We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.
SAM was performed in C-scan mode(gate width 50ns, depth 3500ns) and acoustical data collected along X–Y plane/depth Z. A B- mode scan acquired acoustic data along X–Z plane/ depth A. Time-of-Flight (TOF) scan used to create 3D-like images based on distance between the top of the disc and maximum penetration depth. The IDET catheters were heated according to the 900C 16.5-minute protocol. Discs were subjected to SAM using identical protocols as described. The ROIs were incised and analysed using μNMR. A custom made device was fabricated to prevent rotational effects of varying orientation of the specimen in the magnetic field.
Non-linear regression analysis of Signal Intensity Ratios of 30 different regions using SPSS showed a significant change in T1 weighting on μMRI by a median factor of 40 ( IQR + 16) for the LPL and 20(IQR + 8) for LAL regions. Significant relaxation difference (p<
0.001) caused by “magic angle”effects wer noted in LPL compared to RPL.
determine predictors of pain, function and activity level 1–2 years after revision hip arthroplasty and define quality of life outcomes after revision total hip replacement.
When considering WOMAC pain as an outcome variable, factors predictive of improving category outcome included baseline WOMAC function (p= 0.001), age between 60–70 (p<
0.004), male gender (p= 0.005), lower Charnley class (p<
0.001) and no previous revisions (p <
0.023). Baseline WOMAC pain did not predict final pain outcome. Baseline WOMAC function (p=0.001), the indication for the operation (p=0.007), and the operating surgeon were significant predictors of UCLA activity at follow up. Peri or post-operative complications were not an adverse predictor of physical function, pain or activity.
Revision of a failed acetabular reconstruction in total hip arthroplasty (THA) can be challenging when associated with significant bone loss. In cementless revision THA, achieving initial implant stability and maximising host bone contact is key to the success of reconstruction. Porous tantalum acetabular shells may represent an improvement from conventional porous coated uncemented cups in revision acetabular reconstruction associated with severe acetabular bone defects.
To evaluate the results of open reduction in unreduced posterior dislocation of the elbow, done irrespective of the time since injury or age of the patient. Ten such cases in which the dislocation had been unreduced for more than 3 weeks since injury were included. Stiffness of the elbow was the main indication for the operation. Average age of the patient was 34.3 years (range 13 years to 65 years). Average time since injury was 3.9 months (range 2 month to 6 months). 3 patients had associated fractures around the elbow joint. All the patients had non functional elbow motion to perform any activity of daily living. We used speed’s procedure in all cases. At an average follow up of 18.5 months (range from 11 to 28 months), 8 patients achieved functional range of motion for activities of daily living and maintained an average arc of flexion(median) of 100 degrees and an average supination – pronation arc of 139.5 degrees. According to the Mayo Elbow Performance Index 5 patients achieved excellent results, 3 achieved good results and 2 achieved poor results. Complications included 2 cases of pin site infection, 1 case of ulnar neuritis and 1 case of delayed wound healing. We conclude that open reduction can provide painless, stable and functional elbow even in cases which are unreduced up to 6 months after the original injury.
Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p <
0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.
The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction. We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘Graftologer’ (Neoligaments) and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK). Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer. At five years we have noted no significant difference in Lysholm scoring and Pivot shift between the LK group and patellar tendon group. But there was a significant difference in Tegner activity level and IKDC activity scores with PTG faring better at five years. There is no significance difference in anterior knee symptoms between the groups.
There exists a lot literature referring to the cementing technique of hip replacements, but when talking about longevity of knee prostheses only seldom the cementing technique is mentioned even though 90% of the knees are cemented. Especially the tibial component, that has to cope with different forces such as pressure, rotation, tilt and sliding, is said to last longer when cemented.
When cementing knee prostheses one should give high attention to the cementing technique as especially a good anchorage of the tibial component will lead to longevity of the implant.
A prospective cohort of 222 patients who underwent revision hip replacement between April 2001 and March 2004 was evaluated to determine predictors of function, pain and activity level between one and two years post-operatively, and to define quality of life outcomes using validated patient reported outcome tools. Predictive models were developed and proportional odds regression analyses were performed to identify factors that predict quality of life outcomes at one and two years post-operatively. The dependent outcome variables were the Western Ontario and McMaster Osteoarthritis Index (WOMAC) function and pain scores, and University of California Los Angeles activity scores. The independent variables included patient demographics, operative factors, and objective quality of life parameters, including pre-operative WOMAC, and the Short Form-12 mental component score. There was a significant improvement ( Predictors of quality of life outcomes after revision hip replacement were established. Although some patient-specific and surgery-specific variables were important, age, gender, Charnley class and pre-operative WOMAC function score had the most robust associations with outcome.
We report 79 cases of bone and joint tuberculosis between 1988 and 2005, eight of which were in the Caucasian population and 71 in the non-white population. The diagnosis was made in the majority (73.4%) by positive bacteriology and/or histology. The mean age at the time of diagnosis was higher in the Caucasian group at 51.5 years (28 to 66) than in the South Asian group at 36.85 years (12 to 93). Only one patient had previous BCG immunisation. The spine was the site most commonly affected (44.3%). Surgical stabilisation and/or decompression was performed in 23% of these cases because of cord compression on imaging or the presence of neurological signs. A six-month course of chemotherapy comprising of an initial two months of rifampicin, isoniazide, pyrazinamide and sometimes ethambutol followed by four months treatment with rifampicin and isoniazide, was successful in all cases without proven drug resistance.
We describe the influence of the angle of immobilisation during partial weight-bearing on the forces across the extensor mechanism of the knee. Gait analysis was performed on eight healthy male subjects with the right knee in an orthotic brace locked at 0°, 10°, 20° and 30°, with the brace unlocked and also without a brace. The ground reaction force, the angle of the knee and the net external flexion movement about the knee were measured and the extensor mechanism force was calculated. The results showed a direct non-linear relationship between the angle of knee flexion and the extensor mechanism force. When a brace was applied, the lowest forces occurred when the brace was locked at 0°. At 30° the forces approached the failure strength of some fixation devices. We recommend that for potentially unstable injuries of the extensor mechanism, when mobilising with partial weight-bearing, the knee should be flexed at no more than 10°.
In a 41-year-old man, right-sided infraspinatus muscle weakness was associated with compression of the suprascapular nerve caused by a spinoglenoid ganglion cyst. The lesion was confirmed using electromyography and MRI. In addition, arthroscopy showed an incomplete discoid labrum. The free inner edge of the labrum was removed as in a meniscectomy of a discoid meniscus in the knee joint. Arthroscopic decompression of the cyst was performed through a juxtaglenoid capsulotomy which was left open. Neurological function recovered completely.
Surgical access to the head of the radius is usually performed through a lateral approach. We present an alternative technique through a modified posterior approach which was developed following dissections of 22 human cadavers. An osteotomy of the supinator tuberosity was performed and reflected as a single unit with the attached annular ligament. Excellent exposure of the head of the radius was achieved, replacement of the head was undertaken and the osteotomy site repaired. The elbows were stable and had a full range of movement. The approach was then carried out on 13 patients for elective replacement of the head and was found to be safe and reproducible. In the patient group all osteotomies united, the elbows were stable and had an improved range of supination and pronation. There was no change in flexion and extension of the elbow. Complications included a haematoma and a reflex sympathetic dystrophy. The modified posterior approach provides excellent access to the head and neck of the radius, gives good stability of the elbow and allows early mobilisation of the joint.
Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment. We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104). All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.
We studied 16 hips (eight cadaver specimens) using arthrography, arthroscopy and anatomical dissection, under incremental traction of up to a maximum of 64 kg, to determine the relationship of the portals to nearby neurovascular structures. The distance of each arthroscopic portal (anterior, anterolateral, and posterolateral) to the associated neurovascular structures was measured after the application of 23 kg of traction. Traction of up to 64 kg on the lower limb failed to produce evidence of labral or capsular injury. Furthermore, traction of 23 kg resulted in little change in the position of adjacent neurovascular structures relative to the standard arthroscopic portals.