Anthony J. Bianco

Total hip arthroplasty with cement in patients less than twenty years old. Long-term results.

Sixty-three consecutive total hip arthroplasties were performed with cement in fifty adolescent patients from 1972 through 1980, and the results were determined after a minimum of ten years. A polyethylene cup without a metal backing and a non-modular femoral component with a collar and a fixed neck length were inserted, with use of so-called first-generation cementing techniques, in each hip. Kaplan-Meier survival analysis of all sixty-three hips demonstrated that the probability of failure (defined as revision or symptomatic loosening) increased steadily over time and reached 45 per cent after fifteen years. A number of specific variables were associated with a significantly higher probability of failure: a history of more than one previous procedure involving the hip (p = 0.0002), unilateral arthroplasty (p = 0.006), previous trauma involving the hip (p = 0.01), the absence of other disease that limited function of the ipsilateral lower extremity (p = 0.03), a high postoperative level of activity (involving moderate or strenuous manual labor) (p = 0.03), and a preoperative weight of more than sixty kilograms (p = 0.03). The probability of failure in the patients who had inflammatory arthritis (11 per cent) was significantly lower than that in those who had previous trauma involving the hip (47 per cent) (p = 0.0006). Fifty-two hips (forty patients) were followed for a minimum of ten years or until revision. The mean duration of follow-up for these fifty-two hips was 12.6 years (range, 1.6 to 18.6 years). The result was evaluated clinically and radiographically with use of the Mayo hip-scoring system and was graded as excellent in ten hips (19 per cent), good in sixteen (31 per cent), fair in one (2 per cent), and poor in twenty-five (48 per cent). Most of the poor results were due to symptomatic loosening of the acetabular component. The probability of radiographic loosening after fifteen years was 60 per cent for the acetabular component and 20 per cent for the femoral component. Radiographic evidence of polyethylene wear was associated with probable loosening of the acetabular component (p = 0.03). The findings of the present study suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. Fixation of the acetabular component with cement is not recommended in this setting.

Surgical implications of Klippel-Trenaunay syndrome.

Between January 1956 and July 1981, 40 patients with Klippel-Trenaunay syndrome were seen at the Mayo Clinic. Twenty male and 20 female patients presented with the classic triad of soft tissue and bony hypertrophy of the extremity, hemangioma, and varicosity without evidence of functional arteriovenous fistulae. The lower extremity was involved in 38 patients (95%), the upper extremity in six patients (15%). In four of these cases (10%), both the upper and lower extremities were affected. The disease was unilateral in 34 patients (85%), bilateral in five cases (12.5%), and crossed-bilateral in one case (2.5%). Surgery was done in 13 patients (32.5%), nine of whom were operated on at the Mayo Clinic and four of whom had had previous surgery elsewhere. Excision and stripping of varices were performed in three patients; of these three, a deterioration of symptoms was observed in one, but the procedure was beneficial in the other two. Partial varicectomy was performed in four cases, while resection of the angioma was attempted in eight cases, with good results in three cases of small angiomas. Femoral and tibial epiphysiodesis stopped the overgrowth and produced an excellent result in one case. In four cases of epiphysiodesis at the foot level and two cases of derotational tibial osteotomy, moderate improvement was achieved. The indication for vascular or orthopedic surgery should be carefully considered in each patient who has this syndrome. One patient (2.5%) died of a severe form of the disease, but the relatively benign course is documented by the 21 patients (52.5%) who are free of complaints without any treatment or with elastic support only.

COMPRESSION OF THE COMMON PERONEAL NERVE BY GANGLION CYSTS: REPORT OF NINE CASES.

The results and findings in nine cases of ganglion cyst involving the common peroneal nerve indicate that this condition should be kept in mind whenever a patient complains of pain, paresis, or sensory changes in the distribution of the common peroneal nerve or whenever a mass is noted posterolaterally to the head of the fibula. Only two of the nine patients in our series had poor recovery of motor function. Both had noted onset of foot drop at least one year before surgical exploration. The other seven patients with good or excellent recovery of motor function had undergone surgical exploration less than one year after onset of foot drop. At present, there is no substitute for early exploration and excision of the cyst from the nerve.

Benign Extraneural Soft-Tissue Tumors of the Extremities Causing Compression of Nerves

Thirty-two patients with benign soft-tissue tumors of the extremities, causing nerve compression, exclusive of neurogenic tumors, have been seen at the Mayo Clinic. The peak incidence of these lesions was in the fifth decade, and the most frequent symptoms and signs were progressive weakness of parts of an extremity and a palpable mass. The average period between the onset of symptoms and treatment in this group was 13.6 months. Trauma was probably of significance in two cases of occult bursal enlargement at the elbow. The ulnar nerve was the nerve most commonly involved in the group. Roentgenographic examination revealed the radiolucent soft-tissue mass characteristic of a lipoma in ten patients. Lipomata accounted for approximately half of the tumors in our series. In ten patients, the extraneural tumor was not demonstrable prior to surgical exploration. Treatment should consist in initial complete excision of the lesion with the double-tourniquet technique, with appropriate draping of the entire limb to allow for extra exposure of the nerve, if segmental resection and suture are necessary. A general anesthetic should be used, and the exploration should be performed by a team familiar with soft-tissue or neurogenic tumors. Neurolysis or translocation of the ulnar nerve may be required as well as simple excision of the tumor. Almost complete return of function should he achieved eventually provided that irreversible damage to the involved nerve has not been produced before operation. In the fourteen patients previously mentioned who noticed almost complete or complete return of function, the average duration for this return was three years with the extremes being three months and fourteen years.

Long-Term Outcome of Lumbar Discectomy in Children and Adolescents Sixteen Years of Age or Younger*

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.

Chronic posterior subluxation and dislocation of the radial head.

The clinical and radiographic features of chronic posterior subluxation or dislocation of the radial head were studied in thirty-four elbows of twenty-seven patients. Three characteristic radiographic types were noted: Type I, subluxation; Type II, posterior dislocation with minimum displacement; and Type III, posterior dislocation with substantial proximal migration of the radius. Follow-up of eighteen patients (twenty-one elbows) revealed that posterior displacement did not usually cause serious functional impairment except for loss of rotation of the forearm. The least common presentation, Type-I subluxation, caused pain and clicking and was associated with late degenerative arthritis. Cosmetic deformity due to prominence of the radial head was also a cosmetic problem, particularly with Type-III dislocation.

Abduction contracture of the shoulders and hips secondary to fibrous bands.

The first case of fibrosis of the gluteal muscles causing abduction contracture of the hips associated with fibrous bands in the deltoid muscles causing abduction deformity of the shoulders is reported. As with other cases of fibrous bands, surgical excision provided complete relief.

Possible detrimental effect of large doses of vitamin D in familial hypophosphatemic vitamin D-resistant rickets

Observations in presumably monozygotic twins with familial hypophosphatemicvitamin D-resistant rickets (FHVDRR) have shown that continued vitamin D therapy in one of the twins was associated with occurrence of pseudofractures and histologic evidence of active rickets; her untreated sister did not develop any pseudofractures, had a less severe defect histologically in bone mineralization, and had no evidence of an abnormally increased amount of osteoid. It is suggested that the efficacy of treatment of FHVDRR with high doses of vitamin D should be reinvestigated.

Low-Back Pain and Sciatica: Diagnosis and Indications for Treatment

Protruded intervertebral disc, the most common cause of low-back pain, must be excluded from various conditions and diseases which cause similar symptoms. The characteristic features of the the typical protruded intervertebral-disc syndrome, as well as some of the less common manifestations of the protruded disc, are presented. The most effective treatment for the patient with a protruded disc is rest in bed until the pain subsides. The sudden appearance and progressive development of a neurological deficit is an indications for prompt surgical treatment. A lack of improvement after an adequate trial of rest in bed is a second, but less absolute, indication for surgical treatment.

Treatment of Mild Slipping of the Capital Femoral Epiphysis

Slippinig of time capital femimom-al epiplmysis is a well established ortiiopaedic emmtity, but its exact etiology is umiknowmi. Time immmportammce of this conditiomm imi time growinmg adolescemit child as a cause of paimm immtime imip, lower extm’emmmity, aimd, particularly, time kmmee omm time immvolved side has beeim emmmpimasized in the litemature. Nomietimeless, slippimig of time capital femimoral epipimysis presemmts a difficult diagnostic pl’oI)ienim to pediatn’iciamms amid gemmeral physiciamms who am-c mmot coimstammtiy aware of this emmtity as a cause of paimiful hump iii adolescemmce.