Bergkamp, A.B.M.

Verhaar, J.A.N. (Jan)

AB Bergkamp

JA Verhaar

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Journal of Bone and Joint Surgery - British Volume

Dislocation of the coccyx: a case report

Erasmus University Digital Repository

to walk, but attended five hours later because of persistentpain in the anal region.On examination a step was palpable at the level of theFig. I Fig. 2 Fig. 3BRIEF REPORTS 831VOL. 77-B. No. 5. SEPTEMBER 995long leg brace. Radiographs at 18 months (Fig. lb) con-firmed sound union of the tibia.Discussion. Healey et al ( 1990) used percutaneous bone-marrow grafting for delayed union or nonunion after exten-sive en-bloc resections and reconstructions of primary sar-comas of bone and reported good results. We have used thistechnique experimentally in rabbits (Sharma et al 1992) andfound increased callus production, with early healing ofradial osteotomies and bony defects. The technique has alsobeen used as a substitute for open cancellous bone graftingfor nonunion; approximately 90% success was reported byConnolly et al (199 1) and Garg, Gaur and Sharma(1993).We believe our case to be the first of its type to bereported. The result was encouraging but the type of suit-able patient, and the timing, volume and frequency of bone-marrow injections required will need further studies.No benefits in any form have been received or will be received from acommercial party related directly or indirectly to the subject of thisarticle.REFERENCESConnolly iF, Guse R, Tiedeman J, Dehne R. Autologous marrowinjection as a substitute for operative grafting of tibial nonunions. C/inOrthop 1991:266:259-70.Garg NK, Gaur S, Sharma S. Percutaneous autogenous bone marrowgrafting in 20 cases of ununited fracture. Acta Orthop ScandI 993:64:671-2.Healey JH, Zimmerman PA, McDonnell JM, Lane JM. Percutaneousbone marrow grafting of delayed union and nonunion in cancerpatients. C/in Orthop 1990:256:280-5.Sharma 5, Garg NK, Veliath AJ, Subramanian S, Srivastava KK.Percutaneous bone-marrow grafting of osteotomies and bony defectsin rabbits. Acta Orthop Scand 1992:63:166-9.DISLOCATION OF THE COCCYX: A CASE REPORTA. B. M. BERGKAMP, J. A. N. VERHAARA 26-year-old woman presented after a fall down stairswith her three-month-old baby in her arms. She landed in asitting position. Immediately after the accident she was ableA. B. M. Bergkamp. MD. Senior ResidentJ. A. N. Verhaar, MD, PhD. Orthopaedic SurgeonDepartment of Orthopaedic Surgery. University Hospital, P0 Box 5800,6202 AZ Maastricht, The Netherlands.Correspondence to Dr J. A. N. Verhaar.01995 British Editorial Society of Bone and Joint Surgery0301 -620X195/5R46 $2.(X)J Bone Joint Surg (Br] 1995:77-B:831-2.Received /2 August 1993: Accepted after revision 8 November 1994sacrococcygeal joint. There was no sign of neurologicaldamage. On rectal examination, the painful displacement ofthe joint was confirmed. Radiographs showed an anteriordislocation of the coccyx from the sacrum (Fig. 1). Afterlocal infiltration of 2% Lidocaine into the dislocated joint,an attempt was made to reduce the dislocation manually,taking care to avoid damage to the rectal mucosa. Thismanoeuvre proved unsuccessful and the patient was pre-832 BRIEF REPORTSTHE JOURNAL OF BONE AND JOINT SURGERYpared for an open procedure. Under general anaesthesia andin the knee-elbow position, a central incision was madeover the dislocated joint. There was a local haematomawith minor damage to the periosteum. The coccyx wasfound to be displaced ventrally and 1 cm proximally. Distaltraction alone proved ineffective but reduction was ach-ieved using a raspatory as a lever. The sacrum and coccyxwere fixed together using four vicryl sutures as tensionbands (Fig. 2). Postoperative radiographs confirmed reduc-tion (Fig. 3).The patient was advised not to sit during the first sixweeks after surgery, but rehabilitation was uncomplicatedand she had no pain. Radiological examination at six weeksand six months after operation showed normal alignmentand at two years she had no complaint.Discussion. We have been unable to find any publication ofthis type of traumatic dislocation. Yamashita (1988) men-tioned the condition but his article was not published inEnglish. Fractures are more common, probably because ofthe normal strength of the ligaments.The need for surgical reduction may be questioned.Excision of the coccyx is performed for coccydynia(Tilscher et al 1986), but the application of the normalprinciples of trauma surgery led us to reduce the dislocationwith success.No benefits in any form have been received or will be received from acommercial party related directly or indirectly to the subject of thisarticle.REFERENCESTilscher H, Kantor H, Gangl W, Bogner G. Coccygodynia-a diagnosticand therapeutic problem in orthopaedics. Z Orthop 1986:124:628-32.Yamashita K. Radiological study of 1500 coccyces. Nippon-Seikeigeka-Gakkai-Zasshi 1988:62:23-36.TENOTOMY OF THE LIGAMENTUM PATELLAE IN SPINA BIFIDA:MANAGEMENT OF LIMITED FLEXION RANGE AT THE KNEEP. 5. SANDHU, N. S. BROUGHTON. M. B. MENELAUSAbout 5% of children with spina bifida have fixed exten-sion of the knee with limitation of flexion (Dupr#{233}andWalker 1972). This causes difficulty in the use of wheel-chairs, public seating and getting in and out of vehicles.When the child is small this can be overcome, but by theage of seven or eight years the length of the fixed lowerlimbs is increasingly awkward.Most of these children have no active quadriceps; theknees have a featureless appearance similar to that seen inarthrogryposis multiplex congenita (Birch 1977). In somethe quadriceps is spastic with a mixed spastic and voluntarypattern in the rest of the leg. We describe treatment forthese children by simple division of the ligamentumpatellae.Patients and methods. At the Royal Children’s Hospital,P. S. Sandhu, MB BS, MS. Orthopaedic FellowN. S. Broughton, FRCS Ed, FRCS, FRACS, Consultant OrthopaedicSurgeonM. B. Menelaus, MD, FRCS. FRACS. Senior Orthopaedic ConsultantOrthopaedic Department. The Royal Children’s Hospital, RemingtonRoad, Parkville, Victoria 3052, Australia.Correspondence to Dr M. B. Menelaus.©1995 British Editorial Society of Bone and Joint Surgery0301-620X/95/5R45 $2.00J Bone Joint Surg [Br] l995:77-B:832-3.Received 30 August 1994: Accepted after revision 3 November 1994Melbourne, 297 children with spina bifida born between1960 and 1987 have been examined and kept under review(Broughton et al 1993). Eight presented with limited rangeof flexion of the knee, causing difficulty with everydayactivities. Details are given in Table I.All operations were performed under general anaesthesiaby MBM. With the patient supine, a 1 cm longitudinalincision at the lateral edge of the ligamentum patellae ismade opposite the lower pole of the patella. Using retrac-tors the ligamentum patellae is exposed and divided. Thepatient is then moved so that the lower leg overhangs theend of the operating table. Division of the ligamentumpatellae generally produces 50#{176}to 70#{176}of flexion and byfurther division of the medial and lateral retinacula aflexion range of more than 90#{176}can be achieved. A secondincision is sometimes necessary.A plaster cylinder is applied at 90#{176}flexion. At two weeksthe plaster is bivalved and the posterior half used as a nightsplint for six weeks. During this time passive extension isregained by mobilisation under the direction of aphysiotherapist.Results. All patients had a satisfactory outcome in the longterm although three of the knees required further surgery(cases 6 and 8; Table I). All the children continued to walkafter surgery in knee-ankle-foot orthoses with pelvic bands.In line with our general experience of high-level spinabifida, walking ceased in adolescence but continued forbetween two and seven years after surgery. Case 5 con-

Dislocation of the coccyx: a case report

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