Antibiotic impregnated articulating spacers are used in two-stage revision total knee arthroplasty to deliver local antibiotic therapy while preserving function. We have observed infection control in greater than 95% of cases with functional outcomes approaching those seen in revision for aseptic loosening. Higher failure has been observed with methicillin resistant organisms.

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively.

There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies.

Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

Purpose

There is a postulated association between increased serum metal ions and pseudotumour formation in patients with metal-on-metal hip replacements. The primary aim of this study was to assess the prevalence of pseudotumour in 31 asymptomatic patients with a large femoral head (LFH) metal-on-metal hip implant. This was compared to the prevalence of pseudotumour in 20 matched asymptomatic patients with a hip resurfacing (HRA) and 24 matched asymptomatic patients with a standard metal-on-polyethylene (MOP) total hip. A secondary objective was to assess possible correlation between increased serum metal ions and pseudotumour formation

Purpose

Dislocation after revision total hip is a common complication. The purpose of this study was to assess whether a large femoral head (36/40mm) would result in a decreased dislocation rate compared to a standard head (32mm).

Purpose

Electrothermal arthroscopic capsulorrhaphy (ETAC) was a technology introduced for orthopaedic surgery without good scientific clinical evidence supporting its use. This multicentre randomized clinical trial provides the scientific clinical evidence comparing ETAC to Open Inferior Capsular Shift (ICS), by measuring disease-specific quality of life at 2-years post-operatively, in patients with shoulder instability due to capsular redundancy.

Purpose

This prospective, expertise-based randomized clinical trial compares arthroscopic to open shoulder stabilization by measuring the disease-specific quality of life outcome in patients with traumatic unidirectional anterior shoulder instability, and determining the incidence of recurrent instability at 2-years post-operatively.

Purpose

The outcome following isolated liner exchange for revision knee arthroplasty, while an attractive option for its simplicity, has a mixed outcome reported in the literature. We report our experience in patients who had a minimum of two years follow-up.

Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achieved in the dystrophic group. Revision fusion for nonunion was undertaken in five patients at a mean time of 17 months (7 to 31) and two required revision for fracture. There were three pneumothoraces, two rib fractures, three pleural effusions and six nonunions. The main risk factors for nonunion were smoking, age and previous shoulder girdle surgery.

STF is a salvage procedure that can provide good patient satisfaction in 82% of patients with both dystrophic and non-dystrophic pathologies, but there was a relatively high failure rate (26%) when poor outcomes were analysed. Overall function was better in patients with dystrophic conditions which correlated with better range of movement; however, patients with non-dystrophic conditions achieved greater functional improvement.

Purpose

The purpose of this study was to compare and evaluate the cost-effectiveness of the MIS Anterolateral Approach to that of the MIS Posterolateral and MIS Direct Lateral Approach.

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis.

It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

Introduction

Bearing surfaces used for total hip arthroplasty must have characteristics including bio-compatibility, low friction and low wear rate. Bearing combinations are generally characterised as Soft on Hard/Hard. In general, all newer bearing combinations have reduced wear but may present with other issues that impact on patient outcomes.

Introduction

Bone morphogenetic proteins (BMPs) are members of the TGF-beta superfamily of growth factors and are known to regulate proliferation and expression of the differentiated phenotype of chondrocytes, osteoblasts, and osteoclasts. To investigate the osteoblastic differentiation gene expressions that contribute to BMP-7 dependent ostogenesis, we performed gene expression profiling of BMP-7-treated mouse bone marrow stromal cells.

Purpose: Between 1 and 2% of knee arthroplasties are complicated by infection with its associated patient morbidity. Two stage revision remains the gold standard with the minimum interval considered acceptable between the two stages as 6 weeks, but in some cases can be considerably longer depending on the patients’ clinical response to the first stage and intravenous antibiotics. The interval between the 2 stages is to allow eradication of the causative organism, however, this can result in considerable morbidity for the patient. Patients often have a poor range of movement, instability and considerable discomfort during this time and as a result have poor mobility. Further complications can be encountered at the time of the 2nd stage with considerable scarring of the soft tissues, in part secondary to the lack of mobilisation. Traditionally, spacers which are non-articulating have been used, however, problems of instability, scarring and bone erosion have been reported in the literature. The Prostalac knee spacer constitutes an antibiotic loaded acrylic cement body with a metal on polyethylene surface and enables the patient to undergo rehabilitation in the interval between the 2 stages and may also help maintain soft tissue planes as a result. Previous published results with a mean follow up of 48 months suggest the spacer is just as successful at eradicating infection (91%) as other techniques. The aim of this study is to review 119 patients with a minimum follow up of 5 years.

Method: The Prostalac Knee spacer has 2 components, a femoral and a tibial. Each are made of antibiotic-loaded acrylic cement with a small articulation of metal on polyethylene. The spacers are made from moulds so that a component of a suitable size and thickness could be made. This was a retrospective review of 119 consecutive patients. The inclusion criteria included all patients who had undergone a 2 stage revision with the Prostalac Knee spacer who had more than 5 years of follow up. Patients were assessed using the WOMAC, SF-12, Oxford Knee Score and the Knee Society Score.

Results: Thirteen patients (10.9%) out of a total of 119 had recurrence of infection. This gives an overall rate of control of infection of 89%. Of the 46 patients who completed the outcome score questionnaires with more than 5 years follow up, the mean WOMAC score was 65.9, Oxford Knee score was 61, SF-12 (physical component) was 35.7, SF-12 (mental component) was 54.8.

Conclusion: Although the Prostalac components include polyethylene and metal, they do not seem to have a detrimental impact on the rate of control of infection since our results were similar to those previously reported with other best practice techniques. It is our impression that the Prostalac functional spacer allows earlier pain free mobilisation, allowing the potential for earlier hospital discharge. The savings obtained from earlier hospital discharge greatly outweighing the increased cost of the Prostalac functional spacer system.

Purpose: The purpose of this study was to identify if preoperative pain scores predict postoperative pain and functional outcomes in patients following rotator cuff surgery and if a threshold where increased risk occurs could be established. Establishing a risk threshold may help identify patients who need increased follow-up or rehabilitation.

Method: One hundred six subjects with rotator cuff pathology requiring operative intervention were prospectively followed. The pain subscale of the Shoulder Pain and Disability Index (SPADI) was used as an indicator of pre-operative pain. Postoperative function one year following surgery was determined using the Simple Shoulder Test (SST). Scores with 40% or more deficit (compared to age matched controls) were classified as poor outcomes. The relative risk (RR) of poor SST scores was calculated across different cutoffs for preoperative pain scores.

Results: Having a high preoperative pain score was associated with a poor outcome following rotator cuff surgery at both the six month and one year followup. Preoperative pain scores did predict postoperative functional scores. As preoperative pain levels increased there was a higher risk of poor functional outcomes. The RR of having a poor SST at 1-year was 2.3, if preoperative pain score was greater than 35/50.

Conclusion: The current study indicates that those patients with high preoperative pain scores (> 35/50 or > 70%) are more than twice as likely to have a poor outcome following rotator cuff surgery. This should inform patients and surgeons for postoperative expectations. Whether closer follow-up, pre-rehabilitation, more intensive postoperative rehabilitation or enhanced pain management can alter this prognosis warrants investigation.

Purpose: The reverse total shoulder arthroplasty (RTSA) has shown improvement in both pain control and function in recent studies. The purpose of this study was to prospectively analyze functional outcomes and strength in patients following the use of the Delta III prosthesis in a single center.

Method: Patients treated by one of two surgeons were prospectively evaluated following RTSA. An independent observer administered the Constant Score, SF-12, Shoulder Osteoarthritis (SOAQ), ASES, DASH questionnaires and patient satisfaction. Isometric strength testing was performed using the Powertrack II dynamometer. Follow-up for all patients was available up to 5 years following surgery.

Results: The Delta III RTSA was performed on 51 study patients (67% female, mean age 74 (SD=10)). Improvements following surgery were noted in Quality of life (SF-12 Physical Summary= 30 to 38); shoulder disability (SOAQ= 144 to 79; ASES 7 to 15; DASH= 61 to 46; Constant 21 to 56), Symptoms (SOAQ symptoms 40 to 22), Physical impairments as determined by strength (External rotation = 3 to 5 Nm, Abduction 4 to 10 Nm); and ROM (Flexion= 51 to 115°, abduction 45 to 106°); p< 0.05. All patients had follow up between 2–5 years. Satisfaction was high (86% extremely, 3% not at all).

Conclusion: Our data demonstrates significant improvements in quality of life, symptoms, patient satisfaction and disability with reduced and high at more than 2 years following RTSA. Novel to this study is improved objective evidence of strength in functional planes of motion. This is the first Canadian study to demonstrate such improvements in patients following RTSA.

Purpose: This prospective, randomized double-blinded clinical trial compared cemented fixation of the humeral component to uncemented/tissue-in-growth fixation in total shoulder arthroplasty for primary osteoarthritis of the shoulder.

Method: All patients presenting with primary osteoarthritis of the shoulder requiring replacement were screened for eligibility. Patients were randomized in the operating room after glenoid preparation to the cemented or uncemented group by a computer-generated, stratified randomization procedure. Outcome measures included disease specific QOL assessment (WOOS), SF-12, ASES, MACTAR, radiographic evaluation of component fixation, operative time, complications and revision surgery. Patients were assessed by a blinded evaluator in post-operative intervals of 2 and 6 weeks, and 3, 6, 12, 18, and 24 months. The primary endpoint was the WOOS score at 2 years.

Results: One hundred and sixty-one patients were consented and randomized for the study. There were 80 patients in the cemented and 81 patients in the uncemented group. At baseline, the groups were alike with regards to demographics and baseline evaluations. The WOOS scores at post-operative intervals of 12, 18 and 24 months showed a significant difference (p=0.009, 0.001, 0.028 respectively) in favour of the cemented group. The cemented group also had better strength (3 m p=0.038, 12 m p= 0.036, 18 m p=0.051, 24 m p=0.053) and forward flexion (6m p=0.031, 12 m p=0.04). As expected, the operative time was significantly less for the uncemented group (C = 2.26h +/−.63; U = 1.69h +/− 1.9, p= 0.03).

Conclusion: These findings provide the first evidence that cemented fixation of the humeral head provides better quality of life, strength and ROM than uncemented fixation. This was a Tier 1 Project of the JOINTs Canada group.

Purpose: Shoulder instability is a common problem affecting patients in their most active years resulting in an impact on their quality of life. The WOSI is a validated, disease-specific (shoulder instability) evaluative quality of life measure. It has not been tested for its ability to discriminate between those who require surgical care and those who do not. The purpose of this study is to determine if the WOSI can discriminate between surgical and non-surgical patients and between patients with different types of shoulder instability.

Method: Sixty patients with a confirmed diagnosis of shoulder instability were included as cases. Twenty had documented multidirectional instability requiring surgery: Group 1 Surgical MDI – 20 patients had documented recurrent traumatic anterior dislocations requiring surgery: Group 2 Surgical Anterior – 20 patients were first time anterior dislocators who were followed for a minimum one year who had no further recurrences and did not require surgery: Group 3 Non-Surgical First Time Anterior – The cases were compared to 60 age and gender matched control patients with no history of shoulder problems: Group 4 Control – WOSI scores were analyzed using a one-way ANOVA.

Results: The WOSI scores were as follows: Group 1 Surgical MDI- mean 30.5 (95% CI 23.1–37.8); Group 2 Surgical Anterior- mean 39.8 (95% CI 33.1–46.5); Group 3 Non-Surgical First time Anterior- mean 76.2 (95% CI 66.4–86.0) and Group 4 Control- mean 96.6 (95% CI 95.8–97.4). Based on the 95% Confidence Intervals, there were statistically significant differences between the two surgical groups (Group 1 Surgical MDI and Group 2 Surgical Anterior) compared to the non-surgical patients (Group 3 Non Surgical First Time Anterior) and the controls (P=0.000). There is a trend to discriminate between the two surgical groups (P=0.079).

Conclusion: The WOSI Index clearly discriminates between surgical and non-surgical patients with shoulder instability, and the control population with normal shoulders. There is a trend to discriminate between MDI and recurrent anterior traumatic dislocators.

The non-operative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. Non-compliance with abduction bracing has been proven to be a major risk factor for recurrence of clubfoot. The purpose of this retrospective study was to identify those patients who were non-compliant with the abduction bracing post casting and to then assess the rate and severity of recurrence.

One-hundred and fifty children (184 feet) with unilateral or bilateral clubfoot who were treated with the Ponseti method by the senior author from 1999 to 2008 were reviewed. We identified those patients who were non-compliant with the abduction bracing. Compliance was defined as three months full time wear followed by twelve months night-time/nap-time wear. Recurrence was classified as minor, defined as those requiring an extra-articular surgical procedure and major, requiring an intra-articular procedure.

We identified fifty children with seventy clubfeet who were followed up for a minimum of 12 months. None of these patients were compliant with brace wearing. Of the 70 feet, 40 (57%) required surgical intervention. There were 30 (43%) feet with no clinical recurrence. In 5 of the bilateral cases only one of the feet had required corrective surgery. In the 29 patients who required surgical intervention we identified 52 procedures (37 extra-articular and 15 intra-articular).

Compliance with the post correction abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. Despite non-compliance however there is a significant proportion of patients who do not require any surgical intervention. We recommend initiating the Ponseti technique on all patients with clubfeet rather than being selective due to anticipated compliance issues with the family.

UK military forces have been deployed in Afghanistan since 2006 as part of the International Stabilisation Assistance Force. The Operation is supported by a 50-bedded hospital. In 2007 the Defence Medical Services introduced a massive haemorrhage policy. In asymmetric warfare gunshot wounds (GSW), improvised explosive devices (IED) and mine injuries are prevalent and we hypothesized that they would require significant blood products.

We prospectively collected data from consecutive trauma resuscitations over 3 months (January to March 2008). Pre-hospital time points, mechanism of injury, injury distribution, injury severity score (ISS), new injury severity score (NISS), surgical procedures, blood product utilisation and outcome were recorded.

115 trauma resuscitations were performed over the study period. Median pre-hospital time was 95 minutes (range 30–325), with median 64 minutes to the arrival of the Medical Emergency Response Team helicopter. The cause of injury was landmine (20), IED (31) and GSW (40); mean number of involved body systems was 1.4, 1.8 and 1.5 respectively and injured structures 2.8, 3.5 and 2.3 respectively (IED> GSW p< 0.05). Mean ISS was 16, 16.8, 14.9 and NISS 18.7, 20.9, and 17.9 respectively. Blood transfusion was required in 3 mine, 14 IED and 17 GSW casualties (mine< IED & GSW, p< 0.05) with 10.6, 11.4, and 13.9 units of blood transfused per casualty.

Injury severity for casualties is high with multiple injuries to body systems irrespective of mechanism. Anti-personnel mine injuries were significantly less likely to require transfusion. Large quantities of blood products were still required when necessary in all mechanisms of trauma. It is therefore recommended that during the pre-hospital time the major transfusion protocol should be placed on stand-by.