Currently, the most common approach for the management of a chronic PJI is a Two-Stage Replacement; because of success rates exceeding 90% when using an antibiotic impregnated cement spacer. Reliable information regarding the etiologic microorganism and its sensitivities is essential to select the antimicrobial therapy that should be used locally in the bone cement spacer during the first stage surgery as well as to select the appropriate microbiological systemic agent. Diagnostic algorithms focus to the importance of joint aspiration cultures although in the modern literature, preoperative joint aspiration has a broad range of values of sensitivity and the proportion of “dry-aspirations” is not well assessed. This low sensitivity of aspiration fluid samples in chronic-PJI is partly attributable to the fact that the majority of the microorganisms in these infections grow in biofilms attached to the implant. We have developed this biopsy technique in an effort to improve the identification rates of the causative organism. A sample is harvested through a 4 mm bone trephine and the target is the bone-prosthesis gap. We have compared the results of preoperative PIB with the results of cultures from intra-operative tissue collected during the first stage surgery. In both cases a prolonged culture protocol (10 days) in enrichment media was used. On the basis of this relation, sensitivity, specificity, positive and negative predictive values and accuracy were calculated.Aims
Materials and methods
The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems
Navigation in total knee replacement is controversially discussed in the literature. In our previous study, femoral component positioning was more accurate with computed navigation than with conventional implantation techniques, however tibial positioning showed similar results. Moreover there were no differences between image-free and image-based navigation techniques. To what extent more accurate femoral positioning has an impact on the clinical mid-term follow up is not known. At a mean follow-up interval of 5.3 years, seventy-one patients (84.5%) returned for a review and were examined clinically and radiographically, with use of a methodology identical to that used preop and at 2 years, using the subjective value, the Knee Society Score (KSS), and a.p. and true lateral standard radiographs respectively. Complications, re-operations, persisting pain and resulting range of motion were registered.Background
Methods
Conventional screws achieve sufficient insertion torque in healthy bone. In poor bone screw stripping can occur prior to sufficient torque generation. It was hypothesized that a screw with a larger major/minor diameter ratio would provide improved purchase in poor bone as compared to conventional screws. We evaluated the mechanical characteristics of such a screw using multiple poor bone quality models. Testing groups included: conventional screws, osteopenia screws used in bail-out manner (ie, larger major/minor diameter screws inserted into a hole stripped by a conventional screw), and osteopenia screws used in a preemptive manner (ie, no screw stripping occurrence). Stripping Torque: Screws were inserted through standard straight plates into a low density block of foam with a predrilled hole. Stripping torque was defined as maximum insertion torque reached by the screw before the screw began to spin freely in the foam.Introduction
Methods
The aim of the treatment of children with early onset scoliosis is controlling growth of the spine. Whatever the etiology, early progressive deformations require multiple stages of surgery usually performed every 6–12 months. One have to be reckoned with complications requiring additional surgical intervention. The aim of the study is to present a new method of surgical treatment of early onset scoliosis involving the implantation of specially constructed implants to allow three dimensional correction of spinal deformity with a preserved capacity to continue the growth of spine without distraction staged operations followed by final spondylodesis in mature spine.Introduction
Objective
The long-term impact of dividing Piriformis when performing a standard posterior approach to the hip has not been assessed. A less invasive approach in which the tendon is preserved has been described (the Piriformis-sparing minimally invasive [PSMI] approach). With advances in MRI technology it is now possible to image structures in close proximity to metal without artifact. The aim of the study was to compare the MRI features (muscle grade and bulk) of the divided and repaired Piriformis tendon group (by the standard posterior approach) with the preserved tendon group (by the PSMI approach). As part of an on-going randomized controlled trial comparing the PSMI approach with the standard posterior approach for total hip replacement, a subgroup of 20 consecutive patients who fulfilled the inclusion criteria were recruited. Patients received preoperative and 3 months and 2 year postoperative MRI scans. Patients and evaluators were blinded to allocation. Outcomes assessed included grade, volume and integrity of Piriformis.Background
Methods
Correction and arthrodesis for cervical kyphosis associated with atetoid cerebral palsy has been considered to be difficult because of their involuntary neck movements and severe deformity. The aim of this study is to evaluate the surgical outcome of midline T-saw laminoplasty and posterior arthrodesis using pedicle screws. 15 patients were retrospectively reviewed. There were 6 women and 9 men, with a mean age 52.9 years (range 31–71 years). Mean follow-up period was 43 months (range 24–84 months). For clinical evaluation, the Japanese Orthopaedic Association (JOA) score and Barthel index (BI) which shows independence in ADL were used. For radiographic evaluation, change of C2–C7 Cobb angle of sagittal alignment, adjacent segment instability after the surgery were evaluated.Introduction
Methods
Over 300,000 patients present with fragility fractures each year. Following a hip fracture, the 30 days mortality is around 8.3 to 9.3%. Mortality increases to 20–24% after the first year and this risk may persist for at least 5 years. The most significant variables that influence mortality are age, gender, fracture type, prefracture residence, prefracture mobility and ASA scores. Common reported postoperative complications responsible for mortality in hip fracture patients include; heart failure, bronchopneumonia and infections. Most of the studies in the literature focus on management variables influencing mortality rather than the encountered postoperative medical problems leading to death. The aim of this study is to retrospectively analyze the postoperative medical complications which led to death in a cohort of patients, following a hip fracture. This is a retrospective analysis of a cohort of 82, out of 648, patients with hip fractures who died over a period of 2 years (December 2006–January 2009). Forty nine females and 33 males (ratio 1.5:1) were included in the study with a mean age of 87.8 years (range 59–98 years). For mortality analysis, patients' co-morbidities and medical events leading to death were categorized according to the involved organ system. This included cardiovascular, respiratory, renal, gastrointestinal, neurological and musculoskeletal systems). The timing and decision of DNAR and palliation was noted for each patient. The 30 days and the overall mortality were the set outcome measures to be reviewed.Introduction
Methodology
treatment of femoral neck fractures in the physically active elderly, is still an open question. The comparison of total replacement and partial hip replacement showed substantial superiority of the first approach than the latter. We can not disregard the problems that THR can lead in the elderly: more surgical time, greater blood loss, major sacrifice of bone in osteoporotic subjects. The Tribofit® acetabular system, has the objective to overcome these problems with the implantation of a single 3mm soft, pliable buffer made of polycarbonate-urethane between the large diameter metal femoral head and the subchondral bone, thus replacing the articular cartilage. The surgical technique includes the reaming of the cartilage layer, the creation of a circumferential groove and the snap-fit insertion of the buffer. The purpose of the prospective study was to evaluate the effectiveness of this approach in the treatment of femoral neck fractures in the elderly. from September 2008 to July 2010 we performed 45 implants with the Tribofit® Acetabular Buffer (Active Implants®, Memphis TN, USA). The inclusion criteria for the study were: femoral neck fracture patients over 75 years of age, physically independent before the injury, with good life expectancy, mild or absent arthritis, absence of morphological alterations of the acetabulum. The average age of these patients was 81,2 (75–89), the sex distribution was 36 females and 9 males, with 22 fractures of the left hip and 23 of the right. In all cases an uncemented straight femoral stem was implanted. We recorded per-operative blood loss and intra-per-operative problems encountered. Follow-up were performed at 1, 3, 6 and 12 months post-op with radiographic control and clinical examination. The clinical outcome was objectively measured by the Harris Hip Score, pain Visual Analogue Scale and SF-36 questionnaire.Introduction
Materials and Methods
Medial opening-wedge high tibial osteotomy is one of the common surgical procedures in treatment of knee deformities. Many methods have been proposed to fill the medial side osseous gap. The results of using allograft as void filler compared to iliac crest autograft has not been subject to a randomized clinical trial. The purpose of this study was to examine the results of medial opening-wedge high tibial osteotomy using iliac crest allograft as compared to iliac crest autograft. Forty-six patients with genovarum deformity were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. Medial opening-wedge high tibial osteotomy was done using iliac crest allograft (23 patients) or autograft (23 patients) and the osteotomy site was internally fixed using proximal tibial T-plate. All patients were followed-up to 12 months after surgery. Anatomical indices of proximal tibia, complications of treatment, and functional outcome (using WOMAC osteoarthritis index) were assessed for both groups.Background
Materials & Methods
Intra-articular shoulder pathology has been recognised in more detail following widespread use of shoulder arthroscopy. The purpose of this epidemiological study is to present the incidence and exact type of SLAP lesions in our operated population and to correlate them with the presence of other shoulder lesions. Between 2004 and 2010 425 patients underwent shoulder arthroscopy in our department (311 for rotator cuff tears or subacromial impingement, 102 for shoulder instability, 12 for SLAP lesions). Eighty-two SLAP lesions (19.2% overall) were recognized during these procedures. In 44 cases the lesion was SLAP type I (53.6%), in 10 type II (12.2%), in 1 type III (1.2%), in 1 type IV (1.2%), in 24 type V (29.26%) and finally in 2 type VI (2.43%). In more detail SLAP I lesions were associated in 8 patients with subacromial impingement syndrome, in 33 with RC tear and in 3 patients with anterior instability. Type II, III and IV were preoperatively diagnosed, while type V and VI lesions were found in patients with chronic anterior shoulder instability. SLAP lesions are diagnosed more accurately during shoulder arthroscopy rather than with plain shoulder MRI scan. In our study population only 12 cases were accurately diagnosed with a pre-operative MRI scan, while the remaining 70 cases were missed. Additionally, there was significant correlation between rotator cuff problems and SLAP I lesions, while chronic shoulder instability was associated with SLAP V and VI (25.4% of patients with instability). Shoulder arthroscopy not only has changed SLAP lesion diagnosis and treatment but also reveals the correlation of various SLAP lesion types with specific shoulder pathologies.
The origins of the uncemented tapered wedge hip stem design currently offered by several orthopaedic device companies can be linked back to the cemented Straight Mueller type stem design first used in 1977. The design, a wedge shape with a taper angle of 6 degrees, maintains a single medial curvature for all sizes and increases laterally in the width to accommodate different size femurs. Although evolutionary improvements have been made over the years the basic body geometry of the stem has stayed mainly unchanged with excellent clinical survivorship. Over the past decade, the demographics of hip replacement have changed, with a large increase in younger male patients in the age range of 40 to 60 years. In this study the femoral fit of a novel tapered stem, designed to fit a wide array of patient types, is compared to a standard predicate tapered stem design. A bone morphology study was performed on a patient population of 556 patients using three dimensional digital data from CT-scans. To characterize the fit of the stem designs we analyzed the ratio of a distal (60mm below lesser trochanter) and a proximal (10mm above lesser trochanter) cross section. The same measurements were taken with the standard tapered stem design and the novel tapered stem design, with a given constant implantation height of 20mm above the lesser trochanter. The fit of the stems was classified as Type 1, where there was both proximal and distal engagement, Type 2, proximal engagement only, Type 3, distal engagement only. The distal and proximal engagement, Type 1, was specified with a maximum engagement difference of 2mm proximal to distal.Introduction
Methods
Infections of bone usually require multiple surgery and prolonged periods of treatment. One reason for problems is found in the presence of stationary phase bacteria embedded in biofilms that show increased resistance against conventional antibiotic therapy (up to 1000x MIC). Biofilms adhere to surfaces of avital material making radical debridement a prerequisite for cure. Osseous defects are common in such conditions and need to be addressed. To avoid re-infection high local antbiotic concentrations are necessary. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting concentrations at the site of infection and is likely to restore bone stock simultaneously. Based on this technology we have developed a new surgical technique. 42 patients (10–67yrs) with chronic osteitis were included into a prospective study using a standardized protocol. Infection was at the humerus (1x), femur (10x), tibia (29x) or femur+tibia (2x), respectively. Treatment consisted of removal of foreign material, radical sequestrectomy and soft-tissue debridement followed by pressurized lavage. Surfaces of sclerotic bone were trimmed down to vital areas. The remaining osseous defects were filled with ABC, using an impaction technique resulting in complete dead space management. The allograft was impregnated with vancomycin, in cases with mixed pathogens combinations with tobramycin were used. Internal fixation was performed the same time whenever applicable. Sites were drained and closed immediately; rehabilitation did not differ from uninfected procedures.Aims
Methods
While there is a desperate need for effective treatments for acute spinal cord injury (SCI), the clinical validation of novel therapeutic interventions is severely hampered by the need to recruit relatively large numbers of patients into clinical trials for sufficient statistical power. While a centre might annually admit 100 acute SCI patients, only a fraction may satisfy the basic inclusion criteria for an acute clinical trial, which typically requires patients of a certain injury severity (eg ASIA A), within a specific time window (eg. 12 hours from injury), and without other major injuries or conditions that would cloud the baseline neurologic assessment. This study was conducted to define that “fraction” of SCI patients that would theoretically satisfy standard inclusion criteria of an acute clinical trial. Using a local database, we reviewed patients admitted to our Level 1 trauma center with a complete (ASIA A) or an incomplete (ASIA B, C and D) acute SCI involving bony spinal levels between C0 and sacrum. All patients admitted over the 4 year period from 2005 to 2009 were reviewed. Demographic information and data about the patients' SCI and other injuries were reviewed. We then determined how many of the total number of SCI patients would be eligible for enrolment into a hypothetical acute clinical trial that required a valid baseline assessment of neurologic impairment, and an enrolment window of either 12 hours, 24 hours, or 48 hours.Introduction
Methods
Total hip arthroplasty (THA) has been efficacious for treating hip fractures. However, in these patients with fractures a widely variable prevalence of dislocation has been reported, partly because of varying durations of follow-up for this specific end-point. The purpose of the present study was to determine the risk of dislocation as a function of time after total hip arthroplasty in these patients with fractures and to investigate if constrained liners influence the cumulative risk of dislocation. Between 2000 and 2005, 425 patients with neck fracture underwent primary THA using a constrained acetabular liner (Cemented retentive cup, Groupe lépine, Genay, France). The results of these 425 constrained acetabular liners were compared with 380 THA without constrained liners performed for neck fractures between 1994 and 1999 in the same hospital. All patients were followed for a minimum of 5 years for radiographic evidence of implant failure. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method. For patients without constrained liners, the cumulative risk of a first-time dislocation was 5% at one month and 12% at one year and then rose at a constant rate of approximately 2% every five years to 17% at five years, 19% at ten years, 21% at 15 years for patients who were alive and had not had a revision by that time. For patients with constrained liners, the cumulative risk of a first-time dislocation was 1% at one month, 2% at one year and then did not changed at 5 years and at 10 years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were 80 years old or more (as compared with those who were less than 80 years old) was 1.5. Two underlying diagnoses - cognitively impaired patients or neurologic desease—were also associated with a significantly greater risk of dislocation. At minimum 7 year follow up (range 5 10 yrs), there were 8 radiographic failures (dislocations) of the 425 constrained liners (2%), and no loosenings were noted. The cumulative long-term risk of dislocation for patients with hip fractures is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are old female patients and those with a diagnosis of neurologic desease. Constrained liners in these patients is an efffective technique to prevent post operative hip dislocation.Results
Conclusions
Septic Arthritis is an important life threatening condition affecting all age groups with a mortality of up to 11%. Our aim was to perform a study of the demographics, length of stay, complications and investigate if time delay of surgical treatment from the time of diagnosis has an impact on mortality and morbidity of the patients. We performed a retrospective study of all the patients presented to our Hospital between 2005 and 2009 with septic arthritis who underwent arthroscopic lavage as definitive intervention. We excluded the patients involving minor joints. Data collection was performed from case notes, microbiology and haematology laboratory results. We divided the patients into three groups based on the time from diagnosis to arthroscopic lavage as T1 (less than 12 hours), T2 (12–24 hours) and T3 (more than 24 hours). Our primary outcome measures were mortality and complications such as Intensive Care Admission. Secondary outcome measures included average length of stay in each group. A total of 57 patients were evaluated. The average age of the patients was 49.7 (10 months–94 years). 2 patients of T1 group died (5.4%) 3 patients of T1 group needed Intensive Care Unit (ICU) management (8.1%). There were no deaths or ICU admissions in the other groups. 40.3% of patients needed arthroscopic lavage more than once. The average length of stay of T1 was 19.8 days, T2–11.5 days and T3–27.5 days. Majority of the joints involved were knees (63.1%).23 patients (40.3%) had a preceding intervention performed in the same joint. Staphyloccus aureus was the most common organism isolated in 14 patients (26.3%).Methods
Results
The purpose of this study was to evaluate the results of subcutaneous ulnar nerve transposition in the treatment of Cubital Tunnel Syndrome (CTS) and the influence of prognostic factores such as preoperative McGowan stage, age and duration of symptoms. 36 patients (17 men and 19 women) with CTS who underwent subcutaneous ulnar nerve transposition between 2006 and 2009 were evaluated postoperatively, an average follow-up of 28 months. Sensory and motor recovery was evaluated clinically. The postoperative outcome was based on modified Bishop score, subjective assessment of function and on the degree of patient satisfaction. The dominant side was involved in 61% cases and the mean age was 51.2 years. There were 9 (25%) McGowan stage I, 18 (50%) stage II and 9 stage III patients. We used the Mann-Whitney and Kruskal-Wallis test to compare continuous variables and chi-square and Fisher Exact Test for categorical variables. There was a statistically significant improvement of sensory (p=0.02) and motor (p=0.02) deficits. We obtained 21 (58.3%) excellent results, seven (19.4%) fair, six (16.7%) satisfactory, and two bad ones (5.55%). There was a statistically significant improvement of function (p<0.001). There is controversy in the literature regarding the best surgical treatment for CTS. The duration and severity of symptoms and advanced age, more than the surgical technique, seem to influence prognosis. With the technique used, the satisfaction rate was 86% and 72% recovered their daily activities without limitations. 78% of patients with severe neuropathy improved after surgery. The rates of postoperative complications were comparable with those of other studies. The severity of neuropathy and duration of symptoms (>12months) pre-operatively, but not age, had a negative influence on the outcome. The results showed that the subcutaneous ulnar nerve transposition is safe and effective for postoperative clinical sensory and motor recovery for several degrees of severity in CTS. Given the major prognostic factors, surgical treatment should be advocated as soon as axonal loss has become clinically evident.
A review of the literature showed a discrepancy between biomechanical and clinical studies on fracture fixation failure in patients with poor bone quality. The objective of the present study is to assess the influence of local bone status on complications after surgical treatment of proximal humerus fractures. A prospective cohort study was initiated in 2007. The inclusion criteria were closed displaced fractures of the proximal humerus, primary fracture treatment with a Philos plate, patients aged 50 to 90, normal pre-trauma function of both shoulders in accordance to age, and monotrauma. There was active follow-up for one year with radiological assessment at clinical centers from four countries. Bone quality at the proximal humerus was determined preoperatively for the contralateral side of the fracture by CT scan, and at the contralateral radius within six weeks post-surgery by DXA. The occurrence of complications was monitored up to one year post-surgery. Independent x-ray evaluation and final classification of all complications will be performed at the end by a study review board using anonymous data and x-rays.Introduction
Methods
Osteoarthritis (OA) of the hip is an important cause of pain and morbidity. The mechanisms and pathogenesis of OA'sdevelopment remain unknown. Minor acetabular dysplasia and subtle variations in proximal femoral morphology are increasingly being recognized as factors that potentially compromise the joint biomechanically and lead to OA. Previous studies have shown that risk of hip OA increased as the femoral head to femoral neck ratio (HNR) decreased. Previous work has described the evolutionary change in inferior femoral neck trabecular density and geometry associated with upright stance, but no study has highlighted the evolutionary change in HNR. The aim of this study was to examine evolutionary evidence that the hominin bipedal stance has lead to alterations in HNR that would predispose humans to hip OA. A collaboration with The Natural History Museums of London, Oxford and the Department of Zoology, University of Oxford provided specimens from the Devonian, Jurassic, Cretaceous, Miocene, Palaeolithic and Pleistocene periods to modern day. Specimens included amphibious reptiles, dinosaurs, shrews, tupaiae, lemurs, African ground apes, Lucy (A. Afarensis), H. Erectus, H. Neaderthalis and humans. Species were grouped according to gait pattern; HAKF (hip and knee flexed), Arboreal (ability to stand with hip and knee joints extended) and hominin/bi-pedal. Imaging of specimens was performed using a 64 slice CT scanner. Three-dimensional skeletal geometries were segmented using MIMICS software. Anatomical measurements from bony landmarks were performed to describe changes in HNR, in the coronal plane of the different specimens over time using custom software. Measurements of HNR from the specimens were compared with HNR measurements made from AP pelvic radiographs of 119 normal subjects and 210 patients with known hip OA listed for hip arthroplasty.Introduction
Methods
Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0–9, 10–14, 15–18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up.INTRODUCTION
MATERIAL
The purpose of this study was to evaluate the results after arthroscopic reconstruction of isolated SSP lesions. Does double row repair in smaller lesions lead to better results and a lower retear rate? 80 patients with an isolated full thickness SSP tear were divided into 2 groups. Group 1 (27 men, 13 Frauen, average age 57 y.) was repaired using a single row technique with 2 anchors (Mitek Fastin) with arthroscopic Mason-Allen stiches. Group 2 was repaired using a double row technique using 1 medial anchor (Mitek Fastin) and 2 lateral anchors (Versalok). PreOP an ultrasound and MRI was obtained as well as standard x-rays (a.p., outlet-view, transaxial). Included to this study were only patients matching the following criteria: intraoperative cartilage lesions ≤ Outerbridge Grade2, fatty degeneration ≤ Goutallier Grade 2, ap extent of the tear < 2,5 cm. Prospective follow up after 6, 12 and 24 months using UCLA and Constant Score as well as MRI at last follow up.Aim
Method
Different minimally invasive approaches to the lumbar spine have been proposed but they can be associated with increased risk of complications, steep learning curve and longer operative time. To report the complications associated with a minimally invasive technique of retroperitoneal anterolateral approach to the lumbar spine.Background Context
Purpose
Monomicrobian necrotizing cellulitis affects the skin and subcutaneous tissue as starting point the deepest level of the superficial fascia. The pathogen inoculation is by skin disruption, abrasions, burns, injections or bites. The free base cocaine is used with homemade pipes that generate pulps fingers skin microabrasions. We present 3 patients (one bilateral) with cellulitis necrotizing of the thumb caused by pricking and dermoabrasive trauma secondary to different manipulation methods for drogue use. Experience in 3 patients free base cocaine addicts treated in our Hospital. Medical examination shows febrile syndrome (corporal temperature over 38C), and elevation of heart rate. They present cellulitis in thumb's first and second phalanx, with thenar swelling and digital necrosis with abundant purulent discharged. All of them had a pricking trauma 36 to 48 hours before. They were under surgical intervention, by surgical cleaning with necrotic and devitalized tissue's debridement. In 3 of the 4 patients amputation of the distal phalanx was mandatory. Tissue and bone culture was made in all patients. Intravenous antibiotic was performed. Two patients miss total antibiotic treatment by early no medical discharged.Introduction
Material and Method
The purpose of the present study was to identify risk factors for lag-screw cut-out following osteosynthesis of intertrochanteric fractures. The study was a case-control study using a sex and age matched control group. The fractures were classified according to Evans and OTA/AO classifications. Operative treatment was performed using dynamic hip-screw or cephalomedullary nailing systems. All patients were followed for at least 3–4 months postoperatively. The following risk factors were assessed: fracture type, quality of reduction by blinded assessment using a visual analogue scale, tip-apex distance (TAD) according to Baumgaertner, lag-screw positioning and other relevant additional risk factors in terms of walking ability, osteoporosis, cardio-vascular disease, neurological disease, diabetes, obesity, alcohol consumption and smoking.Introduction
Materials and methods
Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed. We conducted a retrospective review of consecutive patients admitted with femoral neck fractures between April 2008 and October 2009. Patients on Clopidogrel were identified and data including ASA grade, time to operation, medical co-morbidities, and post-admission complications were recorded. Comparative information from the National Hip Fracture Database was used.Introduction
Methods
The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon. The frequency and the severity of the impingement were calculated from a continuous series of 311 cups retrievals collected between 1989 and 2004 by a single surgeon. The reason for retrieval was loosening (131 cases), infection (43 cases), instability (56 cases), osteolysis (28 cases), unexplained pain (48 cases) and prosthetic impingent (5 cases all with hard bearings). The notching at the cup rim was assessed twice by two examiners with optic magnification. The risk factors were analyzed from clinical charts by univariate and cox multihazard.Introduction
Material and Methods
Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method. We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results. We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of Radiolucency along CBI by the total Length of CBI. Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model. New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55. As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories.
In orthopaedics, clinical outcome assessment (COA) is mostly performed by questionnaires which suffer from subjectivity, a ceiling effect and pain dominance. Real life activity monitoring (AM) can objectively assess function and becomes now feasible as technology has become smaller, lighter, cheaper and easier to use. In this study we validated a custom made algorithm based on accelerometry using different orthopaedic patients with the aim to use AM in orthopaedic COA. A small, lightweight 3D-accelerometer taped to the lateral side of the affected upper leg served as the activity monitor. AM algorithms were programmed in Matlab to classify standing, sitting, and walking. For validation a common protocol was used; subjects were asked to perform several tasks for 5 or 10 seconds in a fixed order. An observer noted the starting time of each task using a stopwatch. Accuracy was calculated for the number of bouts per activity as well as total time per activity. 10 Subjects were chosen with different pathologies (e.g. post total knee/hip arthroplasty, osteoarthritis) since the difference in movement dynamics in each pathology poses a challenge to the algorithm.Introduction
Methods
Failure of a primary anterior cruciate ligament (ACL) reconstruction is associated with poor functional outcomes even after revision surgery. The aim of this study is to identify early predictors for failure, so that it may aid in recognition of at-risk patients. An observational study was conducted of 623 patients undergoing primary ACL reconstruction by a single surgeon over a 72 month period. Patient and procedure related parameters including age, gender, BMI, time to surgery, graft size, fixation methods, meniscal and chondral injuries, meniscal surgery, radiological parameters and post-operative IKDC scores. Logistic regression modeling was employed to identify those factors which were statistically significant for failure.AIM
METHOD
Over the last few decades, the All-Poly Monoblock Tibia has been relegated to a minimum use in the major healthcare systems of the western world. The main reason for this has been the perception that this tibial component is inferior in its ability to withstand stresses. This perception originated and subsequently gained ground, due to certain historical reasons, leading to the widespread use of the modular metal-backed tibial component despite a higher cost. The recent economic downturn has enforced even the rich western healthcare systems to look for cost-effective solutions. The author works in India, where the society is still highly price-sensitive and takes value for money very seriously. Further, the routine ADL of the Indian population requires them to adopt high flexion postures such as cross-legged sitting and squatting. The author has used the All-Poly Tibia extensively, which is the most economical of tibial components. Further, he has developed a surgical technique which has resulted in his patients achieving high flexion (greater than 135 degrees) in more than 75% cases. This paper presents the 10 year results of a series of 500 cases of Primary TKR in which the All-Poly Monoblock Tibia had been used. All the patients had cross-legged sitting activity as part of their ADL, thus presumably generating significant pressures on the joint surfaces. Of the original 500 cases, we could follow up 434 cases. We report a 96% survival rate of the implant in this series. There was not a single aseptic plastic failure. The revisions required were due to infection, peri-prosthetic fracture, and instability. The message being conveyed in this paper is that the All-Poly Tibia is a very cost-effective solution in routine Primary TKRs, and is able to deliver excellent long-term results even in high stress situations like cross-legged sitting activity. It would offer a huge cost savings to the healthcare system if the Orthopaedic Surgeons start using this implant more frequently.
Malalignment of some designs of stem is associated with an increased risk of aseptic loosening and revision. We investigated whether the alignment of the cemented polished, double-taper design adversely affected outcome, in a multicentre prospective study. A multicentre prospective study of 1189 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and femoral stem alignment. All patients underwent a primary THR with the Exeter femoral stem (Stryker Howmedica Osteonics, Mahwah, NJ) and a variety of acetabular components. The primary outcome measure was the Oxford hip score (OHS) and change in OHS at five years. Secondary outcomes included rate of dislocation and revision. Radiographic evaluation of the femoral component was also undertaken. The long axis of the Exeter femoral component and the long axis of the femoral canal were located, and the angle at the point of intersection measured. The cementing quality was determined as defined by Barrack et al. Radiolucent lines at the cement-stem and cement-bone interface in the five year radiographs were defined using the zones described by Gruen et al. Subsidence was measured as the vertical dimension of the radiolucency craniolateral to the shoulder of the stem in Gruen zone 1 as described by Fowler et al. Cement fractures were recorded.Introduction
Methods
When introducing new joint replacement designs, it is difficult to predict with any certainty the clinical performance of the new designs. Using roentgen stereophotogrammetric analysis (RSA) to evaluate the first two years of follow-up can serve as a predictor of late mechanical loosening for hip and knee prostheses. This prospectively randomized study was designed to evaluate the clinical performance of the Triathlon total knee system and compare the results between the two versions; posterior stabilized (PS) and cruciate retaining (CR). Sixty patients were consecutively randomized (two patients left the study prior to surgery) to receive either the Triathlon total knee PS (30 patients) or the Triathlon total knee CR (28 patients). All components were cemented. The study was approved by the Ethical Committee for Lund University. All patients met the inclusion criteria. There were no statistically significant differences between the demographics for PS and CR. RSA was set to be the principal evaluation parameter. Patient outcome was assessed by the KSS and KOOS questionnaires.Introduction
Methods
Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability. Patients who underwent a procedure for medial column insufficiency with use of the reverse Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the joints in the medial column contributing to the deformity and also to estimate the angle which the first ray must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position. Gender, age, complications and radiological outcomes were investigated.Introduction
Methods
Acetabular bone deficiency presents one of the most challenging problems during revision hip arthroplasty. A variety of surgical options and techniques are available including impaction bone grafting. We present our medium to long-term experience of 68 consecutive hips in 64 patients who had acetabular revision using impacted cancellous bone grafting with bone cement with a mean follow up of 10.5 ±3.75) years (range 5.1 to 17.7 years). Patients' undergoing acetabular bone grafting during revision hip arthroplasty prior to insertion of a cemented cup between 1993 and 2000 were evaluated. Pre-operative, immediate post-operative, 1 year post-op and final follow-up radiographs were evaluated. The pre-operative bone loss was graded according to the AAOS and Paprosky classifications. The presence of radiolucencies, alignment and incorporation of bone graft were evaluated. The Harris Hip Score (HHS) was used to assess clinical outcome. 13 patients who were unable to attend the department were contacted for a telephone interview. Analysis of the Data was carried out using SPSS17 [SPSS Inc. Chicago, Illinois]Introduction
Methods
Revision type arthroplasties for the treatment of knee osteoarthritis is an effective and secure procedure. It has different indications, but the most relevant is the revision of a failured primary arthroplasty. In our study, we reviewed the results of another indication, the implantation of a revision type arthroplasty as a primary procedure in cases of severe deformities. To assess the radiological, clinical and functional situation and the quality of life of those patients in whom a revision knee arthroplasty had been implanted in the past years.Introduction
Objectives
Carpal tunnel syndrome is a common neuropathy of the median nerve. Occupation has been widely examined as a risk factor for the development of carpal tunnel syndrome. The aim of this study was to examine the validity of the United Kingdom (UK) NS-SEC (National Statistics Socioeconomic Classification) in the assessment of correlation between occupation and CTS. A prospective audit database was collected of patients diagnosed with CTS over a 6 year period. Occupation was assessed using the NS-SEC self coded method, where occupation is classified depending on the type of job and the size of the employer. UK Census data from 2001 was used to compare the occupation profile of the cohort with the regional population.Introduction
Methods
Total knee replacement has been well-established form of treatment both for osteoarthritis and inflammatory arthritis. Both cemented and uncemented TKR have been used successfully. Since 1977 low contact stress (LCS) mobile bearing knee replacement has been in extensive use. Most of the intermediate and long term results reported are in osteoarthritis1–7. Though there are several studies reporting short term performance of TKR in rheumatoid arthritis8–19 there have been rare reports31 of intermediate to long-term performance of LCS uncemented TKR in rheumatoid arthritis. Retrospective, non-randomised and consecutive study. Case notes and radiological assessment done. Kaplan meyer survival analysis used. Radiological assessment between initial and final xrays done using T test statistics. Assessement done by two independent observer.Introduction
Methods
Prosthetic joint infection is one of the most challenging complications of joint alloplasty and the diagnosis remains difficult. The aim of the study was to investigate the bacterial flora in surgical samples from 22 prosthetic patients using a panel of culture-independent molecular methods including broad range 16S rRNA gene PCR, cloning, sequencing, phylogeny, quantitative PCR (qPCR), and fluorescence in situ hybridization (FISH). Concomitant samples were cultured by standard methods. Molecular methods detected presence of bacteria in samples from 12 of 22 patients. Using clone libraries a total of 40 different bacterial species were identified including known pathogens and species not previously described in association with prosthetic joint infections. The predominant species were Propionibacterium acnes and Staphylococcus epidermidis; polymicrobial infections were found in 9 patients. Culture-based methods showed bacterial growth in 8 cases with the predominant species being S. epidermidis. Neither anaerobic bacteria (including P. acnes) nor any of the species not previously described in implant infections were isolated. Additionally, 7 of the 8 culture positive cases were monomicrobial. Overall, the results of culture-based and molecular methods showed concordance in 11 cases (hereof 9 negative by both methods) and discrepancy in 6 cases. In the remaining 5 cases, culture-based methods identified only one species or a group of bacteria (e.g., coagulase negative staphylococci or coryneform rods), while culture-independent molecular methods were able to detect several distinct bacterial species including a species within the group identified by culture. A qPCR assay was developed to assess the abundance of Propionibacterium while S. aureus was quantified by a published S. aureus qPCR assay. These quantifications confirmed the findings from the clone library approach and showed the potential of qPCR for fast detection of bacteria in orthopedic samples. Additionally, both single cells and microcolonies were visualized using FISH and confocal scanning laser microscopy. In conclusion, the molecular methods detected a more diverse bacterial flora in prosthetic joint infections than revealed by standard culture-based methods, and polymicrobial infections were more frequently observed. The pathogenesis of these microorganisms and their role in implant-associated infections needs to be determined.
The development of extendable prostheses has permitted limb salvage surgery in paediatric patients with bone tumours in proximity to the physis. Prostheses are extended to offset limb length discrepancy as the child grows. Aseptic loosening (AL) is a recognised complication. The implant stem must fit the narrow paediatric medullary canal and remain fixed while withstanding growth and increasing physical demands. Novel designs incorporate a hydroxyapatite (HA) coated collar that manufacturers claim improves bony ongrowth and stability, providing even stress distribution in stem and shoulder regions and providing a bone-implant seal, resulting in decreased AL and prolonged survival. This study aims to assess whether there is a relationship between bony ongrowth onto a HA collar and AL. Hypothesis: Bone ongrowth onto the HA collar of extendable prostheses is associated with more stable fixation and less AL despite patient growth. Retrospective review of 51 primary partial femoral extendable prostheses implanted over 12 years from 1994–2006 (followed up to death at a mean of 2.5±2.2 years or last clinical encounter at a mean of 8.6 years) and 24 subsequent revisions, to ascertain failure rate and mode, together with a cohort study reviewing bony ongrowth onto the HA coated collar in 10 loose and 13 well fixed partial femoral, humeral and tibial implants. Patient growth was measured as a change in bone:implant-width ratio.Background/Aims
Methods
Engineered bone tissue to recreate the continuity of damaged skeletal segments is one of the field of interest of tissue engineering. Trabecular titanium has very good mechanical properties and high in vitro and in vivo biocompatibility: it can be used in biomedical applications to promote osteointegration demonstrating that it can be successfully used for regenerative medicine in orthopaedic surgery (1). Purpose of this investigation was to evaluate the behavior of adipose tissue derived stem cells (hASCs) cultured on scaffolds of Trabecular TitaniumTM (Lima-Lto) (TT). hASCs are considered to be multipotent mesenchymal stem cells that are easily induced to differentiate into functional osteoblasts both in vitro and in vivo (2). The hASCs were obtained from the subcutaneous adipose tissue of healthy donors during total hip replacement procedures after digestion with collagenase. They were seeded on monolayer and on the TT scaffolds, and incubated at 37 degrees C in 5% CO2 with osteogenic medium or control medium. The expression of bone-related genes using RT-PCR, time course of alkaline phosphatase activity and morphological investigation with Scanning Electron Microscopy (SEM) were performed to evaluate the osteogenic differentiation of hASCs. Alkaline phosphatase activity, marker of the differentiation toward the osteogenic pattern, was significantly higher in hASCs grown with osteogenic medium than in cells grown with control medium, both in monolayer and TT scaffolds; moreover, also alkaline phosphatase of hASCs grown on TT scaffolds in the presence of control medium increased with time, differently from that of cells grown on monolayer. The osteogenic differentiated hASCs expressed the bone-related genes type I collagen, osteocalcin, Runx-2 and alkaline phosphatase. SEM observations showed that hASCs differentiated toward osteoblast-like cells: they produced a big amount of extracellular matrix that covered the surface of the porous scaffolds with bridges between the pore walls. These data suggest that hASCs are able to adhere to TT scaffolds, to acquire an osteoblastic phenotype and to produce abundant extracellular matrix, with but also without osteogenic medium. We can therefore conclude that this material carries osteinductive properties being responsible of ostegenic differentiation; consequently, this scaffold/cells construct is effective to regenerate damaged tissue and to restore the function of bone tissue.
Continual implant stability is an important factor for the long-term success of cementless hip replacements. The increasing lifespan of patients causes a higher frequency of osteoporosis which may result in implant loosening due to bone loss. This study aimed to evaluate stability of long living implants in patients with advanced age. Nine cementless stems made of Titanium-alloy including adjacent bone tissue obtained post mortem were evaluated by radiologic-microradigraphical, histological and morphometrical analysis. The percentage of the surface area covered by bone (BICI=bone implant contact index) was determined. The age of seven women and two men ranged between 81 and 92 years. The time in situ ranged between 10 and 20 years. From the entire length of the femora bearing implants 5 transverse segments were excised, dehydrated, embedded in methylmethacrylate. After the grinding procedure, the sections were evaluated by light microscopy and morphometrical analysis. The autopsy findings were recorded. Atherosclerosis and their related diseases were evident in all cases.Background
Patients and methods
The standard practice of uncomplicated total ankle replacement (TAR) involves post-operative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the post-operative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs. We have 133 TARs with 3 to 48 months' follow-up. 28 patients were excluded for the following reasons: other major procedure performed concurrently (osteotomy or tendon transfer), custom prosthesis, revision surgery, fusion conversions, or patients involved in a separate RCT (n = 16). We do not routinely immobilise patients post-operatively but allow partial to full weight-bearing as able. Outcome scores were compared to those without fractures.Introduction
Materials and Methods
Distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. Thus implant fixation is more difficult. Dorsal and radial comminution are frequent in these patients and so reduction and angle stable osteosynthesis needed. The angle stable plate, often also multidirectional is today the most common stabilisation device. Because of the introduction of bulky and bended implants as the Micronail or Targon DR wich require difficult opening of the bone with awles we decided to test the XS radius nail witch is a 4,5mm or 3,5mm straight nail and witch is introduced after guide wire placement and over drilling with a canulated drill of the same diameter. It is locked parallel to the joint in 3 different directions with angular stability with threaded wires. Methods 16 radius sawbones were osteotomised corresponding to a A3 Fracture and stabilised with a angle stable plate (8) and XS nail (8). 1000 alternating load cycles from 20–200N were performed and the deformation was registered. Also a FE analysis with the MSC Patran/Marc softwere were performed. Also the calculated deformation in the FE study was 20% lower. Also deformation amplitude was lower with 0.31mm compared to 0.42mm in the plate group. The differences however were not significant. Both devices show good biomechanical results. The XS nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. Styloideus radii and over drilling with a canulated drill of the same size. The exposure of the N rad. superf. must be performed. First clinical evaluation is presented. Due to the results we developed a anatomically adapted XS radius nail. The results of the first 100 patients are presented. Both angular stable plate and XSR nail can be used in unstable distal radius fracture fixation. The mainly intraosseus position of the nail and saving of the pronator quadratus as well as lower deformation are in favour of the XSR nail. However frontal plane fractures and very comminuted fractures are better treated with a multidirectional locking plate due to technical reasones so that we use the XSR nail mainly in A3 and C1 fractures.Conclusions
Application of an external fixator for type B and C pelvic fractures can be life saving. Anteriorly the fixator half pins can be placed in the long and thick corridor of bone in the supra-acetabular region often referred to as the low anterior ex-fix. Pins in this location are favoured as they are more stable biomechanically. The bone tunnel for the low anterior ex-fix can be visualised with an iliac oblique projection intra-operatively. In some cases despite being outside the articular surface it may still be low enough to pass through the capsular attachment of the hip joint on the anterior inferior iliac spine. We aim to provide radiological markers for the most superior fibres of the capsule to help accurate extra-capsular pin placement within the supra-acetabular bone tunnel. Thirteen cadaveric pelves, embalmed with the method of Thiel, were used for this study. An image intensifier was positioned to acquire an iliac oblique outlet view, such that the supra acetabular bone tunnel was visualised. This was achieved by positioning the beam 30 degrees cephalad and 20 degrees medial. Both left and right hemipelves were examined in this way. A standard size metallic disc was included in all images with in the acetabulum to allow for image calibration. The proximal most fibres of the hip joint capsule were marked with a K-wire so that their relation to the bone tunnel could be clearly seen on the images. Once all images were acquired they were calibrated and analysed using ImageJ Software to estimate the height and maximum width of the bone tunnel as seen on the images and the vertical distance of the superior most fibres of the capsule from the dome of the acetabulum.Introduction
Materials and Methods
The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD. A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England.Introduction
Methods
To compare regional body composition, bone mineral density (BMD), and clinical outcome in patients with two different shoulder arthroplasty designs. This cross-sectional study included 54 patients with a total of 63 shoulder arthroplasties. There were 18 men and 45 women with a mean age of 68.9 years SD ± 10.5. Mean follow-up time was 39.2 months SD ± 14.4. The patients were divided into three groups according to their history: 22 patients were diagnosed with a proximal humeral fracture and treated with a stemmed hemi arthroplasty, 11 patients were diagnosed with osteoarthritis and treated with a stemmed hemi arthroplasty, and 30 patients were diagnosed with osteoarthritis and treated with a resurfacing arthroplasty. All patients underwent a one-day protocol: Regional Dual X-ray Absorptiometri (DXA) was used to measure BMD of the distal third of humerus and regional body composition of the upper arm. The clinical outcome was measured using Western Ontario Osteoarthritis of the Shoulder index (WOOS) and Constant-Murley score.Objective
Materials and Methods
We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations. 2000 consecutive unselected patients above 50 years admitted with a hip fracture were included, 1000 of these prospectively after implementation of the algorithm. Demographic parameters, hospital treatment and reoperations within the first postoperative year were assessed from patient records. The algorithm dictated the surgical treatment based on three objective patient parameters: age, new mobility score and fracture classification on pre-operative anterior-posterior and axial radiographs. Intra capsular fractures were treated with two parallel implants, a sliding hip screw, an arthroplasty or resection of the femoral head. Extra capsular fractures were treated with a sliding hip screw or an intramedullary nail. Supervision of junior registrars was mandatory for the prosthesis and intramedullary nail procedures.Introduction
Materials and methods
Hip wear simulation is a widely used technique for the pre-clinical evaluation of new bearing designs. However, wear rates seen in vitro can often be significantly different to those seen clinically. This can be attributed to the difference between the optimal conditions in a simulator and wide ranging conditions in real patients. This study aimed to develop more clinically relevant simulator tests, looking specifically at the effects of cup inclination angle (in vivo) and stop-dwell-start (SDS) protocols on a clinically available product. Five tests using a Paul type walking cycle (ISO 14242) were carried out on two ProSim hip simulators:
28mm MoM, standard walking, cup inclination 45°, (n = 5) 36mm MoM, standard walking, cup 45°, (n = 4) 36mm MOM, SDS: 10 walking cycles and pause of 5s with stance load of 1250N cup 45°, (n = 5) 36mm MOM, SDS: 10 walking cycles and pause of 30s with stance load of 1250N, (n = 5) cup 45° 36mm MOM, standard walking, cup 55°(n = 5), and 65°(n = 5). All samples had matched clearances, measured using a CMM (Prismo Navigator, Zeiss, Germany). Wear was measured gravimetrically (Sartorius ME235S: 0.01mg).Introduction
Method
This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow. We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire. Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement. Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities.
The lateral pillar classification (LPC) is a widely used tool in determining prognosis and planning treatment in patients who are in the fragmentation stage of Perthes disease. The original classification has been modified to help increase the accuracy of the classification system by the Herring group. The purpose of our study was to independently assess this modified Herring classification. 35 standardized true antero-posterior radiographs of children in various stages of fragmentation were independently assessed by 6 senior observers on 2 separate occasions (6 weeks apart). Kappa analysis was used to assess the inter and intraobserver agreement between observations made. The degrees of agreement were as follows: poor, fair, moderate, good and very good. Intraobserver analysis revealed at best only moderate agreement for two observers. 3 observers showed fair consistency, whilst 1 remaining observer showed poor consistency between repeated observations (p<0.01). The highest scores for interobserver agreement varying between moderate to good could only be established between 2 observers. For the remaining observers results were just fair (p<0.01). This study highlights the lack of agreement between senior clinicians when applying the modified LPC. This has clinical implications when applying the classification to the decision making process in treating patients at risk of developing adverse outcomes from the disease. To our knowledge, this is the first time the modified LPC has been independently tested for its reproducibility by another specialist paediatric orthopaedic unit.
Randomized, controlled trials (RCTs) are generally accepted as the “gold standard” for the provision of the most unbiased measures of the efficacy of interventions but are often criticized for the lack of external validity. We assessed the external validity of a RCT examining the efficacy of local infiltration analgesia (LIA) compared with continuous epidural infusion after total knee arthroplasty (TKA) During a one-year period, all patients consecutively admitted for elective, unilateral, primary TKA were identified as potential participants. All underwent eligibility screening to determine who were eligible for participation in a randomized controlled trial. We investigated the distribution of preoperative characteristics and postoperative variables among excluded patients, non-consenters, and enrolled and randomized participants.Background
Methods
Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening).Methods and material
Results
The median nerve compression in the carpal tunnel is the most common compression syndrome of the upper limb. In most cases it is idiopathic but may also occur from anatomical, traumatic, endocrine, rheumatic or tumoral causes. Chow's endoscopic technique was initially used to treat this disease and then modified to a mini-open approach through a single palmar incision. This incision is similar to the one used in endoscopic release by Agee. After exposing the proximal part of the transverse carpal ligament a meniscus knife is advanced until there is a complete section of the ligament, without endoscopic equipment. Between 2004 and 2006, 200 hands in 179 patients with a diagnosis based on clinical and electromyographic criteria were operated by this mini-open technique. The mean follow-up was 49 months (minimum of 34 months and a maximum of 70 months). 50 randomly selected patients were submitted to the self-administered Boston questionnaire. 50 patients treated by the minimal-incision decompression during the same period were also given the questionnaire. The aesthetic satisfaction was registered as well as if they would have surgery on the other hand or would recommend the procedure. This mini-open technique is another technique available to the surgeon that allows very similar functional results to endoscopic surgery, without use of specific material and with a shorter surgical time.
Total hip replacements using highly cross-linked polyethylene show excellent clinical outcomes, low wear, and minimal lysis at 5 years follow-up. A recent RSA study reports a significant increase in femoral head penetration between 5 and 7 years. This study is a multi-center radiographic analysis to determine whether the RSA observation is present in a large patient cohort. Six centers were enrolled for radiographic analysis of primary total hip arthroplasty for standard head sizes (26mm, 28mm, or 32mm). Radiographic inclusion criteria required a minimum of four films per patient at the following time points: 1 year; 2–4.5 years; 4.5–5.5 years; and 5.5–11 years. The Martell Hip Analysis Suite was used to analyze pelvic radiographs resulting in head penetration values. Wear rates were determined in two ways: the longest follow-up radiograph compared to the 1 year film, and individual linear regressions for the early and late periods. For both methods, average wear rates from the early period (1 to 5.5 years) and late period (>5.5 years) were compared using t-tests.Introduction
Methods
Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21. We describe long-term outcomes following precise use of the femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation. All individuals with Trisomy 21, who had hip surgery at Toronto's Hospital for Sick Children between 1998 and 2008, were searched using the hospital databases. 16 hips in 9 children aged less than 10 years, were identified. All had a femoral varus derotation osteotomy (VDRO) with a target femoral neck shaft angle (NSA) of 105° and less than 20° external rotation. All were performed by the senior author JHW. The clinical notes and radiographs were reviewed from presentation to final follow up. Continuous variables were assessed for normality with the d'Agostino Pearson test. Normally distributed variables are presented as means with 95% confidence intervals. Pre and postoperative means were compared using the student's t-test for paired samples.Background
Methods
Osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. To identify the rate of recurrent fractures after vertebroplasty and after the conservative treatment for patients aged 50 years and older who sustained low impact vertebral compressions fractures over a 6-month period.BACKGROUND CONTEXT
PURPOSE
In stabilisations of atlantoaxial instabilities it holds risks to injure the A. vertebralis as well as neurological structures. Furthermore the posterior approach of the upper part of the cervical spine requires a huge and traumatic preparation of the soft tissue. However the anterior transarticular C1-2 fusion (ATF) is less traumatic and offers almost the same strengh of the stabilisation. Since the 01/2007 22 multimorbid patients with atlanto-axial instabilities of different entities were treated via the ATF, were regular examined radiologicaly (x-ray/CT) and the procedure critically judged.Purpose
Methods
To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery. From January 2003 to December 2009, 243 patients (148 men and 95 women; age range, 20–87 years) with painful bone metastases were treated with N-2-butyl Cyanoacrylate. Overall, 309 embolizations were performed; 56 patients had more than one embolization. Embolizations were performed in the pelvis (168 procedures), in the spine (83 procedures), in the upper limb (13 procedures), in the lower limb (38 procedures) and in the thoracic cage (21 procedures). Primary cancer included urogenital, breast, gastrointestinal, thyroid, lung, musculoskeletal, skin, nerve and unknown origin. Renal cell carcinoma was the most commonly treated tumor. In all patients, selective embolization was performed by transfemoral catheterization.Aim
Material and Methods
Insufficient arthroscopic cuff tear reconstruction leading to massive osteoarthritis and irreparable rotator cuff tears might be salvaged by implantation of an inverted total shoulder prosthesis Delta in the elderly. However, despite the generally high success rate and satisfying clinical results of inverted total shoulder arthroplasty, this treatment option has potential complications. Therefore, the objective of this study was a prospective evaluation of the clinical and radiological outcome after a minimum of 2 years follow-up of patients undergoing inverted shoulder replacement with or without prior rotator cuff repair. Sixty-eight shoulders in 66 patients (36 women and 30 men) operated between February 2002 and June 2007 with a mean age of 66 years (ranging from 53 to 84 years) were first assessed preoperatively and then at minimum 2 years follow-up, using the Constant score for pain, Constant Shoulder Score, Oxford Shoulder Score, UCLA Shoulder rating scale, DASH Score, Rowe Score for Instability and Oxford Instability Score. 29 patients (Group A) had undergone previous shoulder arthroscopy for cuff tear reconstruction at a mean of 29 months (range 12 to 48 months) before surgery and 39 patients (Group B) underwent primary implantation of an inverted total shoulder prosthesis Delta. Any complications in both groups were assessed according to Goslings and Gouma.Introduction
Patients and Methods
Patients most at risk of osteoporosis are post-menopausal women. However, for many such women, presentation of osteoporosis is only made following their first fragility fracture. Often in the UK, osteoporosis investigation occurs following discharge, and any subsequent secondary prevention starts in the community. This may result in patients with osteoporosis not being investigated or not receiving correct prophylactic treatment. 143 post-menopausal women (av. age 77.7 years) starting secondary osteoporosis prophylaxis following fragility fractures requiring operative intervention were included in this retrospective study. Osteoporosis was defined by DEXA scan using the WHO criteria (122 hip fractures and 21 wrist fractures), following the UK's national guidelines for osteoporosis prophylaxis. Treatment was started following discussion and explanation of treatment with each patient, and either commenced by the surgical team during the acute hospital admission with the fracture, or in an out-patient setting within 6 weeks of the fracture by an orthopaedic specialist nurse. To check compliance, either the patient themselves or the patients' family physician was contacted. Results showed that 120 of the women (83.9%, 102 hip fractures, and 18 wrist fractures) were still compliant with secondary osteoporosis prophylaxis at an average follow-up of 200 days (5 hip fractures lost to follow-up, 0 wrist fractures). 12 women with hip fractures died (0 wrist fractures), and 6 women stopped taking their prophylaxis (3 hip fractures, 3 wrist fractures): 4 for medical reasons, and 2 for unknown reasons. No women sustained further fractures. Few studies have previously investigated compliance of osteoporosis secondary prevention, and our results compare favorably. We therefore recommend the prompt commencement of secondary prevention treatment by the orthopaedic surgical team following osteoporotic fractures.
Undisplaced femoral neck fractures have been given little attention in the literature. By using data from the Norwegian Hip Fracture Register, this study investigates risk for reoperation and the clinical results, including pain, patient satisfaction, and quality of life, after undisplaced femoral neck fractures in elderly patients. Data on 4,468 patients over 70 years of age with undisplaced femoral neck fractures operated with internal fixation (IF) were compared to 10,289 patients with displaced femoral neck fractures treated with IF (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reported reoperations and patients' assessment (visual analogue scales concerning pain (0–100) and patient satisfaction (0–100), and quality of life (EQ-5D)) four and twelve months postoperatively. The patients were followed for 0–1 year. The Cox multiple regression model was used to construct adjusted survival curves. Subanalyses were performed on undisplaced femoral neck fractures to investigate different risk factors for reoperation.Introduction
Material and Methods
The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. A multicenter retrospective review was performed on 310 lateral ankle reconstructions, with a mean 13 years’ follow-up (minimum FU of 5 years with a maximum of 30). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. 28% of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsulo-ligamentary repair; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon; and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, TelosR or self-imposed varus). The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19–100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in osteoarthritis (2 %), with improved stability (88%); there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration.Material and methods
Results
Juxtafacet cysts of the spine can cause radicular pain, neurological symptoms and are often associated with spinal degeneration. The mainstay of treatment of juxtafacet cysts is surgical resection with laminotomy and resection of the cyst. Other methods, including epidural steroid and facet injections are mostly temporarily effective. The aim of this study is the sufficient decompression with reduced traumatization and destabilization with the full-endoscopic interlaminar and transforaminal technique. 60 patients with unilateral, single-level juxtafacet cysts were included in this study. 30 Patients (group 1) were operated in full-endoscopic technique (22 interlaminar, 8 trans-/extraforaminal) and 30 Patients (group 2) with conventional microscopic-assisted technique. The full-endoscopic operation was performed with 6.9-mm endoscopes with 4.1-mm intra-endoscopic working canal. The follow-up was 18 months. 27 (91%) patients were followed. Additionally to general parameters validated scores were used.Objectives
Methods
Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series. Since 2006, we have performed 150 Mobility TARs with up to 4 years' follow-up. We have excluded 16 that are part of a separate RCT and 10 with less than 3 months' follow-up. 124 TARs were included in our study (117 patients). Three ankles (2.4%) had superficial wound infections treated successfully with antibiotics. One ankle (0.8%) required an arthroscopic washout and débridement but the implant was retained. 11 ankles (8.9%) had a periprosthetic fracture: One was intra-operative; 10 were post-operative (2 fixed). Four patients (3.2%) developed CRPS. One ankle required fusion surgery (following subsidence of the talar component) with another one pending revision (ligament instability causing implant displacement). No patient had a symptomatic deep vein thrombosis or thromboembolic event.Background
Results
ACL (anterior cruciate ligament) partial tears include various types of lesions, and an high rate of these lesions evolve into complete tears. Most of the techniques described in literature for the surgical treatment of chronic partial ACL tears, don't spare the intact portion of the ligament. Aim of this study was to perform a prospective analysis of the results obtained by augmentation surgery using gracilis and semitendinosus tendons to treat partial sub-acute lesions of the ACL. This technique requires an “over the top” femoral passage, which enables salvage and strengthening of the intact bundle of ACL. The study included 97 patients treated consecutively at our Institute from 1993 to 2004 with a mean injury-surgery interval of 23 weeks (12–39). Patients were followed up by clinical and instrumental assessment criteria at 3 months, 1 year and 5 years after surgery. Clinical assessment was performed with the IKDC form. Subjective and functional parameters were assessed by the Tegner activity scale. Instrumental evaluation was done using the KT-2000 instrument: the 30 pound passive test and the manual maximum displacement test were performed. We obtained good to excellent results in 95.9% of cases. We didn't observed recurrences in ligamentous laxity. We believe that the described technique has the advantage of being little invasive, compatible with the ACL anatomy, and enables very rapid functional recovery and return to sport.
The treatment for trochanteric femoral fractures is still challenging. Since 2005, we are using 2 new implants: Gamma3™ nail and the PFN-A™. All patients with a fracture of the trochanteric area were included in an observational study during 3 years. Objectives were radiographics and clinics (complications) comparaison of these 2 new devices. We included 426 patients (236 Gamma3™ nails, 190 PFN-A™). We faced the epidemiological data, per and post-operative complications. The tip-apex distance and the position of the cephalic implant were studied. The 2 implants were well positionned in more than 80%, with no statistic diffferencie. We found a a cut-out rate of 1,4 % and a re-operation rate of 4,9 %. These rates of usual complications are very low in comparaison with litterature. We did not found a statistic difference between these 2 differents nails. But, we observed 2 unusual complications: for the Gamma3™ nail, a high rate of automatic distal locking failure, and for the PFN-A™, many patients complained of thigh pain resulting from a prominent cephalic blade. These 2 new complications can be avoided by small changes in the operative procedure. In our mind these 2 implants can be used for treating all patients with trochanteric fracture, but we need other studies to compare these nails with the new generation of sliding plate
At our Department, we prefer surgical treatment of all patients with Type II and III fractures of the dens, regardless of the age, with the exception of non-displaced fractures or perfectly reduced fractures in young patients. We treated surgically 28 patients 65 years old and older with dens fractures. The group consisted of 13 men and 15 women with a mean age of 77.4 years (range, 65–90 years). According to the type of treatment, anterior srew fixation or posterior C1–C2 fixation, the whole cohort was divided into 2 groups that were subdivided into two age groups of patients 65–74 years old and 75 years old and older. The age group of patients 65–74 years old included 8 patients with a mean age of 68.5 years and the mean age of the age group of patients 75 and more years old was 81 years. The injury was caused in 22 cases by a fall, in 5 by a car accident. Only in 1 case the injury was caused differently. Neurological deficits were found in three patients, all of them Frankel D type. All patients with injury to the dens underwent radiograph examination in the lateral and transoral projections and CT scan including the sagittal and frontal reconstructions of the atlantoaxial complex and in most cases also MRI examination to eliminate injury to the transverse ligament of the atlas. Based on these examinations, the type of injury was determined and method of treatment indicated. Final retrospective evaluation of the patients was carried out at the interval of 12 to 78 months after the primary surgery (mean 31.3 months) taking into account aetiology of the injury, type of injury, neurological finding, method of treatment, union of the dens fracture line or, where appropriate, C1–C2 fusion, stability of the spine and the final outcome. Statistical analysis was based on X2-test.Purpose of the Study
Material and Methods
Tranexamic acid (TA) in total knee replacement surgery (TKR) has shown marked reduction in bleeding and blood transfusion. There are little data on TA in revision TKR. From February 2008 all patients having primary or revision TKR received TA 10mg/kg × 2. We whished to evaluate the effect and possible complications of TA. 49 patients had revision TKR from January to August 2010. 21 patients (group I) operated before the regular use of TA were compared to 28 patients (group II) receiving TA. The groups were compared according to bleeding, blood transfusion, postoperative complication and type of revision. Revision TKR was compared to 157 primary TKR (94 operated without TA (group III) and 63 who received TA (group IV).Background
Patients and Methods
Acetabular labral pathology is now recognized as a more common injury than previously thought. With cost constraints of MRI and invasiveness of MRI arthrogram, physical examination remains essential for diagnosis. Most tests for labral pathology are currently done in the supine position. We have developed the “twist test,” which is done with the patient standing and can evaluate the patient in functional, weight bearing position. The purpose of this study is to describe the twist test and compare its reliability to MRI arthrogram. Between June 2009 and August 2010, the twist test was performed on all patients presenting to our clinic with complaint of hip pain. 371 patients had the twist test performed. Of these, 247 had an MRI arthrogram (MRA) of the affected hip. The twist test results were compared with MRA findings. A labral tear, degeneration, fraying and paralabral cyst were considered as a positive MRA. The twist test is done with the patient facing the examiner, toes pointing forward. The patient bends their knees to 30 degrees and performs a windshield wiper like action with maximal excursion to the left and right. If the patient tolerates this, then the patient first gets on the unaffected leg, again with the knee bent at 30 degrees, and “does the twist” one-legged, with the examiner holding their hands gently for balance. The test is then repeated on the affected hip. A positive test is groin pain on the affected hip, apprehension with performing the test on the affected hip, or gross range of motion deficits on the affected hip compared with the unaffected side.Introduction
Material and methods
Distal radial fractures in the elderly population have been traditionally managed by closed techniques, primarily due to their poor bone quality and low functional demands. Since the introduction of the volar locking plate (VLP), which provides a good fixation in osteoporotic bones, there maybe an increased use of open reduction and internal fixation (ORIF) in the elderly population. We aimed to determine the changes in the management of these fractures in Scotland, and whether this differs between specialist regional centres and district general centres.Background
Aim
Limb salvage surgery is a common treatment for patients who suffer from bone tumors. In the case of pelvic tumors this creates a challenge for the surgeon and the treatment remains controversial because the oncologic complications like local recurrence, dissemination and orthopaedic ones, like infection, haemorrhage, and mechanical problems of reconstructions Tumors affecting the acetabulum are a challenge for the surgeon because of the impact in the function of the extremity. There are many reconstruction techniques described in the literature like prosthesis, allograft systems, arthrodesis, etc…, but still there is not a gold standard due to the poor functional results at long term follow up, and the associated complications of all techniques. In this study we show the experience in our center on pelvic reconstructions after tumors affecting the acetabulum area (zone II). We surgically treated 81 pelvic tumors from 1997 to 2009 following the Enneking and Dunham calssification attending to the localization of the tumor: Zone I 38 (iliac bone)Zone II 25 (acetabulum)Zone III 18 (pelvic branches)In zone II tumors we performed pelvic reconstruction in eight cases, with different type of prosthesis. In 5 cases we performed saddle prosthesis (group A) and in 3 cases we performed Coned-Stanmore Implants type prosthesis with sacro-iliac anchorage. The mean follow up of the serie was 3,5 years (1–6 years). In group A the mean follow up was 5 years and in group A and in group B the mean follow up was 1 year due to the recent implantation in our center of Coned type prosthesis for pelvic reconstruction. We evaluated our results with these two types of prosthesis.INTRODUCTION
MATERIAL AND METHODS
The suicidal jumper's fracture of the pelvis is a special form of sacrum fractures associated with high energy trauma. The typical H-type fracture pattern runs transforaminal on both sides with a connecting transverse component between S1 and S3. Due to the high-grade instability operative treatment is imperative. Aim of this study was to compare iliosacral double screwing (2×7,3mm canulated screw with 16mm thread) with spinopelvic internal fixation. Both methods were tested on 6 synthetic and 6 anatomical pelvises. After osteotomy and alternating osteosynthesis stability was tested with a universal testing machine (Zwick) in a simulated two-leg stand. Data were generated by a 3-dimensional computer-assisted ultrasoundsystem (Zebris©) (3 translational datasets x,y,z and 3 ankles). Testing was performed after preload of 50N and two setting cycles of 100N followed by a full load cycle of 150N. ASCII-data were then transferred to SPSS for statistical analysis.Background
Methods
Fibrous dysplasia is a developmental anomaly of bone formation that may exist in a monostotic or polystotic form. Surgical treatment is considered advisable only with presence of significant or progressive deformity or persistent pain. Early surgery is indicated before the tumor expands or fracture occurs. We reviewed a series of 21 patients, 14 had monostotic whereas 7 had polystotic fibrous dysplasia. There was no case of Mc Cune Albright. We treated all of these patients with curettage and corticocancellous bone graft and also fixation with reconstruction nails. Follow up ranged between 1 and 5 years. Functional and radiographic outcomes were scored.Background
Methods
The Kaplan Meier estimator is widely used in orthopedics. In situations where another event prevents the occurrence of the event of interest, the Kaplan Meier estimator is not appropriate and a competing risks model has to be applied. We questioned how much bias is introduced by erroneous use of the Kaplan Meier estimator instead of a competing risks model in a hip revision surgery cohort. In our previously published cohort study, 62 acetabular revisions (58 patients) were performed between January 1979 and March 1986. Twenty to twenty-five years after surgery, no patients were lost to follow-up. Thirteen patients underwent revision surgery. During the 20 to 25 years follow-up, 30 patients (33 acetabular revisions) died of causes unrelated to their hip surgery.Introduction
Methods
For some years, there has been vast international interest in creating models for joint efforts between geriatricians and orthopedic surgeons. We present data from two such models. For the first time in Denmark, the Department of Orthopedics Bispebjerg University Hospital (BUP) recruited two full-time geriatricians in September 2009. They were assigned an independent unit meant for severely ill orthopaedic patients with high comorbidity and polypharmacy. These two geriatricians had, during the previous two years, consulted another orthopaedic department at Gentofte University Hospital (GUH) in a neighbouring community three times a week. The aim of their intervention was then to optimize treatment for comorbidity, to clarify indication of acute fall-assessment, osteoporosis diagnosis and treatment, presence of delirium and dementia. A total of 1344 hip fracture patients (age 70 years) divided into three populations were included in this study. Mortality data were collected from the Danish Civil Registry. Population 1 (P1), n = 645 was included at GUH from January 1, 2006 to December 31, 2007. During the entire period, the patients had access to a senior consultant in geriatric medicine three times a week. In this population, the majority of patients were assessed for dementia (n = 636), delirium (n = 627) and Barthel Index (Barthel100) at admission (n = 394). Population 2 (P2), n = 381 included at BUH from September 1, 2009 until July 8, 2010 with orthogeriatric access. Population 3 (P3), n = 318 were included at BUH from September 28, 2008 until August 31, 2009 with no orthogeriatric access. Age mean (SD): P1 84.7 (6.8), P2 85.5 (7.3), P3 85.3 (14.3) P = 0.1(ANOVA) Sex ratio: females/males: P1 0.73/0.27, P2 0.80/0.20, P3 0.75/0.25 P = 0.09 Chi square). In-hospital mortality rate: P1 4.8%, P2 6.3%, P3 9.1% P = 0.03 (Chi square). Three month mortality: In P1 dementia, delirium and Barthel Index (below 50 versus above 50) were all strong predictors: No dementia: 53/383 (13.8%) versus dementia present 68/253 (26.9%) died, P = 0001 (log-rank test). No delirium 69/456 (15.1%) versus delirium present 47/171 (27.5%) died F = 0.0004 (log-rank test) Barthel Index 50 38/372 (10.2%) versus Barthel<50 7/22 (31.8%) died P = 0.0004Methods
Results
The assessment of the accuracy of reduction of the ankle syndesmosis has traditionally been made using plain radiographic measurements. Recent studies have shown that computerized tomography (CT) scan is more sensitive than radiographs in detecting diastasis. The ethos has now therefore shifted towards CT scan assessment of the syndesmosis. There is however no validated method to scan the syndesmosis and measure it on the CT scans. This exposes the patient to significant radiation risk and also to anxiety from inappropriate interpretation from these scans. The objectives of this research project are to investigate the current practice of CT scanning the syndesmosis at a University Hospital and to devise a new CT protocol to reduce radiation exposure to patients and to assist surgeons in interpreting the observations. Research Ethics Committee approval was obtained. Current practice was evaluated. A new 5 cut CT protocol was devised. Starting at the level of the distal tibial plafond, 5 cuts were made proximally 0.5 cm apart. Accuracy of the syndesmosis reduction was assessed just above the distal tibial plafond. Both the injured and the normal sides were scanned 12 weeks post surgery. The normal side served as a control.Introduction
Methods
Large diameter metal on metal cups have been used in total hip arthroplasty advocating superior results with respect to dislocation rates, range of motion and long term survival. The Durom cup used as part of the Durom hip resurfacing system has been incriminated with poor short term results sometimes correlated to incorrect positioning of either the femoral or acetabular component. Our objective was to evaluate short term results of the Durom cup used in conjunction with standard stems. We prospectively followed all patients with a large diameter metal-on-metal articulation (Durom) and a standard stem operated upon between 9/2004 and 9/2008. Patients were seen at follow-up for a clinical (Harris hip score=HHS, UCLA scale and patient satisfaction), radiographic and questionnaire assessment.Introduction
Methods
Calcium sulphate is a resorbable void filler that can be used for local antibiotic delivery. Results from clinical studies on chronic osteomyelitis thus treated with local vancomycin have already been published. Despite significant exposure to this drug, there are no pharmacokinetic studies published so far. Based on observations in our patients, a model predicting vancomycin serum and wound fluid levels and toxicity potential is presented. Following implantation of Osteoset® added with vancomycin, serum and wound fluid concentrations of this antibiotic have been monitored systematically. The pharmacokinetic analysis was performed using a non-linear mixed-effects model based on a one-compartment model with first-degree absorption.Introduction
Methods
With the recent trend towards enhanced care in joint replacement, it has become increasingly important to identify and address the areas that affect early patient length of stay, while ensuring that practice remains safe. As part of an enhanced care program we conducted two prospective studies of factors delaying discharge following hip replacement in 2006 and 2010. In each limb of the study data was collected prospectively daily, by an independent observer, on 100 consecutive primary cemented total hip replacements. Reasons for delay to the discharge and variation from the patient pathway were identified and addressed.Background
Materials and Methods
The additive use of an external modular device may improve dorsal compression forces in pelvic external fixation. This would improve the efficiency of indirect reduction and stabilization with an anterior pelvic external fixator. The purpose of this study was to determine the forces of the posterior pelvis achieved by a new device improving the application of a supraacetabular anterior external fixator compared with other constructs. Synthetic pelvic models were used. Complete pelvic ring instability was created by symphyseal and unilateral sacroiliac joint disruption. Four different constructs of fixation were tested. A pressure-sensitive film was placed in the sacroiliac joint. The constructs were applied in a standardized way. The maximum sacroiliacal compression loads (N) of each trial was recorded. Statistics was performed with the student t-test.Objectives
Material and Method
Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months.Introduction
Material & Methods
Balloon kyphoplasty (BKP) is a minimally invasive cementing procedure, occasionally used in patients with painful vertebral compression fractures (VCF). In this multicenter Swedish RCT, we evaluated the cost-effectiveness of BKP compared with standard medical treatment, Control, in osteoporotic patients with acute/sub-acute VCF (<3 months). In a multicenter European clinical study (FREE trial) including 300 patients and FU after one year, BKP was suggested to be a safe and effective procedure in selected patients. The current study includes the Swedish patients in the FREE trial Method: Hospitalized patients with a back pain level of at least 4/10 on a visual analogue scale due to of VCF between Th5–L5 (confirmed by MRI) were randomized to either BKP or Control treatment (standard medical treatment with pain medication and functional support). All VCF-associated costs (hospital, primary care, rehabilitation, community care, private care, pharmaceuticals, assistance by relatives, work absenteeism) were identified and reported from the perspectives of cost to society, and costs to the healthcare system. Primary outcome was quality of life change (QoL) measured with the preference based EQ-5D instrument. The accumulated quality adjusted life years gained (QALYs) and costs per QALY gained was assessed. Willingness to pay (WTP) for a QALY gained in Sweden was estimated at approximately SEK 600,000 (EURO 62,500). Sensitivity analyses were performed. Between February 2003 and December 2005, 70 patients were randomized to BKP (n=35) or to standard medical treatment (n=35). Three patients in the Control group declined to participate in an economic evaluation, and only patients answering EQ-5D at all FU occasions (1-3-6-12-24 months) were included in the analyses, leaving in all 63 patients, BKP=32, Control=31. Baseline data were similar. The mean age in the BKP group was 72 years (71% women) vs. 75 years (78% women) in the Control group. Baseline difference in QoL was adjusted for using statistical methods. There were no cross overs. Four patients in the BKP group and three patients in the Control group died within two years of causes not related to the VCF. Costs were collected using “cost diaries” in mailed questionnaires after 1-3-6-12-18-24 months. Costs and EQ-5D values (0 at FU after death) were carried forward. Total mean societal cost per patient for BKP and Control was SEK 160,017 (SD 151,083) and SEK 84,816 (SD 40,954), respectively. The difference was significant 75,198 (95% CI 16,037 to 120,104). The accumulated mean difference in QALYs was 0.085 (−0.132 to 0.306) units in favour of BKP. Cost per QALY gained using BKP was SEK 884,682 (EURO 92,154) with high uncertainty assessed using the bootstrapping technique, and demonstrated on the cost-effectiveness plane and on the acceptability curve. When the EQ-5D values from all patients in the FREE trials were included in a sensitivity analysis, cost/QALY was SEK 359,146 (EURO 37,411) Conclusion: Costs were significantly higher for BKP compared with standard medical treatment, with no significant difference in QALYs gained. In this selected patient population with vertebral compression fracture due to osteoporosis, BKP could not be concluded as cost-effective after two yearsBackground
Results
To analyse the early results of unconstrained pyrocarbon joint replacements in patients with osteo-arthritis of the metacarpo-phalangeal joints. Silicone arthroplasty, as introduced by Swanson in 1962 has remained the most popular procedure to treat arthritis of the metacarpo-phalangeal (MCP) joints. However, despite providing good pain relief, they have shown to demonstrate breakage rates up to 82% at 5 years. This is of great concern in the osteoarthritis (OA) patient group, who tend to be younger and have higher functional demands compared to their rheumatoid counterparts. The newer unconstrained pyrolytic carbon MCP joint prostheses may therefore be more suitable in OA patients whose soft tissue constraints are intact and whose hand function is strong. This study is the first to analyse the results of this implant in a cohort of OA patients only, with prospective data.Purpose
Background
The options for the treatment of the young active patient with unicompartmental symptomatic osteoarthritis and pre-existing Anterior Cruciate Ligament (ACL) deficiency are limited. Patients with ACL deficiency and end-stage medial compartment osteoarthritis are usually young and active. The Oxford Unicompartmental Knee Replacement (UKA) is a well established treatment option in the management of symptomatic end-stage medial compartmental osteoarthritis, but a functionally intact ACL is a pre-requisite for its satisfactory outcome. If absent, high failure rates have been reported, primarily due to tibial loosening. Previously, we have reported results on a consecutive series of 15 such patients in whom the ACL was reconstructed and patients underwent a staged or simultaneous UKA. The aim of the current study is to provide an update on the clinical and radiological outcomes of a large, consecutive cohort of patients with ACL reconstruction and UKA for the treatment of end-stage medial compartment osteoarthritis and to evaluate, particularly, the outcome of those patients under 50. This study presents a consecutive series of 52 patients with ACL reconstruction and Oxford UKA performed over the past 10 years (mean follow-up 3.4 years). The mean age was 51 years (range: 36–67). Procedures were either carried out as Simultaneous (n=34) or Staged (n=18). Changes in clinical outcomes were measured using the Oxford Knee Score (OKS), the change in OKS (OKS=Post-op − Pre-op) and the American Knee Society Score (AKSS). Fluoroscopy assisted radiographs were taken at each review to assess for evidence of loosening, radiolucency progression, (if present), and component subsidence.Introduction
Methods
In the literature are different data about the allogenic blood transfusion rate after total knee replacement. The common intention in orthopedic surgery is to reduce the requirement for allogenic blood transfusions by optimizing the blood management. The aim of this study is to determine the efficacy of the mechanical autotransfusion system OrthoPAT® to reduce the postoperative allogenic blood transfusion (ABT) rate. According to the preliminary performed power analysis we did a prospective controlled study including 151 patients which were randomized in a group A (OrthoPAT® for intra- and postoperative blood salvage and retransfusion, n=76 patients) and a control group B (no retransfusion system was used, n=75 patients). All patients had a primary osteoarthritis of the knee and were operated on without use of a tourniquet. We implanted in all patients a cemented posterior stabilized total knee prosthesis design. In group A the autotransfusion system was used for 6 hours (intra- and postoperatively) and the collected blood was retransfused. The retransfused blood was anticoagulated, filtered and centrifuged to separate waste products. Red cells were washed with saline and reconcentrated to a high hematocrit. The preoperative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. Because of missing data we finally were able to use the results of 140 patients: 70 group A and 70 in group B. The indications for a blood transfusion were influenced by the clinical symptoms of anemia, the hemoglobin value (hemoglobin < 8.0 g/dl) and the anamnesis of cardiovascular diseases. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values and postoperative need of allogenic blood transfusion.Background
Method
Pre-operative patient education prior to hip and knee arthroplasty is thought to be beneficial for patients in general, although the clinical effect is unproven. Pre-operative education is now standard practice in many orthopaedic units, including our own. Anecdotally, we found patients in the private sector to be more satisfied with their education than those in the public sector, despite very similar education programs. We set out to investigate this observation and establish whether there were differences in the perception of educational quality between these groups. After appropriate power calculation, 60 patients in each group (120 total) were interviewed after hip or knee arthroplasty. Satisfaction with education was assessed on a simple 5 point scale and demographic data including internet access was obtained, as well as Short-Form 12 (SF-12) data to establish physical and mental function. The education program in each group was similar, with written material provided and verbal education given at a single pre-operative session. This included specialist nursing and physiotherapy input. Results were analysed with the chi2 test, Mann-Whitney U test and logistic regression as appropriate, with significance at P<0.05.Introduction
Methods
Infection after total hip arthroplasty is a severe complication. Controversies still exist as to the use of cemented or uncemented implants in the revision of infected THAs. Based on the data in the Norwegian Arthroplasty Register (NAR) we have studied this topic. During the period 2002–2008 45.724 primary THAs were reported to NAR. Out of these 459 were revised due to infection (1,0%). The survival of the revisions with uncemented prostheses were compared to revisions with cemented prostheses with antibiotic loaded cement and to cemented prostheses with plain cement. Only prostheses with the same fixation both in acetabulum and in femur were included in the study. Cox-estimated survival and relative revision risks were calculated with adjustments for differences among groups in gender, type of surgical procedure, type of prosthesis, and age at revision.Introduction
Material and Methods
In a randomized study of 60 patients allergic reactions are evaluated in three joint prosthesis groups, a resurfacing arthroplasty (ReCap), a non-cemented, large metal-on-metal head (Bimetric Magnum) and a non-cemented, alumina ceramic-on-ceramic bearing in a titanium shell (Bimetric C2a). The inclusion criteria were osteoarthritis, ASA I–II, MRI-scan without caput necrosis, DXA-scan without osteoporosis. The exclusion criteria were short neck (<2cm.), large cysts (>1cm.), medical treatment affecting the bone metabolism, severe deformity of the femoral head, impaired kidney function and inability to co-operate. Blood samples were drawn prior to and 6 weeks, 6 months, 1 year, and 3 years after surgery; two tubes from which plasma was prepared, and two tubes for serum. From the last included 20 patients in each group was also taken blood one and three years after surgery for an in vitro lymphocyte assay for scoring of possible hypersensitivity to prosthesis metals. The isolated lymphocytes were subjected to measurement of proliferation and expression of CD69 by flow cytometry and measurement of the Migration Inhibitory Factor (MIF) by ELISA. Plasma concentrations of the cytokines IL-1, IL-4, IL-6, IL-8, IL-12p70, IL-15, interferon-and osteoprotegerin were determined by multiplex-immunoassay. Serum concentrations of chromium and cobalt were determined by graphite furnace atomic absorption spectrometry. The serum concentrations of chromium and cobalt were lowest in patients with the C2a implant and highest with Magnum, some of these differences were significant at 6 weeks, 6 months, and 1 year after surgery. No patient had a very high serum metal concentration. The values of the variables measured in the in vitro lymphocyte assay mainly changed in the expected direction depending on the concentration of the same metal in the serum sample drawn at the same time, but no significant correlation was seen. One patient had uncertain symptoms of metal hypersensitivity and relatively high serum metal concentrations 3 years after arthroplasty with a Magnum prosthesis and was assessed extraordinarily, and elicited the marginally highest MIF responses in the lymphocyte assay. A strong correlation was found between the plasma concentrations of most cytokines, but the cytokine concentrations were not correlated to contemporary metal concentrations.
Assessment of effectiveness of spinal fixation in conditions of general osteoporosis. 112 patients with multiple osteoporotic pathological vertebral body fractures were surgically treated. Multilevel laminar or transpedicular instrumentation with or without ventral stabilization (group A) was used on 64 of them. The cemented polyaxial screws were used in 48 cases (group B). The patients treated with multilevel transpedicular fixation with cemented screws were included in B-I subgroup. The patients treated with monosegmental fixation (around fractures) with same screws were included in B-II subgroup. The parameters of stability (bone resorption around screws and cement, dislocation of implants, clinical symptoms) were studied in both groups. Outcome results and discussion: In group “A” the parameters of stability were the purest. The displacement of instrumentation with lost of correction has been revealed in 21% of cases. The reoperations were done in 17% of them. In groups B-I and B-II the parameters of stability were the same. There were no clinical signs of instability up to2 years of supervision. In 75% of cases the bone resorption around bone cement has been revealed after 3–6 months. But there were no cases of instrumental displacement. Spinal fixation in treatment of multiple pathological vertebral body fractures in conditions of general osteoporosis using the vertebroplasty with cemented screws provide good stability of the spine for long outcome. This method allows to achieve the clinical result with less invasive approach by shortening of extent of fixation.Purpose
Material and methods of studies
The purpose of this study were to investigate whether there is an association between the preoperative body mass index in total knee replacement patients and the effect three to five years postoperative. 197 patients who had undergone primary total knee replacement in the period 1.1.2005–31.12.2006 participated in a three-five years of follow-up study. Outcome measures were self-rated health (SF-36), which consists of eight strands and two component scores, physical component score and mental component scores and the Knee Society rating system (KSS) (knee score and function scores), and improvement of the two KSS scores from baseline to follow-up.Purpose
Method
Tunnelwidening in failed anterior cruciate ligament reconstruction (ACLR) can result in the staged revision procedures with a need for bone transplantation prior to revision reconstruction. Limited knowledge exist regarding to quality of different transplantation methods. The present study used CT-scanning to evaluate tunnel bone density after allogenic bone chips and bone cylinder transplantation. We hypothesized that bone chips transplantation resulted in higher bone density than bone cylinder transplantation due to possible voids between individual cylinders in the tunnels. The records of 24 patients operated for 1st stage revision ACLR from April 2003 to march 2010 were included in the study. twelve patients had their tunnels transplanted with bone chips and twelve patients with bone cylinders from allogenic femoral heads. Bone chips were created by fine bone milling and cylinders were extracted by 7–8 mm core drilling. Bone density 3–4 months after transplantation were evaluated by CT scanning reconstruction slides with 5 mm intervals throughout the tunnel length using histomorphometry.Introduction
Methods
Pseudotumours have been associated with metal-on-metal (MoM) hip replacements. We define it as a solid mass which may have cystic components that is neither neoplastic nor infectious in aetiology. The cause of a pseudotumour is not fully understood but could be due to excessive wear, metal hypersensitivity or due to an as-yet unknown cause. We present the retrieval analysis of early failure MoM hips revised for pain, loosening or a symptomatic mass. Tissues and implants were examined for the possible causes of failure and pseudotumour formation. Corrosion as a potential new cause for pseudotumour formation will be presented.Background
Aim
Controversy persists regarding preference between Herbert and Acutrak screw for internal fixation of scaphoid non-union. Acutrak screw has been shown to have better biomechanical compression properties than Herbert screw in the laboratory setting. The aim of this study was to assess the clinical, radiological and functional outcome of patients treated with the two different screw systems. A retrospective review of the results of patients with scaphoid non-union treated by a single surgeon. Group 1 comprised of 61 patients treated with Herbert screw between July1996 and June2000 and Group 2 comprised of 71 patients treated with Acutrak screw between July 2000 and December 2005. Union rates were assessed radiologically and clinically. Functional outcome was measured by using modified Mayo wrist score.Background
Methods
In elderly patients the temporary loss of function of the upper extremity due to immobilization for treatment of unstable proximal humeral fractures is a very disabling condition. Stable fixation of such fractures allowing immediate functional aftercare may contribute to early social reintegration in this group of patients. Aim of this study is to present the surgical technique of humeral blade plate fixation and the clinical and radiographic results after fixation of unstable surgical neck fractures with this implant followed by immediate functional treatment in patients older than 60 years. 20 patients (4 male, 16 female) with a mean age of 74 years (59y–93y) were included in this study and treated consecutively for an unstable/displaced surgical neck fracture with a humeral blade plate. Postoperatively functional treatment was allowed. All but one patient had a clinical and radiographic follow-up 6 weeks po. At an average final follow-up of 18,8 months (12–24 months) 4 patients had died from causes unrelated to surgery.OBJECTIVES
PATIENTS
Our understanding of the spectrum of pathological lesions of the shoulder anterior capsular-labral complex in anterior instability continues to evolve. In a previous study using magnetic resonance arthrography we have showed three variants of the essential lesion of the anterior capsular-labral complex. This is the first large arthroscopic study to finely evaluate the nature and relative proportions of these three lesions in anterior instability. We studied 122 patients, 101 male and 21 female patients with an average age of 28 (17 to 47 years old), undergoing primary arthroscopic stabilization for anterior instability between 2004 and 2008. The pathoanatomy of the anterior capsule-labral complex was documented. Based on our previous MRI arthrography experience we were able to categorize the lesions seen arthroscopically in three subgroups: the Bankart lesion, the Perthes lesion and the ALPSA (anterior periosteal sleeve avulsion).Purpose
Methods
Osteoarthritis of basal joint of the thumb represents one of the commonest degenerative diseases of the hand and wrist region. Depending on the severity of clinical symptoms surgical treatment is often recommended. Resection arthroplasty of the CMC joint with tendon interposition can be regarded as the gold standard. The aim of our study is to compare the Burton Pellegrini technique with a new modified technique of resection arthroplasty with interposition of local capsule tissue. We retrospectively evaluated 2 groups of patients. Two Consultant Surgeons took part in the study, one for each group, with each consultant performing trapeziectomies using only one of the techiniques for all his patients. The first group underwent trapeziectomy and local capsule interposition. It consists of 26 patients with a female/male ratio of 20/6, an average age of 64 years (range 53–88), an average follow up of 3.15 years (range 9–1) and a left/right ratio of 16/10. The second group underwent a standard Burton Pellegrini including flexor tendon interposition. It consists of 13 patients with a female/male ratio of 5/8, an average age of 68 years (range 58–85), an average follow up of 4.46 years (range 9–1) and a left/right ratio of 5/8. The outcomes were compared using the Michigan Hand Outcomes Questionnaire. A 2-tailed independent samples t-test was used for the statistical analysis of our data.Background
Materials and Methods
Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery. Over a twenty-two month period all patients undergoing interventional hip arthroscopy were recorded on a prospective database. Patient demographics, diagnosis, operative intervention and complications were noted. Patients were scored pre-operatively and postoperatively at 6 months and 1 year using the McCarthy score.Background
Methods
The legion knee revision system was designed as a follow and improvement to the Genesis II knee system- allowing for a surgeon directed femoral rotation as opposed to the in-built femoral rotation in the previous system. This is a prospective review of consecutive patients who underwent knee revision surgery using the legion knee system. Clinical and functional assessments were carried out preoperatively, one year and 2 years post op. Radiographic evaluation was done at 1 and 2years follow up. Standard knee scoring systems (American Knee Scores-AKS, and Oxford score were used for the clinical and functional evaluation of these patients. The WOMAC score was also used to assess for pain, stiffness and social function in these patients. The radiographic assessment included review of standing AP, lateral and skyline views. Figgie's method was used to measure the joint line reproduction. A difference of 5 mm (pre = op/post-op) was deemed satisfactory.Introduction
Methods
Chondral injuries of the knee are extremely common and present a unique therapeutic challenge due to the poor intrinsic healing of articular cartilage. These injuries can lead to significant functional impairment. There are several treatment modalities for articular osteochondral defects, one of which is autologous chondrocyte implantation. Our study evaluates the mid to long term functional outcomes in a cohort of 828 patients who have undergone an autologous chondrocyte implantation procedure (either ACI or MACI), identifying retrospectively factors that may influence their outcome. The influence of factors including age, sex, presence of osteoarthritis and size and site of lesion have been assessed individually and with multivariate analysis. All patients were assessed using the Bentley Functional Score, Visual Analogue Score and the Cincinnati Functional Score. Assessment were performed pre-operatively and of their status in 2010. The majority of patients had several interim scores performed at varying intervals. The longest follow-up was 12 years (range 24 to 153 months) with a mean age of 34 years at time of procedure. The mean defect size was 486 mm2 (range 64 to 2075 mm2). The distribution of lesions was 51% Medial Femoral Condyle, 12.5% Lateral Femoral Condyle, 18% Patella (single facet), 5% Patella (Multifacet) and 6% Trochlea. 4% had cartilage transplant to multiple sites. 30% failed following this procedure at a mean time of 72 months. 52% patients stated a marked improvement in their functional outcomes within the first two years. 49% stated an excellent result following their procedure. High failure rate was noted in those with previous cartilage regenerative procedures, transplants occurring on the patella, particularly if involving multifacets. Multiple site cartilage transplantation was also associated with a high failure rate. Autologous chondrocyte implantation is an effective method of decreasing pain and increasing function, however patient selection plays clear role in the success of such procedure.
Anterior Cruciate ligament reconstruction is a common operation in orthopaedics surgery. A common complication of whilst havesting the hamstring tendon is injury to the infra-patellar branch of the saphenous nerve (IPBSN), resulting in altered sensation to the anterior and lateral aspects of the knee and leg. The aim of this study was to further understand the course of this nerve in relation to surgical approach to anterior cruciate ligament reconstruction.Introduction
Aim
