Introduction

The first VRAS TKA was performed in New Zealand in November 2020 using a Patient Specific Balanced Technique whereby VRAS enables very accurate collection of the bony anatomy and soft tissue envelope of the knee to plan and execute the optimal positioning for a balanced TKA

Background

Prospective study to compare patient reported outcome measures (PROM) for sacroiliac joint (SIJ) fusion using HA-coated screw (HACS) vs triangular titanium dowel (TTD). First study of its kind in English literature.

Aim

In the context of total knee arthroplasty (TKA), trauma with perigenicular fracture fixation or oncological surgical treatment, soft tissue defects can expose critical structures such as the extensor apparatus, the knee joint, bone or implants. This work compares soft tissue reconstruction (STR) between a classical pedicled gastrocnemius (GC) muscle flap and a pedicled chimeric sural artery perforator (SAP) musculocutaneous GC flap in complex orthoplastic scenarios.

Introduction This is an outcome study of the patients with spina bifida treated for scoliosis by anterior and posterior spinal surgery by a single surgeon at one institution. Method The clinical notes and radiographs were reviewed of all spina bifida patients with scoliosis undergoing surgery between January 1991 and January 2001. In addition all patients were sent the Spina Bifida Health Related Quality of Life Questionnaire (HRQOL) and the Spina Bifida Spine Questionnaire (SBSQ). Results There were 19 consecutive patients with an average age at surgery of 13 years 5 months (range). The average neurologic level was T10 (range). 14 patients had staged procedures. At latest follow-up which averaged 60 months (range), there was an overall improvement in scoliosis of 61% from a mean of 83 degrees preoperatively to a mean of 34 degrees postoperatively. There was a corresponding 70% improvement in pelvic obliquity from 27 degrees preoperatively to 8 degrees postoperatively. At latest follow-up which averaged 60 months (range). The major complications included 4 deep infections and 2 pseudarthroses. The deep infections occurred in older patients with more severe curves and were always staged procedures. The patients scored an average of 68.8 on the SBSQ (what does this mean?). The average score on the HRQOL questionnaire for patients 5–12 year old was 178 and 163 for 13–20 year olds. Discussion There are good radiological results with combined anterior/posterior surgery in this group of spina bifida patients. The outcome scores show that this group of patients enjoy a good quality of life when compared to control groups of similar children with the same condition. An early single stage anterior and posterior spinal fusion is recommended for these patients before the scoliotic curve becomes too large and stiff

One hundred and ninety six unselected patients who had 200 consecutive primary total hip replacements between January 1994 and May 1995 using the Elite Plus cemented femoral component (DePuy International Leeds UK) were enrolled in a prospective outcome study. 155 patients (159 hips) were followed up for a minimum of 4.5 years (mean 5.4, range 4.5 to 6.9).Twenty four patients (24 hips −12%) died and 15 patients (15 hips) were lost to follow up. Two hips had been revised prior to the 5 year follow up. The average age was 68.4 years (range 35 to 94) at the time of the index arthroplasty. The patients were evaluated clinically using the Harris Hip Score and also radiologically. A self administered Oxford Hip Questionnaire was also used. A Kaplan-Meier survivorship analysis was performed with revision as the end point. The mean Harris Hip Score was raised from 39.3 pre-operatively to 89.6 at five years. The mean Oxford Hip Score was 23. There were no revisions for aseptic loosening. Radiographic review at 5 years showed mean femoral subsidence was 1.4mms with an average of 0.28mms per year. The cumulative survivorship at 5 years was 98.7% and the mean annual rate of re-operation was 0.2%. In the present series, the Elite Plus hip arthroplasty has produced clinical and radiological results which would justify its position as a modern progression of the Charnley with comparable results at five years

The purpose of this study is to audit the early clinical outcomes of a consecutive series of hip arthroscopies performed by one surgeon.

Pre-operative WOMAC and Non Arthritic Hip scores were performed on the patients. All patients had MRI arthrograms. These were correlated with the clinical findings at the time of surgery. Postoperatively all complications were recorded and at one year post surgery the pre-operative scores were repeated.

There are 37 consecutive cases. 15 males and 22 females. Average age 39 years. 76% of cases were accident related. The average length of symptoms pre-operatively was 21 months. There were 2 false negative MRI arthrograms and one false positive. The surgical treatment included debridement of 18 labral tears and 10 labral tears associated with an articular cartilage defect. The average traction time was 39 minutes. The complications were minor and all have resolved.

There are many indications for hip arthroscopy however the outcomes of labral debridement are not clearly defined. This paper attempts to measure the success of arthroscopic labral debridement in a consecutive series of patients. The clinical symptoms and MRI arthrograms seem to have a good correlation with the arthroscopic findings. The short term results of this treatment are encouraging as is the low morbidity associated with the surgery itself.

Summary

Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease.

Unicompartmental knee arthroplasty has been a popular treatment option for osteoarthritis, since popularised by Marmor in the early 1970’s. The Miller-Galante prosthesis has been in widespread use in Taranaki since 1992. The initial results were encouraging, however, recently a number of failures have caused us to review our results.

The indications for the procedure were osteonecrosis or osteoarthritis limited to one tibiofemoral compartment of the knee. 145 patients were available for assessment from January 1992 – December 2001. Patients were retrospectively reviewed with a clinical assessment, questionnaire and radiographic examination. The Knee Society Scoring System was used. There were 175 knees available for review.

There was 100% follow-up. The average age of patient was 69 years. The average follow-up time was 6 years. The10 year survival was 94%. The major cause for failure was polyethylene wear (4.5). There was no statistical difference between age, tibial insert size and different surgeons.

The unicompartmental Miller-Galante knee prosthesis has very good results at 10 years. However, a high percentage of polyethylene wear is a concern and requires further investigation into the possible causes for this.

This paper presents the first report of a prospective study to assess the outcome of using coregistration localisation and selective arthrodesis in chronic midfoot degenerative arthritis.

In a previous report from Cambridge (J Bone Jt Surg [Br]1998; 80B:777), a new coregistration imaging technique in the foot was described, using superimposed X-rays and technetium scintigram and showing significantly higher anatomical localisation of active joint disease than either alone.

Nineteen consecutive patients over a three-year period (1996–9) with severe midfoot joint pain and disability of over six months’ duration underwent coregistration imaging followed by selective arthrodesis. The procedures involved 17 patients with one-level single or multiple fusions of the metatarsocuneiform, metatarsocuboid or naviculocuneiform joints, and two patients with two-level multiple fusions.

Pain and functional assessments were recorded pre-operatively and at one and at two to four years postoperatively using the American Orthopaedic Foot and Ankle Society Midfoot Scoring System. Bone union was determined clinically and with X-rays.

Results showed fusions in all 19 patients between 10 and 15 weeks. Three K-wires and one screw required removal for later prominence and there was one delayed wound healing. Pian and functional scores showed significant differences between the pre- and post-operative and one year measurements, and less between the one year and two to four year scores.

This preliminary study concludes that there is a high correlation between the coregistration localisation of the midfoot degenerative arthropathies and the successful results of selective fusion of these joints for the one to four year follow-up period.

We present our experience with the use of the Anterior Tension Band plate (ATB) following ALIF, which utilises the existing surgical approach obviating the need for posterior fixation. The ATB is a small, smooth, low profile plate. It can be placed through the existing approach (anterolateral retroperitoneal or anterior transperitoneal) across the reconstructed level to prevent extension of the graft space and anterior migration of the spacer. The primary objective of this study is to measure radiographic fusion success in patients with lumbar degenerative disc disease using the ATB system. The secondary objective is to accurately define the clinical benefits to the patient. This is a prospective multi-center outcome study. Each patient was treated with an ATB plate at one or two levels between L2 & S1 and 1 ALIF or FRA allograft spacer per level. Patient data (VAS Pain, SF-12 and Oswestry) was collected preoperatively, and at six, twelve and twenty-four month post-operative intervals. Fusion was evaluated upon demonstration of bridging trabecular bone through or external to the femoral ring. Secondary endpoint success includes demonstration of 15% improvement over baseline on the VAS, Oswestry and SF-12 patient questionnaires. To date one hundred and thirty-one patients have undergone surgery. There were ninety-two (70%) single-level ALIF procedures and thirty-nine (30%) two-level ALIF procedures. Patients that have returned for twelve month follow-up (n=41) have had a fusion success rate of 81%. The fusion rate among one-level patients is 89% (n=25) and 67% (n=15) among two-level patients. Four of five of the un-fused two-level patients had one level fused but not the other. At twelve months, Oswestry scores improved by an average of 40% with thirty-one of forty-seven (66%) patients achieving success and VAS scores improved by 42% with thirty-five of forty-seven (75%) being successful. Preliminary analysis of current data shows positive outcomes using the ATB plating system in ALIF procedures. Primary and secondary outcomes are compatible with current standards of care, and device related complications are minimal. Further analysis of outcome data including will be reported upon the completion of the study

We present a retrospective study on the outcome of Clayton’s forefoot arthroplasty in 23 patients with rheumatoid arthritis.

The average age at surgery was 51.2 years (range 26–88). Pre-operative symptoms were pain, deformity, and footwear problems. Hallux valgus, lesser toe deformities and callosities were the common signs. One surgeon performed all procedures. All patients were assessed radiologically and clinically using American Orthopaedic Foot and Ankle Society (AOFAS) rating system.

Thirteen patients had bilateral correction, and 10 had single foot surgery, providing a total of 36 feet for analysis. Complications included eight wound infections, two toe tip ulceration, two ischaemic toes and two painful feet.

The AOFAS average score was under 45 before surgery and it improved to 83 (range 47–100) for hallux and 79 (range 40–100) for the lesser toes. Overall 91% patients were pleased with the procedure. Our results suggest that Clayton’s forefoot arthroplasty is a procedure, which provides predictable comfort and immediate, functional improvement in advanced rheumatoid arthritis.

Total hip arthroplasty (THA) allows patients to return to an active lifestyle. Unfortunately one of the more common complications of cementless THA is a fracture of the greater trochanter (GT) or the calcar. These may compromise the outcomes of THA, but there are no large studies looking into this hypothesis.

Between September 1998 and August 2005 the Hamilton Arthroplasty group performed 2282 THA operations. Demographic and outcome data on these patients was collected and tabulated in a prospective database. Radiographs were available on a picture archiving system for 1075 of the patients, 85% of which were primary THAs. GT and calcar fractures were identified. Statistical comparisons on the normal distributed outcome data were made using the Student’s T-test comparing repaired and missed fractures.

A total of 60 GT fractures were found in the review of 1075 radiographs, giving an incidence of 5.6%. This included 19 isolated GT fractures and 10 GT fractures with associated calcar fractures that were found in primary hip arthroplasties, 48% of the total. Revision hip surgeries had 14 isolated GT fractures and 17 GT fractures with associated calcar fracture. We found that 23 (40%) of all GT fractures were missed intra-operatively and did not receive any fixation. All calcar fractures were noted and repaired, even if the associated GT fracture was not.

106 isolated calcar fractures were noted, 10% of all arthroplasties, only one of which did not receive fixation. Of this, 85 (80%) were from primary total hip arthroplasty and 21 (20%) from revision hip arthroplasty.

Evaluation of the outcome data showed no significant difference between repaired and missed GT fractures. Reported outcomes compared favourably with the average for all THA in that time period.

Adoption of cementless total hip arthroplasty in North America undoubtedly increases the rate of GT and calcar fractures. Most calcar fractures were noted and fixed but only 50% of GT fractures were discovered intraoperatively, an area of potential improvement. Greater trochanter and recognized calcar fractures may not have long-term detrimental effects.

Background

Morton's Neuroma is a proximal neuralgia that affects the web spaces of the toes and is currently of unknown aetiology. Currently surgical excision is considered the gold standard treatment based on RCT and cohort studies. However patient derived outcomes have not previously been assessed. We addressed these aspects with our study.

We undertook the current study to analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability. Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two and the average follow up was fifty-eight months. There were sixteen females and fifty-eight males. All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. Ten had a recurrence of instability. Of these two had significant trauma. Of the remaining, six were in the arthroscopic group and two in the open procedure group.

Analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability.

Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two years (range nineteen to forty-seven). There were sixteen females and fifty-eight males. The average follow up was fifty-eight months (range seven to eighty-three). All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. The arthroscopic procedure involved two Suretac II labral reattachment and capsular shrinkage using electrocautery. The open procedure involved a Bristow/Latarjet procedure using a delto-pectoral approach and reattachment of coracoid process using a single malleolar screw.

Ten patients had a recurrence of instability. Of these two had significant trauma, one each group. Of the remaining eight, six were in the arthroscopic group and two in the open procedure group. In the arthroscopic recurrence group, three had a large Hill Sach’s lesion and one a large Bankart Lesion. In the open procedure group, both had a large Hill Sach’s and Bankart’s lesion. This gave a recurrence rate of 12.7% in the arthroscopic group and 7.4% in the open group.

A large Hill-Sach lesion > 2mm is a contra-indication to arthroscopic repair and the optimum stabilisation procedure is an open repair (Bristow/Laterjet). Without a significant Hill-Sach’s lesion an arthroscopic Suretac II labral re-attachment is an effective way of achieving stability. Those who have a large Hill-Sach and significant Bankart’s lesion may need a combination of Bankart’s repair plus an extra-articular procedure like a Bristow/Laterjet procedure.

L5-S1 interbody fusion is a successful technique for treating patients with isolated degenerative disc disease. Traditionally through an open technique, the anterior laparoscopic approach for this was first described in 1991.

The purpose of this study was to review the long-term outcome results of L5-S1 interbody spinal fusion, using an anterior endoscopic technique, performed on patients with isolated degenerative L5-S1 disc disease. The first 41 spinal fusions performed by the senior authors were analysed. Patients received clinical, functional and radiological review by an independent assessor.

Clinical outcomes were excellent with > 90% of patients having significant improvement in back assessment scores (Fraser and Greenough, Japanese Orthopaedic Association). There were no intraoperative complications, no vascular complications, and no reports of retrograde ejaculation.

The anterior endoscopic approach for L5-S1 inter-body fusion results in good clinical outcomes, with a very low rate of morbidity. Surgical recovery time is quicker compared to open techniques, however, two skilled surgeons and an increase in theatre resources is required.

A prospective randomised study was undertaken of patients with displaced Colles’ type distal radial fractures. Group 1 underwent bridging external fixation with a Pennig device; group 2 underwent manipulation and plaster immobilisation. All patients were initially treated for 6 weeks and reviewed regularly for 12 months.

At a mean of 7.8 years 86 fractures were available for review (36 treated by fixator and 50 treated in plaster). They were assessed to determine the anatomical and functional outcome of their wrist and also the incidence of post-traumatic degenerative change.

The patients had standard anteroposterior and lateral radiographs taken, to allow standard measurements to be made. The degree of arthritic change was also documented. An independent physiotherapist carried out a functional assessment, consisting of range of movement and grip strength in both wrists.

A Gartland and Werley demerit score was calculated, 94% of patients in each group had an excellent or good outcome. Patient satisfaction was comparable, 94% in the fixator and 92% in the plaster group were entirely satisfied.

Although a significant difference was found in terms of radial shortening between the groups, favouring the fixator group (p< 0.05), shortening of > 2mm did not adversely effect the functional outcome. However bridging external fixation did not improve the dorsal angulation in this study. No other radiological or functional parameter showed a statistical difference between the groups.

One patient in this series developed symptomatic post-traumatic arthritis. Grade 1 radiological signs (Knirk & Jupiter) occurred in 25% of patients but only half of these had sustained intra-articular fractures.

In conclusion: no overall long term benefit has been found to treating Colles’ type distal radial fractures with bridging external fixator as compared to plaster immobilisation.

The aim was to compare the medium term results of metacarpophalangeal joint (MCPJ) arthroplasty using three different types of silicone hinged implants.

All rheumatoid arthritis patients undergoing four finger MCPJ arthroplasty at Burwood Hospital have had standardised pre and post operative assessments for up to four years consisting of: measurement of MCPJ active arc of motion (AOM); finger ulnar drift (UD) and the Baltimore upper extremity function test (UEFT). All surgery was undertaken or directly supervised by one surgeon using a standardised technique followed by a dynamic and static splintage programme supervised by the same hand therapists.

Implants – Swanson; 25 hands, 100 joints, 1989 to 1995 – Avanta; 27 hands, 108 joints, 1995 to 2000 – Neuflex; 11 hands, 44 joints, 1999 to 2003

Swanson – at two years the AOM changed from 46 – 80° to 15 – 51°; UD reduced from 33 to 4°and 66% had improved from partial and poor to functional UE categories.

Avanta – the AOM changed from 51 – 79 to 15– 60; UD from 31 to 7° and 67% had improved to functional.

Neuflex – the AOM changed from 42 – 68 to 17 – 63°; UD from 32 to 11 and 45% had improved to functional classification.

From two to four years the UEFT for the Swanson and Avanta had significantly deteriorated.

The medium term outcomes for the three implants were very similar. Neuflex use was discontinued in 2003 because of early recurrence of ulnar drift. The significant deterioration of hand function from two to four years is likely to be the effect of progressive rheumatoid disease as the AOM and UD remained unchanged.

Objective: To evaluate the subjective clinical outcomes, radiographic results and complications associated with single solid rod anterior instrumentation in neuromuscular scoliosis.

Design: Retrospective clinical case series with a mean follow up of 30 months (range 24 – 42 months).

Subjects: 9 consecutive cases (6F, 3M) with a mean age 15 years (range 11 – 24 years), underwent single solid rod anterior instrumentation of their neuromuscular thoracolumbar scoliosis between 1994 and 2000. The heterogeneous patient group consisted of 5 spinal dysraphism, and 1 each of prune belly syndrome, arthrogryposis, myotonic dystrophy and congenital myopathic dystrophy (muscle eye brain syndrome). All patients were ambulatory and had minimal pelvic obliquity (< 15 degrees).

Outcome measures: Pre-operative, post-operative and final follow up measurements were collected for 1) Cobb angles, 2) apical vertebral translation (AVT), 3) thoracic kyphosis (T5-12) and 4) lumbar lordosis (L1-5). Operative complications, pseudarthrosis, metalwork failure and loss of correction were also recorded.

Results: There was 1 each of rod breakage and upper thoracic curve progression requiring supplementary posterior surgery. For the remaining 7 patients, the average follow-up corrections for Cobb angle was 56% (49 to 22 degrees), AVT was 49% (5.1 to 2.6 cms), and both the thoracic kyphosis and lumbar lordosis remained unchanged. No significant loss in correction occurred during the post-operative period to final follow-up in all the above parameters. No pseudarthrosis, vascular or neurological complications were encountered. Subjectively, there were 6 excellent and 1 good results.

Conclusions: In this limited case review, selective anterior instrumentation for neuromuscular scoliosis using a single solid rod system resulted in acceptable clinical and radiographic outcomes. Our results appear to compare favourably with those published for the recommended method of posterior instrumentation. Advantages include preservation of distal lumbar motion segments whilst maintaining segmental saggital and coronal alignment. We believe that this method of scoliosis correction has a definite yet select role in patients who are ambulatory, have minimal pelvic obliquity (< 15 degrees), non-progressive pathology and near normal mental function.

Abstract

Introduction: There is little evidence for the long term efficacy of selective nerve root injections (SNRI) in the control of lumbar radiculopathy. We report the 5 year results of a prospective study of SNRI in the lumbar spine.

Methods: All patients considered to be operative candidates by two treating surgeons (JMP and DJS) with unilateral/bilateral radicular leg pain were included. Patients had a mean history of radicular symptoms of 12.8 months (4 months–3 years). All had an SNRI under image intensifier control with local anaesthetic and steroid. Each patient was evaluated pre-operatively, 2 months, 6 months, 1 year, 2 year and 5 years with VAS and ODI scores.

Results: Sixty-two consecutive patients were reviewed. The mean age of patients was 54.5 years (36–80 years). 92 injections were performed. Symptoms were caused by degenerative disease (n=32), disc herniation (n=25), and previous surgery (n=3).

The ‘disc’ group was significantly younger than ‘degenerative’ group (49.4 yrs vs. 58.4 yrs; p=0.004). There were significant improvements in low back pain (LBP), leg pain (LP), and ODI at 2 months in all patients. At 5 years the disc group did better with both leg and back pain; whilst there was only a significant reduction in leg pain in the degenerative group. Over 90% (n=56) of patients had no operative intervention; a subgroup of 8 had further injections. Within the degenerative group, ODI and VAS deteriorate early on indicating that a second injection option in this group may be worthwhile.

Conclusion: At five-years, most patients avoid operative treatment because of improved symptom control with SNRI. Regression analysis showed “duration of symptoms” and “age” is predictive of good outcome at one year post SNRI, but gender and, diagnosis are not.