Roger Atkins

INTRAVENOUS CLODRONATE IN THE TREATMENT AND RETREATMENT OF PAGET'S DISEASE OF BONE

The effects of short courses (5 days) of intravenous clodronate 300 mg daily were studied in 31 patients with active Pagets disease of bone. The diphosphonate induced a striking reduction in biochemical indices of disease activity, which was sustained for at least 6 months after withdrawal of treatment. Apparent resistance to further treatment in patients previously treated for Pagets disease was an artefact due to incomplete relapse before retreatment. There was no significant difference in the degree of suppression of alkaline phosphatase activity between patients given intravenous clodronate and 45 patients given clodronate 1.6 g daily by mouth for 6 months. Short-term intravenous clodronate provides a useful alternative strategy for the treatment of patients with Pagets disease.

Algodystrophy is an early complication of Colles' fracture: What are the implications?

One hundred patients who had sustained a Colles’ fracture were observed for features of algodystrophy at 1, 5, 9 and 12 weeks following injury. The diagnosis of algodystrophy was possible as soon as 1 week after fracture. Early diagnosis has important clinical implications: the aetiological factors may become apparent and different treatment modalities be identified; furthermore, early treatment can be started, limiting the morbidity of the condition. It is proposed that patients with features of algodystrophy require physiotherapy after a Colles’ fracture. Those without features may not.

COMPLEX REGIONAL PAIN SYNDROME

Complex regional pain syndrome (CRPS), previously termed ree ex sympathetic dystrophy (RSD) comprises abnormal pain, swelling, vasomotor instability, contracture and osteoporosis. It used to be considered a rare, sympathetically mediated, devastating complication of injury, seen mainly in psychologically-abnormal patients. Modern research has changed this view and this article summarises current understanding within an orthopaedic context. Terminology

Assessing outcome following calcaneal fracture: a rational scoring system

Six existing clinical scoring systems for assessing outcome after calcaneal fracture are reviewed. All were applied to a diverse group of 75 patients who had sustained this injury. Stepwise multiple regression analysis was used to identify the most relevant variables within these systems. Based on this, a simplified and rational outcome scoring system was devised. This system was then tested on a further group of 41 patients and shown to comply well with the characteristics required of an objective outcome score.

Computer hexapod assisted orthopaedic surgery (CHAOS) in the correction of long bone fracture and deformity

Summary: We describe a surgical technique using the Taylor Spatial Frame intraoperatively to correct complex multiplanar deformities of the distal femur prior to definitive internal fixation using minimally invasive stabilization techniques. Eight procedures were done in 7 patients. All deformities were complex oblique plane deformities, often with a rotational component, and ranged from 10 degrees valgus to 35 degrees varus; up to 45 degrees of external rotation; 10 mm of translation and in 1 case, 100 mm of shortening. All patients underwent acute intraoperative deformity correction mediated by the Taylor Spatial Frame prior to definitive internal fixation using either a percutaneous locking plate or locked intramedullary nail. Deformity correction and restoration of the mechanical axis were achieved in all cases. There were no cases of wound breakdown, infection, nerve palsy or compartment syndrome. We believe the Taylor Spatial Frame can be effectively and safely used to assist the acute correction and subsequent internal fixation of limb deformity.

The distal course of the sural nerve and its significance for incisions around the lateral hindfoot.

Twenty preserved cadaver limbs were dissected to show the distal course of the sural nerve and the number and site of origin of its branches. The mean position of the main nerve trunk was calculated at various points related to bony landmarks of the fibula and the fifth metatarsal base. Ninety-five percent confidence limits for the course of the main nerve trunk could be described. A fibula incision may damage the nerve if it extends more than 7 mm inferior to the lateral malleolar tip with the foot in equinus. Dorsolateral foot incisions may damage both the main trunk and the major anterior branch.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999–2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92–99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the “direct approach” which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Tumors around implants

In 1989, A. G. Apley recommended cautious surveillance of malignant tumors that developed in association with orthopaedic implants. This retrospective review of the Bristol Bone Tumour Register between 1980 and 1992 reports on 240 malignant soft tissue sarcomas. Eighteen developed in the thigh region of patients more than 50 years old, and 4 of these developed in the soft tissues around a hip arthroplasty.

Properties of tissue from around cemented joint implants with erosive and/or linear osteolysis

Levels of bone remodeling agents were measured in conditioned media from cultures of periprosthetic pseudosynovial membranes and related to the radiographic features of the failed joint implants. Radiographs of both cemented hip (n = 28) and cemented knee (n = 11) implants were examined and the pattern of radiolucency was classified as erosive linear, or mixed. Similar levels of interleukin-1-beta (IL-1 beta), interleukin-6, tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta-1, and prostaglandin E2 (PGE2) were found in pseudosynovial membrane conditioned media from all 3 groups of hips and the knee group (all linear). Significant correlations were evident only between PGE2 and TNF-alpha levels in the linear hip group and PGE2 and IL-1 beta levels in the knee group. A close correlation was found between IL-1 beta and TNF-alpha in both linear and erosive hips. It is suggested that coregulation of these bone remodeling agents differs with the radiographic appearance of the failed joint implants. As all the implants were cemented and the results contrast with those of others obtained with pseudosynovial membrane conditioned media from cementless implants, it is considered that cement critically influences the process of implant failure.

Bone-membrane interface in aseptic loosening of total joint arthroplasties

In 19 patients who underwent revision arthroplasty for aseptic loosening of total joint arthroplasty, specimens were taken at the time of operation to include the bone-membrane interface. In 16 (84%) of the specimens, sufficient visualization of the interface was possible to allow histologic interpretation. In 13 of these cases, there was prominent evidence of classic bone remodeling with osteoclast-mediated resorption and active new bone formation. These results suggest that the osteolysis in aseptic loosening is mediated through osteoclastic bone resorption and that the bone found in such areas is extremely active. The findings help to explain the efficacy of impacted morselized bone-graft in the treatment of bone lysis in aseptic loosening.