One method of femoral head preservation following avascular necrosis
(AVN) is core decompression and insertion of a tantalum rod. However,
there may be a high failure rate associated with this procedure.
The purpose of this study was to document the clinical and radiological
outcomes following total hip arthroplasty (THA) subsequent to failed
tantalum rod insertion. A total of 37 failed tantalum rods requiring total hip arthroplasty
were identified from a prospective database. There were 21 hips
in 21 patients (12 men and nine women, mean age 37 years, 18 to
53) meeting minimum two year clinical and radiographic follow-up
whose THAs were carried out between November 2002 and April 2013
(mean time between tantalum rod implantation and conversion to a
THA was 26 months, 6 to 72). These were matched by age and gender
to individuals (12 men, nine women, mean age 40 years, 18 to 58)
receiving THA for AVN without prior tantalum rod insertion.Aims
Patients and Methods
Latissimus dorsi tendon transfer (LDTT) is technically
challenging. In order to clarify the local structural anatomy, we undertook
a morphometric study using six complete cadavers (12 shoulders).
Measurements were made from the tendon to the nearby neurovascular
structures with the arm in two positions: flexed and internally
rotated, and adducted in neutral rotation. The tendon was then transferred
and measurements were taken from the edge of the tendon to a reference
point on the humeral head in order to assess the effect of a novel
two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances
between the superior tendon edge and the radial nerve, brachial
artery, axillary nerve and posterior circumflex artery were 30 mm
(26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to
21), respectively. The mean distance between the inferior tendon
edge and the radial nerve, brachial artery and profunda brachii
artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively.
Moving the arm to a neutral position reduced these distances. A
mean of 15 mm (8 to 21) was gained from a standard soft-tissue release,
and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of
this region and the potential for transfer of the latissimus dorsi
tendon. Cite this article:
The recent emergence of autologous blood concentrates, such as platelet rich plasma (PRP), as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. Our objective was to determine the effectiveness of autologous blood concentrates compared with control therapy in improving pain in patients with orthopaedic bone and soft tissue injuries. We conducted a systematic review of MEDLINE and EMBASE from 1996 and 1947, respectively, up to July 2010. Additional studies were identified by contacting experts, searching the bibliographies of the included studies as well as orthopaedic meeting archives. We included published and unpublished randomized controlled trials or prospective cohort studies that compared autologous blood concentrates with a control therapy in patients with an orthopaedic injury. Two reviewers, working in duplicate, abstracted data on study characteristics and protocol. Reviewers resolved disagreement by consensus.Purpose
Method
Computer navigation for hip resurfacing has been shown to reduce the incidence of technical error during femoral head preparation and provides increased accuracy compared to conventional instrumentation for insertion of the initial femoral guidewire. Limitations to the widespread use of navigation in hip resurfacing include access and cost. A novel, patient specific nylon jig has been developed as a cost effective alternative for placement of the initial guidewire. The purpose of this study was to compare the accuracy of femoral guidewire insertion between imageless navigation, conventional instrumentation and a new type of CT-based custom jig. Six pairs of cadaveric femora were used in the study. Each pair was divided randomly between a group utilizing firstly a conventional lateral pin jig (BHR, Smith & Nephew Inc.) followed by navigation (Vector Vision SR, BrainLAB) and a group utilizing a CT-based, patient specific custom jig (Visionaire, Smith & Nephew Inc.). A single surgeon inserted all guidewires. The planned guidewire position was approximately 10 degrees of relative valgus to the native neck-shaft angle in the coronal plane and neutral version in the sagittal plane. The same coronal alignment angle was used between paired femora. Femurs were positioned in a draped synthetic foam hip model prepared with a standard posterior approach. Guidewire insertion time and placement accuracy for each of the three alignment methods was assessed. Guidewire placement accuracy for coronal inclination and version was assessed by anteroposterior and lateral digital radiographs and was defined as the mean deviation from the planned alignment value.Purpose
Method
There is no clear definition of a critical sized defect of the tibia. We defined it as a fracture gap at least one centimeter in length and involving over 50% of the cortical diameter. We explored if the presence of a critical-sized defect predicted reoperation, and which other factors predict reoperation in patients with the critical defect. The patient based outcomes of these patients were compared to patients without a critical defect. Patients enrolled in the SPRINT trial with a critical sized defect were evaluated for secondary interventions to gain union. Other factors predicting the need for reoperation were studied. We also compared the patients with critical sized defects to the larger cohort of patients without a defect with respect to demographics, injury mechanism, fracture characteristics, and patient-based outcome.Purpose
Method
Our hypothesis was that closed tibia fractures treated with intramedullary nails are impacted by surgeon and center volumes. Data from 813 patients with closed tibia fractures were obtained from the SPRINT study. Using multiple regression, we examined the effect of center and surgeon volume (categorized as high, moderate, or low), and geographic differences by country (Canada, USA, and the Netherlands) on health-related quality-of-life and revision surgeries to gain union at one year. Our measures of quality-of-life were the Short-Form 36 Health Survey Questionnaire (SF-36 PCS) and the Short Musculoskeletal Function Assessment (SMFA).Purpose
Method
Cross-linking of polyethylene greatly reduces its wear rate in hip simulator studies. We conducted a systematic review and meta-analysis of randomized controlled trials comparing cross-linked to conventional polyethylene liners for total hip arthroplasty to determine if there is a clinical reduction of: 1) wear rates, 2) radiographic osteolysis, and 3) need for total hip revision. A systematic search of MEDLINE, EMBASE, and COCHRANE databases was conducted from inception to May 2010 for all trials involving the use of cross-linked polyethylene for total hip arthroplasty. Eligibility for inclusion in the review was: use of a random allocation of treatments; a treatment arm receiving cross-linked polyethylene and a treatment arm receiving conventional polyethylene for total hip arthroplasty; and use of radiographic wear as an outcome measure. Eligible studies were obtained and read in full by two co-authors who then independently applied the Checklist to Evaluate a Report of a Nonpharmacological Trial to each study. Pooled mean differences were calculated for the following continuous outcomes: bedding-in, linear wear rate, three dimensional linear wear rate, volumetric wear rate, and total linear wear. Pooled risk ratios were calculated for radiographic osteolysis and revision hip arthroplasty.Purpose
Method
To review prospectively collected data on patients undergoing primary total hip arthroplasty utilizing two different cementless acetabular components. All patients undergoing primary total hip replacement surgery at our institution are entered prospectively into a database which includes history and physical examination, radiology, WOMAC and SF-36 scores. The patients are re-examined, re-x-rayed and re-scored at 3 months, 6 months and 1 year after surgery and yearly thereafter. Using this database we are able to identify patients who have undergone total hip replacement using one of two geometric variants of the acetabular component. The first design is hemispherical and the second design has a peripheral rim expansion designed to increase initial press-fit stability.Purpose
Method
The purpose of the study was to determine the rate of conversion from RSA to THR in a number of Canadian centers performing resurfacings Retrospective review was undertaken in 12 Canadian Centers to determine the rate of revision and reason for conversion from RSA to THR. Averages and cross-tabulation with Chi-Squared analysis was performed. kaplan Meier survivorship was calculated.Purpose
Method
There is increasing evidence that primary fixation of displaced mid-shaft fractures of the clavicle results in superior short-term outcomes when compared to traditional non-operative methods. However, the results from published studies are limited to relatively short-term (one year or less) follow-up. Accurate data of longer follow-up is important for a number of reasons, including patient prognostication, counseling and care, the design of future trials, and the economic analysis of treatment. The purpose of this paper was to examine the results of the two year follow up of patients enrolled in a previously published randomized clinical trial of operative versus non-operative treatment of displaced fractures of the clavicle. Using a comprehensive and standard assessment that included DASH (Disabilities of the Arm, Shoulder and Hand) and CSS (Constant Shoulder Scores) scores, we evaluated ninety-five patients of the original cohort of one hundred and thirty-two patients at two years following their injury.Purpose
Method
Femoroacetabular impingement (FAI) may contribute to the development of early onset hip osteoarthritis (OA). A cam lesion (or pistol grip deformity) of the proximal femur reduces head-neck offset resulting in cam type FAI. The alpha angle is a radiographic measurement recommended for diagnosis of cam type FAI. The purpose of this study was to determine if patients that develop end stage hip OA prior to 55 years of age have radiographic evidence of cam type FAI. The anteroposterior (AP) pelvis and lateral hip radiographs of 244 patients (261 hips) who presented to our institution for hip arthroplasty or hip fracture fixation between 2006 and 2008 were retrospectively reviewed. Three cohorts were compared: 1) patients with end stage hip OA < 55 years old (N=76); 2) patients with end stage hip OA > 55 years old (N=84); 3) hip fracture patients > 65 years old without radiographic evidence of hip arthritis were used as controls (N=101). Patients with inflammatory arthritis, avascular necrosis and post-traumatic hip OA were excluded. Alpha angles were measured on the AP pelvis and lateral radiographs by three coauthors using ImageJ 1.43 software (National Institutes of Health, USA). For patients with end stage hip OA, AP alpha angles were measured on both the hip with OA and the contralateral hip. Lateral alpha angles were measured only on the hip with OA. For patients with hip fracture, AP alpha angles were measured on the non-fractured hip and lateral alpha angles were measured on the fractured hip. A one-way ANOVA with post hoc Tukeys HSD test was used to compare the AP and lateral alpha angles for the three cohorts.Purpose
Method
Angiogenesis and osteogenesis are essential for bone growth, fracture repair, and bone remodeling. VEGF has an important role in bone repair by promoting angiogenesis and osteogenesis. In our previous study, endothelial progenitor cells (EPCs) promoted bone healing in a rat segmental bone defect as confirmed by radiological, histological and microCT evaluations (Atesok, Li, Schemitsch 2010); EPC treatment of fractures resulted in a significantly higher strength by biomechanical examination (Li, Schemitsch 2010). In addition, cell-based VEGF gene transfer has been effective in the treatment of segmental bone defects in a rabbit model (Li, Schemitsch et al 2009); Purpose of this study: Evaluation of VEGF gene expression after EPC local therapy for a rat segmental bone defect. Rat bone marrow-derived EPCs were isolated from the rat bone marrow by the Ficoll-paque gradient centrifuge technique. The EPCs were cultured for 7 to 10 days in endothelial cell growth medium with supplements (EGM-2-MV-SingleQuots, Clonetics). and collected for treatment of the rat segmental bone defect. EPCs were identified by immunocytochemistry staining with primary antibodies for CD34, CD133, FLK-1, and vWF. A total of fifty six rats were studied. A five millimeter segmental bone defect was created in the middle 1/3 of each femur followed by mini plate fixation. The treatment group received 1×106 EPCs locally at the bone defect and control animals received saline only. Seven control and seven EPC treated rats were included in each group at 1, 2, 3 and 10 weeks. Animals were sacrificed at the end of the treatment period, and specimens from the fracture gap area were collected and immediately frozen. Rat VEGF mRNA was measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and quantified by VisionWorksLS. All measurements were performed in triplicate.Purpose
Method
Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study.Purpose
Method
Femoral shaft fractures are routinely treated using antegrade intramedullary nailing under fluoroscopic guidance. Malreduction is common and can be due to multiple factors. Correct entry point identification can help minimize malreduction and the risk of iatrogenic fracture. This study aims to compare landmark identification used to guide nail entry, the piriformis fossa (PF) and the trochanteric tip (T), via computer navigation and conventional fluoroscopy. The location of the PF and T were digitized under direct visualization with a three-dimensional scribe on ten, fresh-frozen cadaveric right femora (two male, eight female) by three fellowship trained orthopaedic surgeons. To estimate inter- and intraobserver reliability of the direct measurements, an intraclass correlation coefficient was calculated with a minimum of two weeks between measurements. Under navigation, each specimen was draped and antero-posterior (AP) and lateral radiographs of the proximal femur were taken with a c-arm and image intensifier. The c-arm was positioned in a neutral position (0 for AP, 90 for lateral) and rotated in 5 increments, yielding a range of acceptable images. Images, in increments of 5, within the AP range (with a neutral lateral) were loaded into a navigation system (Stryker, MI). A single surgeon digitized the T and PF directly based on conventional fluoroscopy, and again directed by navigation, yielding two measurements per entry point per specimen. This was repeated for the lateral range. Hierarchical linear modelling and a Wilcox rank test were used to determine differences in accuracy and precision, respectively, in the identification of PF and T using computer navigation vs. conventional fluoroscopy.Purpose
Method
The SPRINT trial randomized 1226 patients with tibial shaft fractures treated by intramedullary (IM) nailing to reamed versus unreamed groups. Using data from this trial, we completed a subgroup analysis of those patients who required two or more reoperations following the initial IM fracture stabilization. We identified 44 patients with tibial shaft fractures who required two or more reoperations following IM nailing. We considered those that were reamed vs unreamed, open vs closed, those that were planned for reoperation after the 12 month follow up, and the indications for reoperation.Purpose
Method
This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces at a minimum of five years. One hundred and two primary total hip replacements were performed in ninety one patients between February 2003 and March 2005. All patients were younger than 65 (mean 52.7, 19–64). They were randomised to receive one of the three bearing surfaces. All patients had 28mm articulations with a Reflection uncemented acetabular component and a Synergy stem (Smith & Nephew, Memphis, Tennessee). Patients were followed up periodically up to at least sixty months following surgery. Outcome measures included WOMAC and SF12 scores. Radiological assessment included implant position, evidence of osteolysis and measurement of linear wear.Purpose
Method
The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with compromised femoral head anatomy. It is unclear, however, if an uncemented, metaphyseal fixed stem confers a mechanical advantage to that of a traditional hip resurfacing in which the femoral prosthesis is cemented to the prepared femoral head. Thus, we aimed to determine if a metaphyseal fixed, bone preserving femoral component provided superior mechanical strength in resisting neck fracture compared to a conventional hip resurfacing arthroplasty. Sixteen matched pairs of human cadaveric femurs were divided evenly between specimens receiving a traditional epiphyseal fixed hip resurfacing arthroplasty (BHR) and those receiving a metaphyseal fixed BMHR. Pre-preparation scaled digital radiographs were taken of all specimens to determine anatomical parameters as well as planned stem-shaft angles and implant sizes. A minimum of 10 degrees of relative valgus alignment was planned for all implants and the planned stem-shaft angles and implant sizes were equal between femur pairs. Prior to preparation, bone mineral density scans of the femurs were obtained. Prepared specimens were potted, positioned in single-leg stance and tested to failure using a mechanical testing machine. Load-displacement curves were used to calculate construct stiffness, failure energy and ultimate failure load.Purpose
Method
The ideal bearing surface for young patients
undergoing total hip replacement (THR) remains controversial. We report
the five-year results of a randomised controlled trial comparing
the clinical and radiological outcomes of 102 THRs in 91 patients
who were <
65 years of age. These patients were randomised to
receive a cobalt–chrome on ultra-high-molecular-weight polyethylene,
cobalt–chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic
bearing. In all, 97 hip replacements in 87 patients were available
for review at five years. Two hips had been revised, one for infection
and one for peri-prosthetic fracture. At the final follow-up there were no significant differences
between the groups for the mean Western Ontario and McMaster Universities
osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness,
p = 0.99), Short Form-12 (physical component, p = 0.878; mental
component, p = 0.818) or Harris hip scores (p = 0.22). Radiological
outcomes revealed no significant wear in the ceramic group. Comparison of standard and highly cross-linked polyethylene,
however, revealed an almost threefold difference in the mean annual
linear wear rates (0.151 mm/year
