Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

Aims

In the last decade, interest in partial knee arthroplasties and bicruciate retaining total knee arthroplasties has increased. In addition, patient-related outcomes and functional results such as range of movement and ambulation may be more promising with less invasive procedures such as bicompartmental arthroplasty (BCA). The purpose of this study is to evaluate clinical and radiological outcomes after a third-generation patellofemoral arthroplasty (PFA) combined with a medial or lateral unicompartmental knee arthroplasty (UKA) at mid- to long-term follow-up.

Aims. The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging. Methods. A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard. Results. In order to detect dorsal screw penetration, the sensitivity of dorsal tangential views was 39% with a negative predictive value (NPV) of 91% and an accuracy of 91%; compared with a sensitivity of 25% for 3D fluoroscopy with a NPV of 93% and an accuracy of 93%. On the postoperative CT scans, we found penetrating screws in: 1) 40% of patients in the 2D fluoroscopy group; 2) in 32% of those in the 2D fluoroscopy group with AP, lateral, and dorsal tangential views; and 3) in 25% of patients in the 3D fluoroscopy group. In all three groups, the second compartment was prone to penetration, while the postoperative incidence decreased when more advanced imaging was used. There were no penetrating screws in the third compartment (extensor pollicis longus groove) in the 3D fluoroscopy groups, and one in the dorsal tangential views group. Conclusion. Advanced intraoperative imaging helps to identify screws which have penetrated the dorsal compartments of the wrist. However, based on diagnostic performance characteristics, one cannot conclude that 3D fluoroscopy outperforms dorsal tangential views when used for this purpose. Dorsal tangential views are sufficiently accurate to detect dorsal screw penetration, and arguably more efficacious than 3D fluoroscopy. Cite this article: Bone Joint J 2020;102-B(7):874–880

Introduction. Patella implant research is often overlooked despite its importance as the third compartment in a total knee replacement. Wear and fracture of resurfaced patellae can lead to implant failure and revision surgeries. New simulation techniques have been developed to analyze the performance of patella designs as they interact with the trochlear groove in total knee components, and clinical validation is sought to ensure that these simulations are appropriate. The objective of this work was to subject several patellar designs to patient-derived deep knee bend (DKB) inputs on a 6 degree of freedom (DOF) simulator and compare the resultant wear scars to clinical retrievals. Materials and Methods. Previously reported DKB profiles were developed based on in vivo patellofemoral data and include a wide range of patient variability. The profiles chosen for this body of work were based on the stress in the patellar lateral facet; maximizing this stress whilst maintaining the ability to run the profile stably on the simulator. Load/kinematic profiles were run on three patellar designs (n=3 per group) for 220,000 cycles at 0.8Hz on an AMTI VIVO joint simulator. A comparison cohort of clinically retrieved devices of the same design was identified in an IRB-approved database. Exclusion criteria included gross delamination, cracking secondary to oxidation, and surgeon-reported evidence of malalignment leading to mal-tracking. 29 Patellae were included for analysis: PFC. ®. All Poly (n=14), ATTUNE. ®. Anatomic (n=6), and ATTUNE. ®. Medialized Dome (n=9). Mean in vivo duration was 70.1 months. Patellae were analyzed under optical microscope in large-depth-of-field mode to map the surface damage profile. Burnishing ‘heat-maps’ were generated for retrievals and simulated patellae by normalizing the patellar size and overlaying silhouettes from each component of the same type using a custom-developed MatLAB code. Results. Burnishing heat-map comparisons between retrievals and simulator specimens for each of the three designs were compared. Retrievals show more variation than simulator devices, however the general loci and relative area of burnished regions is closely aligned for each of the three designs. The retrieved and simulated burnishing scar heat-maps on all-poly PFC. ®. patellae are centered medio-laterally with a wider profile on the lateral aspect. The burnishing marks are continuous. A similar observation may be made of the ATTUNE. ®. medialized dome, retrievals and simulator specimens, though the contact areas appear to be more concentrated away from the apex. The anatomic patellae show two primary regions of contact, and minimal burnishing at the apex. The simulator specimens likewise show two principal regions of contact. Discussion. Wear scar analysis shows that joint simulation on AMTI VIVO yields clinically relevant wear patterns across a variety of device types. Clinically relevant damage provides insight that load and motion inputs to the simulator deliver results that may be used to interpret in vivo performance or analyze future designs and/or materials. This qualitative surface contact analysis will help to inform future quantitative mass loss and fatigue failure studies. For any figures or tables, please contact authors directly

Despite the successful, durable results, concern remains for using TKA in patients with isolated patello-femoral OA, as it requires an extensive surgical exposure and bone resection, a long recovery time, and a potentially more complex revision than that required for a patient with a failed patello-femoral arthroplasty (PFA).

PFA was introduced in the late 1970s. While PFA was successful in providing pain relief, the procedure did not gain widespread use because of initial design limitations that predisposed to PF maltracking, catching, and subluxation. The mechanical complications associated with first-generation PFA offset the potential advantages of maintaining the knee's native soft tissues and spurred efforts to improve implant design, and to refine surgical techniques and patient selection.

Over the past two decades, second generation PFAs incorporated changes in implant design and instrumentation and have shown promising results when used in the properly selected patient population. In addition, with improved instrumentation and robotics, adequate implant alignment and rotation can be achieved in the majority of patients, including those with severe patellofemoral dysplasia.

Our meta-analysis of TKA and PFA for the treatment of isolated patello-femoral OA showed that the rate of complications of patients undergoing PFA was 30% after a median follow up of 5.3 years, which is significantly higher than the 7% rate of complications in patients who underwent TKA. The most frequent type of complication associated with PFA was mechanical (including loosening and instability), which is consistent with the malalignment and maltracking-related failures previously reported. The incidence of re-operation after PFA (21%) was significantly higher than that seen after TKA (2%). The most frequent indication for re-operation after PFA was mechanical failure (7%), followed by progression of OA (6%), and persistent pain or stiffness (5%). The most common re-operations after PFA were conversion to TKA, revision of PFA components, lateral releases, open or arthroscopic debridement, manipulations under anesthesia, and bony and/or soft tissue extensor mechanism re-alignment procedures. In our study, 11% of patients treated with PFA underwent a revision arthroplasty, with 4% undergoing revision PFA and 7% undergoing conversion to TKA.

Our comparison of patients who were treated with second-generation PFA designs versus TKA showed no difference in the rate of complications, re-operation, or revision arthroplasty. Additionally, length of follow-up did not significantly influence any of these outcomes when comparing second-generation PFA and TKA.

These observations provide support for the use of current PFA designs. The mechanical complications and subsequent re-operations that affected first-generation PFA designs appear to be of less concern with proper patient selection, meticulous surgical technique, current implant designs and peri-operative care. While it is difficult to predict the survivorship of current PFA designs, it is our expectation that patient selection will continue to be a critical component in determining long-term results. The potential benefit of providing pain relief while preserving the tibiofemoral articulations makes PFA a promising treatment option.

Isolated patellofemoral arthritis is not an uncommon problem, with no clear consensus on treatment. Nonoperative and many forms of operative treatments have failed to demonstrate long-term effectiveness in the setting of advanced arthritis. Total knee arthroplasty (TKA) has produced excellent results, but many surgeons are hesitant to perform TKA in younger patients with isolated patellofemoral arthritis. In properly selected patients, patellofemoral arthroplasty (PFA) is an effective procedure with good long-term results. Contemporary PFA prostheses have eliminated many of the patellar maltracking problems associated with older designs, and short-term results, as described here, are encouraging. Long-term outcome and prospective trials comparing TKA to PFA are needed.

Aims

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

Introduction

Epidemiologic studies indicate that isolated patellofemoral (PF) arthritis affects nearly 10% of the population over 40 years of age, with a predilection for females. A small percentage of patients with PF arthritis may require surgical intervention. Surgical options include non-arthroplasty procedures (arthroscopic debridement, tibial tubercle unloading procedures, cartilage restoration, and patellectomy), and patellofemoral or total knee arthroplasty (PFA or TKA). Historically, non-arthroplasty surgical treatment has provided inconsistent results, with short-term success rates of 60–70%, especially in patients with advanced arthritis. Although TKA provides reproducible results in patients with isolated PF arthritis, it may be undesirable for those interested in a more conservative, kinematic-preserving approach, particularly in younger patients, who may account for nearly 50% of patients undergoing surgery for PF arthritis. Due to these limitations, patellofemoral arthroplasty (PFA) has become utilised more frequently over the past two decades.

Isolated patellofemoral arthritis is not an uncommon problem, with no clear consensus on treatment. Nonoperative and many forms of operative treatments have failed to demonstrate long-term effectiveness in the setting of advanced arthritis. Total knee arthroplasty (TKA) has produced excellent results, but many surgeons are hesitant to perform TKA in younger patients with isolated patellofemoral arthritis. In properly selected patients, patellofemoral arthroplasty (PFA) is an effective procedure with good long-term results. Contemporary PFA prostheses have eliminated many of the patellar maltracking problems associated with older designs, and short-term results, as described here, are encouraging. Long-term outcome and prospective trials comparing TKA to PFA are needed.

The aims of this study were to assess the efficacy of a newly designed radiological technique (the radial groove view) for the detection of protrusion of screws in the groove for the extensor pollicis longus tendon (EPL) during plating of distal radial fractures. We also aimed to determine the optimum position of the forearm to obtain this view. We initially analysed the anatomy of the EPL groove by performing three-dimensional CT on 51 normal forearms. The mean horizontal angle of the groove was 17.8° (14° to 23°). We found that the ideal position of the fluoroscopic beam to obtain this view was 20° in the horizontal plane and 5° in the sagittal plane.

We then intra-operatively assessed the use of the radial groove view for detecting protrusion of screws in the EPL groove in 93 fractures that were treated by volar plating. A total of 13 protruding screws were detected. They were changed to shorter screws and these patients underwent CT scans of the wrist immediately post-operatively. There remained one screw that was protruding. These findings suggest that the use of the radial groove view intra-operatively is a good method of assessing the possible protrusion of screws into the groove of EPL when plating a fracture of the distal radius.

Cite this article: Bone Joint J 2013;95-B:1372–6.

Total knee arthroplasty (TKA) has produced excellent results, but many surgeons are hesitant to perform TKA in younger patients with isolated patellofemoral arthritis. In properly selected patients, patellofemoral arthroplasty (PFA) is an effective procedure with good long-term results. Contemporary PFA prostheses have eliminated many of the patellar maltracking problems associated with older designs, and short-term results, as described here, are encouraging. Long-term outcome and prospective trials comparing TKA to PFA are needed.

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

We describe a new technique for fixing the proximal pole scaphoid fractures both in acute and chronic setting and present our preliminary results. We prospectively studied fixation of 25 proximal pole scaphoid fractures (1 acute displaced and 24 non unions) with this technique between 1999 and 2007. Mean age of patients was 25 years and mean time to the operation was 6 months. The technique involves making a transverse dorsal incision over the radius along the radio-carpal junction. The retinaculum is split in line with its fibres. Access to the radio-carpal joint is achieved through the third extensor compartment. The ligament attachment to the scaphoid is preserved by using a modified Mayo approach. A window is created initially at the proximal end of the dorsal ridge. The fracture is reduced and stabilised with an appropriate length Herbert screw. The fracture site is curetted through this window and cancellous bone graft from the distal radius is packed into the fracture site. The capsule and extensor retinaculum is then closed in layers. Radiological union was achieved in 23 cases, one case required refixation and one case was lost to follow up. Our technique is tendon sparing, capsule retaining, and ensures maintenance of articular surface congruity. So far this technique has led to excellent results

A retrospective analysis of the treatment of distal radius fractures with an angularly stable locking plate (Matrix Plate, Stryker, UK) via a dorsal approach performed at Southend University Hospital in the United Kingdom. 91 fractures were treated over a three year period between 2004 and 2007. Dorsally angulated and displaced (including intraarticular) fractures were included. All patients commenced early mobilization without splintage on the first post-operative day. The study group consisted of 42 men and 49 women with a mean age of 63 years. The average time to follow up was 19 months (range 6–29). The average tourniquet time was 44 minutes (20–81). Assessment consisted of range of motion and grip strength measurement, Mayo wrist score, quick DASH questionnaire and Gartland and Werley scoring. Complications consisted of 1 EPL rupture and 3 patients suffered extensor irritation. To date only 5 plates (5.4%) have been removed. We demonstrate that dorsal plating using a low profile, angularly stable plate produces comparable results to volar plating. The combination of a low profile, angular stable plate, together with a modification of the standard dorsal approach, a sub-periosteal approach via the fourth and deep to the third extensor compartment reduces the incidence extensor tendon irritation. The modified approach has the benefit of direct visualization of the articular surface and direct reduction with the plate being used in both and angularly stable and buttress mode

The use of volar locking compression plates for the treatment of fractures of the distal radius is becoming increasingly popular because of the stable biomechanical construct, less soft-tissue disturbance and early mobilisation of the wrist. A few studies have reported complications such as rupture of flexor tendons. We describe three cases of rupture of extensor tendons after the use of volar locking compression plates. We recommend extreme care when drilling and placing the distal radial screws to prevent damaging the extensor tendons.

Strains applied to bone can stimulate its development and adaptation. High strains and rates of strain are thought to be osteogenic, but the specific dose response relationship is not known. In vivo human strain measurements have been performed in the tibia to try to identify optimal bone strengthening exercises for this bone, but no measurements have been performed in the distal radial metaphysis, the most frequent site of osteoporotic fractures. Using a strain gauged bone staple, in vivo dorsal metaphyseal radial strains and rates of strain were measured in ten female patients during activities of daily living, standard exercises and falls on extended hands. Push-ups and falling resulted in the largest compression strains (median 1345 to 3146 με, equivalent to a 0.1345% to 0.3146% length change) and falling exercises in the largest strain rates (18 582 to 45 954 με/s). On the basis of their high strain and/or strain rates these or variations of these exercises may be appropriate for distal radial metaphyseal bone strengthening.