Purpose: The glenoid status is a crucial aspect of planning for shoulder replacements. This study revisits the classification proposed by Walch et al and discusses its value to orthopedic surgeons in terms of reproducibility and reliability.
The theoretical benefit historically attributed to rota-tionplasty lies in the provision of a functional and durable hinge joint, however these results suggest that this advantage has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology.
Our research goal was to determine the percentage of patients returning to their living situation prior to their fracture.
Our results challenge the prejudice that hip fracture patients live or end up living in a nursing home. These data can be used to calculate the amount of specific discharge locations needed in the near future.
Press-fit cups have given excellent clinico-radiographical results. This is a retrospective clinico-radiographical study about the long term performance of pure Titanium cementless modular press-fit cups (FitekTM) having, on the outer surface, an oriented multilayer titanium mesh (SulmeshTM) with 65% porosity (average pore size=400–640 micron). The cup was implanted after underreaming the acetabulum by 2 mm. In the cup’s equatorial area there are two “fins” originary designed to improve rotational stability but actually representing two excellent primary mechanical stabilizers. We have evaluated the first 100 consecutive cups implanted in 92 patients with an average FU of 9,7 years (range 9–11 years). All operations have ben performed by the two Senior Authors (PGM and RB). Regarding etiology, we had 43 Primary Arthritis, 37 Dysplastic Arthritis, 12 Osteonecrosis and 8 Post-traumatic Arthritis. results were evaluated with the Harris score. Radiographic evaluation was performed using AP and lateral x-rays pre-op. post-op and at the last follow-up. We had 86 Excellent, 10 Good, 2 Fair and 2 Poor. The 2 Poor results were 2 aseptic loosenings of the stem The Mann-Whitney nonparametric U test and the Kruskal-Wallis test showed that the survival rate of the 100 analyzed cups, after a mean follow-up of 9.7 years, was 100% (end point: revision for any cause) Etiology was not statistically correlated with post-op score. Nevertheless, dysplastic patients showed inferior results compared to arthritic patients in different parameters, as pain, limp, Range Of Motion (p <
0.05), putting socks and shoes (p <
0.05). Our cups were intentionally implanted and radiographically appear in a fairly horizontal position (36.5° on average). In 6 cases we could calculate an eccentricity of the metal heads proving bidimensional linear wear of the liner (average 0.265 mm / year). At the last follow-up we had 3 femoral osteolysis, while in the acetabular side radiolucent lines were present in 14 % of the cases, never progressive. In no case we found a change of position of the cup. FitekTM cementless cups gave excellent results at 10 years with complete stability and osteo-integration. Excellent primary mechanical stability was given by the rough surface (SulmeshTM) and by the two “fins” in the equatorial area.
Reconstruction following internal hemipelvectomy for bone tumors remains a major surgical challenge. Most of the cases are considered not suitable for reconstruction because of high complication occurrence. Allografts coupled with standard prosthesis is a reliable method of reconstruction. 26 patients received a McMinn stemmed cup (Link, Germany) after periacetabular tumor resection from February 1999 to 2006. In 18 patients the reconstruction followed resection of the acetabular area while in other 8 an extrarticular resection of the proximal femur was performed. In 21 cases a stemmed acetabular cup were associated with massive bone allograft. There were 13 female and 13 male with a mean age of 41 years (13 to 70). Average follow-up was 45 months (7 to 105). Six patients were affected by local recurrence of the tumour and five underwent hindquarter amputation. In 4 of them the index surgery followed a previous recurrence of the tumour. Finally 6 patients died for related causes within 2 years. All the other 20 have been followed clinically and radiographically for a minimum of 24 months. Deep infection occurred in one case, there were no cases of dislocation. Radiolucency at the prosthesis-bone interface was observed in 3 cases, 2 patients had proximal migration <
of 20 mm. Only one patient was treated for aseptic loosening because of incorrect initial position of the implant. The iliac osteotomy was consolidated in all cases, while a delayed union was frequently observed in the pubic osteotomy, however without compromise the stability of implant. Functional result were evaluated according to the MSTS system and this showed 65% of excellent or good clinical results. The procedure requires appropriate patient selection, accurate preoperative planning, meticulous selection and preparation of allograft. Usually artificial ligaments are applied to reduce hip instability, however, this type of reconstruction do not require complex fixation, thus reducing surgical time and early complications.
Synovial sarcoma (SS) is rare but increasingly diagnosed and associated with poor prognosis. Primary surgical resection with wide margins and adjuvant radiation-therapy is considered gold standard in treatment of primary SS. Although (Neo)adjuvant chemo- and radiationtherapy are used in the primary treatment of SS, they are not advocated outside a clinical trial setting. In patients with primary SS and pulmonary metastases, (neo)adjuvant chemotherapy is often added to the treatment protocol but it’s effect on overall survival seems limited. Between 1985 and 2004 33 patients with primary SS were treated in our clinic. Seventeen patients were diagnosed with pulmonary metastases at presentation (9) or during postoperative follow-up (8). Wide resection or focally marginal resection followed by radiotherapy was used as primary treatment for all patients. All primary metastasized patients were treated with adjuvant multi-agent chemotherapy including Isofosfamide. Average survival in this group was 32 months (5 year OS 50%), compared to 60 months in the late metastasized patient-group (2 and 5 year OS 50 and 11%). Wide resection was not related to improved overall survival when compared to marginal margins and additional radiation therapy. In the early metastasized group combined chemo-radiaton therapy provided no significant improvement in overall survival over adjuvant chemotherapy or radiation therapy alone. However additional chemotherapy in the late metastasized group was slightly associated with increased overall survival (5 year OS 0% vs 66%). Treatment of early pulmonary metastasized SS remains highly dependent of the individual preference of patient and physician. In contrast to the reported prolonged disease free/overall survival of Enneking stage IIA and IIB SS patients, aggressive surgical and chemo-radiation therapy has not yet been associated with improvement of disease free/overall survival in stage III disease. Patients presenting with late pulmonary metastasis might benefit from adjuvant multi-agent chemotherapy treatment.
Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.
Detection of local recurrence after sarcoma resection can be impaired by metal implants locally, or by the patient ‘s general condition. Metal implants cause severe distortion and scattering of either MRI or CT data acquisition. Therefore the detection of local recurrences in proximity of heavy metal implants such as prostheses or osteosynthesis material can be difficult. Patient related conditions, e.g. renal insufficiency, allergy, claustrophobia, may completely prohibit the use of contrast media or even a scan itself. Ultrasound provides several advantages, and can be used for different indications in sarcoma patients. Patient related conditions prove no obstacle for this technique. Currently our indications are local follow-up after soft-tissue sarcoma resection and evaluation of regional lymph nodes, detection of local recurrence of bone sarcoma in proximity of metal implants, and amputation stump evaluation. We describe a patient study population of 103 patients. Seventeen had only diagnostic and staging ultrasound, four had an evaluation of their amputation stump, 24 were followed after resection of a soft-tissue sarcoma, and 58 were followed by this method after sarcoma resection and implantation of metallic implants. Evaluation modalities are described according to the indications.
Little is published about the use of cementless conical stems in primary hip arthroplasty for congenital hip disease. A conical stem was designed in the 80’s by Prof. Wagner. The stem is made of a rough blasted titanium alloy with a cone angle of 5° and 8 sharp longitudinal “ribs” that cut into the inner cortex, designed to achieve rotational stability: The ribs depth of penetration ranges between 0.1 and 0.5 mm and is also very important to achieve osteo-integration. The CCD angle is 135°. The stem is straight and can be implanted in any degree of version thus being very useful for dysplastic arthritis with significant femoral neck anteversion. Between 1993 and 1998 the senior author (RB) implanted 92 conical stems in 88 consecutive patients with dysplastic arthritis. The acetabular component was cementless and titanium with tridimensional porosity. The articulating surface was a second generation Metal-on-Metal.with a femoral head of 28 mm. According to the Hartofilakidis classification 63 patients had type A, 18 type B and 11 type C. The average follow-up was 11.2 years (range 10.1–14.8) Using the Harris Hip Scoring system we had 82 (89%) satisfactory results, with excellent correction of pre-op pain (42/44 Harris) and no case of anterior thigh pain; 88% of patients had no or slight limp at follow-up. No patient required revision of the stem, but one cup required revision for loosening (Type C class). We had one dislocation (1%) that was treated conservatively Radiographically, all stems were osteo-integrated, 17% showed some resorption in femoral zone 1 and 7. In the same zones we observed 4 cases of real osteolysis without loosening. No radiolucent line was observed in other femoral zones. In the acetabular side we had 13 cases (14%) of radiolucency, but in only 1 case (1%) was it progressive. A straight conical titanium femoral stem gave very satisfactory clinico-radiographical results in dysplastic arthritis at a mean of 11.2 years of follow-up.
Multi-ligament knee injuries require complex surgery. Hinged external fixators propose to control the tibio-femoral relationship, protect reconstructions and allow early mobilisation. However, a uniaxial hinge may be too simplistic for such a complex joint. We investigated the influence of an external fixation device on ligament strains and joint contact forces. Six fresh frozen cadaveric lower limbs (41–56 years old) were obtained. Displacement transducers (Microstrain, USA) were attached to mid-substance lateral (LCL) and medial collateral (MCL) ligaments, and the anterior and posterior cruciate (PCL) ligaments through minimal soft tissue incisions. Joint pressures were measured by transducers (Tekscan) introduced in the medial and lateral compartments through small sub-meniscal arthrotomies. Flouroscopic imaging was used to construct the hinged fixator centred over the epicondylar axis. Ligament tensile strains and joint contact forces were determined through a passive arc of 20 to 110 degrees of flexion and extension, with and without the external fixator (ExFix™, EBI Biomet Australia). The application of the external fixation device resulted in minimal change in the mean peak percentage strain of the PCL, MCL and ACL ligaments, while the LCL peak percentage strain decreased. Generally the peak percentage strain for each ligament occurred at or near the same flexion angle in both the un-instrumented and instrumented case within each limb, but the peak percentage strain flexion angles varied significantly across limbs. Peak joint contact forces increased significantly (p <
0.05) in the lateral compartment after attachment of the external fixation device. There was no difference seen in the medial compartment joint contact forces. This study shows that a uniaxial hinged external fixator can be used in a multi-ligament reconstructed knee to maintain joint congruence and allow early postoperative rang of motion without compromising the results of reconstructions or repairs.
Data were prospectively collected from the tumour register and patient records. Functional scores of the affected limbs were assessed according to the Musculo-Skeletal Tumour Society scoring system.
The minimal follow up was two years, and the average follow up 50 months (range 24–119 months). At follow up three recurrences had occurred in patients treated for enchondroma. One residual tumour was diagnosed in a patient with chondrosarcoma grade Ib. All patients were treated again with curettage and cryosurgery and disease free at the latest follow-up. Of the 37 complications the most common were a fracture at the surgical site (18), fracture of osteosynthesis (6), 3 wound infection (3), delayed soft tissue healing (3), and transient nerve palsy (3). Functional MSTS scores increased in time to an average of 28 points (94%) at two year follow up. No significant difference in scores were found regarding to localisation of the lesion, age or gender. A significant discrepancy in functional scores was observed between patients who did suffer from one or more complications and patients who did not.
Long-term clinical study to explore the curative effect and mechanism of the treatment of adult chronic osteomyelitis by implant Osteoset T. The study object were 65 case adult chronic osteomyelitis patient from November 1977 to April 2003 in a University-based hospital. Age ranged from 18 to 69 years old. 40 cases were treated by general debridement (Method I); 25 cases were treated by general debridement and implant Osteoset T in dead space (Methods II). Stage IA(The UTMB Staging System) osteomyelitis 39 cases; The Organism was Staphylococcus Aureus 28 cases. In all cases (group A), 40 cases were treated with Method I (group AI), 25 cases were treated with Method II (group AII). The majority of the patients, 39 resulted as Stage IA (group B); 22 were treated with Method I (group BI) and 17 cases were treated with Method II (groupBII). Finally, 28 patients were chronic Staph Aureus osteomyelitis (Group C); 13 were treated with Method I (group CI) and 15 cases with Method II (group CII); Followed from 36 to 334 months, mean 75.0 months. Then respectively evaluate and analysis analyze the success rate of different method with standard. The success rate of group BI was 59.09%, group BII was 94.12%, contrast the success rate there was significant difference (p<
0.05). The success rate of group AI was 60.00%, group AII was 80.00%. The success rate of group CI was 46.15%, group CII was 80.00%. The use of Osteoset T has demostrated better healing rate than left the empty cavity there after debridement and irrigation. Osteoset T can local delivery antibiotic, filler of the dead space, It can be mixed with different antibiotics, reduces the hospitalization time, reduces the number of operation. Unfortunately, Osteoset dos not help with the bone growth.
The widely used classification systems (King and Lenke) are useful for documentation of the deformities. Unfortunately explicit guidelines for surgery are not clear. A multi-centre database with pre and postoperative patient data including photographic images and x-rays will be very useful in decision making. It will allow surgeons to find similar cases in the database that will help them in their decision making for surgical planning and execution. Furthermore it will provide extensive data to perform outcome studies, and to develop general treatment guidelines. Surgery for spinal deformities will become more evidence based and less dependent on the individual surgeons judgement.
The patient data can also be stored and printed as a PDF-file, so that it can be used as a patient chart and for patient information purposes. Scolisoft allows the user to select patients based on all the individual characteristics, e.g. curve classification. For pre-operative planning of a specific deformity, a cohort of patients with the same deformity (patient demographics, curve pattern, bending films etc) can be selected and the postoperative results viewed. With the same selection tool, cohorts of patients can be selected for outcome studies. Furthermore Scolisoft provides the possibility of discussing difficult cases with other spine surgeons using the system. Finally, complications are registered according to the existing Scoliosis Research Society complication registry system.
The system already has the possibility for documenting other spine pathology such as sagittal plane deformities, fractures and spondylolisthesis.
Hydroxylapatite (HA) is widely employed as coating of cementless hip stems. Nevertheless there is a deficiency of long-term follow-up studies, and none, to our knowledge, with a ceramic on ceramic coupling, that it is important to avoid the effect of polyethylene wear on stem survival. Between June 1990 and December 1991, 151 prostheses with an anatomic fully HA-coated cobalt-chrome stem, alumina bearing surfaces, and a threaded Ti-6Al-4V cup, were implanted in 147 consecutive patients (57 males, 90 females, average age 58 years). All were primary surgeries, there were no specific exclusions. Ten died for unrelated causes to the surgery, one died from postoperative complications; thirty nine of the surviving patients were lost to follow-up. The Merle D’Aubigné and Postel score was recorded before and after surgery at each review. An anteroposterior view and a frog-lateral view of the involved hip were taken at each follow-up review. The results were analysed by the Kaplan-Meier method to estimate the cumulative probability of revision. In two cases, the prosthesis was completely removed with Gilderstone’s procedure because of septic loosening. Among the others, 10 cups required revision surgery for aseptic loosening, and 6 stems were revised for thigh pain. The mean Merle D’Aubigné rating improved from 10 before operation to 16.4. Bone stability was recorded in all cases but three in which there was a painfree fibrous stability. The Kaplan-Meier analysis at 12 years predicted asurvival rate for the prosthesis of 86% (95% CI 79 to 92), and for the stem of 93.8% (95% CI 89.7 to 98). At 12 years the HA-coated stem has shown an overall good outcome while the threaded non HA-coated cup employed had a bad survival that had influenced the survival of the prosthesis. In conclusion we are confident to consider HA a viable and effective coating.