The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation.Introduction
Materials and Methods
The concept of “bone graft expanders” has been popularised to increase the volume and biological activity of the implanted Material. Orthoss® granules support exogenously seeded MSCs and attract neighbouring host MSCs.Introduction
HYPOTHESIS
The internal fixation of osteochondral fragments in fractures normally utilizes intra-articular screws inserted through a pilot hole drilled into cartilage/bone. This trauma causes cartilage injury leading to chondrocyte death. We have quantified the cell death following cartilage drilling and identified irrigation conditions that can protect chondrocytes. Articular cartilage of bovine metacarpophalangeal joints of 3yr-old cows was irrigated in the presence/absence of saline of various compositions. Holes were then made using a standard 1.5mm drill (Ortho Solutions Ltd.) at 18,000 rpm through the articular cartilage into bone. Osteochondral explants were then harvested and cultured in Dulbecco's Modified Eagle's Medium containing chloromethylfluorescein-di-acetate and propidium iodide (10uM each), to label living chondrocytes green and dead cells red, respectively. Axial images were taken by confocal microscopy and the width of the zone of cell death (ZCD) around the hole determined. With no irrigation, new drills caused a ZCD of 171±25um, which was increased when drills used 50+ times were tested (279±31um;p=0.03). With saline irrigation, the ZCD was reduced for old drills (150±6um;p=0.016) but not for new drills (124±8um) suggesting the heating effect of the old drills caused additional chondrocyte death. However for new drills, the ZCD was further reduced significantly to 82±7um when the osmolarity of the saline irrigation solution was raised to 480mOsm using sucrose. Data are mean±s.e.m., from at least 5 separate experiments each with a minimum of 3 replicates. The results demonstrate a chondroprotective effect of raising the osmolarity of saline used during drilling of cartilage which could be clinically beneficial.
Traditional Total Knee Arthpolasty (TKA) replaces all 3 compartments of the knee for patients diagnosed with OA. There might be functional benefit to replacing only damaged compartments, and retaining the normal ligamentous structures. There is a long history of performing multi-compartment arthroplasty with discrete components. Laskin reported in 1976 that good pain relief and acceptable clinical results were achieved at two years in patients with bi-unicondylar knee replacement [Laskin 1976]. Other authors also have reported on bi-unicompartmental knee arthroplasty achieving successful clinical outcomes [Stockley 1990; Confalonieri 2005]. Banks et al. reported that kinematics of bi-unicompartmental arthroplasties during gait demonstrated some of the basic features of normal knee kinematics [Banks 2005]. These reports suggest that a modular approach to resurfacing the knee can be successful and achieve satisfactory clinical and functional results. The primary objective of this study is to compare the functional outcomes of three patient groups treated for osteoarthritis.Introduction
Objective
Total Knee Arthroplasty (TKA) aims to deliver relief from pain and restore normal function. Unfortunately, a significant cohort of patients report poor outcomes. Synovial fluid metabolite concentrations at surgery predict outcome of TKA, assessed by a validated measure.Introduction
Hypothesis
There is mounting evidence to suggest a vascular insult is responsible for Perthes' disease, and it is suggested that this may have long-term implications for the vascular health of affected individuals. This study sought to use ultrasound measures to investigate vascular structure and function in children affected by Perthes' disease. This case control study encompassed 149 cases and 146 controls, frequency matched for age and sex. Endothelial function was measured using the technique of flow-mediated dilatation of the brachial artery, and alterations in arterial flow were recorded in response to an ischaemic stimulus.Objective
Material and Methods
The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI. Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31).Objectives
Methods
Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information. An electronic 18 item, single response multiple-choice questionnaire was designed to investigate various aspects of the surgical management of supracondylar fractures, with particular focus on areas that remain controversial in the literature. Members of BSCOS were invited by email, on three occasions, to complete the questionnaire, which was posted on the web-based SurveyMonkey™ platform (Aim
Methods
To determine if the instigation of Magnetic Resonance Extremity (MRE) scanning in our unit as part of the management of suspected paediatric scaphoid fractures has prevented overuse of splints or casts reduced unnecessary clinic appointments and saved our department financially. Children with traumatic anatomical snuffbox tenderness and negative radiographs are seen 10 days following injury having been given a Futura® splint. If repeat radiographs are negative with on-going positive clinical findings the child has an MRE scan, which is usually reported the same day. If negative, the splint is removed on that day, but if positive, a cast is applied and the child referred onto paediatric fracture clinic.Aim
Methods
Case Report presentation of traumatic cartilage loss in a child. We present a case report of a 3-year-old girl who sustained a severe open fracture dislocation of her talus with complete loss of full thickness articular cartilage and subchondral bone over 80% of the talar dome. At presentation there was also a Salter Harris I fracture of the fibular, and an extensive soft tissue defect including absent anterior joint capsule. She required a free anterolateral thigh (ALT) flap to reconstruct this defect. The talar dome defect was treated with a cell-free chondro-inductive implant. This was the first use of this implant in the UK and the first use of such an implant in a child anywhere in the world.Aim
Method
Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis in young active individuals but the pathophysiology remains unclear. Increasing mechanistic studies point toward an inflammatory component in OA. This study aimed to characterise inflammatory cell subtypes in FAI by exploring the phenotype and quantification of inflammatory cells in FAI versus OA samples. Ten samples of labrum were obtained from patients with FAI (confirmed pathology) during open osteochondroplasty or hip arthroscopy. Control samples of labrum were collected from five patients with osteoarthritis undergoing total hip arthroplasty. Labral biopsies were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD202), T cells (CD3), mast cells (mast cell tryptase) and vascular endothelium (CD34). Labral biopsies obtained from patients with FAI exhibited significantly greater macrophage, mast cell and vascular endothelium expression compared to control samples. The most significant difference was noted in macrophage expression (p<0.01). Further sub typing of macrophages in FAI using CD202 tissue marker revealed and M2 phenotype suggesting that these cells are involved in a regenerate versus a degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r=0.4, p<0.05) in FAI samples. We provide evidence for an inflammatory cell infiltrate in femoroacetabular impingement. In particular, we demonstrate significant infiltration of mast cells and macrophages suggesting a role for innate immune pathways in the events that mediate hip impingement. Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement.
To evaluate the influence of arthrodiatasis in the natural history of the stages of the disease radiologically and also the timing of arthrodiatasis. 44 patients with Perthes' disease that had articulated hip distraction were radiologically evaluated. We assessed these based on Joseph's modified Elizabethtown classification before, during and soon after distraction. Other parameters used were the application of common radiological grading systems and other features.Aim
Materials and methods
The knee is the commonest joint to be affected by osteoarthritis, with the medial compartment commonly affected. Knee osteoarthritis is commonly bilateral, yet symptoms may initially present unilaterally. Higher knee adduction moment has been associated with the development and progression of medial compartment knee osteoarthritis. To assess the effect of lateral wedge insoles on the asymptomatic knee of patients with unilateral symptoms of medial compartment knee osteoarthritis.Background
Objectives
We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard. We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated.Introduction
Methods
Acute renal dysfunction (ARD) following orthopaedic surgery is known to increase morbidity, mortality, and length of hospital stay. The aim of this study was to compare the incidence of new acute post-operative renal dysfunction between two cohorts of elective orthopaedic surgical patients receiving either cefuroxime or a combination of gentamicin and flucloxacillin as prophylactic antibiotic regimes. The study was initiated following a change in antibiotic prophylaxis within our unit from cefuroxime to gentamicin and flucloxacillin. Using a standardised data collection tool we retrospectively reviewed medical records of 238 patients who had received 1.5g of cefuroxime (TKR: n = 128; THR: n=110). This data was compared to prospectively collected data from 254 patients (TKR=117 THR=137) who had received Flucloxacillin 2g and Gentamicin (with the dose based on height). Primary outcome measure for the study was the RIFLE criteria which grades renal impairment: 0-Nil, 1-Risk, 2-Injury, 3-Renal failure.Introduction
Method
Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011. Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded.Introduction
Methods
The aim of this study was to investigate PDGF release in the peripheral circulation following trauma and to correlate it with the numbers of MSCs in iliac crest bone marrow (BM) aspirate. Trauma patients with lower extremity fractures (n=18, age 21–64 years) were recruited prospectively. Peripheral blood was obtained on admission, and at 1, 3, 5 and 7 days following admission. The serum was collected and PDGF was measured using ELISA. Iliac crest (BM) aspirate (20ml) was obtained on days 0–9 following admission. MSCs were enumerated using standard colony-forming unit fibroblasts (CFU-F) assay.Objective
Methods
Subtle deformities of the acetabulum and proximal femur are recognised as biomechanical risk factors for the development of hip osteoarthritis (OA) as well as a cause of hip and groin pain. We undertook this study to examine relationships between a number of morphological measurements of the acetabulum and proximal femur and the hip pain in a 20-year longitudinal study. In 1989 women of 45–64 years of age were recruited. Each had an AP-Pelvis radiograph at Year-2. These radiographs were analysed using a validated programme for measuring morphology. All morphological measurements were read blinded to outcome. At year 3 all participants were asked whether they experienced hip pain (side specific). This was repeated at visits up to and including 20-years. Logistic regression analysis (with robust standard errors and clustering by subject identifier) was performed using hip pain as a binary outcome. The model adjusted for baseline age, BMI and joint space and included only participants who were pain free on initial questioning.Introduction
Methods
Segmental tibia fractures are high-energy injuries that are difficult to treat. We report on the use of the Ilizarov Method to treat 40 consecutive AO42C (35) and AO42B3 (5) fractures by a single surgeon. Fractures with bone loss requiring transport were excluded, as were fractures initially treated with nail or plate. 28 adult males, 12 adult females, average age 43. The most common mechanism of injury was RTA (50%). 12 (30%) had associated injuries. 19 (48%) fractures were open (6 3A, 13 3B) and 21 closed. 24 (60%) had temporary monolateral external fixation before definitive treatment. The mean time from injury to definitive Ilizarov frame was 8 days.Introduction
Patients
To study the results of using recombinant human bone morphogenic protein-2 (rhBMP-2) to achieve bone union in children with complex orthopaedic problems including skeletal dysplasia, congenital limb deficiencies and complex trauma. Between November 2006 to April 2010, rhBMP-2 was used to achieve bone healing in a total of 19 children. The indications were delayed union or non-union in 16 long bones where previous surgeries had failed and 4 posterior spinal fusions. All children had underlying complex orthopaedic problems predisposing them to delayed bone healing. The average age at the time of surgery was 13 years and 8 months (Range: From 4 years to 19 years and 4 months). There were 7 boys and 12 girls.Aim
Materials & Methods
To review the outcome of deep prosthetic infection in patients following hip hemiarthroplasty surgery. A retrospective case-note analysis was performed of deep infection coded hip hemiarthroplasty patients between 2004–2009. Patients were selected when there was proven microbiology from deep wound swabs or tissue specimens.Aim
Method
Total hip arthroplasty (THA) in teenagers is uncommon and previously associated with poor survival rates. However it is sometimes the only option remaining to relieve pain and improve function in patients with advanced hip disease. We report on the clinical and radiological outcomes of THA in teenage patients. Medical records and radiographs of all consecutive teenage patients undergoing THA at a tertiary referral centre between 2006–2011 were reviewed. Mean follow-up was 3.4 years (range 0.6–6.8) with 9 patients having at least 5 years follow-up. Post-operative Harris hip, Oxford hip (OHS) and University of California Los Angeles (UCLA) activity scores were recorded. 51 THAs were performed in 43 patients (21 male, 22 female) with a mean age of 17 years (range 12–19). The 5 most common indications were slipped upper femoral epiphysis osteonecrosis 15 (29.4%), developmental hip dysplasia osteonecrosis 5 (9.8%), multiple/spondylo-epiphyseal dysplasia 5 (9.8%), chemotherapy-induced osteonecrosis 4 (7.8%) and idiopathic osteonecrosis 4 (8.2%). 46 (90%) were uncemented THAs and 5 (10%) were reverse hybrid THAs with 7 computer assisted design/manufacture (CADCAM) femoral implants. Articular bearings were ceramic/ceramic in 40 (78.4%), metal/metal 6 (11.8%), metal/polyethylene 3 (5.9%) and ceramic/polyethylene 2 (3.9%). The survival rate was 96% with 2 acute head revisions for 1 sciatic nerve palsy and 1 instability. Other complications (8.2%) included 1 dislocation, 1 sciatic nerve palsy that resolved, 1 surgical site infection and 1 unexplained pain. At latest follow-up, the mean Harris hip score was 90 (68–99), OHS was 42 (32–48) and UCLA activity score was 6 (4–9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. As one of the largest studies on teenagers undergoing THA, we report good clinical and radiological outcomes at short to intermediate term follow-up.
To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit.Aim
Method
This RCT compared electromagnetic (EM) navigated and conventional total knee arthroplasty (TKA) in terms of clinical and functional outcomes. 200 patients (navigated=102, conventional=98) were recruited. Oxford Knee Scores (OKS) and the American Knee Society Score (AKSS) were recorded pre operation, 3 and 12 months after surgery. Post operative (coronal, sagittal and rotational) alignment was analysed from 3D CT scans taken 3 months after surgery. An objective functional assessment was completed using electrogoniometry on a sub group (navigated=60, conventional=57) at 12 months post surgery. The EM group showed statistically significantly improved OKS (p=0.04) and AKSS (p=0.03) scores at 3 months post operation. However at 12 months post surgery there was no difference between the two groups. At the 1 year follow up it was reported that 9% of the navigated compared to 14% of the conventional group were dissatisfied with their surgical outcome. The mechanical axis alignment of 90% of the navigated group was within 3 degrees of neutral compared to 84% of the conventional group. Although all alignment parameters except for tibial rotation was improved in the navigated group they did not reach significance apart from femoral slope alignment (p=0.01). There was no statistically difference between the surgical groups in terms of the maximum, minimum and excursion knee joint angles during 12 functional activities. Only the knee kinematic function cycles for level walking resulted in statistically significant higher knee joint angles during 55–70% of the gait cycle in the navigated group. Knee alignment was better restored following EM navigated TKA relative to conventional TKA, but the difference was not significant. The EM group showed greater clinical and functional improvements at early follow-up; however this difference was not sustained at 12 months. The EM group reported minimal gait improvements. Proving cost-effectiveness for navigation systems in TKA remains a challenge.
Solid or cystic pseudotumour is a potentially destructive complication of metal on metal (MoM) couples, usually needing revision surgery. However, complete clearance of the pseudotumour is unlikely at times. This prospective case-controlled study reports cases which had recurrence after revision surgery for pseudotumour related to metal on metal hip couples. A total of 37 hips (33 MoM hip resurfacing and four big head MoM total hip arthroplasty (THA)) were revised for pseudotumour during the last 10 years. The patient demographics, time to revision, cup orientation, operative and histological findings were recorded for this cohort. Patients were divided into two groups - group R (needing re-revision for disease progression) and group C (control - no evidence of disease progression). Oxford hip scores (OHS, 0–48, 48 best outcome) were used to assess clinical outcome. The diagnosis of disease progression was based on recurrence of clinical symptoms, cross-sectional imaging, operative and histological findings.Introduction
Methods
Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre. Data on 80 patients who had received caudal epidural (n=36), nerve root block (n=28) and facet joint injections (n=16) form August 2010 to October 2011 consented to be in the study. 40 patients in each group completed Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) before and 6 weeks after the procedure and patient satisfaction questionnaire investigating their experience and any complications related to the spinal injection retrospectively. The study included 32 males and 48 females. Mean age 57 years, range 21–88. [Consultant group M:17, F:23 mean age: 55, range 21–81. ASP group M:15, F:25 mean age 59, range 22–88]. Measures of patient satisfaction and outcome were obtained; using 2 tailed independent samples Introduction and aims
Method and Materials
Pyogenic spinal infection (PSI) is an increasingly common presentation to spinal units in the UK. Its investigation and diagnosis is often delayed. The purpose of this study was to determine the prognostic significance of the inflammatory marker levels on admission on achieving a positive microbiological diagnosis in patients with PSI. Retrospective case series review of all patients presenting with PSI to our unit.Objective
Study design
A retrospective analysis was carried out to determine the influence of pre-existing spinal pathology on the outcome of Total Knee Replacement surgery. Data was collected from 345 patients who had undergone Total Knee Replacement, at four centres in the UK, between 2000 and 2007. Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 questionnaires were recorded prospectively. Data was collected pre-operatively and then post-operatively at 3 months, 1 year and 2 years. Patients were divided into those with (n=40) and without a history of low back pain (n=305). In addition to determining the influence of low back pain on outcome after Total Knee Replacement we also examined the influence of concomitant hip and ankle pathology in the same cohort of patients. OKS scores were significantly worse for patients with symptomatic low back pain at 3 (p=0.05), 12 (p=0.009) and 24 months (p=0.039) following surgery. SF-12 physical scores followed a comparable pattern with significance demonstrated at 3 (p=0.038), 12 (p=0.0002) and 24 months (p=0.016). AKSS followed a similar pattern, but significance was only reached at 1 year (p=0.013). The mental component of the SF-12 measure demonstrated a significant improvement in patients' mental health post-operatively for patients with no history of low back pain. In contrast patients with low back pain showed no improvement in mental health scores post-operatively. In contrast to low back pain, hip and ankle pathology had no statistically significant detrimental effect on the outcome of Total Knee Replacement surgery. This study demonstrates that low back pain significantly affects the functional outcome after Total Knee Replacement surgery and that patients with low back pain show no improvement in mental health post-operatively.
It has been speculated that impact deformation of thin 1-piece cups used for modern metal-on-metal hip replacement may contribute to early failure. The purpose of this study was to reproduce typical impact deformation and quantify the effect of this on the frictional torque generated at the hip. We tested nine hip couples of three designs (the ASR, BHR and Durom) and three sizes (42mm, 46mm and 50mm). A custom compression device was designed to replicate the in vivo forces and impact deformation of 1-piece metal cups reported in the literature. Each cup was mounted in the device, which itself was mounted on a mechanical testing machine. The cups were compressed with incremental loads up to a maximum of 2000N. At each increment we measured cup deformation, and then the head component was seated into the cup. The hip was lubricated and the head component rotated 60 degrees axially within the cup and the axial torque was measured.Introduction
Methods
The aim of the study was to characterise gait in patients with achondroplasia post lengthening. Full kinematic and kinetic lower limb gait analysis was performed at the Sheffield Children's Hospital gait laboratory, Sheffield, using a Vicon system (6 cameras working at 50Hz) and processed using Plug In Gait modelling software. The lengthened Achondroplasia group (n=11, mean age = 24.5 ± 6.1) had previously undergone surgical lengthening of the legs. The lengthened Achondroplasia group was compared to a control group of 11 adult normal subjects.Aim
Patients/Materials and Methods
To examine the effect of limb lengthening on the quality of life of people who have disproportionate short stature (DSS). Thirteen previous patients, completed the SF-36, the Derriford Appearance Scale and participated in face to face semi structured interviews to establish the impact on their physical and social functioning, their present situation including employment, education, housing and leisure activities and their thoughts about whether they felt the treatment had been worthwhile. To increase understanding about the patient and family experience of limb lengthening, participants were asked about their memories of the procedure and the treatment period.Purpose
Method
Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown. The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL. Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded. Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05). Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05). Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee.
The aim of this study was to determine the influence of electromagnetic (EM) navigation in total knee arthroplasty (TKA) on post operative function. In this double blinded randomised control trial, patients with osteoarthritis either received TKA using conventional techniques (n = 49) or EM navigation (iNav Portable Navigation System, Zimmer Orthopaedics) (n = 52). All of the patients were reviewed in the Outcomes Clinic at 3 and 12 months. At 12 months post operation the patients completed an objective biomechanical functional assessment using flexible electrogoniometers, which recorded dynamic knee kinematics during daily activities. Knee joint flexion and extension moments were recorded at the 12 month post operation assessment. The functional assessment included validated questionnaires (Oxford Knee Score, American Knee Society Score, WOMAC Score and Short Form SF-36 Score). All patients underwent CT scanning of the implanted prosthesis to assess component alignment. Improved alignment was recorded in the navigated group. However there was no significantly significant difference between the two surgical groups in terms of the subjective questionnaire scores. The biomechanical assessment showed no statistically significant differences in the maximum, minimum or excursion knee joint angles between the two surgical groups during the 12 daily functional tasks. However, significant differences were reported in level and slope walking activities during pre-swing phase (at around 60% of the gait cycle). The navigated group had significantly higher knee joint angles during pre swing suggesting a more vigorous push off into swing phase and a more ‘normal’ gait cycle. The two surgical groups were sub divided into males and females for the strength test. The female navigated group recorded a significantly greater hamstring (p = 0.03) and quadriceps (p = 0.003) moment. There was no significant difference in hamstring or quadriceps moments between the navigated and conventional male groups. The knee kinematics and moment data suggests that the navigated group had an improved functional outcome. However the difference in the post-operation function of the two groups remains minimal despite the better alignment achieved using navigation.
Over the last two decades, anatomic anterior cruciate ligament (ACL) reconstructions have gained popularity, while the use of extraarticular reconstructions has decreased. However, the biomechanical rationale behind the lateral extraarticular sling has not been adequately studied. By understanding its effect on knee stability, it may be possible to identify specific situations in which lateral extraarticular tenodesis may be advantageous. The primary objective of this study was to quantify the ability of a lateral extraarticular sling to restore native kinematics to the ACL deficient knee, with and without combined intraarticular anatomic ACL reconstruction. Additionally, we aimed to characterise the isometry of four possible femoral tunnel positions for the lateral extraarticular sling. Eight fresh frozen hip-to-toe cadavers were used in this study. Navigated Lachman and mechanised pivot shift examinations were performed on ACL itact and deficient knees. Three reconstruction strategies were evaluated: Single bundle anatomic intraarticular ACL reconstruction, Lateral extraarticular sling, Combined intraarticular ACL reconstruction and lateral extraarticular sling. After all stability tests were completed, we quantified the isometry of four possible femoral tunnel positions for the lateral extraarticular sling using the Surgetics navigation system. A single tibial tunnel position was identified and digitised over Gerdy's tubercle. Four possible graft positions were identified on the lateral femoral condyle: the top of the lateral collateral ligament (LCL); the top of the septum; the ideal tunnel position, as defined by the navigation system's own algorithm; and the actual tunnel position used during testing, described in the literature as the intersection of the linear projections of the LCL and the septum over the lateral femoral condyle. For each of the four tunnel positions, the knee was cycled from 0 to 90® of flexion and fiber length was recorded at 30® intervals, therefore quantiying the magnitude of anisometry for each tunnel position. Stability testing: Sectioning of the ACL resulted in an increase in Lachman (15mm, p = 0.01) and mechanised pivot shift examination (6.75mm, p = 0.04) in all specimens compared with the intact knee. Anatomic intraarticular ACL reconstruction restored the Lachman (6.7mm, p = 3.76) and pivot shift (−3.5mm, p = 0.85) to the intact state. With lateral extraarticular sling alone, there was a trend towards increased anterior translation with the Lachman test (9.2mm, p = 0.50). This reconstruction restored the pivot shift to the intact state. (1.25mm, p = 0.73). Combined intraarticular and extraarticular reconstruction restored the Lachman (6.2mm, p = 2.11) and pivot shift (−3.75mm, p = 0.41) to the intact state. There was no significant difference between intraarticular alone and combined intraarticular and extraarticular reconstruction. (p = 1.88) Isometry: The ideal tunnel position calculated by the navigation system was identified over the lateral femoral condyle, beneath the mid-portion of the LCL. The anisometry for the ideal tunnel position was significantly lower (5.9mm; SD = 1.8mm; P<0.05) than the anisometry of the actual graft position (14.9mm; SD = 4mm), the top of the LCL (13.9mm; SD = 4.3mm) and the top of the septum (12mm; SD = 2.4mm). In the isolated acute ACL deficient knee, the addition of a lateral extraarticular sling to anatomic intraarticular ACL reconstruction provides little biomechanical advantage and is not routinely recommended. Isolated lateral extraarticular sling does control the pivot shift, and may be an option in the revision setting or in the lower demand patient with functional instability. Additionally, the location of the femoral tunnel traditionally used results in a significantly more anisometric graft than the navigation's system mathematical ideal location. However, the location of this ideal tunnel placement lies beneath mid-portion of the fibers of the LCL, which would not be clinically feasible.
Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown. The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL. Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded. Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05). Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05). Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee.
Fractures of the femoral head are a challenging problem. The most often performed head preserving procedure worldwide is closed reduction and insertion of cannulated screws under fluoroscopic control. The use of navigation is still experimental in general trauma since rigid reference markers must be attached to all fragments. The examined system (Surgix®, Tel Aviv, Israel) is a fluoroscopy based image analysing system. It consists of a workstation and X-ray opaque markers in surgical tools. When the tool is visible in a C-arm shot a trajectory is displayed as additional layer in the image to serve as guidance for the surgeon. Forty synthetic femurs (Synbone®, Malans, Switzerland) were used and placed inside foam to simulate the soft tissue of the thigh. The models were equipped with 4.5mm radio-opaque markers at the fovea capitis femoris as target point. The aim was to bring the tip of a K-wire as close as possible to the target point entering the bone at the lateral base of the greater trochanter in a center-center position. Twenty were done under image guidance and 20 were operated the conventional way. Outcome measures included the accuracy (the distance between the tip of the wire and the target in a CT), the number of guide wire insertions, procedure duration, radiation exposure and learning curve. In the image guided group optimal guide wire placement was accomplished on first pass in 65% of the cases as compared to 5% in the conventional group (p = < 0.0001). The average number of trial and error was significantly lower in the guided group (1.7 vs. 5.8, p = < 0.0001). Consequently the average duration of the guided procedure was significantly shorter (p = 0.0008) along with radiation exposure time reduced by over 70% (p = 0.0002). The guidance system hit averaged 5.8 mm off target as compared to 5.3 mm for the freehand method (p = 0.3319). Image based guidance significantly shortened the procedure, reduced the radiation exposure and the number of trials without changing the surgeons workflow and can be used in trauma cases were reference marker based navigation is not applicable.
Computer assisted surgery (CAS) is used in trauma surgery to reduce radiation and improve accuracy but it is time consuming. Some trials for navigation in small bone fractures were made, but they are still experimental. One major problem is the fixation of the dynamic reference base for navigation. We evaluated the benefit of a new image based guidance-system (Surgix®, Tel Aviv, Israel) for fracture treatment in scaphoid bones compared to the conventional method without navigation. The system consists of a workstation and surgical devices with embedded radio opaque markers. These markers as well as the object of interest must be on the same C-arm shot. If a tool is detected in an image by the attached workstation additional information such as trajectories are displayed in the original fluoroscopic image to serve the surgeon as aiming device. The system needs no referencing and no change of the workflow. For this study 20 synthetic hand models (Synbone®, Malans, Switzerland) were randomised in two groups. Aim of this study was a central guide-wire placement in the scaphoid bone, which was blindly measured by using postoperative CT-scans. Significant distinctions related to the duration of surgery, emission of radiation, radiation dose, and trials of guide-wire positioning were observed. By using the system the surgery duration was with 50 % shortened (p = 0.0054) compared to the conventional group. One reason might be the significant reduction of trials to achieve a central guide-wire placement in the bone (p = 0.0032). Consequently the radiation exposure for the surgeon and the patient could be shortened by reduction of radiation emission (p = 0.0014) and radiation dose (p = 0.0019). By using the imaged based guidance system a reduction of surgery duration, radiation exposure for the patient and the surgeon can be achieved. By a reduced number of trials for achieving a central guide-wire position the risk of weakening the bone structure can be minimised as well by using the system. The system seems helpful where navigation is not applicable up to now. The surgical workflow does not have to be chanced.
There is great interest to provide repeatable and durable treatments for arthritis localized to one or two compartments in the cruciate-ligament intact knee. We report a series of efforts to develop and characterize an implant system for partial knee resurfacing. We studied distal femoral morphology and found that the sagittal-plane relationships between the condylar and trochlear surfaces are highly variable (Figs 1 and 2). In response, we report the design of a multi-compartmental system of implants intended to anatomically resurface any combination of compartments (Fig 3). Finally, we report the results of a pilot fluoroscopic study of the in vivo knee kinematics in patients who received medial, medial plus patellofemoral and bi-condylar knee arthroplasty. The kinematic results suggest these treatments provide a stable knee with intact cruciate ligament function. This work shows various partial knee resurfacing treatments have the potential to provide excellent knee mechanics and clinical outcomes.
The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion. The mean patient age was 34 years (range 28–58), the majority were female (n = 6). All movements resulted in statistically significant changes in peak systolic velocity (p = <0.05). In order of decreasing peak velocity the exercises which had greatest effect on calf pump function were: Ankle dorsiflexion (101cm/s), Ankle plantarflexion (84cm/s), Toe dorsiflexion (63cm/s), Toe plantarflexion (59cm/s). We have shown that all four exercises significantly increased calf pump function. The greatest effect was seen with ankle movements.Introduction
Results
MSCs have long promised benefits of synthesising bone/cartilage, treating non-unions and potentially accelerating fracture repair. This potential has been tempered by MSC scarcity in the ‘gold-standard’ iliac crest bone marrow aspirate (ICBMA) and the resulting need to expand numbers via cell-culture. Culture of MSCs is time-consuming, expensive and results in cells with a reduced differentiation capacity. The reamer-irrigator-aspirator (RIA) is an innovation designed to reduce intra-medullary (IM) pressures during reaming of long-bones via continuous irrigation and suction. Aspirated contents are passed via a coarse filter, which traps bony-fragments before moving into a ‘waste’ bag - from which MSCs have been previously isolated. We examined liquid and solid phases found in this ‘waste’, performed a novel digestion of the solid phase and made a comparative assessment in terms of number, phenotype and differentiation capacity with matched ICBMA. The filtrate ‘waste’ bag from RIA reaming (6 patients) was filtered (70μm) and the solid fraction digested for 60min (37°C) with collagenase. MSCs were isolated from liquid & solid fractions and from 10ml matched ICBMA. Enumeration of MSCs was achieved via colony-forming-unit-fibroblast (CFUF) assay and flow-cytometry on fresh sample using CD45low, CD271+. MSCs were cultured by virtue of their plastic adherence and passaged in standard, non-haematopoietic media. Passage (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages with their phenotype assessed with flow cytometry CD33 CD34 CD45 CD73 CD90 CD105.Introduction
Methods
Total hip arthroplasty (THA) is regarded as one of the most successful surgeries in medicine. However, recent studies have revealed that ideal acetabular cup implantation is achieved less frequently than previously thought, as little as 50% of the time. It is well known that malalignment of the acetabular component in THA may result in dislocation, reduced range of motion, or accelerated wear. This study reports accuracy of a tactile robotic arm system to ream the acetabulum and impact an acetabulur cup compared to manual instrumentation. 12 fresh frozen cadaveric acetabulae were pre-operatively CT scanned and 3D templating was used to plan the center of rotation, and anteversion and inclination of the cup. Each specimen received THA, six prepared manually and six prepared with robotic arm guidance. Tactile, visual, and auditory feedback was provided through robotic guidance as well as navigated guided reaming and cup impaction. The robotic guidance constrained orientation of instruments thus constraining anteversion, inclination, and center of rotation for reaming, trialing, and final cup impaction. Post-operative CT scans were taken of each specimen to determine final cup placement for comparison to the pre-operative plans.INTRODUCTION
METHODS
Knee prostheses retrieved at revision often show patterns and severity of damage neither seen nor predicted from standard wear simulator testing. We hypothesized that this is because these implants are exposed to combinations of loads and motions that are more damaging than the simple loading profiles utilized in laboratory testing. We examined the magnitude, direction, and combination of forces and moments acting on the knee during various activities in order to guide the future development and testing of high-performance knee replacements. In vivo data from five patients with instrumented tibial implants were obtained from an open database (www.orthoload.com). We determined the direction and magnitude of forces and moments that the knee experiences during the following common physiologic activities: stair descent, stair ascent, deep knee bend, one leg stance, and walking. In order to capture the loading pattern, we investigated the three component forces and moments acting on the knee at several high demand points for each of these activities. The e-tibia data were compared to the loading profiles used in conventional laboratory testing (ISO 14243-1).Introduction
Methods
Carpal tunnel syndrome (CTS) is said to be a condition of middle-aged women. Our experience is that it more commonly occurs in older people and also in a younger working population. The aim of this study is to describe the epidemiology of CTS requiring carpal tunnel decompression (CTD). Over a 10.5 year period 3073 CTD were performed on 2309 patients aged 15 – 93 years. This included all public, private and ACC funded cases in our region. During this period we had no restriction to access to CTD as all publicly funded cases were performed under local anaesthetic in a day surgery unit. Neurophysiological studies were performed pre-operatively by the same neurophysiologist. Population data from the national census (2006) was used to calculate the annual incidence of patients requiring CTD for each 5 year age band. There were 1418 females (61.4%) and 891 males (38.6 %). In contrast females comprised 116 of 306 (37.8%) patients who had their surgery funded by ACC. The mean age at surgery was 45 years for ACC cases compared with 56 years for non-ACC funded cases. The incidence of males having surgery funded by ACC was 1.7 times higher than females. There was a biphasic pattern in females with an incidence of 3.0/1000 at age 50–54 years, and a second higher peak of 3.1 to 3.4/1000 from 70 to 5 years. Males had a linear increase in incidence peaking at 3.1/1000 for age 65–69 years declining slightly to 2.8/1000 for age 70–85 years. The incidence was significantly higher in females than males overall (1.8 v 1.1/1000) and in patients under 65 years (1.4 v 0.8/1000). In patients over 65 years there was no significant difference in incidence (female 2.8, male 2.5/1000). Within our region, the incidence of surgically treated carpal tunnel syndrome increases with age. The highest rates are seen over the age of 70 in women and 65 years in men with no significant difference in rates between men or women over 65 years.
Open Prospective study of 47 patients. 22 patients had MIS In the MIS group, the median follow up was 11 months (4–23). The median preoperative MOXFQ score was 34/64(23) and the median postoperative score was 19/64 (p = <0.02). In the open group the median follow up was 17 months (9–27). The median preoperative MOXFQ score was 35/64 and the median postoperative score was 7.5/64 (p = <0.0001). The metric score of the three domains of the MOXFQ showed statistical improvement in both groups. The improvement didn't reach statistical significance between the open and MIS groups. There were three failures in the open group (Fusion) compared to none in the MIS.Methods
Results
The royal victoria hospital is a tertiary trauma centre receiving pelvic injury referrals for a population of 1.7 million. The use of ilio-sacral screw fixation with low anterior frame stabilisation has been adopted as the principle treatment for unstable pelvic ring injuries in our institution. We aim to describe our practice and outcomes following the use of percutaneous screw fixation of the pelvis. The review included standardised assessment of health-related quality of life (SF-36) as well as the Iowa pelvic score and Majeed pelvic injury outcome scores. Data was also collected on associated injuries, post-operative complications, nerve injury and pain scores. A total case series of 45 patients undergoing percutaneous ilio-sacral screw fixation following traumatic pelvic injury were identified over a 5 year period. Of these 23 were contactable to follow-up or responded to questionnaire review. The mean follow up was 680 days (range 151–1962). The mean age was 33 (range 18–57). The mean SF-36 physical and mental scores were 38 and 46 respectively. The mean Majeed score was 69 and Iowa pelvic score was 65. The mean pain score was 3.5 (range 0–7). There were no incidences of deep infection, post-operative PE or nerve injury related to screw insertion. Patients with isolated pelvic injuries performed better on outcome scoring however the low SF-36 scores highlight the severity of pelvic injuries
Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system. 41 patients were implanted with a collarless polished tapered (CPT) femoral stem (Zimmer, Warsaw, Indiana), which was made of either cobalt-chromium (CoCr) (n=21) or stainless steel (n=20). RSA was used to measure dynamically inducible micromotion (DIMM: difference in stem position in going from double-leg stance (DLS) to single leg stance (SLS)), prosthesis bending (difference in the head-tip distance when going from DLS to SLS), and mean migration of the head, tip and the cement restrictor. DIMM and bending were measured at 3 months, migration at 6, 12 and 24 months. All analyses were carried out using SPSS for windows (v.15.0.0, Chicago. IL, USA). Results were reported as mean ± 95% confidence interval (CI) and regarded as significant when p < 0.05.Introduction
Methods
Replacing bone lost as a consequence of trauma or disease is a major challenge in the treatment of musculoskeletal disorders. Tissue engineering strategies seek to harness the potential of stem cells to regenerate lost or damaged tissue. Bone marrow aspirate (BMA) provides a promising autologous source of skeletal stem cells (SSCs) however, previous studies have demonstrated that the concentration of SSCs required for robust tissue regeneration is below levels present in iliac crest BMA, emphasising the need for cell enrichment strategies prior to clinical application. To develop a novel strategy to enrich skeletal stem cells (SSCs) from human BMA, clinically applicable for intra-operative orthopaedic use.Background
Aims
This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis. Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).Introduction
Methods
Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site. Analysis of retrieved tissue-engineered bone as part of ongoing follow-up of this translational case series.Background
Aims
Since the introduction of 3rd generation Metal-on-Metal-Hip-Resurfacing-Arthroplasty (MoMHRA), thousands of such prostheses have been implanted worldwide in younger patients with end-stage hip osteoarthritis. However, no independent centre has reported their medium-to-long term outcome. The aim of this study is to report the ten year survival and outcome of the Birmingham Hip Resurfacing (BHR), the most commonly used MoMHRA worldwide. Since 1999, 648 BHRs were implanted in 555 patients, the majority of which were male (326). The mean age at surgery was 52.1years (range: 17–82), with primary OA as most common indication (85%). Mean follow up was 7.1years (range: 1–11). The Oxford Hip Score (OHS) and UCLA questionnaires were sent to all patients. Implant survival was established, with revision as the end point. Sub-analysis was performed by gender, femoral component size (small: <45mm, standard: 46–52, large: >53mm) and age at surgery (young:<50yrs, old:>50yrs).Introduction
Methods
