Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting. Cite this article:
Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes. A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale (‘not important’ to ‘critically important’). A consensus meeting was held to finalize the CMS.Aims
Methods
The current evidence favors replacement for the treatment of displaced femoral neck fractures in the older patients.
There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article:
The anatomy and microstructure of the menisci
allow the effective distribution of load across the knee. Meniscectomy
alters the biomechanical environment and is a potent risk factor
for osteoarthritis. Despite a trend towards meniscus-preserving
surgery, many tears are irreparable, and many repairs fail. Meniscal allograft transplantation has principally been carried
out for pain in patients who have had a meniscectomy. Numerous case
series have reported a significant improvement in patient-reported
outcomes after surgery, but randomised controlled trials have not
been undertaken. It is scientifically plausible that meniscal allograft transplantation
is protective of cartilage, but this has not been established clinically
to date. Cite this article:
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
The aim of this review is to address controversies
in the management of dislocations of the acromioclavicular joint. Current
evidence suggests that operative rather than non-operative treatment
of Rockwood grade III dislocations results in better cosmetic and
radiological results, similar functional outcomes and longer time
off work. Early surgery results in better functional and radiological
outcomes with a reduced risk of infection and loss of reduction compared
with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular
fixation and coracoclavicular ligament reconstruction. Although
non-controlled studies report promising results for arthroscopic
coracoclavicular fixation, there are no comparative studies with
open techniques to draw conclusions about the best surgical approach.
Non-rigid coracoclavicular fixation with tendon graft or synthetic
materials, or rigid acromioclavicular fixation with a hook plate,
is preferable to fixation with coracoclavicular screws owing to
significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical
ligament reconstruction with autograft or certain synthetic grafts
may have better outcomes than non-anatomical transfer of the coracoacromial
ligament. It has been suggested that this is due to better restoration
horizontal and vertical stability of the joint. Despite the large number of recently published studies, there
remains a lack of high-quality evidence, making it difficult to
draw firm conclusions regarding these controversial issues. Cite this article:
Congenital pseudarthrosis of the tibia (CPT)
is a rare but well recognised condition. Obtaining union of the pseudarthrosis
in these children is often difficult and may require several surgical
procedures. The treatment has changed significantly since the review
by Hardinge in 1972, but controversies continue as to the best form
of surgical treatment. This paper reviews these controversies. Cite this article:
Introduction. Infection after total hip arthroplasty is a severe complication.
This review summarises the opinions and conclusions
reached from a symposium on infected total knee replacement (TKR)
held at the British Association of Surgery of the Knee (BASK) annual
meeting in 2011. The National Joint Registry for England and Wales
reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused
by infection. The diagnosis of infection beyond the acute post-operative
stage relies on the identification of the causative organism by
aspiration and analysis of material obtained at arthroscopy. Ideal
treatment then involves a two-stage surgical procedure with extensive
debridement and washout, followed by antibiotics. An articulating
or non-articulating drug-eluting cement spacer is used prior to
implantation of the revision prosthesis, guided by the serum level
of inflammatory markers. The use of a single-stage revision is gaining popularity
and we would advocate its use in certain patients where the causative
organism is known, no sinuses are present, the patient is not immunocompromised,
and there is no radiological evidence of component loosening or
osteitis. It is our opinion that single-stage revision produces high-quality
reproducible results and will soon achieve the same widespread acceptance
as it does in infected hip arthroplasty.
Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the correction of Stage 2 deformity. Stage 1 deformity, uncommonly corrected surgically, involves tenosynovitis with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson's 1992 patient population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage 2 deformity becomes the mainstay of operative treatment of the adult flatfoot. Stage 2 deformity patients present with swelling medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is functionally torn. In recent years, authors have subdivided Stage 2 deformity even further into A and B subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B patients more than 50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients who have forefoot varus. Thus, Stage 2 patients suffer from pain that begins medially and progresses to the subfibular region over time. Most important, recognition of the continued sub classification in Stage 2 disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties that, if unrecognized, lead to a poor patient outcome. The mainstay of treatment in Stage 2 disease is the medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the medial arch, protects the FDL tendon transfer, and allows the Achilles tendon to become a strong inverter. Over shift of the calcaneus can compromise the outcome, as will a lack of recognition of the congenital subtleties such that a valgus hindfoot can have a varus orientation to the calcaneus, both leading to lateral overload. A pure medial slide of a calcaneus that has a varus orientation does not correct deformity, rather, it creates it. Thus, an axial calcaneal view must be studied carefully, for a varus orientation may be corrected via a closing wedge osteotomy commensurate with the medial shift of the tuberosity. As noted above, the flexor digitorum longus tendon transfer is the staple procedure to replace the damaged posterior tibial tendon. This transfer balances the eversion power of the peroneal tendons, works in phase with the former posterior tibial tendon in the stance phase of gait, and replaces a painful diseased posterior tibial tendon. However, over tensioning the transfer results in a tenodesis rather than a functional tendon transfer, the relative weakness of the FDL tendon (30% as strong as the PTT) creates difficulty with heel raise, and inappropriate transfer to distal tarsal bones may compromise the result by limiting torque from the transferred tendon. Preservation of the posterior tibial tendon in combination with the transferred FDL tendon remains a consideration without answer, though Rosenfeld (2005) suggests a substantial improvement in strength through PTT preservation. Failure of the above protocol for treating Stage 2 disease most often revolves around the insufficient corrective power of the tandem procedures in longstanding ruptures. According to Guyton (2001), only 50% of patients report a perception in deformity improvement following FDL/calcaneal osteotomy procedures, and only 4% report a significant improvement in pre-existing deformity. Sangeorzan (2001) found such patients could not achieve a painless plantigrade foot due to acquired ligament laxity (primarily the Spring Ligament). Sangeorzan applied Evans' pediatric procedure to adults without confirming the pathomechanics of correction. Some speculate the windlass effect on the plantar fascia creates correction (refuted by Horton, 1998, finding the plantar fascia is loosened by a lateral column lengthening), others believe tightening the peroneus longus through lateral column lengthening increases first ray plantarflexion, restoring the medial arch. Controversy also remains in answering Cooper's (1997) claim that lengthening through the calcaneus creates static increase in pressure about the calcaneocuboid joint (1.4mPa total) that may lead to an arthritic joint long term. Painful lateral overload following lateral column lengthening remains difficult problem to both prevent and correct. This last point leads to some focusing their efforts on restoration of the medial column. This group focuses on the “C” type deformity noted by Anderson, those with forefoot varus. It is known that the medial column is supported by the navicular, the cuneiforms, and the first, second, and third metatarsals. While a Cotton (opening wedge medial cuneiform) osteotomy, a first tarsometatarsal joint arthrodesis, or a metatarsal osteotomy has value, the surgeon must note that this only corrects the first ray. Complete correction of the medial column is best achieved through naviculocuneiform joint arthrodesis. Standing radiographs commonly reveal collapse at that level; however, surgeons are reticent to perform such fusions in light of the higher nonunion rate.
Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type
sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of
information on optimal conservative and operative management. Treatment. Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required. if the mortise is normal, even with external rotation stress test positive,
conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling
acutely, at regaining range of motion and strength subacutely, and then
progressed to functional training and finally return to sport. The
timeframe for these was in the range of 2 to 6 weeks without very specific
progression criteria. In the athlete, pain with rotational stress, greater severity of sprain,
may treat operatively to stabilize the syndesmosis and aggressive rehab
with earlier return to sport. Tightrope vs screw fixation vs both. Use of arthroscopy. Chronic sprains with recalcitrant pain and functional instability usually
require operative treatment. very poor evidence exists as to the timing or type of procedure.
Arthroscopy is required to confirm the diagnosis, treat intraarticular
problems, and provide fixation of the distal tibiofibular syndesmosis. The
postoperative regimen used is generally the same as the one used when
treating an acute syndesmosis disruption. Tight rope vs Screw Fixation. clinical studies tightrope fixation has been acceptable and comparable to screw
fixation. laboratory studies demonstrate comparable construct stability in the
laboratory/cadaveric setting. indications for tightrope fixation are becoming more clear with more
experience. my indications:. syndesmotic sprains with complete or incomplete disruption. fractures with syndesmotic disruption augment with screws, leave in place
following screw removal. Summary and
Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) disruptions are uncommon orthopaedic injuries. They are usually caused by high- or low-velocity knee dislocations. Because knee dislocations might spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee. Both of the cruciate ligaments are usually disrupted, and they are often combined with a third ligamentous disruption (medial collateral ligament or lateral collateral ligament and/or posterior lateral complex). Associated neurovascular, meniscal, and osteochondral injuries are often present and complicate treatment. Classification Knee dislocations are classified by relating the position of the displaced tibia on the femur; anterior, posterior, medial, lateral, or rotational. Both cruciate ligaments might be disrupted in all these injuries. A rotatory knee dislocation occurs around one of the collateral ligaments (LCL) leading to a combined ACL and PCL injury and a tear of the remaining collateral ligament. Knee dislocations that spontaneously reduce are classified according to the direction of instability. Knee dislocations are classified as acute (<
3 weeks) or chronic (>
3 weeks). Initial management The vascular status of the limb must be determined quickly. The knee should be reduced immediately through gentle traction-countertraction with the patient under anesthesia. After reduction, repeat vascular examination. If the limb remains ischemic, emergent surgical exploration and revascularisation is required. If the initial vascular examination is normal, postreduction a formal angiogram should be done especially if the patient has a high velocity injury, is polytraumatized or have altered mental status. Compartment syndrome, open injury, and irreducible dislocation are other indications for emergent surgery. Definitive management Many authors have noted superior results of surgical treatment of bicruciate injuries when compared to nonsurgical treatment. In most cases early ligament surgery (at the second or third week) seems to produce better results compared to late reconstructions. Still the management of knee dislocations remains controversial.
