Inter- and intra-observer variation has been noted in the analysis of radiographic examinations with regard to experience of surgeons, and the monitors used for conducting the evaluations. The aim of this study is to evaluate inter/intra observer variation in the measurement of mechanical alignment from long-leg radiographs. 40 patients from the elective waiting list for TKA underwent long leg radiographs pre-operatively and 6 months post-operatively (total of 80 radiographs). The x-rays were analysed by 5 observers ranging in experience from medical student to head orthopaedic surgeon. Two observers re-analysed their results 6 months later to determine intraobserver correlation, and one observer re-measured the alignment on a different monitor. These measurements were all conducted blindly and none of the observers had access to the others’ results. 80 radiographs were analysed in total, 40 pre-op and 40 post-op. The mechanical alignment was analysed using Pearson's correlation (r = 0 no agreement, r = 1 perfect agreement) and revealed that experience as an orthopaedic surgeon has little effect on the measurement of mechanical alignment from long leg radiograph. The results for the different monitor analysis were also analysed using Pearson's correlation of long leg alignment. Monitor quality does seem to affect the correlation between alignment measurements when reviewing both intra and inter observer correlation on different computer monitors. Surgical experience has little impact on the measurement of alignment on long leg radiographs. Of greater concern is that monitors of different resolution can affect measurement of mechanical alignment. As there might be a range of monitors in use in different institutions, and also in outpatient clinics to surgical theatres, close attention should be paid to the implications of these results.
Revision total hip arthroplasty is a common operation. The MP Link (Waldemar Link, Hamburg, Germany) system is a distally loading, modular, tapered femoral stem component for revision hip surgery. MP Link in revision total hip arthoplasty was investigated clinically, radiologically and with Oxford hip scores. A prospective study was conducted of 43 patients undergoing revision total hip arthroplasty with MP Link prostheses between 2004 and 2010. The patients were operated upon by one of the senior authors (JM, JS, RC). Outcome data was collected in clinic and via patient questionnaires.Aims
Methods
A retrospective review was conducted to evaluate the long term results of surgically excised wrist ganglia over a six year period between January 1998 and March 2005. The study involved patients who had undergone ganglion surgery around the wrist joint who were contacted by telephone and on whom a follow-up questionnaire was performed. The study included 117 patients with a mean follow up period of 4.2 years (range 1.5 – 8.7 years). There were 40 (34%) dorsal and 77 (66%) volar ganglia. The recurrence rate for surgically excised dorsal ganglia was 32.5% and for volar ganglia was 46.8%. Recurrence occurred in 58% of patients who had previously had their ganglion aspirated. The overall risk of developing a moderate to severely tender scar was 19% and an unsightly scar 9%. In those patients with recurrence of their ganglia, this was 33% and 8% respectively. Despite 49 patients experiencing recurrence, 24 were still satisfied with their treatment and 30 patients would still choose surgical treatment again knowing the risk of recurrence This study questions the effectiveness of surgery in the treatment of wrist ganglia in that recurrence rates are similar to rates seen in studies merely observing or aspirating ganglia. Not only does one have to question the surgical risks that are undertaken but also the demands on healthcare resources.
Stress fractures of the pars interarticularis of the lumbar spine in professional fast bowlers have become commonplace in modern times with a recently reported prevalence of 16.1%. We report 25 years of experience in the management of this patient group. Between 1982 and 2007, we diagnosed pars defects in 21 professional cricketers. 8 were managed conservatively by a combination of rest, supervised rehabilitation, bowling action analysis and re-training to a ‘safe’ action. Surgery was considered in those players who did not respond to these conservative measures and this group essentially compromised of the fast bowlers. Surgery was by Buck’s direct repair of the pars lesion. This treatment regime has given very good results enabling all of these players to return to professional sport with an average follow-up of over 5 years. Two of the surgical group have over 10 years follow-up and 4 have played to international level subsequent to their surgery. We recommend treatment of this group of sportsmen in a unit consisting of a specialist physiotherapist, a bowling coach and a spinal surgeon. Should conservative measures fail, we recommend Buck’s repair as the operation of choice.
Stress fractures of the pars interarticularis of the lumbar spine in professional fast bowlers have become commonplace in recent times. Should conservative measures in their treatment fail, surgery can give good results. Postoperative rehabilitation is of the utmost importance following surgery and a suggested programme is outlined. Post operatively, exercises and rehabilitation should proceed at a rate that is proportional to graft incorporation at the surgical site. Our rehabilitation programme has been fine tuned over several years giving much clearer guidance regarding that bowlers’ progress. We have rehabilitated 12 fast bowlers subsequent to Bucks repair of the pars interarticularis stress fracture in the lumbar spine. We have identified 7 stages in this process to rehabilitate the bowler to the highest level. We emphasise that the process of rehabilitation involves a team approach, the most important members being surgeon, physiotherapist, bowling coach and trainer. Surgery to the fast bowler with a stress fracture of the pars interarticularis can give good results. However it is necessary to have a multidisciplinary rehabilitation programme that proceeds in a stepwise manner to enable a return to full sport.
The use of MRI scanning has been described after open reduction of the hip in DDH to check hip position but has not previously been reported after open reduction with femoral osteotomy and the use of metalwork. We performed a prospective study utilising MRI to document the adequacy of reduction. An MRI scan was performed on the second postoperative day in order to confirm the satisfactory reduction of the hip following surgery. Previously a CT scan was performed. 10 consecutive cases were scanned and all gave diagnostic information of satisfactory reduction. Sedation was not required. The mean scanning time was 3 minute 45 seconds and the total time in the MRI suite ranged from 7 to 10 minutes. Satisfactory images, the lack of need of sedation, comparable time and cost to CT scanning and most importantly the lack of exposure of the child to ionising radiation make MRI a most appealing method of imaging. We therefore recommend it as the investigation of choice in this patient group. Demographic data reviewed included gender, MP at time of primary surgery, GMFCS level, age at time of surgery, type of adductor release procedure performed, and experience of surgeon. Outcome variables assessed were type of subsequent failure, time of failure after primary procedure, and length of follow-up. Three hundred and thirty children underwent hip adductor surgery. The number of children per GMFCS Level was 33 Level II, 55 level III, 103 level IV, and 139 level V. The average age at time of primary surgery was 4.19 years, mean MP at time of primary surgery 43.16%, and mean length of post-operative follow-up was 7.10 years. Eighty two children had adductor longus and gracilis lengthening alone, 97 also had an iliopsoas release, 97 had psoas tenotomy and phenolisation of the obturator nerve, and 54 had a psoas tenotomy and neurectomy of the anterior branch of the obturator nerve (in addition to longus &
gracilis lengthening). At time of audit 106 children did not require further surgery (‘surgery success’ of 32%). Thirty one were in children of GMFCS level II (94%), 27 level III (49%), 28 level IV (27%), and 20 level V (14%). A Cox proportional hazards survivorship analysis was constructed to chart the time course of progression to further surgery over time to reveal statistically significant ‘surgery success’ rates according to GMFCS. Differences in the success rates according to GMFCS become more apparent beyond 3 years post-surgery. The most important determinant for predicting the success of hip adductor surgery in preventing hip displacement is GMFCS at the time of primary surgery. Current treatment strategies need to be re-evaluated with the context of undertaking long-term post-operative follow up, particularly for children GMFCS levels VI and V.
The physical demand of the modern game of cricket on the fast bowler is known to cause stress fractures of the lumbar spine. Between 1983 and 2001, we diagnosed pars interarticularis defects in 18 professional cricketers contracted to a single English county cricket club. Initial management was conservative based on a combination of rest, supervised rehabilitation, bowling action analysis and re-education if indicated. Re-deployment (for example an all rounder to concentrate on batting alone) was also considered. 8 of the patient group responded to these measures. The remaining 10 were treated surgically, 9 by Buck’s repair of the spondylolytic lesion. All 9 returned to professional sport with an average follow-up of 5 years 8 months and a maximum follow-up of 10 years. We recommend treatment of this group of sportsmen in a unit consisting of a specialist physiotherapist, a bowling coach and a spinal surgeon. Should conservative measures fail, we recommend Buck’s repair as the operation of choice. Whether treated conservatively or surgically, we believe the vast majority of this patient group should be able to return to full professional sport
