Abstract

Introduction

Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace.

Objectives

All Polyethylene Tibial components in Total Knee Arthroplasty have been in use for some years, studies showing equivalent results to Total Knee Arthroplasty (TKA) with metal-backed Tibial components at 10 years have shown no significant difference between the two on radiostereometric analysis and revision rates[1].

Post operative patient outcome data using standard metal-backed Tibial components is widely reported in the literature. This study is looking at patient outcomes following All-polyethylene tibial component TKA. We hypothesize that using standard patient outcome measures, an improvement comparable with that expected for metal-backed tibial component TKA will be shown with All-polyethylene tibial component TKA.

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure.

The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone.

A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion.

We report a 10% failure rate for aseptic loosening and overall revision rate of 15% at 5 years mean follow up in 190 patients using the Cormet 2000 Dual coat ace-tabular component.

Between April 2001 and March 2004, this cup was used in our region by 4 surgeons. It was peripherally expanded and comprised a cobalt chrome shell, plasma sprayed with a further layer of cobalt chrome which was then coated with hydroxyapatite. This backing has since been abandoned in favour of a titanium plasma coat beneath the hydroxyapatite because of a higher than expected incidence of early loosening.

There were 190 cups implanted in 174 patients, 142 with resurfacing heads. The average age was 54 and 99 were male.

Revision for aseptic loosening was required in 20 cups (10%) at a mean interval of 23 months including five within 2 months, Of the early revisions three developed a deep infection. Undiagnosed groin pain in four further patients appeared at revision to arise from an inflamed bursa secondary to impingement of psoas tendon on the rim of the cup. There was one primary infection, one infection following revision of a trochanteric osteotomy and two neck fractures. Persistent unexplained groin pain was seen in three patients who have declined further surgery

Failure of this backing to integrate with bone led to an unacceptably high early loosening rate. Positioning of the larger resurfacing cups is critical to avoid painful irritation of psoas. Early revision carries a high risk of infection.

Between January 2003 and December 2004, 14 patients underwent bilateral resurfacing arthroplasty via a Ganz trochanteric osteotomy. This bilateral group was mobilised fully weight-bearing with crutches. During the same period 139 Ganz trochanteric osteotomies were performed for unilateral hip resurfacing. These patients were mobilised with crutches, weight-bearing up to 10 kg on the operated leg.

Nine osteotomies (32%) in the bilateral group subsequently developed a symptomatic non union requiring revision of fixation. This compares with 10 patients (7%) in the unilateral group. Applying the Fisher’s exact test, the difference reached significance (p=0.0004). In 2 patients a second revision was required to achieve union. In 1 patient, revision of trochanteric fixation precipitated a deep infection.

Protected weight-bearing following a Ganz trochanteric osteotomy is important to the success of the procedure. Simultaneous bilateral hip arthroplasty through a Ganz approach should be avoided. If it is undertaken, we recommend that patients should be non weight-bearing for 6 weeks following surgery. Non union following a Ganz trochanteric osteotomy for arthroplasty carries a significant morbidity.

Introduction: The open treatment of hip impingement is now a well-recognised technique with numerous publications about pathogenesis and surgical technique. There are very few publications of very small series discussing surgical results.

We present the results of 148 hips at a mean follow-up of 20 months (range 4 – 55).

Methods: This is a two surgeon series of sequential patients including the early learning curve. Patients were treated for impingement through a Ganz trochanteric osteotomy and open surgical hip dislocation. Patient data, operative findings and methods, complication and clinical follow up were recorded as a prospective audit and include Oxford and McCarthy Non Arthritic Hip scores.

Results: The patient demographics are as follows:

141 patients, 148 hips.

We have had the following complications: 4 trochanteric non unions requiring revision fixation, 2 deep vein thrombosis, 2 haematomas, 1 superficial infection, no deep Infections.

Life table survival curve with revision to arthroplasty defined as failure.

Discussion: The early to midterm results of this innovative procedure are encouraging even when including the decision making and surgical technique learning curves. We will present the hip scores and discuss the failures in detail to warn others embarking on this surgery which cases are more likely to lead to unsatisfactory outcomes.

Thinning of the femoral neck occurs in 77% of patients undergoing hybrid Birmingham hip resurfacing using a posterior approach (Shimmin 2007). Villar recently reported lower neck thinning rates in uncemented Cormet resurfacings (11.7%) compared with hybrid Birmingham resurfacing (13.4%), both via a posterior approach.

We have evaluated implant position and femoral neck thinning in a cohort of 273 uncemented HA coated Cormet 2000 hip resurfacings using ‘B’-series (Titanium/HA coated) cups in 269 patients (mean age 54 years, 39% female) with a mean follow-up of 3 years (range 1–4 years).

Mean cup inclination was 45° (30°–63°), mean SSA 138° (120°–178°). No lucent or sclerotic zones have been identified around the stem of the component. Only one femoral neck fracture has occurred (incidence 0.36%)

We have identified only one case of femoral neck thinning in our series (0.36%).

Whilst Villar has demonstrated a slight reduction in neck thinning rates using the same implants compared to a hybrid fixation Birmingham resurfacing, his neck thinning rates are almost 40 times higher than in our series. Shimmins ‘severe neck thinning (> 10%) rates (27%) are approximately 120 times higher than our series. In addition, we have been unable to confirm the relationship between implant position and neck thinning described by Shimmin in our series using the combined Ganz/uncemented resurfacings compared with Birmingham resurfacings.

Implant design and surgical approach have an impact on ‘neck thinning after resurfacing; we should be wary of treating all resurfacing implants and techniques as a uniform cohort.

Aim: To assess the clinical and functional outcome of proximal humeral fractures (2,3 and 4 parts) fixation with PHILOS (Proximal Humeral interlocked Osteosynthesis) plate using Oxford and DASH scoring system.

Methods: Forty-eight consecutive patients were treated with PHILOS plate from the complex proximal humeral fractures. One senior surgeon, using PHILOS plates, operated all patients. The patients were regularly assessed clinically, and plain radiographic evaluation was performed for fracture healing, avascular necrosis, and implant failure. Clinical outcome was measured using Oxford shoulder scores and DASH (Disability of the arm, shoulder, and hand) scores. Patients, who died, lost the follow up or the follow up was less than 3 months were excluded from the study.

Results: There were nine male patients (Age: 29–89 yrs) and twenty-nine female patients (Age: 35–93 yrs). Average age: 65 yrs. 74% were two part and three part fractures. Five patients died and four were lost in follow-up. These patients were excluded from the study. Mean follow-up time: 21.7 months (range: 6–44 months). Mean oxford shoulder scores: 41.8 (range: 14–60), Mean DASH scores: 30.2 (range: 0–83.3). There were no cases of non-union. Two plates were removed after fracture healing for complications of impingement and screw cutout.

Discussion & conclusion: Proximal humeral fractures constitute 5–7% of all fractures and 26% of humeral fractures.13–16% of proximal humeral fractures are 3 & 4 parts. Proximal humeral fractures have been a challenge to acquire stable fixation. Difficulties have been multifactorial, including osteoporotic bone, angular instability and non-availability of the low-profile implant to avoid impingements. PHILOS plate having locking screws provides angular stability and better hold in osteoporotic bone. It is low profile, which avoids subacromial impingement. Multiple holes in the proximal part of plate for suture anchors helps for soft tissue augmentation. PHILOS plate can provide an excellent stable construct even in multifragmented Osteoporotic proximal humeral fractures.

Our study has shown that PHILOS plates are reliable implants for internal fixation of proximal humerus fractures. An inverse correlation was seen between oxford shoulder scores and DASH scores. Patients with higher oxford scores indicating a good outcome had lesser disability scores. Comminuted fractures (four part fractures) had less than satisfactory shoulder scores and higher disability scores. In general, younger patients did better than older patients. This study demonstrates that PHILOS plates provide stable internal fixation for proximal humerus fractures. Age and fracture configuration play a significant role in the clinical outcome of these fractures after internal fixation.

Three methods to reattach avulsed finger flexor tendons to the distal phalanx were compared: a 1.8 mm metal barbed suture anchor, twin 1.3 mm PLA (polylactic acid)absorbable anchors, or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, and 90 degrees to the anchor’s axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure. The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3 mm absorbable anchors than the other methods; this method was significantly weaker. The 1.8 mm anchor gave similar performance to the pull-out suture over button technique, while the twin 1.3 mm absorbable anchors were weaker and vulnerable to gap formation even with passive motion alone.

Dynamic Hip Screw fixation for intertrochanteric fracture of femur is one of the most common operations in the trauma list of any DGH. The operation is commonly performed by the registrar or senior house officer as it is considered to be a relatively simple procedure. However the reality is slightly different as we audit our results of DHS fixation over a period of 2 years from May 2002 to August 2004. Out of 184 DHS fixation done during the abovementioned period, we identified 18 (10%) failures within 2–8 weeks postoperative period. We reviewed the pre-operative and post-operative X-rays to identify the possible reasons for failure. The reasons were inappropriate indication for DHS – 3 cases, inadequate fracture reduction – 6 cases, inappropriate implant placement −12 cases. 3 cases (16%) of failure had to be treated conservatively due to poor medical condition, 7 cases (39%) had the implant removed or revised and some type of arthroplasty was done in rest 8 cases (45%). Of the 15 cases treated operatively 12 had satisfactory outcome in terms of pain relief and movement and the rest 3 had residual pain, inadequate restoration of mobility affecting the quality of life. All patients had significant morbidity (prolonged hospital stay, depression) due to the failure of fixation and further operative procedures. Therefore we think appropriate guidance by experienced personnel is necessary for correct indication and meticulous operative technique.