Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme. To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6). The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs). The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.
Hip resurfacing arthroplasty has become a popular treatment option for younger active patients. The early published results from designing surgeons/centers have been favourable. We undertook a prospective multi-center trial to determine the outcome of hip resurfacing arthroplasty at independent centers. The clinical, radiographic and functional results were assessed. A prospective IRB approved study was initiated in July 2003 to assess the outcome of hip resurfacing arthroplasty using a contemporary design implant. (Conserve Plus - Wright Medical Technology) Disease specific (Harris Hip Score/WOMAC) and global (Rand self assessment index) outcome measures were used. Radiographs were reviewed for component position and migration as well as any signs of lysis or loosening. Complications and re-operations were recorded. A total of one hundred and eighty-eight patients have been enrolled in the study to date. One hundred and four patients have a minimum one year follow-up and forty-six patients have a minimum two year follow-up. Mean Harris Hip Scores (pre-op, one year, two years) were fifty-five, eighty-nine and ninety-one. Mean WOMAC pain scores were forty-seven, ninety and ninety. Mean WOMAC stiffness scores were forty, seventy-eight and eighty-two. Mean WOMAC function scores were forty-six, eighty-seven and eighty. RAND physical function mean scores were thirty-three, seventy-six and seventy-six and the RAND physical limitations mean scores were nineteen, sixty-seven and seventy-five. Radiographic analysis showed average cup abduction to be forty-six degrees (range twenty-six to sixty-three). Average femoral stem position was one hundred and thiry-eight degrees (range one hundred and eighteen to one hundred and fifty-seven). Nine patients have been revised to date (4.8%). Four for acetabular loosening, two for neck fracture, one for femoral loosening, one for impingement and one for persistent pain. There have been eight other patients requiring re-operation without revision. Medical complications occurred in fifteen patients. Early results have demonstrated a good return of function in patients with hip resurfacing arthroplasty. A high early revision rate (4.8%) was seen in our study. Technical factors appear to be the main contributor to the high early complication rate. Hip resurfacing is associated with a steep learning curve. We continue to utilise hip resurfacing in select patients but recommend caution for those who are new to the technique.
The primary objective of this study was to report the progression of functional status over time after hemiarthroplasty surgery for displaced femoral neck fractures in one hundred patients. One of the secondary outcomes was to determine factors predictive of bad outcome (age, co-morbidities, type of anesthesia, surgical approach, etc). Another secondary objective was to determine if early functional assessment correlates and/or predicts long term function. Finally, our group was compared to a normal control group database. A hundred patients treated with hemiarthroplasty for Garden-type III and IV femoral neck fractures were evaluated prospectively using validated functional outcome measures. Baseline data and preoperative functional level was determined for all patients. Functional recovery was evaluated using the Lower Extremity Measure (LEM) and the Time Up and Go (TUG). Clinical outcome was equally measured using the Harris Hip Score and SF-36 (Short-Form 36). Follow-up was done at one and a half, three, six, nine, twelve and twenty-four months. Preliminary results show that this study group is comparable to the group used in Jaglal et al.’s original study of the Lower Extremity Measurement score. LEM scores at one year follow-up are significantly lower than pre-operative scores. TUG scores at three months follow-up were significantly lower in the female sub-group in comparison to normal controls. This study of patients undergoing hemiarthroplasty for femoral neck fractures demonstrates the significant post operative functional repercussions as shown by the deterioration of scores of functional outcome measures used. Predicting functional outcomes based on pre-operative patient baseline data and function is relevant in that it could potentially impact decision to operate and determination of surgical procedure of choice.
This study is a prospective randomised clinical trial which primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for hemiarthroplasty in acute femoral neck fractures. Fifty-five patients have been randomised: twenty-four patients in the mini-incision surgery group (MIS) and thirty-one patients in the standard incision group (STD). The mini-incision was defined as less than 8cm. Data were collected preoperatively and at four days, three and six weeks, three, six, twelve, and twenty-four months postoperatively. The Jaglal Lower Extremity Measurement (LEM) and the Time Up and Go (TUG) where evaluated. Secondary endpoints of pain, function, and quality of life where assessed by the components of the Harris hip Score and SF-36. Radiograghic outcomes where also evaluated. The demographic data where similar between the two groups for age, gender, weight, type of anaesthesia used, pre-operative haemoglobin and preoperative comorbidities. There was no significant difference for operative time, blood losses, 72h postoperative haemoglobin and the need for transfusion therapy between the two groups. Also, there was no difference between the groups for post-operative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using the LEM, TUG, Harris Hip score and SF-36 scores did not demonstrate any statistically significant difference between mini and standard incision. This study demonstrates that the clinical and functional outcomes measured are similar between the two groups, thus limiting the potential benefits of MIS in hip fracture patients.
In the recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that innovative technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied. This study is a prospective clinical randomized trial which primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for hemiarthroplasty in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. To date, 45 patients have been randomized between the two surgery groups has follows: 22 patients in the mini-incision surgery group (MIS) and 23 patients in the standard incision group (STD). Data were collected preoperatively as well as 4 days, 3 and 6 weeks, 3, 6, 12, and 24 months postoperatively. The following validated disease-specific outcome instruments where used: the Jaglal Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life where assessed by the components of the Harris hip Score and SF-36. Radiograghic outcomes where also evaluated as well as the rates of all reported complications and adverse events during the two years follow-up. The demographic data where similar between the 2 groups for age, gender, weight, type of anaesthesia used, pre-operative haemoglobin and preoperative comorbidities. There was no significant difference for operative time, blood losses, 72h postoperative haemoglobin and the need for transfusion therapy between the 2 groups. Also, there was no difference between the groups for post-operative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using the LEM, TUG, Harris Hip score and SF-36 scores did not demonstrate any statistically significant difference between mini and standard incision. This study demonstrates that the clinical and functional outcomes measured are similar between the two groups, thus limiting the potential benefits of MIS in hip fracture patients.
The most commonly used surgical techniques used to treat recurrent or habitual patellar dislocation in the child do not specifically address the patella alta, one of the major causes of patellar dislocation. Twelve knees in eight patients had a lowering of the patella by total tendon transfer, lateral release and vastus medialis obliquus advancement. At two years of follow-up, only one knee had redislocated. Radiographically, the patellar height was anatomically restored in all other knees. All patients were pain free. This surgical technique is a good treatment option in the immature patient with recurrent or habitual patellar dislocation. Patella alta is one of the major causes known to predispose children to recurrent or habitual patellar dislocation. However, the surgical treatment of such a condition, before squeletal maturity, is rarely if ever mentioned in the literature. Twelve knees in eight patients were treated with a surgical procedure designated to correct patella alta, the major predisposing factor causing recurrent patellar dislocation. The technique involves lowering of the patella by total tendon transfer, lateral release and vastus medialis obliquus advancement. All patients were complaining of recurrent or habitual dislocations leading to functional disability. Patellar height was assessed radiographically by the Koshimoto index (PT/FT) and Caton-Deschamps index (AT/AP). The average at surgery was 10.9 years and mean follow-up was 45.1 months. Follow-up revealed redislocation in one knee. This patient required a second operation to achieve patellar stability. At the latest follow-up, all operated knees were functionally stable and pain free. The average preoperative ratios were 1.28 (PT/FT) and 1.53 (AT/AP) which improved to 0.97 (PT/FT) and 0.96 (AT/AP) at the time of follow-up. Few complications were noted. This technique is a valid surgical alternative to treat the immature patient presenting with functional disability related to recurrent or habitual patellar dislocation associated with patella alta.
This study evaluates metal ion levels in patients enrolled in a prospective evaluation of hip resurfacing arthroplasty utilizing the Conserve Plus implant (Wright Medical Technology). Serum, urine and erythrocyte metal ion levels were assessed preoperatively and postoperatively. Average levels at three months were 24 nmol/l for cobalt and 40 nmol/l for chromium. These increased to 40 nmol/l for cobalt and 80 nmol/l for chromium at the six-month mark. The clinical significance of increased metal ion levels is yet to be determined. To evaluate the clinical, functional and radiographic outcome of hip resurfacing arthroplasty utilizing the Conserve Plus implant (Wright Medical Technology). Serum, urine and erythrocyte metal ion levels were evaluated both pre and postoperatively. Ion levels for both cobalt and chromium increased from the three-month to the six-month mark postoperatively and were significantly elevated relative to preoperative values. This study helps to establish a baseline for metal ion levels following hip resurfacing arthroplasty. Serum, urine and erythrocyte metal ion levels were assessed preoperatively and postoperatively. All levels were within normal range preoperatively. Average serum levels at three months were 24 nmol/l for cobalt and 40 nmol/l for chromium. These increased to 40 nmol/l for cobalt and 80 nmol/l for chromium at the six-month mark. Average erythrocyte metal ion levels at three months were 0.92 ug/l for cobalt and 1.8 ug/l for chromium. The average erythrocyte levels at six months were 1.3 ug/l for cobalt and 2.0 ug/l for chromium. A prospective multi-center study to evaluate the outcome of hip resurfacing arthroplasty was initiated in July 2003. Each patient was evaluated preoperatively and postoperatively with outcome scores, radiographs as well as serum, urine and erythrocyte metal ion levels. The results of this prospective evaluation show a rise in ion levels from three to six months postoperatively. Further follow-up is necessary to assess future trends with respect to the ion levels as well as the clinical significance. Funding: This study has been sponsored in part by Wright Medical Technology.
The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Three patients died from their injuries. At a mean follow-up of 3.5 years, patients exhibited profound functional deficits compared to the normal population. Those with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. To evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. These results will allow us to further investigate which injury is dictating prognosis in the combined injury – the pelvic or the acetabular fracture. One-hundred and fifteen patients with combined pelvic and acetabular injuries were identified at a level One trauma centre. 63% were male; mean age was thirty-seven years (13–88); mean ISS was thirty (16–75). Three patients died from their injuries. 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures involved the anterior column or both column. Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed validated functional outcome questionnaires at a mean follow-up of 3.5 (one to eleven) years. Patient function was significantly compromised with a mean MFA score of 33.8 (SD 21.8). Function was worse for all 8 SF-36 domains and the two component scores compared to the health status of the Canadian normal population (p<
0.001). Those individuals with an acetabular fracture involving the posterior wall or an associated lower extremity injury have a particularly poor prognosis. There was no relationship found between treatment or the pre-defined stability groups and functional outcome.
The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. One hundred and fifteen patients were identified. 63% were male; mean age was thirty-seven years; mean ISS was thirty. Four died from their injuries. Five patients had open injuries. Only 18% were treated with ORIF for both injuries. At a mean follow-up of 3.5 years, patients with combined pelvic and acetabular fractures exhibit profound functional deficits compared to the normal population. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. The purpose of this study was to evaluate functional outcome in patients with combined pelvic and acetabular fractures and to identify factors associated with outcome. Combined pelvic and acetabular injuries are associated with high mortality and functional morbidity irrespective of treatment. Those individuals with an acetabular fracture involving the posterior wall and an associated lower extremity injury have a particularly poor prognosis. Individuals who have sustained high energy combined injuries exhibit profound functional impairments compared to the general normal population even in the long term. One hundred and fifteen patients with combined pelvic and acetabular injuries were identified using a trauma database at a level one trauma centre. 63% were male; mean age was thirty-seven years (13–8); mean ISS was thirty (9–5). 16% involved bilateral pelvic fractures; 7% bilateral acetabular fractures; and for 2%, both were bilateral. 64% were Tile B and 34% were Tile C. Most acetabular fractures were anterior column (31%) or both column fractures (26%). Only 18% were treated with ORIF for both injuries. 25% had ORIF of their acetabulum and 14% had ORIF on their pelvis. Sixty-five patients completed functional outcome questionnaires at a mean follow-up of 3.5 years (1–21). Function was significantly compromised with a mean MFA score of 33.8±21.8. Function was worse for all eight SF-36 domains and the two component scores compared to the Canadian normal population (p<
0.001). There was no relationship found between severity of pelvic or acetabular injury and patient function nor between treatment and functional outcome.
We compared internal fixation augmented with a trabecular metal implant to internal fixation augmented with morcellized bone grafting for depressed lateral tibial plateau fractures. Six cadaveric tibia pairs were prepared and tested on a MTS machine for both cyclic loading and static load to failure. Results showed greater resistance in cyclic loading and load to failure in the trabecular metal group. We found half the loss of reduction of the tibial articular surface compared after cyclic loading over 10 000 cycles. These surprising results show the biomechanical superiority of our trabecular metal construct over the current standard of care. Restoration and maintenance of the plateau surface are the key points in the treatment of tibial plateau fractures. Any deformity of the articular surface jeopardises the future of the knee by causing osteoarthritis and axis deviation. The purpose of this study is to develop a more solid way to fix the Shatzker III fracture and to test a trabecular metal implant in the trauma setting for the first time. Six matched pairs of fresh frozen human cadaveric tibias were fractured and randomly assigned to be treated with either the standard of care (two 4,5mm cortical raft screws augmented with morcellized bone graft) or the new method (the same screws supporting a 2 cm diameter trabecular metal disc placed under the comminuted articular surface). The specimens were tested in cyclic loading and put at load to failure. The trabecular metal construct showed 40% less caudad displacement of the articular surface (1,43 mm vs 0,81 mm) in cyclic loading (p<
0.05). Its mechanical failure occurred at a mean of 3275 N compared to 2650 N for the standard of care construct (p<
0,05). The current study shows the biomechanical superiority of our trabecular metal construct compared to the current standard of treatment with regards to both its resistance to caudad displacement of the articular surface in cyclic loading and its strength at load to failure. Trabecular metal is a good metaphyseal void filler in the studied fracture.
