The aim of our study was to assess lateral tracking of the patella with differing designs of Total Knee Arthroplasty (TKA) and compare to that of the native patella. A modified caliper was used to measure the width and position of the patella relative to the femur at different degrees of knee flexion. The relationship of the patella midpoint to that of the femur was subsequently assessed. Group 1 consisted of 25 native knees. Group 2 consisted of 25 patients with antero-posterior stabilised knee implant with a spherical medial condyle and a deep lateralised patellar groove, and Group 3 consisted of 25 patients with a conventional cam-and-post design with a midline patellar groove. The mean follow-up was 28 months.Aim
Method
For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics.
Univariate analysis established a significant relationship between the need for postoperative transfusion and preoperative Hb levels (p<
0.0001), length of surgery (p=0.01), age (p=0.03), history of respiratory disease (p=0.028) and hypertension (p=0.01). There was no significant relationship with respect to ASA grade and procedure type. Multivariate logistic regression analysis revealed pre-operative Hb (p<
0.0001) and age (p=0.015) as the strongest predictors of the need for post-operative transfusion. There is a strong correlation between length of surgery and time interval to transfusion (p=0.037).
We investigated the hypothesis that autologous bone marrow stromal cells (BMSC) sprayed on the surface of acetabular cups would improve bone formation and bone implant contact. Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undcalcified histology. Implant bone contact in both groups was compared, by microscopically noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded. Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ±173.72 at the centre). Conversely direct bone contact with the implant surface was significantly greater around the cups with stem cells. BMSC sprayed on surface of implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.
Our aim was to ascertain the opinion of Orthopaedic Consultants, General Practitioners, and Patients on the proposed primary care based follow up of joint replacements. An email questionnaire was sent Orthopaedic Consultants registered with the BOA. Responders had to answer simple questions regarding follow up practices after hip and knee arthroplasty and safe alternatives to the existing system. General practitioners in London were sent a different questionnaire to assess their familiarity with follow up of arthroplasty patients and their competence in identifying complications. Finally, arthroplasty patients were directly questioned on their preference for follow up. Eigthy-one Orthopaedic Consultants who undertake lower limb arthroplasty responded, 89.06% advocated follow up and review of radiographs by the surgeon. The Arthroplasty Practitioner, the Radiologist and the Physiotherapist were deemed suitable for follow up of patients by 50%, 14.06% and 4.69 % respectively. All responders unanimously disagreed with initial follow up by General Practitioners (0%). However, after a 12 month review, 30.15% thought primary arthroplasty patients could be discharged to the care of their General Practitioner and 11.11% were happy to discharge revision arthroplasty patients. Of the 52 General Practitioners who returned our questionnaire, only 37% were confident of interpreting symptoms related to prosthetic loosening or infection and 98% did not feel competent identifying radiological changes after arthroplasty. 94% of the General Practitioners did not think that they would be happy to follow up arthroplasty patients even if they were offered further training. The reasons for this were lack of specialty skills, work-load concerns, funding issues and surgeons’ duty of care towards the patient. All of the 104 patients who were questioned preferred to be followed up by the arthroplasty team. In conclusion, Orthopaedic Surgeons, General Practitioners and patients prefer a hospital based dedicated Orthopaedic team for the post operative follow-up of arthroplasty patients.
Radiographs are frequently ordered following acute knee injury. However, it is suggested that only 6 % of patients with a knee trauma have a fracture. Decision rules such as the Ottawa rules and the Pittsburgh rules have been developed to reduce the unnecessary use of radiographs following knee injury. We prospectively reviewed all acute knee injury patients who were referred to our clinic from the emergency department over a 3 month period. The reason for ordering radiographs was analysed. The Ottawa and the Pittsburgh rules were applied to individual patients to evaluate the need for radiographs. In patients with a diagnosis of fracture, the accuracy of the Ottawa and the Pittsburgh rules was studied. A total, of 106 patients were referred to the acute knee clinic from the emergency department. 95.28 % (101) of these patients had radiographs of their knee in the emergency department. Five (4.72%) patients had a fracture of their knee and all these cases, the Ottawa and the Pittsburgh knee rules for ordering radiographs was fulfilled. In a vast majority of cases without any fracture, the clinical reason for ordering radiographs was not clear. Using the Ottawa rules for knee radiography 25.47% (27) radiographs could be avoided without missing a fracture. Using the Pittsburgh rules, 30.19 % (32) knee radiographs could be avoided without missing a fracture. The Ottawa and the Pittsburgh rules have a high sensitivity for the detection of knee fractures. Use of these rules can aid efficient clinical evaluation of the knee in an emergency situation without adverse clinical outcome. They may also have an implication on reducing the work load of radiology department and reduction of health costs.
Radiographic evaluation of the anterolateral femoral head is an essential tool for the assessment of cam type of femoroacetabular impingement. Computerised tomography (CT), magnetic resonance imaging and frog lateral plain radiograph views have all been suggested as imaging options for this type of lesion. Alpha angle is accepted as a reliable indicator of cam type of impingement and this may also be used as an assessment tool for successful operative correction of the cam lesion. The aim of our study was to analyse the reliability of frog lateral view plain radiographs to analyse the alpha angle in cam femoroacetabular impingement. Thirty two patients who presented with femoroac-etabular impingement were studied. Interobserver reliability for assessment of alpha angles on frog lateral radiographic view was analysed using intraclass correlation coefficient. The alpha angles measured on frog lateral views using digital templating tools were compared to those measured on CT scans. A high interobserver reliability was noted for the assessment of alpha angles on frog lateral views with a correlation coefficient of 0.83. The average alpha angles measured on frog lateral views was 58.71 degrees (range 32 to 83.3). The average alpha angle measured on CT was 65.11 degrees (range 30 to 102). However, a poor correlation (Spearman r of 0.2) was noted between the measurements using the two systems. Frog lateral plain radiographs are not reliable predictors of alpha angle. Various factors may be responsible for this such as the projection of the radiographs, patient positioning and quality of images. CT imaging may be necessary for accurate prediction of alpha angle.
The aim of our study was to determine the usefulness of preoperative digital templating of cementless total hip arthroplasty (THA). 60 consecutive cementless THA (synergy stem &
reflection cup) were templated digitally by two senior hip arthroplasty fellows (GM, YG) independently. A metallic marker ball of known diameter was used in all images to help scale for magnification. A blinded observer then collated information on the actual implant sizes, size of head component, offset, and level of neck cut intraoperatively. This was used to statistically analyse the correlation (Interclass correlation coefficient) between the digitally templated implant sizes and actual implant sizes used and the reliability of digital templating. A high rate of coincidence between digitally templated estimates and actual implant sizes was noted for both groups of templates. A high intraclass correlation coefficient (ICC) for the acetabular cup, stem and head were noted (ICC of 0.825, 0.794, and 0.884 respectively). Moderate agreement was noted for neck cut (ICC of 0.567) and leg length (ICC of 0.612). In conclusion, digital templating can reliably estimate implant sizes in cementless total hip arthroplasty. Valuable information on neck cut and leg length can be obtained by preoperative templating.
We describe our novel approach to managing infected periprosthetic fractures using a revision implant for temporary fracture stabilisation. A series of 12 consecutive patients aged between 74 and 83 years (average age 81.51, SD 6.32) who were referred to the senior author with periprosthetic fracture and microbiologically proven infection, were managed by radical debridement and antibiotic therapy along with temporary implantion of a long stem cannulated, proximally hydroxyappatite coated and distally locked femoral prosthesis (Cannulock, Orthodesign, Christ-church, UK). Strut grafts, demineralised bone matrix and cable plating system where used in addition where indicated. Post operatively patients were allowed to mobilise as allows and antibiotics were continued until biochemical markers returned to normal. A good clinical outcome and excellent functional outcome was noted in all 12 cases. No cases of immediate post operative complications such as DVT or PE were noted in any cases. In particular there were no instances of infections associated with prolonged immobilisation and hospital stay. Ten patients underwent a definitive revision hip replacement procedure within an average of 4.3 weeks (range 3.9 to 5.7, SD 2.15). Two patients required a second debridement and delayed definitive treatment due to persistently high inflammatory markers. We believe that this novel approach significantly improves functional outcome in the management of infected periprosthetic fractures.
Despite advances in total hip arthroplasty, failure of acetabular cup remains a concern. The role of bone marrow stromal cells (BMSCs) to aid osseointegration of orthopaedic implants have been recently studied. We investigated the hypothesis that autologous BMSCs sprayed on the surface of acetabular cups would improve bone formation and bone implant contact. Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undecalcified histology. Implant bone contact in both groups was compared microscopically, by noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded. Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ± 173.72 at the centre). Conversely, direct bone contact with the implant surface was significantly greater around the cups with BMSCs. Our data demonstrate that BMSC sprayed on surface of acetabular implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.
25 (41.67%) patients presented with complications (synovitis in 10 patients, prominent tibial swelling in 21 patients and both in 7 patients). In comparison, no complications were noted in 60 other age and sex matched patients in whom PLLA (Bio RCI; Smith &
Nephew) screws were used by the same surgeon. The symptoms in the PLC screw group often settled conservatively and did not affect knee stability. 6 patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was noted which was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw size did not have any correlation to the occurrence of complications. 2 patients required multiple washouts, one of whom developed a deep infection.
Theofilos Karachalios et al. described the new ‘Thessaly test’ and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery (Ref: J Bone Joint Surg Am. 2005 May; 87(5):955–62). Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test.
McMurray’s test and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated. Our study showed a much lower diagnostic accuracy for the Thessaly test (61.25 % for medial meniscus and 80 % for lateral meniscus) It is comparable to McMurray’s test (57.14 % for medial meniscus and 77.38 % for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (80.95 %for medial meniscus and 90.48 % for lateral meniscus). Combining the joint line tenderness test with McMurrays test or the Thessaly test further increased the diagnostic accuracy. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Arthroscopy was diagnostic and therapeutic in all cases.