The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach. We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon. Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport. With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport.
Biologic resurfacing of the glenoid combined with surface replacement hemiarthroplasty for relatively young patients suffering from advanced glenohumeral arthritis has the advantages of both humeral head and glenoid bone preservation. The longer term results of this procedure are reported. Twenty two shoulders in 21 patients had a surface replacement hemiarthroplasty with resurfacing of the glenoid with the anterior capsule. At follow up one had died, and another was not contactable. The prosthesis was removed in one for deep infection, and the fourth patient had undergone revision to a total shoulder arthroplasty for ongoing pain. Therefore, 17 patients with 18 operated shoulders were available for clinical assessment. The average age of the patients was 54.8 years (35–78) at the time of surgery. The average length of follow-up was 4.8 years (2–10.6). The average Constant Score was 71.4 points (41–95), and the sex- and age-adjusted Constant Score was 83.9%. The mean ASES score was 74.4 points (35–100). The average arc of forward flexion was 130 degrees (100–160), and external rotation was 39 degrees (20–60). On a VAS scale of 0 to 10, the average pain score at rest was 0.5 (0–3), while pain with activity was 2.4 (0–6). Sixteen of the 17 patients (94%) had a satisfactory result, and would have the operation again. Eight of the 17 patients (47%) were able to return to their previous sporting activities. Radiographic follow-up demonstrated there were 2 mild and 2 moderate cases of superior subluxation of the humeral head. There was no subsidence or signs of loosening of any humeral prosthesis. The average glenohumeral joint space was 0.13mm (0–2). Glenoid erosion was none in one case, mild in 6 cases, moderate in 6 cases, and severe in 3 shoulders. Although the results of this procedure compare favourably with other series, the extent of glenoid erosion is concerning. A more robust tissue for interposition may give better results
Bone allograft use in trauma and orthopaedic surgery is limited by the potential for cross infection due to inadequate acceptable decontamination methods. Current methods for allograft decontamination either put the recipient at risk of potentially pathogenic organisms or markedly reduce the mechanical strength and biological properties of bone. This study developed a technique of sterilization of donor bone which also maintains its mechanical properties. Whole mature rat femurs were studied, as analogous to strut allograft. Bones were inoculated by vortexing in a solution of pathogens likely to cause cross infection in the human bone graft situation. Inoculated bones were subjected to supercritical carbon dioxide at 250 bar pressure at 35 degrees celsius for different experimental time periods until a set of conditions for sterilization was achieved. Decontamination was assessed by vortexing the treated bone in culture broth and plating this on suitable culture medium for 24 hours. The broth was also subcultured. Controls were untreated-, gamma irradiated- and dehydrated bone. Mechanical testing of the bones by precision three-point bending to failure was performed and the dimensions and cross-section digitally assessed so values could be expressed in terms of stress. Mechanical testing revealed bone treated with supercritical carbon dioxide was consistently significantly stronger than that subjected to gamma irradiation and bones having no treatment (due to the minor dehydrating effect of the carbon dioxide). Terminal sterilization of bone is achieved using supercritical carbon dioxide and this method maintains the mechanical properties. The new technique greatly enhances potential for bone allograft in orthopaedic surgery.
A technical goal in total knee arthroplasty is the production of a neutral coronal plane mechanical axis. Errors may produce large mechanical axis deviations precipitating early implant failure. This study sought to test if measured distal femoral resection produced more accurate and consistent coronal alignment than arbitrarily set distal femoral resection. Data from a cohort of 255 consecutive unselected primary total knee arthroplasties undertaken by the senior author (PM) was collected prospectively and independently assessed. In the first 167 cases distal femoral resection was arbitrarily set to 5 degrees of valgus. In the remaining 88 cases the distal femoral resection angle was determined on a preoperative long leg standing AP radiograph. Postoperative coronal alignment was measured on long leg standing AP radiograph in all cases. The measured distal femoral valgus angle was between 4 and 7 degrees. An equal number measured either 5 or 6 degrees and accounted for 85% of the total number. Statistically insignificant improvements in mean axis and standard deviation were observed in the measured group: mean axis deviation −0.31 vs −0.51: p=0.17 (independent samples t test) and standard deviation 0.91 vs 1.09: p=0.055 (Levene test). Acceptable coronal alignment in total knee arthroplasty can reliably be obtained with conventional instrumentation. Improvement in standard deviation with measured distal femoral valgus angle approaches statistical significance.
Deterioration in knee joint proprioception has been postulated to occur following injury, resulting in further instability due to disruption of receptors and feedback mechanisms. Surgical reconstruction techniques may also influence post-operative proprioceptive ability (PA). We hypothesised that anterior cruciate ligament (ACL) reconstruction techniques which disrupt the knee capsule would result in a decrease in PA. Following ethical approval, a total of 48 subjects (mean age: 28.1 ± 10.5, 34 male, 14 female) undergoing ACL reconstruction surgery were included in the study. Fifteen subjects underwent “open” capsule ACL surgery and patellar tendon graft, whereas 33 subjects had “closed” capsule surgery with a hamstring tendon graft. Knee proprioception was measured on a custom-designed test apparatus incorporating electromagnetic position sensors (Polhemus Fastrack) located on femoral and tibial landmarks to accurately track knee angle during flexion-extension (no load). Leg flexion-extension under partial weight-bearing (5kg) was also evaluated. Pre-operative PA was assessed bilaterally, and then again on operated joints at three, six and twelve months post-op. Proprioceptive ability was measured as the cumulative absolute error in knee angle (°) between five repeat measurements and a target angle. We observed no significant difference in PA between injured and contralateral knees prior to ACL reconstruction. Post-operatively, no significant difference in PA was observed between “open” versus “closed” ACL techniques, irrespective of loading conditions. While trends indicated that PA during knee extension (no load) and leg flexion (partial weight-bearing) improved over the 12 months compared to pre-operative values in closed ACL surgery, these were not significantly different to open ACL results. The proportion of subjects whose PA improved in at least two out of the three post-op evaluations was also similar (approx 50%) across all groups, irrespective of joint loading. The only difference was PA during leg flexion under partial weight bearing, where 27% of open ACL surgery patients showed improvement in two or more follow-up tests, as opposed to 58% of closed ACL surgery patients. We present a method to determine pre- and postoperative PA during knee flexion/extension under no load as well as under partial weight-bearing. We saw no significant difference in PA of the knee under no-load versus load. We also saw no significant difference in postoperative PA following open capsule, patellar tendon graft versus closed capsule, hamstring tendon graft ACL reconstruction technique after 1 year follow-up.
Distraction osteogenesis (DO) is useful for bone lengthening and deformity correction. Unfortunately, this often requires prolonged use of an external fixator with concomitant morbidities. This study investigates whether low-magnitude, high-intensity vibrations (Dynamic Motion Therapy, DMT) can accelerate maturation of regenerate bone in DO, thus reducing the duration of external fixation. 28 NZ White Rabbits underwent a right mid-tibial osteotomy with application of an Orthofix M-103 fixator (Orthofix, Busselengo, Italy). Distraction commenced on day 3 at 0.5 mm every 12 hours for 12 days. All animals were sacrificed on day 45. Animals were randomly assigned into 4 groups:
control group; DMT only during distraction period; DMT only during consolidation period; DMT during distraction and consolidation periods. DMT was applied with the Juvent platform (Juvent, Somerset, NJ) for 10 minutes/day. X-ray and CT scans were taken prior to mechanical testing. All specimens were processed for histology. X-rays and CT scans showed evidence of cortical remodelling and re-establishment of the medullary canal in animals treated with DMT (groups 2, 3 and 4). This was most pronounced in animals treated during the distraction and consolidation phases (group 4). Regenerate bone in the control group (group 1) was more disorganised, with a delayed union evident in 1 animal. Group 1 achieved peak torque and stiffness values of 70% and 50% of the contralateral (unoperated) tibia respectively. No significant difference was seen in peak torque and stiffness between groups 2, 3, and 4, however each was significantly higher than group 1 (P<
0.05). H&
E staining revealed less porosity in the newly formed cortical bone and a more defined medullary canal in animals treated with DMT than in the control group. Low-magnitude, high-intensity vibrations appear to accelerate cortical remodelling and reestablishment of a medullary canal. Regenerate bone in animals treated with DMT was also mechanically superior. The timing of DMT therapy did not appear to be important. Further studies are required to determine the optimal timing and duration of DMT therapy.
Infrapatellar Contracture Syndrome describes a postoperative complication characterised by a vertical migration of the patella due to Patella Tendon (PT) shortening and/or PT adhesion (PTA) formation. We investigated how removal of the central one-third of the PT influences both PT length (LP) and in vitro knee kinematics in 18 sheep divided into 3, 6, 12 and 24 week groups. At time of sacrifice the pelvis-lower extremities complexes were left in a supine position until rigor mortis set in. Limbs were CT-scanned (0.5mm) whilst frozen and LP measured (ProEngineer, PTC, MA). Specimens were fixed into a loading frame with 50N applied to the rectus femoris and knee kinematics obtained (Polhemus, VT). Bones and associated registration block portions of the receiver assemblies were CT-scanned (0.5mm), reconstructed, and imported into ProEngineer where coordinate systems were created in accordance with the Joint Coordinate System (JCS). Registration was accomplished by aligning models of the receiver assemblies with the reconstructed surfaces. Post-processing and statistical analysis (ANOVA) was performed using Matlab (MathWorks, MA) and data referenced to the contralateral controls. No significant changes in LP were observed. The mean PT length ratio (LP/LC) in the 3 week group was 1.0028±0.004 (mean±SD). In the 6 week group this ratio had increased to 1.0282±0.0246, returning to 1.005±0.0035 at 12 weeks and back to 1.0159±0.0217 at 24 weeks. No PTA’s were observed. A significant proximal shift of the patella reflecting the increase in LP was observed which correlated well with a retardation of patellar flexion (r = 0.880, p<
0.001). A significant decrease in medial patellar tilt was also observed but was not coupled with changes in tibial rotation. Proximal and lateral tibial shifts were also detected. The results of this study seem to suggest that the changes in knee kinematics and LP induced by removal of the central one-third of the PT do not recover 24 weeks post-operatively.
Radiation induced pathologic fractures present a difficult problem for musculoskeletal oncologists. The purpose of this study was to determine the outcomes of management of radiation-induced pathologic fractures in a group of patients who had previously undergone combined management of extremity soft tissue sarcoma. A review of our retrospective database was undertaken. From 1986 to present, thirty-two patients with soft tissue sarcomas were found to have radiation induced pathologic fractures. The records of these patients were reviewed for patient demographics, tumour size and anatomic site, presence of periosteal stripping at time of surgery, radiation dose, time to fracture, fracture treatment and fracture outcome. There were twenty-three females and nine males with a mean age of sixty-three (range thirty-six to eighty-nine) years. Fractures occurred at a mean of forty-five months after resection of the sarcoma (range three to one hundred and fifty months). Anatomic distribution of fractures were : proximal femur(twelve), femoral diaphysis (eight), distal femur (two) tibia (five), acetabulum (two), metatarsal (two) and patella (one). Periosteal stripping was performed in half of the patients. Twenty-three patients had received high dose radiation (6600Gy). Seven fractures were managed conservatively while twenty-five were treated surgically. Only eleven of the thirty-two fractures united. Six patients underwent amputation, three for local recurrence and three for non-union of their fracture. Eight patients ultimately underwent arthroplasty, while seven patients have persistent non-unions. In the proximal femur, only three out of twelve fractures healed while six patients eventually underwent arthroplasty and three continue to have non-unions. Of eight femoral diaphyseal fractures, only one united. Patients who eventually underwent prosthetic replacement had good function and pain relief. Radiation induced pathologic fractures are a difficult clinical problem. In particular patients with fractures in the proximal femur often undergo multiple attempts at fixation before definitive management with resection and endoprosthetic replacement. Fractures of the femoral diaphysis rarely heal despite aggressive surgical management. Primary arthroplasty may be considered in some patients as an alternative to fixation in radiation-induced pathologic fractures of the femur in order to avoid long term morbidity and repeated operations.
The purpose of this study was to evaluate the impact of dalteparin use on transfusion rates and blood loss in patients undergoing primary total joint arthroplasty at our center. We prospectively studied the transfusion patterns of 1642 patients who underwent primary total hip or knee arthroplasty between January 2004 and December 2005 by five arthroplasty surgeons. The influence of daltaperin use, release of tourniquet in total knee arthroplasty, and the turnover of house staff were analyzed using SPSS V14.0 statistical software. We identified seven hundred and three total hip and nine hundred and thirty-nine knee arthroplasty patients. The mean haemoglobin drop was statistically significant between 2004 and 2005 (p<
0.001). This was seen in both hip (p=0.014) and knee (p<
0.001) patients. Subgroup analysis of total knee arthroplasty revealed a significant difference in haemoglobin drop between surgeons who released the tourniquet prior to closure compared to release at the end of the case (p=0.005). In addition, there were significant monthly differences that corresponded with the turnover of house staff (p=0.039). Overall, no statistically significant increase in allogeneic transfusion rates was observed between years, months, and individual surgeons. The use of dalteparin was found to be associated with a significantly increased haemoglobin drop in primary total joint replacement when compared to warfarin. However, the use of dalteparin was not associated with an increase in allogeneic transfusions at our center. The results also suggest that there may be an advantage to releasing the tourniquet and achieving hemostasis prior to closure in knee arthroplasty. Finally, the results emphasise the importance of educating new house staff on methods to reduce intra-operative blood loss and transfusion rates.
The aim of this study was to determine the torsional and 4-point bending properties of a midshaft humeral osteotomy reconstructed with either an intramedullary nail or locking plate.
A transverse midshaft osteotomy was created and a spacer ensured a constant 3-mm gap between the bone ends. Reconstruction was performed with either
Trigen humeral nail (Smith &
Nephew, TN) – 10 specimens Humeral locking plate (Synthes, PA) – 9 specimens Non-destructive 4-point bending was repeated, and then each humerus was embedded in a low-melting point alloy proximally and distally for torsional testing. Torque was applied at 5 deg/min until failure. Maximum torque, maximum angle and stiffness were calculated. All data were analysed with SPSS for Windows (SPSS Inc., Il) using ANOVA.
4-point bending: the bones reconstructed with the intramedullary nail were ~50% as stiff as the intact state in both planes. There was no statistically significant difference in stiffness between the intact bones and those reconstructed with the locking plate. Torsional testing: the locking plate specimens were 3 times as stiff as the intramedullary nail specimens (P<
0.05) and failed at twice the torque (P<
0.05).
Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed.
Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum. The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N)
. There is less information on normal foetal hip . Magnetic resonance imaging (MRI) allows development to be followed in the healthy baby.
To establish normal patterns of hip development. To obtain charts that could be used to detect abnormality earlier. There are three aspects to this study:
Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies. Measurements will be gained for foetus in utero Similarly for pre and term babies.
For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.
Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius &
diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.
With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs = 0.98) for all but depth (ICCs = 0.86). The measurements for all dimensions were in line with previous post mortem studies.