified 12 patients with humeral shaft atrophic, gap nonunions with failed surgical fixation underwent open reduction and internal fixation using LCP with autologous fibula graft and iliac crest cancellous bone graft. ResultsWe have followed all twelve patients for a minimum period of 24 months. All patients had radiological and clinical union with a mean time to union of 17 weeks. In one case superficial surgical site infection was noted and successfully treated with intravenous antibiotics, and in another, transient peroneal nerve palsy was identified and resolved in six months. ConclusionLCP with ANVFG and AICBG is a reliable option for “complex” diaphyseal humerus atrophic and gap non unions, especially with significant bone loss. This construct provides mechanical stability and supports biological healing in these complex fractures.

Revisiting the Pedicled Gastrocnemius Flap for Orthoplastic Limb Reconstruction

INTRODUCTION: Gastrocnemius muscle flap is performed in a combined approach of the orthopaedic and plastic team for limb reconstruction in the developed countries. However, this practice is not readily available in Malaysia because of the smaller numbers of plastic surgery services in government hospitals. This study reviews the outcome of the gastrocnemius flap performed by the orthopaedic team. MATERIALS AND METHODS: Thirty-two patients underwent gastrocnemius flap surgery with a mean age of 35.3 years (range 13-82). The flaps were done to cover the upper third (22), upper half (4), knee (2), distal femur (2) and the popliteal fossa (1). The initial problems were open fracture (21), infection following plating (5), necrotising fasciitis (3), degloving injury (1), pin site infection (1) and melioidosis (1). Five patients were having underlying Diabetes mellitus, 3 Hepatitis B, 2 HIV and 1 Hepatitis C infections. RESULTS: There was no flap necrosis. Complications include persistence infection in 3 patients which required advancement of the flap (1) and additional fasciocutaneous flap (2) to cover the wound breakdown. All fractures achieved union but one patient with infection following double plating for tibial plateau fracture developed chronic osteomyelitis. One patient develops transient peroneal nerve palsy following the lateral gastrocnemius transfer. Both patients who had patella ligament reconstruction with gastrocnemius flap develop knee stiffness. CONCLUSIONS: Gastrocnemius flap is a reliable and safe procedure in salvaging the leg from amputation related to open fractures and infections in orthopaedic surgery. It should be one of the options for the operative procedure thought during the orthopaedic training.

THE ANALGESIC EFFICACY OF A STANDARDIZED LOCAL INFILTRATION ANALGESIA TECHNIQUE OVER EQUIVALENT EPIDURAL ANALGESIA IN TOTAL KNEE ARTHROPLASTY AND A COMPARATIVE ANALYSIS WITH MOST CITED RCTs

Background: Managing postoperative pain in TKA is a challenge and needs an imperative strategy to bring maximal knee function early, with minimal side effects and less hospital stay. Though local infiltration analgesia emerged as a potent alternative, consensus on whether local infiltration analgesia offers clinically relevant pain relief is still lacking due to inconsistent studies and lack of standardization. The present study is an attempt to deduce the analgesic efficacy of a standardized single-shot local infiltration analgesia (LIA) with epidural analgesia with comparative analysis of previous most cited studies. Study Design & Methods: This is a prospective, randomized clinical trial done in n=74 patients with moderate to severe arthritis (Mean OKS - 15.24, SD 6.153) undergoing unilateral primary TKA in the south Indian population in a single center. The choice of analgesia, surgical technique, postoperative medications, and rescue analgesia and rehabilitation protocol on both groups are kept identical. In the LIA group, the CPN area is carefully avoided. The primary outcome is postoperative pain at rest and at activity, knee flexion and mobilization time quantified for 72hrs postoperatively. The student t-test, the chi-square test is used for analysis. Results: The LIA group had significantly lower mean VAS scores at rest (P = <0.001) and during activity (p= < 0.001) for 72 hrs postoperatively, and the mean difference in knee flexion angle is low (7.20 ± 1.07) yet higher in LIA on D0 and a significantly better knee flexion angle is noted at postoperative D1 & D2 (P=0.001, 0.005). The mobilization time is significantly lower in the LIA group (P = <0.001) with a mean difference of 14.50 ± 6.236 hrs. Conclusions: The multimodal local infiltration analgesia offers better pain relief, ROM and earlier mobilization than epidural analgesia if consistently standartized, facilitating rehabilitation and early return to day to day activities with lesser side effects and no transient peroneal nerve palsy if used methodically.

To study outcome in patients of extra articular distal tibia fractures managed with interlocking nail

As surface of tibia is subcutaneous along most of its length and its vascular supply of tibia is perilous compared to any other bone surrounded by heavy muscles? These type of fracture are often associated with compartment syndrome or neuro-vascular injuries. As there is existence of hinge joint at the knee and the ankle that permits no adjustment for rotational deformity after fracture, distinctive care is being required during reduction of these type of fractures to correct such deformity. The problems associated with fixation of distal tibia fractures include local and deep infections, local implant irritation, knee pain, stiffness of ankle, transient peroneal nerve palsy, malalignment and subsequent malunion and non-unionThis study deals with the ability to maintain a mechanically stable reduction in extraarticular distal one third tibia fractures managed with intramedullary nailing.Materials and Methods: This was a hospital based prospective study on the outcome in 20 patients of extra articular distal one-third tibia fractures, who will be admitted in the Department of Orthopaedics of Muzaffarnagar Medical College, Muzaffarnagar over a period of 18 months.Results: Mean age of patients was 39.05 years (18-80). Fracture union was seen radiologically within 3 to 6 months depending upon the pattern of fracture.Conclusion: We conclude that fractures of extraarticular distal one-third tibia with or without associated fractures of fibula managed with closed intramedullary nailing had least number of complications, allows early partial weight bearing and 95% of the patients achieved union by the end of 6 months. Thorough planning and placement of the nail at the center of a wide metaphysis in anteroposterior and lateral view is essential to overcome varus, valgus and posterior tilt.

Erratum: Total Knee Arthroplasty for Fixed Valgus Deformity Correction Using a Modified Lateral Parapatellar Approach

Total knee arthroplasty (TKA) for patients with valgus deformity (> 10 degrees) is technically challenging and has produced variable clinical results in terms of deformity correction, instability, and overall outcomes. The lateral parapatellar approach (LPA) is an alternative to the traditional medial parapatellar approach with potential advantages of direct access for release of tight lateral ligamentous structures with preservation of the medial structures, optimized patellar tracking, preserved medial blood supply to the patella, and less use of constrained implants. We present a case series of a single institution's experience with use of a modified LPA using a Z-capsuloplasty for 35 primary TKA cases in 30 patients with osteoarthritis and Ranawat's type-II fixed valgus deformity with attenuation of medial soft tissues. The mean age of patients was 64.8 years (range: 42–78 years). Follow-up duration was a mean of 47.3 months (range: 3–130 months). The patients were assessed pre- and postoperatively using radiographic measurement of the anatomic femorotibial angle (FTA) and clinical measurement of range of motion (ROM) and the Chinese knee society score (KSS). Complications and reoperations were recorded. The mean coronal alignment was corrected from 20.4 degrees of valgus (range: 11.3–42 degrees) preoperatively to 7.0 degrees of valgus (range: 3.6–15.1 degrees) postoperatively. One case required use of a constrained condylar design implant. At a mean of 47.3 months, the mean Knee Society objective and functional scores improved to 91.8 ± 6.6 and 84.3 ± 18.2 points, respectively. Mean ROM was 94.9 degrees preoperatively and 105.7 degrees postoperatively. Three cases (8.6%) had postoperative complications, including transient common peroneal nerve palsy, hematoma, and deep infection. One patient underwent two-stage revision for infection. There were no cases of late instability. The modified LPA using a Z-capsuloplasty is a reproducible and effective surgical technique for performing TKA in the setting of osteoarthritis and severe valgus deformity.

Two-stage total hip arthroplasty following skeletal traction after extensive soft tissue release for severe limb-length discrepancy.

To maximise limb-length discrepancy (LLD) resolution during total hip arthroplasty (THA) for untreated developmental hip dysplasia or septic hip sequelae, THA following limb lengthening was introduced using different methods. We aimed to evaluate 2-stage THA results following limb lengthening via skeletal traction after extensive soft tissue release. In total, 24 hips with severe LLD in 10 men and 14 women (mean age, 49.6 ± 15.2 years) underwent 2-stage THA and were followed thereafter (mean 6.3 ± 3.7 years). The entire abductor muscle origin was subperiosteally released from the ilium, and the soft tissue around the hip joint, including the psoas tendon, short external rotator, joint capsule, and adductor tendon, was extensively released. 2-stage THA was performed after 2-week skeletal traction using proximal tibial pins. During the final THA, 7 hips necessitated subtrochanteric shortening osteotomy (STO) for hip joint reduction. We evaluated the clinical and radiological results and especially focused on LLD and neurological complications. The Harris Hip Score improved from 57.1 ± 9.6 to 88.3 ± 6.3 points. No patients showed worse abductor power. LLD improved from 5.0 ± 2.0 to 1.4 ± 1.0 cm. No permanent neurological complications occurred except for 1 transient peroneal nerve palsy during traction, which resolved fully after cessation of traction. There were 2 hips with STO nonunion treated with osteosynthesis and stem revision. 2-stage THA following skeletal traction after extensive soft tissue release showed favourable results in terms of neurologic complication prevention and LLD resolution. However, a large proportion of patients still necessitated shortening osteotomy with a risk for nonunion at the osteotomy site. Though surgical procedures might be complicated and necessitate longer hospital stays, 2-stage THA with extensive soft tissue release might be an alternative treatment option for patients with severe LLD willing to resolve their limb length discrepancy.

Distal Femoral Extension Osteotomy with 90° Pediatric Condylar Locking Compression Plate and Patellar Tendon Advancement for the Correction of Crouch Gait in Cerebral Palsy.

Background:Various treatment modalities are available for the correction of crouch gait, ranging from hamstring lengthening to a combination of soft-tissue and bony procedures. We report the results of distal femoral extension osteotomy (DFEO) fixed with 90° pediatric condylar locking compression plate (LCP) and patellar tendon advancement (PTA) for crouch gait in children with cerebral palsy.Materials and Methods:A total of 26 patients (52 knees) with a mean age of 14.36 years (range 11.6–20 years) who presented with crouch gait were treated with DFEO and PTA. Patients were analyzed prospectively using clinical (knee flexion deformity, knee range of motion, extensor lag), functional (modified Ashworth, Tardieu scores, muscle strength, gross motor functional classification system [GMFCS], functional mobility scale [FMS], gross motor functional measure [GMFM]) and radiological (Koshino Index) outcome measures and followed up at a mean of 22 months (range 12–53 months).Results:There was an improvement in all outcome measures postoperatively, with improved function and independence. The mean knee flexion deformity improved significantly from 20.7° ± 6.59 to 0.67° ± 2.62, mean muscle strength of quadriceps improved from 3.01 ± 0.5 to 3.5 ± 0.54 and mean extensor lag improved from 20° ± 7.14 to 4.13° ± 4.16. The mean Koshino Index improved from 1.4 ± 0.16 to 1.0 ± 0.08. The mean GMFM-D improved from 15.58 ± 6.2 to 26.31 ± 5.8 and mean FMS for 5 m improved from 2.9 ± 1.09 to 3.6 ± 0.84, indicating significant improvement in household ambulation. There were four complications; transient peroneal nerve palsy in 3 patients, which recovered completely and 1 superficial wound dehiscence. There was no loss of fixation, tendon pull-out or deep infection.Conclusion:The combined procedure of DFEO and PTA can correct knee flexion deformity, restore knee extensor strength, and improve function in patients with crouch gait. The pediatric condylar LCP provides stable fixation to allow early mobilization and faster rehabilitation.

Shortening subtrochanteric osteotomy and cup placement at true acetabulum in total hip arthroplasty of Crowe III\u2013IV developmental dysplasia: results of midterm follow-up

IntroductionThe anatomic abnormalities in developmental dysplasia of hip (DDH) often make total hip replacement (THR) inevitable at a younger age. However, there is no universal gold standard technique of THR for high dislocated dysplastic hips.Materials and methodsHere we present the outcomes of midterm follow-up after THR in patients diagnosed with DDH Crowe type III and IV hospitalized in a tertiary center in Iran for whom placement of a cup in true acetabulum and selective transverse subtrochanteric osteotomy was performed. Pre- and postoperative Harris Hip Score, leg length discrepancy and postoperative complications were evaluated.ResultsA total of 48 patients with DDH Crowe type III and IV (uni- or bilateral which made 52 hips) were studied. Mean age of patients was 41 years with minimum follow-up ranging from 12 months to 3 years. Mean Harris Hip Score significantly improved from 41.70 preoperatively to 88.1 at last follow-up postoperatively. Leg length discrepancy of less than 2 cm was observed which was well tolerated using shoe lifts. Regarding postoperative complications, two patients had transient peroneal nerve palsy in early postoperative period which recovered within 2 months. No other major complication was encountered.ConclusionTHR in patients with DDH (Crowe III and IV) with a cup positioned in true acetabulum and transverse subtrochanteric osteotomy is a safe successful procedure.

15 Years Review of Gastrocnemius Flap Done in Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Kuantan

Introduction: Gastrocnemius flap is the workhorse for wound coverage in the proximal tibia. It can be perform by general orthopaedic surgeon because it is done without the need of microscopic instrumentation. Its coverage can be extended to cover the knee and midshaft of tibia when skin overlying it is included in the flap. Materials and method: From July 2002 till January 2017, 47 patients underwent gastrocnemius flap in our hospital (26 muscular and 21 musculocutaneous flap). 41 flaps were raised from medial, 5 lateral and 1 from both muscle belly. There were 41 males and 6 females with the mean age of 21.4 years old (range 13-82). The flaps were done to cover upper third (29), upper half (6), midshaft tibia (6), knee (2) and distal femur (1). The initial problems were open fracture (30), infection following plating (9), necrotising fasciitis (4), degloving injury (2), pin site infection (1) and melioidosis (1). Eight patients have underlying Diabetes mellitus, 2 Hepatitis B, 3 HIV or 1 COAD. Two patients have sciatic nerve palsy. Results: There was no flap necrosis. Complications include persistence infection in 6 patients which require repeated debridement (5), below knee amputation (1), advancement of flap (1) and additional fasciocutaneous flap (1). Two patients with gastrocnemius musculocutaneous flap had partial failure of skin graft that heals with dressing. One patient develops transient peroneal nerve palsy following the lateral gastrocnemius transfer. Conclusion: Gastrocnemius flap is a reliable and safe procedure in orthopaedic surgery. Problems that occur are associated with inadequate debridement and underestimate the size of flap required.

Surgical Hip Dislocation is Safe and Effective Following Acute Traumatic Hip Instability in the Adolescent.

A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients. This is a retrospective analysis of a consecutive series of patients presenting with nonconcentric reduction after traumatic hip instability. All patients were treated with a transtrochanteric SHD with concomitant procedures based on intra-articular findings. Radiographic evaluations and Harris Hip Scores were completed at final follow-up. Eleven male patients, mean age of 12.3 years (range, 9.3 to 16.1 y) and mean body mass index 19.6 kg/m (range, 15.4 to 28.0 kg/m). Intraoperative findings included: labral tear (8), femoral cartilage injury (5), acetabular rim fracture (4), acetabular cartilage delamination (3), loose body (2), and femoral head osteochondral fracture (1). Postoperatively, 1 patient developed a transient peroneal nerve palsy. At a mean 24.5 months (range, 12.0 to 48.1 mo) postoperatively, no hips have radiographic evidence of osteonecrosis. The mean lateral center edge angle was 20 degrees (range, 9 to 38 degrees) with 6 hips of <20 degrees; mean acetabular index 9 degrees (range, -2 to 23 degrees) with 5 hips of >10 degrees; mean α-angle 56 degrees (range, 48 to 62 degrees) with 6 hips of >55 degrees; mean acetabular version 12 degrees (range, 8 to 16 degrees) with 8 hips of <15 degrees. At 1-year follow-up, the mean Harris Hip Score was 95.8 (range, 84.7 to 100). Early results suggest that SHD is a safe approach to treat an incomplete reduction following posterior hip instability and is effective for identification and treatment of acute intra-articular pathology. Acetabular dysplasia, relative acetabular retroversion, and/or decreased femoral offset may be risk factors for posterior hip instability in adolescents. Level IV.

Tibial lengthening with a submuscular plate in adolescents.

Lengthening over an intramedullary nail has become a common technique for reducing the period of external fixation. However, the technique presents difficulties in patients with an open physis or a small marrow canal. Lengthening using a submuscular plate offers a new substitute in such situations, but few studies have been undertaken to determine its efficacy in teenagers. A retrospective review was performed on 20 consecutive tibiae of 16 patients who underwent tibial lengthening with the aid of external fixator and submuscular plate. Charts and radiographs were reviewed for demographics, surgical details, and complications related to the technique. The average age of the 16 patients was 14.3 years (range 10-17), and the amount of lengthening averaged 4.1 cm (range 3.0-5.0 cm), which represented 12.7 % of preoperative bone length (range 9.1-15.8 %). Mean time in the fixator was 60.3 days, mean external fixation index was 14.8 days/cm (range 13.2-22.5 days/cm), and mean healing index was 49.1 days/cm (range 37-59.3 days/cm). Twenty-seven complications occurred giving an overall complication rate of 1.35. Twenty of the 27 were minor complications, but 7 were major. These major complications were resolved surgically or by a resolution period exceeding 3 months. There were 3 cases of transient angular deformity of distraction callus, 2 cases of transient peroneal nerve palsy, 1 case of clamp loosening, and 1 case of plate failure. Functional results were good or excellent with an average score of 95.6 according to modified Paley's criteria. Although complications were not uncommon, tibial lengthening with a submuscular plate proved to be a reliable technique for treating limb length discrepancy in adolescents with reduced external fixation duration. Level IV, case series.

Total knee arthroplasty for severe valgus knee deformity

Background Primary total knee arthroplasty (TKA) in severe valgus knees may prove challenging, and choice of implant depends on the severity of the valgus deformity and the extent of soft-tissue release. The purpose of this study was to review 8 to 11 years (mean, 10 years) follow-up results of primary TKA for varient-III valgus knee deformity with use of different type implants. Methods Between January 2002 and January 2005, 20 women and 12 men, aged 47 to 63 (mean, 57.19±6.08) years old, with varient-III valgus knees underwent primary TKA. Of the 32 patients, 37 knees had varient-III deformities. Pie crusting was carefully performed with small, multiple inside-out incisions, bone resection balanced the knee in lieu of soft tissue releases that were not used in the series. Cruciate-retaining knees (Gemini MKII, Link Company, Germany) were used in 13 knees, Genesis II (Simth &amp; Nephew Company, USA) in 14 knees, and hinged knee (Endo-Model Company, Germany) in 10 knees. In five patients with bilateral variant-III TKAs, three patients underwent 1-stage bilateral procedures, and two underwent 2-stage procedures. All implants were cemented and the patella was not resurfaced. The Hospital for Special Surgery (HSS) knee score was assessed. Patients were followed up from 8 to 11 years. Results The mean HSS knee score were improved from 50.33±11.60 to 90.06±3.07 (P &lt;0.001). The mean tibiofemoral alignment were improved from valgus 32.72°±9.68° pre-operation to 4.89°±0.90° post-operation (P &lt;0.001). The mean range of motion were improved from 93.72°±23.69° pre-operation to 116.61±16.29° post-operation (P &lt;0.001). No patients underwent revision. One patient underwent open reduction and internal fixation using femoral condylar plates for supracondylar femoral fractures secondary to a fall at three years. Three patients developed transient peroneal nerve palsies, which resolved within nine months. Two patients developed symptomatic deep vein thrombosis that was managed with rivaroxaban and thrombo-embolic deterrent stockings. There was no incidence of pulmonary embolism. Postoperative patient satisfaction was 80.7±10.4 points in the groups. Prosthetic survival rate was 100% at mean 10 years postoperative. Conclusions Not only hinged implants can be successfully used in variant-III valgus knees. As our results show, if proper ligament balancing techniques are used and proper ligament balance is attained, the knee may not require the use of a more constrained components. Our results also present alternative implant choices for severe knee deformities.

External fixation for closed pediatric femoral shaft fractures: where are we now?

Recent advances in external fixation technique and pin design have sought to minimize complications such as pin site infection and premature removal of the external fixator. Although newer forms of internal fixation have gained popularity, external fixation may still have a role in managing pediatric femoral shaft fractures. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of pediatric patients with closed femoral shaft fractures who were treated with external fixation. Over a 15-year period, one surgeon treated 289 pediatric patients with femur fractures, 31 (11%) of whom received an external fixator. The general indications for use of an external fixator during the period in question included length-unstable fractures, metadiaphyseal location, refracture, and pathologic fracture. Six patients (19%) had inadequate followup data and four patients (13%) were treated with a combination of flexible intramedullary nails and external fixation, leaving 21 patients for analysis. Mean age at injury was 10years (range, 6-15years) and followup averaged 22months (range, 5-45months) after removal of the fixator. Radiographs were examined for alignment and limb length discrepancy. Complications were recorded from a chart review. Mean time in the fixator was 17weeks (range, 9-24weeks). One patient sustained a refracture and one patient with an isolated femur fracture had a leg length discrepancy>2cm. There were no pin site infections requiring intravenous antibiotics or additional surgery. One patient with Blount disease and previous tibial osteotomy developed transient peroneal nerve palsy. Despite improvements in pin design and predictable fracture healing, complications such as refracture and leg length discrepancy after external fixation of pediatric femoral shaft fractures can occur. However, external fixation remains a viable alternative for certain fractures such as length-unstable fractures, metadiaphyseal location, pathologic fractures, and refractures. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Total knee arthroplasty treatment of rheumatoid arthritis with severe versus moderate flexion contracture

BackgroundThis study aims to explore the technique of soft tissue balance and joint tension maintenance in total knee arthroplasty (TKA) for the rheumatoid arthritis (RA) patients with flexion contracture of the knee.MethodsThis retrospective study reviewed flexion contracture deformity of RA patients who underwent primary TKA and ligament and soft tissue balancing. Based on the flexion contracture deformity, the remaining 76 patients available for analysis were divided into two groups, i.e., severe flexion group (SF) and moderate flexion group (MF).ResultsThere were no intraoperative complications in this study. All patients had improved Knee Society Rating System scores and range of motion. The flexion contracture was completely corrected in MF and SF patients. There were no cases of patellar dislocation, but three cases had mild mediolateral instability in severe flexion group. Four knees (two knees in SF versus two knees in MF) had transient peroneal nerve palsy but recovered after conservative therapy.ConclusionsTKA can be performed successfully in the RA knees with severe flexion contracture. It is very important in TKA to maintain the joint stability in the condition of severe flexion contracture deformity of the RA knee.

Early Results of the Bernese Periacetabular Osteotomy for Symptomatic Dysplasia in Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth disease (CMTD) is one of the most common inherited neurologic disorders and can be associated with hip dysplasia. Little is known regarding outcomes of the PAO for patients with CMTD. Our purpose is to document the early results and complications of the PAO for hip dysplasia associated with CMTD. A two centre, retrospective clinical and radiographic review was performed. Demographic and surgical data were recorded. Pre- and postoperative lateral centre edge angle (LCEA), acetabular index (AI), ventral centre edge angle (VCEA), and Tönnis osteoarthritis grade were compared. Hips were classified according to Severin. The Harris Hip Score (HHS) and the Western Ontario and McMasters University (WOMAC) index documented self-reported function. Nineteen hips in 14 patients underwent PAO, mean age 16.2 (range 11.2-21 years). Thirteen concomitant procedures were performed, including seven proximal femoral osteotomies. Average follow-up was 3.4 years (range 0.9-8.5). Postoperative radiographic measurements significantly improved. Complications included femoral head AVN, transient complete bilateral peroneal nerve palsy, inferior rami fractures, and heterotopic ossification (Brooker stage 3). The HHS significantly improved from a mean 49.6 preoperatively to 82.2 at final follow-up of four patients. Seven subjects reported a mean postoperative WOMAC score of 94 (range 58.3-100). Most patients presented with severe dysplasia in the second decade of life. The PAO successfully corrected the radiographic abnormalities. Complications were common. The majority of patients reported improved outcomes, although seven showed signs of radiographic progression of osteoarthritis.

Strategies to Prevent Positioning-Related Complications Associated with the Lateral Suboccipital Approach

The lateral positioning used for the lateral suboccipital surgical approach is associated with various pathophysiologic complications. Strategies to avoid complications including an excessive load on the cervical vertebra and countermeasures against pressure ulcer development are needed. We retrospectively investigated positioning-related complications in 71 patients with cerebellopontine angle lesions undergoing surgery in our department between January 2003 and December 2010 using the lateral suboccipital approach. One patient postoperatively developed rhabdomyolysis, and another presented with transient peroneal nerve palsy on the unaffected side. Stage I and II pressure ulcers were noted in 22 and 12 patients, respectively, although neither stage III nor more severe pressure ulcers occurred. No patients experienced cervical vertebra and spinal cord impairments, brachial plexus palsy, or ulnar nerve palsy associated with rotation and flexion of the neck. Strategies to prevent positioning-related complications, associated with lateral positioning for the lateral suboccipital surgical approach, include the following: atraumatic fixation of the neck focusing on jugular venous perfusion and airway pressure, trunk rotation, and sufficient relief of weightbearing and protection of nerves including the peripheral nerves of all four extremities.

Single-Stage Flexor Tendon Transfer for the Treatment of Severe Concomitant Peroneus Longus and Brevis Tendon Tears

Although peroneal tendon injuries are a common cause of lateral ankle pain, there is a paucity of literature specifically addressing the treatment of severe concomitant peroneus longus and brevis tears. The purpose of this study was to evaluate patient outcomes following a single-stage flexor tendon transfer for the treatment of severe concomitant tears of both peroneal tendons. Eight patients were treated with a single-stage flexor tendon transfer for severe concomitant peroneus longus and brevis tears over a 15-year period. Mean age at the time of surgery was 54 years (range, 41-67 years), including 4 male and 4 female patients. Tendon transfer of either the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) was performed when both peroneal tendons were found intraoperatively to have severe nonreconstructable tears. Mean follow-up time from surgery was 58 months (range, 12-91 months). Preoperative and postoperative AOFAS hindfoot and visual analog pain scores were prospectively collected, and patient charts were reviewed for complications. A postoperative outcome questionnaire was administered during latest follow-up to assess return to activities, satisfaction, and self-rated patient outcome. Mean pre- and postoperative AOFAS hindfoot scores increased from 64 (range, 54-77) to 86 (range, 69-100), whereas mean score for pain on a visual analog scale decreased from 4.2 (range, 0.5-6) to 0.7 (range, 0-3). One surgical complication occurred following FDL transfer in a patient who developed a transient peroneal nerve palsy, and 1 patient underwent a subsequent calcaneal osteotomy. Seven of 8 patients reported a return to preoperative activity levels, and no patient required bracing for activities of daily living. All patients reported satisfaction with surgical results, and 7 rated their outcomes as good or excellent. Single-stage flexor tendon transfer is an effective surgical option for the treatment of severe concomitant peroneus longus and brevis tendon tears. Level IV, case series.

Resection and Arthrodesis of the Knee Joint for Giant Cell Tumours of Bone

To evaluate functional outcomes and complications following resection and arthrodesis of the knee for giant cell tumours (GCTs) of bone, in comparison to treatment by endoprosthetic replacements reported elsewhere. 18 men and 14 women aged 18 to 40 (mean, 28) years underwent resection and arthrodesis of the knee for GCTs of bone involving the distal femur (n=17) and proximal tibia (n=15). After wide resection, 2 struts were fashioned from the harvested fibula/ fibulae and inserted into the medullary canal at the resected ends of the tibia and femur. The corresponding ends of the struts were inserted into peg holes made in the unaffected condyles in a divergent fashion. The knee was arthrodesed in 5 to 10 degrees of flexion, with the limb kept 1 cm short. A 95-degree AO condylar bladeplate (10-12 holes) was fixed at the resected ends, with a minimum of 8 cortices purchase. Cancellous bone grafts were placed transversely along the struts and circumferentially over the host-graft junctions. Outcomes and complications were evaluated and compared with those of endoprosthetic arthroplasty reported elsewhere. Patients were followed up for a mean of 8 (range, 3-12) years. The mean size of the tumours was 10x8x6 cm. All patients achieved arthrodesis and full weight bearing without pain within 6 to 10 (mean, 6) months. No shortening, loss of alignment, loosening, implant breakage ensued. One patient had a deep infection and absorption at the host-graft junction. Another had a stress fracture of the fibular strut after plate removal. Two patients had a transient peroneal nerve palsy. One patient had local recurrence and extensive fungation and underwent amputation. The mean functional score was 26 (87% of the full score), compared to 66 to 85% in endoprosthetic arthroplasty reported elsewhere. Arthrodesis is a viable alternative to customised arthroplasty and provides a long-lasting and cost-effective reconstruction for average patients in developing countries.

Evaluation of interlocking intramedullary nailing in distal tibial fractures and nonunions

The aim of this study was to evaluate the results of interlocking intramedullary nailing in the treatment of extra-articular distal tibial fractures and nonunions. The study included 45 patients (mean age 42 years; range 27 to 52 years) who were treated with interlocking intramedullary nailing for distal tibial fractures (n=35) and nonunions (n=10). Of 35 fractures, 31 were closed and four were open. The fractures were AO A1 (n=27), A2 (n=6), and A3 (n=2). In addition, two patients had medial, and 14 patients had lateral malleolus fractures. A Gross-Kempf (Howmedica) nail was used in 38 patients and an Expert nail (Synthes) was used in seven patients. Dynamic nailing was performed in 22 patients and static nailing was performed in 23 patients. No grafting was used. The patients were assessed clinically and radiographically within a mean follow-up period of 37 months (range 24 to 60 months). Union was achieved in all the patients within a mean of 4.6 months (range 3 to 7 months). Dynamization was required in three patients. The mean time to union was 4.4 months (range 3 to 6 months) with dynamic nailing and 4.8 months (range 3 to 7 months) with static nailing. Complications were not serious. Transient peroneal nerve palsy developed in one patient (2.2%). Knee pain was seen in four patients (8.9%) due to the protrusion of the nail and it disappeared after removal of the nail. Five patients (11.1%) had limitation of ankle movements in a range of 5 to 10 degrees. None of the patients had restriction in knee motion. Intramedullary interlocking nailing is a reliable method of treatment for distal tibial fractures and nonunions, with a high rate of union and low complication rate.

Total Hip Arthroplasty in Chronic Unreduced Hip Fracture-Dislocation

We treated 15 patients with chronic unreduced hip fracture-dislocations at our hospital; all patients sustained the fracture-dislocations in motor vehicle accidents. All presented to our institution more than 6 months after initial treatment at their local hospitals with uncontained femoral heads; all underwent 1-stage total hip arthroplasty with bone grafting. These patients were monitored for a mean of 71.5 months (range, 36-96 months). All patients had significantly decreased pain, increased function, and increased range-of-motion scores using the Merle d'Aubigné scoring system. All grafts showed radiographic evidence of union. There were 2 dislocations, 1 transient peroneal nerve palsy, and 1 superficial infection. Total hip arthroplasty is effective for relieving pain and restoring function in chronic unreduced hip fracture-dislocations.