- Email: [email protected]
Herbert screw fixation of osteochondral fractures of the patella
116
Injury:
others (Arons, 1984). Ten per cent of chronic schizophrenics commit suicide and between 18 and 55 per cent attempt suicide (Roy, 1986). It is unusual even in psychotic patients for self-inflicted neck injuries to be extensive and most are caused by accidents (Parulekar, 1974). This is the first reported case with such severe self-inflicted neck injury and cerebrospinal fluid leakage. The treatment of an open cervical fracture with dural wound must include accurate neurological assessment, antimicrobials, stabilization of the cervical spine as necessary and water-tight dural closure with close attention to wound toilet and primary repair of the wound. In this case, tension air encephalocele also required treatment by temporary ventricular drainage. Requests
Oxford
the British Journal of Accident Surgery (1988) Vol. 19/No. 2
REFERENCES
Arons M. S., Lattanzi W. E. et al. (1984) Severe selfmutilation of hands in a nonpsychotic, nonretarded patient. Plast. Reconstr. Surg. 74, 282. Gee D. J. (1972) Two suicidal transfixions of the neck. Med. Sci. Law. 12, 171.
Parulekar S. S. (1974) Open injuries of the neck front. J. Laryngol. Otol. 88, 1195. Roy A. (1986) Depression, attempted suicide, and suicide in patients with chronic schizophrenia. Psychiatr. Clin. North Am. 9, 193.
Stefaniu A., Romascanu G. et al. (1973) Glossopharyngeal neuralgia causing tonsillar autotraumatism. (Author’s translation.) Otorinolaringologie 18, 453. Paper accepted 17 September
1987.
for reprints shoufd be uddressed to: Mr P. J. Teddy, Department of Neurological Surgery, Radcliffe Infirmary, Woodstock Road,
OX2 6HE.
Herbert screw fixation of osteochondral fractures of the patella P. S. Rae and 2. M. Khasawneh Ayr County Hospital, Ayr Summary
INTRODUCTION
Two cases of osteochondral fractures of the patella are presented. These osteochondral fractures have been reduced and fixed with the Herbert scaphoid screw. This screw has several advantages over conventional methods of treatment of osteochondral fractures in that the screw is entirely buried in the bony fragment and no portion of the screw lies proud. The differential pitch of the two threads in the screw allows interfragmentary compression. The size of the screw is such that minimal articular cartilage damage is incurred in inserting the screw and this method of treatment does not require a second arthrotomy for removal of the screws.
OSTEOCHONDRAL
fractures
of the patella
are not com-
mon injuries. They occur in adolescents and they are the result of a shear force applied to the patella as it crosses the lateral femoral condyle during patellar dislocation (Rorabeck and Bobechko, 1976 Rockwood and Green, 1984). Rorabeck and Bobechko (1976) estimate that osteochondral fractures occur in around 5 per cent of dislocations of the patella and they stated that these osteochdndral fractures can occur alone or in combination with osteochondral fractures of the lateral femoral condyle. Because of their rarity and the difficulty often experienced in identifying the defect from the standard radiographs of the knee, skyline views of the patella are usually necessary (McDougall and Brown, 1968; Rorabeck and Bobechko 1976; Rockwood and Green, 1984). Early diagnosis and treatment is desirable and
Figs. 1,2. Case I. Radiographs showing, on the lateral view, a large osteochondral in the medial femoral condyle (arrowed). @ 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/0201l&O4 $03,00
fracture and, on the skyline view, the defect
Case reports
117
various techniques have been suggested including excision of the fragment and excision of the fragment plus realignment of the extensor mechanism (Rorabeck and Bobechko, 1976), but most authors agree that if the fragment is large enough, it should be replaced (King, 1970; Smillie, 1978; Rockwood and Green, 1984; Rees and Thomson, 1985). We present two cases where large osteochondral fractures of the patella have been treated by operative bone screw. fixation with the Herbert differential-pitch CASE REPORTS
Postoperatively she was treated in a wool and crepe bandage and allowed to move the knee freely, but without weight bearing. By 2 weeks postoperatively, she had achieved 90” of knee flexion and by 6 weeks postoperatively, full active movements had been regained and full weight bearing was permitted. At 6 months postoperatively, she had no symptoms in the knee. On examination there was no effusion and she had recovered full quadriceps bulk. She had a full range of active movement in the knee and the radiograph showed the fracture to have healed with the Herbert bone screws in situ (Figs. 3 and 4). She was last seen in June 1987 and the knee remains asymptomatic.
Case 1
In June 1986, a lCyear-old girl injured her left knee while playing football. The exact mechanism of injury was unclear but it was sustained during a tackle. She presented that day with a tense haemarthrosis of the knee which was aspirated. A radiograph revealed on the lateral view, and more clearly on the skyline view, an osteochondral fracture of the medial facet of the patella (Figs. 1 and 2). Arthrotomy was performed the following day and a large 3cmX2cm osteochondral fracture of the patella was identified. It was reduced and fixed with two Herbert bone screws.
Case 2
A 15year-old boy presented in November 1986 having injured his right knee by twisting it while kicking a football. Examination revealed a tense haemarthrosis and radiographs revealed an osteochondral fracture of the medial facet of the patella which was obvious only on the skyline patellar view (Figs. 5 and 6). Arthrotomy was performed the day following injury and a 2 cm X 1.5 cm osteochondral fracture identified, This frac-
4
6
Figs. 3, 4. Case I. Lateral and skyline view 6 months postoperatively showing healing of the fracture and the Herbert screws in situ.
Figs. 5, 6. Case 2. Radiographs showing, on the lateral view, no evidence of the osteochondral fracture but, on the skyline view, the defect at the medial femoral condyle (arrowed).
118
Injury: the British Journal of Accident Surgery (1988) Vol. 191No. 2
was reduced and fixed with two Herbert bone screws. Postoperatively, he was treated in wool and crepe bandage and allowed to move the knee freely but without weight bearing for a period of 6 weeks. At 2 months postoperatively the knee was symptom free. At that state he could flex the knee actively from O-150” but he still had some quadriceps wasting. Four months postoperatively, he was again playing football when he twisted on the knee and sustained a further episode of patellar subluxation. This resulted in a recurrence of an effusion in the knee joint which improved with physiotherapy. Radiographs of the knee taken immediately following this episode of subluxation show that there had been no change in the position of the osteochondral fracture which appeared to be healing with the Herbert screws in situ (Figs. 7 and 8). ture
DISCUSSION
The Herbert bone screw was designed initially for the treatment of scaphoid fractures (Herbert and Fisher, 1984; Ford et al., 1987). The screw is designed with a thread at each end to allow the screw to be completely buried within the bone. The threads are designed with different pitches which has the effect of compression across the fracture line as the screw is turned fully home. Applications for its use other than in scaphoid fractures have been expanded and its use has been reported in small joint fusions in the hand (Faithful1 and Herbert, 1984) and in the fixation of radial head fractures (Bunker and Newman, 1985). Its use in the
fixation of osteochondral fractures has, to our knowledge, not yet been reported. The difficulties in diagnosis of osteochondral fractures of the patella are well known because of their relative rarity (Rorabeck and Bobechko, 1976) and because they are often not visible on standard anteroposterior and lateral radiographs of the knee. Skyline views of the patella are usually required for their diagnosis (McDougall and Brown, 1968; Rockwood and Green, 1984). This difficulty was amply illustrated in the second of these two cases where the osteochondral fracture was only obvious on the skyline view of the patella. Having been diagnosed, various treatments are possible. These include excision of the free fragment which is advisable only if the fragment is small, since it is known that small defects heal well by fibrocartilage but larger defects do not (Convery et al., 1972). The concept of continuous passive motion resulting in better healing of these small defects could perhaps be utilized in the treatment of these smaller osteochondral fractures (Salter et al., 1980). Rorabeck and Bobechko (1976) recommended excision of the fragment and patellar realignment to prevent further patellar dislocations but they state that only one of their 18 osteochondral fractures was large enough to merit replacement. The fact that Case 2 has had one further episode of patellar subluxation adds weight to the view that patellar realignment should be carried out. Most authors agree that if the fragment is large, it should be replaced and fixed (King, 1970; Smillie, 1978; Rockwood and Green, 1984; Rees and Thomson, 1985). It has also been shown that when healing has occurred, these lesions are indistinguishable from the surrounding articular cartilage (Smillie, 1978) and that if compression can be applied, microscopic healing occurs by a tissue which appears histologically to be identical to hyaline cartilage (Mitchell and Shepard, 1980). Fixation with Smillie pins has traditionally been the method of choice but their use required a second arthrotomy to remove them because of their tendency to migrate and to cause synovitis if they protruded (Smillie, 1978; Rockwood and Green, 1984). Porous coated pins of similar dimensions were developed to overcome this problem of migration (Cameron et al., 1974) and methods of intra-osseus wiring have been
Figs. 7, 8. Case 2. Anteroposterior and skyline radiographs 6 months postoperatively and f&owing patellar subluxation (showing healing of the fracture and the Herbert screws in situ).
one further episode of
Case reports
119
developed (Rees and Thomson, 1985). AO-ASIF screws could be used but with the relatively large head there would have to be considerable excavation of the articular cartilage to allow the screw head to be countersunk to prevent it sitting proud (Muller et al., 1979). Again, the use of these implants would require a second arthrotomy for their removal. The use of the Herbert screw in this situation has many advantages over other methods. The screw is of a small diameter and therefore creates a minimal defect in the articular cartilage for its introduction. The screw is designed to be embedded in the bone with no portion
of the screw protruding, thus avoiding the problem of local irritation. The screws have shown no tendency to loosen in these two cases and therefore a second arthrotomy is not required for removal of the implants. This screw compresses the fragments and this should allow physiological healing of the articular cartilage. We would recommend the use of the Herbert bone screw for fixation of large osteochondral fractures. REFERENCES Bunker T. D. and Newman J. H. (1985) The Herbert differential pitch bone screw in displaced radial head fractures. injury 16, 621 Cameron H. U., Piliar R. M. and MacNab I. (1974) Fixation of loose bodies in joints. Clin. Orthop. 100, 309. Convery F. R., Akeson W. H. and Keown G. H. (1972) The repair of large osteochondral defects. Clin. Orthop. 82,
the hand using the Herbert bone screw. J. Hand Surg. 9B, 167. Ford D. J., Khoury G. et al. (1987) The Herbert screw for fractures of the scaphoid. J. Bone Joint Surg. 69B, 124. Herbert T. J. and Fisher W. E. (1984) Management of the fractured scaphoid using a new bone screw. J. Bone Joint Surg. 66B, 114. King D. (1970) Osteochondral fractures of the knee J. Bone Joint Surg. 53B, 356.
McDougall A. and Brown recurrent dislocation of 50B, 841. Mitchell N. and Shepard cartilage in intra-articular
J. D. (1968) Radiological signs of the patella. J. Bone Joint Surg. N. (1980) Healing of articular fractures in rabbits. J. Bone Joint
Surg. 62A, 628.
Muller M. E., Allgower
M., Schneider
R., et al. (1979) Heidelberg,
Manual of internal Fixation, 2nd ed. Berlin,
New York, Springer Verlag, 30. Rees D. and Thompson S. K. (1985) Osteochondral fractures of the patella. J. R. Call. Surg. Edinb. 30(2), 88. Rockwood C. A. Jr and Green D. P. (1984) Fractures in Children, 2nd ed. Philadelphia, J. P. Lippincott Co., 936. Rorabeck C. H. and Bobechko W. P. (1976) Acute dislocation of the patella with osteochondral fracture. J. Bone Joint Surg. 56B, 237. Salter R. B., Simmonds D. F. et al. (1980) The biological effects of continuous passive motion on the healing of full thickness defects in articular cartilage. J. Bone Joint Surg. 62A, 1232.
Smillie I. S. (1978) Injuries of the Knee Joint. 5th ed. Edinburgh, Churchill Livingstone, 291.
253.
Faithful1 D. C. and Herbert T. J. (1984) Small joint fusions of
Paper accepted 31 July 1987.
Requestsfor reprints should be addressed to: Mr P. S. Rae, Consultant Orthopaedic Surgeon, Ayr County Hospital, Ayr KA7 3AY.
Development fracture
of a Charcot joint after intertrochsntwic
D. W. H. Mok St George’s Hospital, London
A. Cashyap and C. J. Good Newham
General Hospital, London
CASE REPORT An 85year-old Caucasian man was diagnosed as having tabes dorsalis in 1968 after he had presented with a neuropathic bladder, needing long-term catheterization. He was admitted after he had had a fall and was found to have sustained an intertrochanteric fracture of his left femur (Fig. 1). The fracture was reduced and internally fixed by a compression screw and plate (Fig. 2u, b). He made satisfactory progress and was discharged 2 weeks later with a walking frame. Three months later, he presented with bilateral swollen legs. On examination he appeared well and apyrexial. The left hip was found to be warm, but had a full range of pain-free movements. Radiographs of the left hip showed the Screw cutting out of the femoral head with hypertrophic osseous debris around the joint (Fig. 3). Laboratory investigations showed a raised ESR of 45 mm/ 1st hour and raised alkaline phosphatase of 646 units (80-280 units). A venogram confirmed bilateral deep vein thrombosis. He was treated with rest in bed followed by gradual mobi-
lization. At the time of discharge 3 months later, he required a frame for walking indoors and a wheelchair for outdoors. At 1 year from operation, he had no pain in his hip. There was 40’ of flexion and other movements were grossly limited. Radiographs showed an increase in bony debris around the hip (Fig. 4).
DISCUSSION In 1967, Johnson reviewed 118 patients with Charcot joints and made the following observations: 1. Over 50 per cent of fractures of the femoral neck in tabetics developed Charcot joints. 2. Untreated, the fracture usually failed to unite and a neuropathic joint invariably followed. 3. If treated by replacement, dislocation of the prosthesis with or without destruction of the joint was most likely. This was thought to be because surgery added further trauma to the soft tissue around the joint. 0 1988 Butterworth L Co (Publishers) Ltd 0020-1383/88/020119-03 $0340
Injury:
others (Arons, 1984). Ten per cent of chronic schizophrenics commit suicide and between 18 and 55 per cent attempt suicide (Roy, 1986). It is unusual even in psychotic patients for self-inflicted neck injuries to be extensive and most are caused by accidents (Parulekar, 1974). This is the first reported case with such severe self-inflicted neck injury and cerebrospinal fluid leakage. The treatment of an open cervical fracture with dural wound must include accurate neurological assessment, antimicrobials, stabilization of the cervical spine as necessary and water-tight dural closure with close attention to wound toilet and primary repair of the wound. In this case, tension air encephalocele also required treatment by temporary ventricular drainage. Requests
Oxford
the British Journal of Accident Surgery (1988) Vol. 19/No. 2
REFERENCES
Arons M. S., Lattanzi W. E. et al. (1984) Severe selfmutilation of hands in a nonpsychotic, nonretarded patient. Plast. Reconstr. Surg. 74, 282. Gee D. J. (1972) Two suicidal transfixions of the neck. Med. Sci. Law. 12, 171.
Parulekar S. S. (1974) Open injuries of the neck front. J. Laryngol. Otol. 88, 1195. Roy A. (1986) Depression, attempted suicide, and suicide in patients with chronic schizophrenia. Psychiatr. Clin. North Am. 9, 193.
Stefaniu A., Romascanu G. et al. (1973) Glossopharyngeal neuralgia causing tonsillar autotraumatism. (Author’s translation.) Otorinolaringologie 18, 453. Paper accepted 17 September
1987.
for reprints shoufd be uddressed to: Mr P. J. Teddy, Department of Neurological Surgery, Radcliffe Infirmary, Woodstock Road,
OX2 6HE.
Herbert screw fixation of osteochondral fractures of the patella P. S. Rae and 2. M. Khasawneh Ayr County Hospital, Ayr Summary
INTRODUCTION
Two cases of osteochondral fractures of the patella are presented. These osteochondral fractures have been reduced and fixed with the Herbert scaphoid screw. This screw has several advantages over conventional methods of treatment of osteochondral fractures in that the screw is entirely buried in the bony fragment and no portion of the screw lies proud. The differential pitch of the two threads in the screw allows interfragmentary compression. The size of the screw is such that minimal articular cartilage damage is incurred in inserting the screw and this method of treatment does not require a second arthrotomy for removal of the screws.
OSTEOCHONDRAL
fractures
of the patella
are not com-
mon injuries. They occur in adolescents and they are the result of a shear force applied to the patella as it crosses the lateral femoral condyle during patellar dislocation (Rorabeck and Bobechko, 1976 Rockwood and Green, 1984). Rorabeck and Bobechko (1976) estimate that osteochondral fractures occur in around 5 per cent of dislocations of the patella and they stated that these osteochdndral fractures can occur alone or in combination with osteochondral fractures of the lateral femoral condyle. Because of their rarity and the difficulty often experienced in identifying the defect from the standard radiographs of the knee, skyline views of the patella are usually necessary (McDougall and Brown, 1968; Rorabeck and Bobechko 1976; Rockwood and Green, 1984). Early diagnosis and treatment is desirable and
Figs. 1,2. Case I. Radiographs showing, on the lateral view, a large osteochondral in the medial femoral condyle (arrowed). @ 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/0201l&O4 $03,00
fracture and, on the skyline view, the defect
Case reports
117
various techniques have been suggested including excision of the fragment and excision of the fragment plus realignment of the extensor mechanism (Rorabeck and Bobechko, 1976), but most authors agree that if the fragment is large enough, it should be replaced (King, 1970; Smillie, 1978; Rockwood and Green, 1984; Rees and Thomson, 1985). We present two cases where large osteochondral fractures of the patella have been treated by operative bone screw. fixation with the Herbert differential-pitch CASE REPORTS
Postoperatively she was treated in a wool and crepe bandage and allowed to move the knee freely, but without weight bearing. By 2 weeks postoperatively, she had achieved 90” of knee flexion and by 6 weeks postoperatively, full active movements had been regained and full weight bearing was permitted. At 6 months postoperatively, she had no symptoms in the knee. On examination there was no effusion and she had recovered full quadriceps bulk. She had a full range of active movement in the knee and the radiograph showed the fracture to have healed with the Herbert bone screws in situ (Figs. 3 and 4). She was last seen in June 1987 and the knee remains asymptomatic.
Case 1
In June 1986, a lCyear-old girl injured her left knee while playing football. The exact mechanism of injury was unclear but it was sustained during a tackle. She presented that day with a tense haemarthrosis of the knee which was aspirated. A radiograph revealed on the lateral view, and more clearly on the skyline view, an osteochondral fracture of the medial facet of the patella (Figs. 1 and 2). Arthrotomy was performed the following day and a large 3cmX2cm osteochondral fracture of the patella was identified. It was reduced and fixed with two Herbert bone screws.
Case 2
A 15year-old boy presented in November 1986 having injured his right knee by twisting it while kicking a football. Examination revealed a tense haemarthrosis and radiographs revealed an osteochondral fracture of the medial facet of the patella which was obvious only on the skyline patellar view (Figs. 5 and 6). Arthrotomy was performed the day following injury and a 2 cm X 1.5 cm osteochondral fracture identified, This frac-
4
6
Figs. 3, 4. Case I. Lateral and skyline view 6 months postoperatively showing healing of the fracture and the Herbert screws in situ.
Figs. 5, 6. Case 2. Radiographs showing, on the lateral view, no evidence of the osteochondral fracture but, on the skyline view, the defect at the medial femoral condyle (arrowed).
118
Injury: the British Journal of Accident Surgery (1988) Vol. 191No. 2
was reduced and fixed with two Herbert bone screws. Postoperatively, he was treated in wool and crepe bandage and allowed to move the knee freely but without weight bearing for a period of 6 weeks. At 2 months postoperatively the knee was symptom free. At that state he could flex the knee actively from O-150” but he still had some quadriceps wasting. Four months postoperatively, he was again playing football when he twisted on the knee and sustained a further episode of patellar subluxation. This resulted in a recurrence of an effusion in the knee joint which improved with physiotherapy. Radiographs of the knee taken immediately following this episode of subluxation show that there had been no change in the position of the osteochondral fracture which appeared to be healing with the Herbert screws in situ (Figs. 7 and 8). ture
DISCUSSION
The Herbert bone screw was designed initially for the treatment of scaphoid fractures (Herbert and Fisher, 1984; Ford et al., 1987). The screw is designed with a thread at each end to allow the screw to be completely buried within the bone. The threads are designed with different pitches which has the effect of compression across the fracture line as the screw is turned fully home. Applications for its use other than in scaphoid fractures have been expanded and its use has been reported in small joint fusions in the hand (Faithful1 and Herbert, 1984) and in the fixation of radial head fractures (Bunker and Newman, 1985). Its use in the
fixation of osteochondral fractures has, to our knowledge, not yet been reported. The difficulties in diagnosis of osteochondral fractures of the patella are well known because of their relative rarity (Rorabeck and Bobechko, 1976) and because they are often not visible on standard anteroposterior and lateral radiographs of the knee. Skyline views of the patella are usually required for their diagnosis (McDougall and Brown, 1968; Rockwood and Green, 1984). This difficulty was amply illustrated in the second of these two cases where the osteochondral fracture was only obvious on the skyline view of the patella. Having been diagnosed, various treatments are possible. These include excision of the free fragment which is advisable only if the fragment is small, since it is known that small defects heal well by fibrocartilage but larger defects do not (Convery et al., 1972). The concept of continuous passive motion resulting in better healing of these small defects could perhaps be utilized in the treatment of these smaller osteochondral fractures (Salter et al., 1980). Rorabeck and Bobechko (1976) recommended excision of the fragment and patellar realignment to prevent further patellar dislocations but they state that only one of their 18 osteochondral fractures was large enough to merit replacement. The fact that Case 2 has had one further episode of patellar subluxation adds weight to the view that patellar realignment should be carried out. Most authors agree that if the fragment is large, it should be replaced and fixed (King, 1970; Smillie, 1978; Rockwood and Green, 1984; Rees and Thomson, 1985). It has also been shown that when healing has occurred, these lesions are indistinguishable from the surrounding articular cartilage (Smillie, 1978) and that if compression can be applied, microscopic healing occurs by a tissue which appears histologically to be identical to hyaline cartilage (Mitchell and Shepard, 1980). Fixation with Smillie pins has traditionally been the method of choice but their use required a second arthrotomy to remove them because of their tendency to migrate and to cause synovitis if they protruded (Smillie, 1978; Rockwood and Green, 1984). Porous coated pins of similar dimensions were developed to overcome this problem of migration (Cameron et al., 1974) and methods of intra-osseus wiring have been
Figs. 7, 8. Case 2. Anteroposterior and skyline radiographs 6 months postoperatively and f&owing patellar subluxation (showing healing of the fracture and the Herbert screws in situ).
one further episode of
Case reports
119
developed (Rees and Thomson, 1985). AO-ASIF screws could be used but with the relatively large head there would have to be considerable excavation of the articular cartilage to allow the screw head to be countersunk to prevent it sitting proud (Muller et al., 1979). Again, the use of these implants would require a second arthrotomy for their removal. The use of the Herbert screw in this situation has many advantages over other methods. The screw is of a small diameter and therefore creates a minimal defect in the articular cartilage for its introduction. The screw is designed to be embedded in the bone with no portion
of the screw protruding, thus avoiding the problem of local irritation. The screws have shown no tendency to loosen in these two cases and therefore a second arthrotomy is not required for removal of the implants. This screw compresses the fragments and this should allow physiological healing of the articular cartilage. We would recommend the use of the Herbert bone screw for fixation of large osteochondral fractures. REFERENCES Bunker T. D. and Newman J. H. (1985) The Herbert differential pitch bone screw in displaced radial head fractures. injury 16, 621 Cameron H. U., Piliar R. M. and MacNab I. (1974) Fixation of loose bodies in joints. Clin. Orthop. 100, 309. Convery F. R., Akeson W. H. and Keown G. H. (1972) The repair of large osteochondral defects. Clin. Orthop. 82,
the hand using the Herbert bone screw. J. Hand Surg. 9B, 167. Ford D. J., Khoury G. et al. (1987) The Herbert screw for fractures of the scaphoid. J. Bone Joint Surg. 69B, 124. Herbert T. J. and Fisher W. E. (1984) Management of the fractured scaphoid using a new bone screw. J. Bone Joint Surg. 66B, 114. King D. (1970) Osteochondral fractures of the knee J. Bone Joint Surg. 53B, 356.
McDougall A. and Brown recurrent dislocation of 50B, 841. Mitchell N. and Shepard cartilage in intra-articular
J. D. (1968) Radiological signs of the patella. J. Bone Joint Surg. N. (1980) Healing of articular fractures in rabbits. J. Bone Joint
Surg. 62A, 628.
Muller M. E., Allgower
M., Schneider
R., et al. (1979) Heidelberg,
Manual of internal Fixation, 2nd ed. Berlin,
New York, Springer Verlag, 30. Rees D. and Thompson S. K. (1985) Osteochondral fractures of the patella. J. R. Call. Surg. Edinb. 30(2), 88. Rockwood C. A. Jr and Green D. P. (1984) Fractures in Children, 2nd ed. Philadelphia, J. P. Lippincott Co., 936. Rorabeck C. H. and Bobechko W. P. (1976) Acute dislocation of the patella with osteochondral fracture. J. Bone Joint Surg. 56B, 237. Salter R. B., Simmonds D. F. et al. (1980) The biological effects of continuous passive motion on the healing of full thickness defects in articular cartilage. J. Bone Joint Surg. 62A, 1232.
Smillie I. S. (1978) Injuries of the Knee Joint. 5th ed. Edinburgh, Churchill Livingstone, 291.
253.
Faithful1 D. C. and Herbert T. J. (1984) Small joint fusions of
Paper accepted 31 July 1987.
Requestsfor reprints should be addressed to: Mr P. S. Rae, Consultant Orthopaedic Surgeon, Ayr County Hospital, Ayr KA7 3AY.
Development fracture
of a Charcot joint after intertrochsntwic
D. W. H. Mok St George’s Hospital, London
A. Cashyap and C. J. Good Newham
General Hospital, London
CASE REPORT An 85year-old Caucasian man was diagnosed as having tabes dorsalis in 1968 after he had presented with a neuropathic bladder, needing long-term catheterization. He was admitted after he had had a fall and was found to have sustained an intertrochanteric fracture of his left femur (Fig. 1). The fracture was reduced and internally fixed by a compression screw and plate (Fig. 2u, b). He made satisfactory progress and was discharged 2 weeks later with a walking frame. Three months later, he presented with bilateral swollen legs. On examination he appeared well and apyrexial. The left hip was found to be warm, but had a full range of pain-free movements. Radiographs of the left hip showed the Screw cutting out of the femoral head with hypertrophic osseous debris around the joint (Fig. 3). Laboratory investigations showed a raised ESR of 45 mm/ 1st hour and raised alkaline phosphatase of 646 units (80-280 units). A venogram confirmed bilateral deep vein thrombosis. He was treated with rest in bed followed by gradual mobi-
lization. At the time of discharge 3 months later, he required a frame for walking indoors and a wheelchair for outdoors. At 1 year from operation, he had no pain in his hip. There was 40’ of flexion and other movements were grossly limited. Radiographs showed an increase in bony debris around the hip (Fig. 4).
DISCUSSION In 1967, Johnson reviewed 118 patients with Charcot joints and made the following observations: 1. Over 50 per cent of fractures of the femoral neck in tabetics developed Charcot joints. 2. Untreated, the fracture usually failed to unite and a neuropathic joint invariably followed. 3. If treated by replacement, dislocation of the prosthesis with or without destruction of the joint was most likely. This was thought to be because surgery added further trauma to the soft tissue around the joint. 0 1988 Butterworth L Co (Publishers) Ltd 0020-1383/88/020119-03 $0340