6.0% of the THRs performed in Canada in 2002–2003 were for NOFs. 2.9% of THRs performed in Australia since 1999 were for NOFs. 1.9% of the THRs performed in the UK in the period April – December 2003 were for NOFs. The registries from Finland and New Zealand had no detailed information on their websites regarding the indications for THA surgery.
Arthroscopic procedures may be associated with considerable pain in the first 24 hours. Intra-articular bupi-vacaine provides good analgesia but is short lasting. Intra-articular morphine has been shown to prolong postoperative analgesia in knee and ankle arthroscopy. The aim of this study is to assess the safety and analgesic effect of intra-articular morphine following day case wrist arthroscopy. Ethical approval was firstly obtained. 31 patients were randomly assigned to one of 2 groups in a double blind clinical study. Group 1 received 5ml of 0.5% bupi-vacaine intra-articularly with 5mg of morphine subcutaneously. Group 2 received 5ml of 0.5% bupivacaine and 5mg of morphine intra-articularly. There were 15 patients (mean age 41.2 years) in group 1, and 16 patients (mean age 38.9 years) in group 2. Postoperatively pain was assessed using a 100mm visual analogue pain scale (VAPS) at 1, 2, 6 and 24 hours. Analgesia requirements were recorded at these times post operatively. The presence of nausea, vomiting, other complications and patient satisfaction were recorded. Visual analogue pain scores did not show any significant difference between the groups at 1, 2, 6 and 24 hours. Supplementary analgesic consumption over the 24 hour period was slightly greater in group 1 than in group 2. None of the patients who had intra-articular Morphine had vomiting nor any other complications and did not require anti-emetics. Most patients in either group were satisfied with the level of postoperative analgesia. Intra-articular bupivacaine with or with out morphine provides adequate postoperative pain relief following wrist arthroscopy. There seems to be little difference between the two methods studied.
Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction. Computed tomography is an accepted method for evaluating this and attempts to quantify hip reduction, by various angular and linear measurements, have been reported. The aim of this study was to assess initial CT scans, following open reduction in the older child with DDH, with comparison of outcome to evaluate prognostic value.
In conclusion, despite the significant differences noted between DDH and normal hips they did not predict acetabular development or persistent acetabular dysplasia.
Early migration of the new stem design was determined by Roentgen Stereophotogrammetric Analysis (RSA). Rapid early migration of a component relative to the bone, measured by RSA, is predictive of subsequent aseptic loosening for a number of femoral stems. As there was rapid early migration and rotation of the Charnley Elite stem, we predicted that the long-term results would be poor. An outcome assessment is required as stems of this type are still being implanted.
Preliminary clinical scores in the patients who had not undergone any subsequent surgery were adequate (Oxford Hip Score mean average of 23.9). Thirteen percent of radiographs analysed had evidence of loosening, giving an overall loosening rate of 14% at 8 years.
We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation.
Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used. Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon. Each surgeon graded 176 MRI images twice. The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5
The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%. It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time.
We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure. Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.
We performed a clinical and radiological study to determine the rate of failure of the Charnley Elite-Plus femoral component. Our aim was to confirm or refute the predictions of a previous roentgen stereophotogrammetric analysis study in which 20% of the Charnley Elite-Plus stems had shown rapid posterior head migration. It was predicted that this device would have a high early rate of failure. We examined 118 patients at a mean of nine years after hip replacement, including the 19 patients from the original roentgen stereophotogrammetric study. The number of revision procedures was recorded and clinical and radiological examinations were performed. The rate of survival of the femoral stems at ten years was 83% when revision alone was considered to be a failure. It decreased to 59% when a radiologically loose stem was also considered to be a failure. All the patients previously shown in the roentgen stereophotogrammetric study to have high posterior head migration went on to failure. There was a highly significant difference (p = 0.002) in posterior head migration measured at two years after operation between failed and non-failed femoral stems, but there was no significant difference in subsidence between these two groups. Our study has shown that the Charnley Elite-Plus femoral component has an unacceptably high rate of failure. It confirms that early evaluation of new components is important and that roentgen stereophotogrammetric is a good tool for this. Our findings have also shown that rapid posterior head migration is predictive of premature loosening and a better predictor than subsidence.
In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna. There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.
Surgical treatment of complex deformities necessitates a detailed appreciation of the complex three dimensional abnormal anatomies involved. Preoperative planning for these complex cases traditionally involves x-ray and computerised tomography (CT). These modalities offer only two-dimensional images to represent three-dimensional anatomy. Advances in digital imaging have allowed three-dimensional reconstructions to be derived from CT images. These greatly improve understanding of complex deformities, but will never be able to replace the intuitive understanding that is gained by handling a physical model. The Rapid Prototyping technique Selective Laser Sintering (SLS) is used in the industrial setting to manufacture prototype models from Computer Aided Designs (CAD). This technology can be utilised to convert CT images into accurate three-dimensional physical models of the human bony anatomy. We present the use of SLS modelling to aid in the preoperative planning of complex reconstructive surgery in children. Cases include bladder exstrophy, developmental dysplasia of the hip and reconstruction of a complex elbow malunion. The models provide invaluable visual and tactile information to the operating surgeon, accurately demonstrating the abnormal anatomy in an easily comprehensible manner. They allow estimation of the magnitude and degree of corrections necessary and evaluation of bony deficiencies.
Adherence with follow up including footwear review minimises risk. Re-ulceration at 5 years is associated with risk of amputation. Ten-year mortality is high due to vascular complications.
We report a case of fatal haemorrhage following a low-energy fracture of the pubic ramus in an 85-year-old woman.
This study presents the 2 year migration results of the BHR femoral component using Roentgen Stereophoto-grammteric Analysis (RSA).
Accurate and relevant patient chart notes are a key component in successful patient care. Hospital charts also constitute an important medicolegal record. The key to defensibility of at least 40% of medical claims rests with the quality of the medical records. With this in mind, we decided to assess the quality of chart note keeping in our unit. A retrospective review of fifty randomly chosen charts was performed. A scoring system was devised to audit ten key criteria comprising patient details, admission note, daily progress notes, signature clarity, consent form, operation note, post-operative plan, post-operative x-ray review, specification of right or left side and discharge letter. Members of the orthopaedic surgical staff were then informed of the chart review and the nature and purpose of the study was explained in detail. They were also told that there would be another chart audit at some random time over the following three months. Subsequently, a further fifty charts were assessed using the same criteria and scoring system. Overall, charts scored poorly in the areas of patient details, clarity of signatures, post-operative x-ray review and left-right specification. Criteria that scored satisfactorily included admission note, consent form, operation note, post-operative plan an discharge letter. Meticulous hospital notes are vitally important in the day-to-day management of patients for successful continuity of care and also for protection of the medical staff should any adverse outcomes arise. In this litigious society consultants and junior medical staff need to be reminded of the importance of optimal note keeping.
We have investigated the role of the penetration of saline on the shear strength of the cement-stem interface for stems inserted at room temperature and those preheated to 37°C using a variety of commercial bone cements. Immersion in saline for two weeks at 37°C reduced interfacial strength by 56% to 88% after insertion at room temperature and by 28% to 49% after preheating of the stem. The reduction in porosity as a result of preheating ranged from 71% to 100%. Increased porosity correlated with a reduction in shear strength after immersion in saline (r = 0.839, p <
0.01) indicating that interfacial porosity may act as a fluid conduit.
Polished, tapered stems are now widely used for cemented total hip replacement and many such designs have been introduced. However, a change in stem geometry may have a profound influence on stability. Stems with a wide, rectangular proximal section may be more stable than those which are narrower proximally. We examined the influence of proximal geometry on stability by comparing the two-year migration of the Exeter stem with a more recent design, the CPS-Plus, which has a wider shoulder and a more rectangular cross-section. The hypothesis was that these design features would increase rotational stability. Both stems subsided approximately 1 mm relative to the femur during the first two years after implantation. The Exeter stem was found to rotate into valgus (mean 0.2°,
In this cross-over study, we evaluated two types of knee brace commonly used in the conservative treatment of osteoarthritis of the medial compartment. Twelve patients confirmed radiologically as having unilateral osteoarthritis of the medial compartment (Larsen grade 2 to grade 4) were studied. Treatment with a simple hinged brace was compared with that using a valgus corrective brace. Knee kinematics, ground reaction forces, pain and function were assessed during walking and the Hospital for Special Surgery scores were also determined. Significant improvements in pain, function, and loading and propulsive forces were seen with the valgus brace. Treatment with a simple brace showed only significant improvements in loading forces. Our findings suggest that although both braces improved confidence and function during gait, the valgus brace showed greater benefit.
Clinical experience of impaction bone grafting for revision knee arthroplasty is limited, with initial stability of the tibial tray emerging as a major concern. The length of the stem and its diameter have been altered to improve stability. Our aim was to investigate the effect of the type of stem, support of the rim and graft impaction on early stability of the tray. We developed a system for impaction grafting of trays which we used with morsellised bone in artificial tibiae. Trays with short, long thick or long thin stems were implanted, with or without support of the rim. They were cyclically loaded while measuring relative movement. Long-stemmed trays migrated 4.5 times less than short-stemmed trays, regardless of diameter. Those with support migrated 2.8 times less than those without. The migration of short-stemmed trays correlated inversely with the density of the impacted groups. That of impaction-grafted tibial trays was in the range reported for uncemented primary trays. Movements of short-stemmed trays without cortical support were largest and sensitive to the degree of compaction of the graft. If support of the rim was sufficient or a long stem was used, impacted morsellised bone graft achieved adequate initial stability.
The patient fell whilst mobilising indoors at home during the fifth post operative week and sustained rapid hyperflexion injures to both knees. Ultrasound scans of the knees demonstrated bilateral discontinuities of the quadriceps mechanisms and a large fluid collection filling the defect. The patient returned to the operating where a direct repair was achieved. Post operatively the patient was rested in bilateral cylinder casts until the sutures were removed at two weeks. For two week periods the knees were then mobilised in a hinged cast brace allowing 0–30, 0–60 and 0–90 degrees making the total time in cast 8 weeks At the time of removal of the casts the patient had 110 degrees of flexion in the right leg and 85 degrees of flexion in the left. At six months postoperatively the patient flexes freely to over 100 degrees
Diabetes mellitus is considered an indicator of poor prognosis for acute ankle fractures, but this risk may be specific to an identifiable subpopulation. We retrospectively reviewed 42 patients with both diabetes mellitus and an acute, closed, rotational ankle fracture. Patients were individually matched to controls by age, gender, fracture type, and surgical
Pain drawings are quick and easy for patients to complete. Our study demonstrates pain drawings can reliably be used to predict outcome following intradiscal electrothermal therapy.
On reviewing the patients’ histories further: One patient had reported a broken tooth reported at the time of surgery and been given reassurancethat it was safe to proceed. One patient had an overt dental abscess ongoing for 15 years and one patient had an occult dental abscess revealed on radiology. Two other patients had extensive dental caries with blackened stumps as teeth. Follow-up after antibiotic treatment and revision arthroplasty is limited in these cases but results appear satisfactory at up to five years.
We report early major complications encountered following TEN fixation of femoral fractures in children. A case series of four children aged 8– 16 years who had primary TEN fixation of isolated femoral diaphyseal fractures. Three of the four patients had major complications. These were: significant knee stiffness requiring manipulation, haemarthrosis requiring washout and nail removal, loss of position and refracture. Two required revision to locked intramedullary nails without early complication. In the skeletally immature child TEN fixation of femoral fractures has a significant major complication rate. This needs to be recognised when comparing TEN fixation with other treatment options.
The median time between the first and second stage was 147 (range 50–619) days. Fractures of the Biomet antibiotic loaded acrylic spacer occurred in 11% revisions when associated with an increase in time between stages and there was a 7% dislocation rate. Patients did not receive a revision prosthesis in 19% cases and had early recurrent sepsis following their two stage procedure in 6%. Three patients had a single episode of dislocation of their revision hip prosthesis within a month postoperatively. Two patients had a proximal DVT and one patient had a pulmonary embolus. The mortality within eight weeks was 7%, rising to 10% within a year. This may be related to patient sepsis and comorbidities or the energy expenditure required to mobilise following a first stage procedure that we have analysed.
The Biomet antibiotic loaded cement system articulates and maintains soft tissue length in the majority of patients for the duration required between stages.
We report intermediate term results of a technique of acetabular augmentation using block femoral head autograft and the uncemented expansion cup for adult hip dysplasia. A retrospective review of one surgeon (BFH) series of consecutive total hip replacements for hip dysplasia using femoral head acetabular augmentation was carried out. The technique involves sectioning the femoral head longitudinally reversing and fixing it to the deficient acetabulum with 6.5mm AO screws. This is then reamed to accept the uncemented expansion cup. Patients were identified from audit databases. Patients completed clinical questionnaires, examination and radiographic evaluation. Fifteen hips were identified in twelve patients (three bilateral). The average at age at surgery was 54 (44–58) years. There were eight females (eleven hips). Three patients (three hips) were unable to be contacted. Average follow up was 8.4 (4.8–11.4) years. Preoperative centre edge angle was 14 (−10–30) degrees. One patient developed a deep infection requiring early staged revision. One patient was not satisfied with her results at follow up. Mean Harris Hip Score was 83 (63–100), mean WOMAC Score was 76 (50–95). Range of motion was well maintained in all patients. Four patients had other co-morbidities affecting their results. Radiological review shows all grafts to have united with no screw breakage and no cup loosening. At eight year follow up there is high satisfaction, good clinical and radiological results. These results demonstrate good intermediate term results using this technique in total hip replacement with acetabular dysplasia.
The aim of this study was to determine the outcome of carpal tunnel decompression in elderly patients and whether this can be predicted by the severity of pre-operative nerve conduction studies. A retrospective study was undertaken of all patients over 70 years who had carpal tunnel release (CTR) at Dunedin Hospital between April 1999 and April 2002 with a minimum one year follow up. A grading system for pre-operative nerve conduction studies (NCS) was formulated which scored patients from 1 to 6 according to severity. Patients were followed up by postal questionnaire (Boston Carpal Tunnel Score) with telephone follow up of non-responders. There were 105 CTR procedures performed in 96 patients. Median pre-operative NCS Score was 4 with 47% scoring 5 or 6. 4 Patients had died. Post-operative symptom severity scores were low and the majority of patients were very satisfied with the results of surgery. Despite nerve conduction studies consistent with severe median nerve compression, patients had low postoperative symptom severity scores and overall were very satisfied. Carpal tunnel release in patients over 70 years of age is justified and associated with good outcome.
We compared initial fixation strength of two commonly used tibial side hamstring ACL reconstruction fixation implants – the RCI interference screw and the Intrafix device. Using a sheep model 36 hamstring grafts were prepared and implanted into the distal femoral metaphyseal bone using either a RCI screw or an Intrafix device. They were then pulled out until failure using an Instron Materials Testing Machine. Maximum strength of graft fixation and mode of failure were recorded. The average strength of the graft was 48kg using the RCI screw and 90 kg using the Intrafix device. This difference was statistically significant. The maximum pull-out strength was 91kg for the RCI screw and 130 kg for the Intrafix device. The most common mode of failure in the RCI screw fixation was graft shredding on the screw and whole graft pullout whereas in the Intrafix device it was intratendinous failure. The Intrafix device demonstrated a clear strength advantage over the RCI screw with regard to initial fixation strength. The Intrafix device may reduce tibial side graft creep which is a problem with hamstring ACL reconstruction.
The aim of this surgery was to determine current practice amongst orthopaedic surgeons in New Zealand with regard to Anterior Cruciate Ligament Reconstruction. All current members of the NZOA were sent a questionnaire on the numbers and proportions of grafts performed, methods of fixation, operative technique and return to sport. One hundred and ten of 140 questionnaires were returned completed. Ninety two orthopaedic surgeons were performing ACL reconstructions. Eight per cent performed patellar tendon grafts in preference to hamstring grafts, whereas 16% preferred hamstring over patellar tendon grafts. Almost 2000 patellar tendon grafts at an average of just over 20 per surgeon are performed each year compared to just over 500 hamstring grafts at an average of just over 15 per surgeon. Metal interference screws were the most common fixation device in patellar tendon and hamstring grafts. Patellar tendon grafts are the most common grafts used for ACL reconstruction with 80 % of those surveyed preferring to use patellar tendon over hamstring grafts. Metal interference screws were the most common fixation device. There is reasonable consensus regarding return to activity and sport.
In view of the size of the lesions these were both fully investigated with pre-operative radiology and an image guided biopsy. The first case was found to be a large degenerate myxoid cyst involving the majority of the tibial plateau. The second case appeared similar radiologically yet was a large metastasis from a bladder cancer. The only history offered by the after this had been established was that she had had a benign polyp removed some years previously.
To determine whether increased sagittal laxity has an effect on functional outcome following posterior cruciate retaining total knee replacement using two differing tibial insert designs. Ninety-seven patients were reviewed clinically, radiologically and underwent KT1000 testing of their TKR at a minimum follow up of 5 years (mean 6.5 yrs). The femoral component design was the same in all patients (Duracon/PCA). Fifty two patients had a relatively flat tibial insert design (group 1), while 45 patients had an AP lipped insert (group 2) following a change in design in 1995. The 2 groups were comparable for age, sex, Charnley category, BMI, tibial slope and follow up. There was no significant difference in laxity measurements, IKS or WOMAC scores between the groups. There was no significant correlation between laxity and outcome score or flexion range. Increased sagittal laxity in a knee replacement does not have a strong influence on functional outcome. The differing tibial insert designs had no significant effect on either laxity or function.
The 10 year survival in the bilateral hip arthroplasty group for the Charnley femoral component (Median follow up 138 months) and Harvard femoral component (Median follow up 120 months) using aseptic loosening as an end point was 95.2% (92.4%-98%) and 77.2% (69.2%-85.2%) respectively.
Revision hip surgery is becoming increasingly common, 300 procedures being performed in 2001 at our institution. In order to achieve a good outcome bone stock needs to be of good quantity frequently necessitating the use of impaction bone grafting using allograft bone. Donor bone may frequently take three months before it becomes available for use due to the stringent screening procedure. Donor patients must have a clean bill of health, swabs taken at the time of surgery must obviously demonstrate no growth and blood samples taken at donation and an interval of three months, free from viral infectious diseases. It is thus easy to see the lag from the time of donation to availability and why, with increasing demand, need for allograft bone is rapidly exceeding supply. We need to look for an alternative supply of human bone allograft. We have compared the harvest of bone at the time of primary total knee replacement with that of the femoral head by both mass and volume. Sixty consecutive patients undergoing primary hip or knee arthroplasty were included in the study, and the masses and volume of the femoral heads compared with that of the total bone cuts in knee arthroplasty. The type of knee replacement used was documented as was whether the femoral head had had a bone block removed. It was found that the mass of femoral heads was 81g, that of knee cuts 95g this is a statistically significant difference; the volume of femoral heads 66ml and that of knee cuts 75ml. The volumes of bone available from knee arthroplasty cuts are at least comparable femoral heads obtained using hip replacement and could, perhaps, provide a realistic source of bone allograft.
There was radiographic evidence of fusion in 81.3% of patients. There was an improvement in mean pain VAS, and mean scores of all physical components of the SF36. Patient satisfaction was high (71%). Subgroup analysis demonstrates that the fusion rates in non-smokers versus smokers, and primary fusions versus previous surgery, were the same. The fusion rate following multiple level fusions was lower at 72.2%.
We prospectively reviewed 24 patients (35 feet) who had been treated by a Scarf osteotomy and Akin closing-wedge osteotomy for hallux valgus between June 2000 and June 2002. There were three men and 21 women with a mean age of 46 years at the time of surgery. The mean follow-up time was 20 months. Our results showed that 50% of the patients were very satisfied, 42% were satisfied, and 8% were not satisfied. The mean American Orthopaedic Foot and Ankle Society score improved significantly from 52 points pre-operatively to 89 at follow-up (p <
0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15° and 33° to 9° and 14°, respectively. These improvements were significant (p <
0.0001). The change in the distal metatarsal articular angle was not significant (p = 0.18). There was no significant change in the mean pedobarographic measurements of the first and second metatarsals after surgery (p = 0.2). The mean pedobarographic measurements of the first and second metatarsals at more than one year after surgery were within the normal range. Two patients had wound infections which settled after the administration of antibiotics. One patient had an intra-operative fracture of the first metatarsal and one required further surgery to remove a long distal screw which was irritating the medial sesamoids. We conclude that the Scarf osteotomy combined with the Akin closing-wedge osteotomy is safe and effective for the treatment of hallux valgus.
The understanding of biological systems is increasingly dependent on modelling and simulations. Numerical simulation is not intended to replace in vivo experimental studies, but to enhance the understanding of biological systems. This study tests the hypothesis that pressure pulses in the SAS are high adjacent to areas of arachnoiditis and investigates the validity of a numerical model by comparison with in vivo experimental findings.
The relationship between the bone mineral density (BMD) and Charcot arthropathy is unclear. Prospectively, 55 consecutive diabetic patients presenting with a Charcot arthropathy of the foot or ankle were classified as having a fracture, dislocation, or a combination fracture-dislocation pattern of initial destruction. In these groups we used dual-energy x-ray absorptiometry to compare the peripheral bone of the affected and unaffected limbs. The clinical data relating to diabetes and related major comorbidities and the site of the arthropathy (ankle, hindfoot, midfoot, forefoot) were also compared. There were 23 patients with a fracture pattern, 23 with a dislocation pattern, and nine with a combination. The age-adjusted odds ratio for developing a Charcot joint with a fracture pattern as opposed to a dislocation pattern in patients with osteopenia was 9.5 (95% confidence interval 2.4 to 37.4; p = 0.0014). Groups also differed as to the site of the arthropathy. Fracture patterns predominated at the ankle and forefoot whereas dislocations did so in the midfoot. Diabetic Charcot arthropathy of the foot and ankle differs according to the pattern of the initial destruction. The fracture pattern is associated with peripheral deficiency of BMD. The dislocation pattern is associated with a normal BMD.
Compressive myelopathy, occurring through traumatic fracture/dislocation of vertebrae, iatrogenic injury, cervical spondylotic myelopathy (CSM), or metastatic tumour, causes much socio-economic and emotional disability for patients as well as physical consequences. In such conditions, APP is recognised as an early and specifi c marker of axonal injury. The proteolysis of APP in both acute and chronic compressive myelopathy has not yet been described. Studies analysing axonal injury after brain trauma suggest a role for Caspase-3 in the cleavage of APP
Traditional osteotomies are posterior or horizontal. A technique of an oblique osteotomy from the sciatic notch to the iliac crest has been developed at Great Ormond Street since 1996, along with a system of external fixation. It is undertaken concurrently with urological reconstruction. The system of external fixation is relatively simple compared with other published work.
Also children with classical exstrophy were divided into 4 groups on the basis of continence. The mean post-operative percent reduction in the amount of the original diastasis was determined for all age groups. Comparison of pubic approximation was made between the two types of post-operative immobilisation
The average improvement in pubic approximation was 37% for the whole series. Chidren who were older at the time of surgery (18–60 months) were found to maintain better correction over time (76%). Children immobilised with an external fixator maintained better closure of the pelvis than those treated with plaster cast alone. (51% and 12.2% respectively). Maintenance of pubic approximation was associated with a higher level of bladder continence. Complications included 3 cases of infection and loosening of the external fixator requiring early removal. There were no neurovascular complications.
It is a reliable operation and the technique is applicable to all age groups.
Initially the Urologist will make an infra-umbilical incision then identify and mobilise the anatomical structures intended for their subsequent reconstruction and repair. This wound is then temporarily closed. The Orthopaedic surgeon will then approach the ilial crest through bilateral oblique incisions made inferior to the anterior superior ilial spine as described for the Salter osteotomy The interval is developed distal to the anterior superior ilial spine after identification and protection of the lateral femoral cutaneous nerve which is taken medially. After the interval between sartorious and tensa fascia lata are identified the iliac apophysis is split and reflected off the inner and outer ilial crests. The exposure may be improved by also developing the interval between rectus femorus and gluteus medius. Each side of the pelvis is exposed sub-periosteally from the iliac crest extending into the sciatic notch. A Gigli saw is then passed through the sciatic notch. The line of the osteotomy is from the posterior part of the sciatic notch extending anteriorly and superiorly to exit the iliac crest 2cm posterior to the anterior superior iliac spine (figure 2). The most anterior 1.5cm of iliac crest from the distal pelvic fragment is trimmed to allow closure of the iliac apophysis after rotation. The size of the half pin utilised is determined by the age of the patient. A baby under 18 months old will have a 3.5mm pin from the AO wrist external fixator frame and an older child over 2 years, a 4.5mm half pin. One half pin is inserted on each side of the pelvis. The half pin is placed in the distal fragment from anterior and lateral to posterior and medial with the tip of the screw just exiting the cortical bone of the medial aspect of the sciatic notch (figure 3a). Consideration of pin placement must take into account rotation of the distal fragment and preventive skin pressure areas. The iliac apophysis is repaired and the skin wounds are closed. The Urologist completes the reconstruction procedure planned via their infra-umbilical approach. The final stage involves the medial and superior rotation of both distal pelvic fragments and subsequent closure of the symphyseal diastasis. This position is maintained with the application of an anterior A-shaped frame from the wrist, AO fixation set in the younger infant or the AO pelvic fixator in the older child (figure 3b). Symphyseal approximation is confirmed intra operatively by palpatation. Bilateral above knee front slabs casts are applied to prevent kicking the hips or knees. The post-operative management involves pin site care on alternate days. The front slab casts are removed at 3 weeks and the anterior A-frame is removed at 6 weeks after union is confirmed on a pelvic radiograph. Depending on the social situation the children may go home during the post-operative period.
The reported revision rate of total hip arthroplasties (THAs) due to wear and osteolysis is around 10% at 10 years. However, the actual rate is probably higher: the incidence of osteolysis is reported to be 10% to 45%. Apart from design improvements, improved or new materials and/or and combinations are important in reducing particle-induced osteolysis, especially in young and active patients. Wear reduction of up to 40% after inert gas sterilisation of polyethylene (PE) has been demonstrated, both in vitro and in vivo. An effective means of providing further increases in wear resistance is to cross-link PE extensively. Early clinical results of non-melt-annealed PE at three years showed wear reduction of up to 85% compared to inert gas radiation-sterilised PE. In hip joint simulator investigations, bearings with a ceramic ball-head articulating against a composite cup demonstrated wear rates similar to those of ceramic-ceramic bearings. The wear particles are benign. Clinical data collected over two years suggest no disadvantages compared to the standard articulation controls. The wear resistance of alumina-alumina articulation has been enhanced. In-vitro investigation demonstrated that even with a cup inclination of 60° the wear rate is not increased. The effect of micro-separation of the artificial joint is also minimised. Several prospective multi-centre alumina-alumina studies have shown no additional complications with this articulation. However, alumina is a brittle material with an inherent risk of fracture. The addition of 25% zirconia to alumina (ZTA) in the manufacturing process improves its fracture resistance, increasing its strength by more than 50%, while maintaining its other properties. The wear properties of ZTA are even better than that of alumina, especially in micro-separation articulation mode. Highly cross-linked and optimised PE and composite technology are promising concepts in address wear particle-induced osteolysis.
The ‘first generation’ Metal on Metal bearing devices was typically produced from cast, high carbon CoCrMo alloy and was in the as-cast condition. They exhibited course, hard primary, and block carbides supported by a softer matrix material. This bi-phasic condition has been verified through reported literature and forensic scientific studies of ‘long-term survived’ retrieved ‘first generation’ devices. The as-cast microstructure of CoCrMo alloys possesses superior wear resistance to the microstructures formed following post cast thermal treatments. It has been well reported that the improvement of mechanical properties, such as tensile or fatigue strength, can be achieved through the thermal treatment of this alloy. Thermal treatments of this alloy have been found to alter its’ microstructure with a significant modification to the carbide phase morphology. The modifications vary with a tendency for a refinement of the carbide size through dissolution of the chromium and molybdenum through solid state solution. Through the examination of the wear patterns of retrieved devices and wear testing of this material in its’ various microstructural conditions, it has been shown that modifications to the carbide morphology, to achieve improved mechanical properties, reduces its’ bio-tribological properties/performance leading to a lower wear resistance. The as-cast carbide morphology is the most mechanically stable condition and with its’ volume fraction, reduces the potential for adhesive wear of the matrix through ‘matrix to matrix’ contact of the two opposing bearing surfaces. It has been reported that abrasive wear is the typical mechanism for metal on metal bearings due to the generation of ‘third body’ particles from carbide asperity tips fracturing during the initial ‘running-in’ period [typically 500k to 1M cycles]. After this stage the carbides become almost level with the surrounding softer matrix material with ‘third body’ scratches dominating the surface topography. Evidence of surface pitting on ‘first generation’ devices [McKee Farrar and Muller] and modern high carbon wrought devices [Metasul] has been attributed to adhesive/fatigue wear following surface-to-surface contact. Therefore, in microstructural conditions, where there is a reduced carbide volume fraction, or no carbides present, wear resistance is reduced. To test this hypothesis two wear tests have been carried out on CoCrMo samples produced from the same chemistry alloy, with varying microstructures, using Calowear [abrasive] and Pin on Dist [adhesive] tests. The as-cast microstructural condition was determined to have the lowest wear coefficient [k=mm3/Nm] in both tests, however statistical significance at 90% confidence interval was only confirmed in the Calowear Test. Examination of wear scars confirmed the mechanical stability of the as-cast carbide phase. It is noted, however that there are papers which have been published offering a divergence of opinion to this hypothesis and which have been considered by this author.
The treatment of acetabular dysplasia in adolescents (age>
12) is difþcult and various complex pelvic osteotomies have been described. The aim of surgery being improvement in pain and to delay the onset of secondary osteoarthrosis.
Increasing the width of the proximal section of a polished tapered stem enhances its rotational stability.
There were 3 male and 21 female patients with a mean age of 46 years. The mean follow up was 17 months. Statistical analysis was carried out.
Bilateral, uncemented hip replacements were performed on a 45-year-old woman with autosomal dominant osteopetrosis. The hips showed degenerative changes and protrusio acetabuli. Difficulties were encountered especially during preparation of the femoral canal. At ten-year follow-up she has an excellent clinical and radiological result with no sign of osteolysis. Uncemented hip replacement, while technically demanding, can be successful in the intermediate term for patients with this condition.
The Birmingham hip resurfacing (BHR) arthroplasty is a metal-on-metal prosthesis for which no medium- or long-term results have been published. Despite this, it is increasing in popularity as an alternative to stemmed prostheses for younger patients. Since the fixation of the socket is conventional, the major concern is long-term failure of the femoral component. This can be predicted by the use of roentgen stereophotogrammetric analysis (RSA). We have therefore undertaken such a study of the BHR femoral component over a period of two years. Twenty patients (22 hips) underwent a standard BHR procedure. Migration of the femoral component was measured by RSA at intervals of three, six, 12 and 24 months. At 24 months the total three-dimensional migration of the head was 0.2 mm. This was not statistically significant. Previous studies have shown that implants which loosen quickly have rapid early migration. Our results therefore suggest that the BHR femoral component is an inherently stable device which is likely to perform well in the long term.
Patient outcome was assessed by means of a visual analogue scale (VAS) for pain, SF36 health assessment questionnaire, a patient subjective outcome assessment, employment status and analgesic usage.
The mean VAS reduced by 2.2 points from 8.2 to 5.9 (p=0.007). There was a significant improvement in all the physical component scores of the SF36. The subjective outcome was either excellent or good in 65% of patients. Analgesia usage reduced in 71% of patients. 4 patients underwent further surgery. One patient died in the post operative period. There was no significant difference in the fusion rate in smokers compared to non smokers, or those that had undergone previous spinal surgery. The subjective outcome was either excellent or good in 59% of smokers, but only 37% in those that had undergone previous surgery.
Patient outcome was assessed by means of a visual analogue scale (VAS) for pain, SF36 health assessment questionnaire, a patient subjective outcome assessment, employment status and analgesic usage.
The mean VAS reduced by 3.2 points from 8.3 to 5.1 (p=0.0001). There was a significant improvement in all the physical component scores of the SF36. The subjective outcome was either excellent or good in 24 (71%) patients. Of the 26 patients working prior to surgery, 20 (77%) returned to work. Analgesia usage reduced in 21 (61%) patients. One patient died in the post operative period.
Immunohistochemical analysis of each specimen was conducted using markers of apoptosis, as well as the biochemical apoptotic marker TUNEL. A total of 1800 histopathological slides were analysed. Specimens were also analysed using confocal microscopy to identify the immunopositive cell type. A combination of morphological, immunohistochemical and in situ end-labelling techniques were used to investigate the mechanism of cell death in this experiment. The analytical techniques employed were aimed at showing firstly the presence of apoptosis and secondly the size and position of the damaged regions.
Surgical joint stabilisation can be achieved by ligamentous plication or thermal shrinkage, and as such, we hypothesized that there is no difference in mechanical and morphological properties after reduction of laxity in ligaments treated by either technique. Methods: 30 mature female rabbits underwent either ‘thermal’ treatment of their left medial collateral ligament (MCL) using a bipolar radiofrequency probe, or plication with two 4/O non-absorbable sutures following division along its midsubstance and loaded positioning of the free ends. After 12 weeks convalescence, the animals were euthanised and MCL complexes were procured from left and contralateral knees to undergo viscoelastic (creep) testing, quantitative Transmission Electron Microscopy (TEM) and immunohistochemistry. The TEM data was quantified by two data procurement protocols; computational analysis and manual graticule. Mean creep strain in both thermal (1.85 +/− 0.32%) and plicated ligaments (1.92+/−0.36%) was almost twice that of the control (1.04+/−0.15%), although there was no difference between treatment modalities. Similar findings were seen in the thermal (1.77+/−0.45%), plication (1.85+/−0.40%) and control groups (0.92+/−0.20%) for viscoplastic deformation. However, collagen morphological parameters of all three groups were significantly different (p<
0.001). The thermal ligaments demonstrated predominantly small fibrils, whilst the plicated group displayed an intermediate distribution of heterogenous fibrils. Immunohistochemistry followed by TEM revealed a sparse random distribution of alpha-smooth muscle actin staining fibroblasyts in both thermal and plicated groups. There was an insignificant difference in computational and manual procurement methods (p=0.84). Susceptibility to creep, and residual deformation after recovery, is similar after thermal shrinkage or plication, although inferior to intact ligaments. However, the plicated results suggest remodeling on a pre-existing fibrillar scaffold, yet the thermal group demonstrated histomorphometry similar to scar tissue, suggesting de novo synthesis. The absence of contractile myofibroblasts suggests that these cells may have an insignificant role in regulation of matrix tension during healing.
The use of exhaust suit systems is commonplace in arthroplasty surgery where isolation of the surgical team is desirable in an attempt to reduce the risk of infection transmission. Elevated carbon dioxide levels have been reported in the non-clinical setting with such systems the consequences of which can include fatigue, diapho-resis, nausea, headache and irritability. The aim of our study was to determine the levels of carbon dioxide present within an exhaust suit system during hip arthroplasty and to compare these with the recommended occupational exposure limit levels published by the Health and Safety Executive (HSE). Data was collected during ten primary hip replacements performed by the same surgeon whilst wearing the Stryker Steri-Shield Helmet Exhaust System. This is a self-contained unit with an integrated blower used in conjunction with a full-length gown. In addition the helmet was fitted with an air-sampling probe connected to a portable infrared CO2 monitor and also a temperature probe. Thus continuous monitoring of both CO2 and temperature level during surgery was possible. The mean initial CO2 concentration in the helmet at the beginning of surgery was 3 000 parts per million (ppm) and the mean maximum CO2 level recorded was 13 000 ppm. The mean time the surgeon was within an exhaust suit to perform a primary hip replacement was 1 hr 54 mins and for 86% of this time period the CO2 level within the helmet exceeded the recommended level of 5 000 ppm as stipulated by the HSE. In conclusion we have demonstrated significantly elevated CO2 levels within the Stryker Steri-shield Exhaust Suit System during hip surgery. Surgeons who use this system should be aware of this together with the physical symptoms that may result.
In 1997 the “step-less” SL Plus (Endoprothetik, Rotkreuz, Switzerland) cementless total hip arthroplasty was introduced to our unit. During the passed 12 months, a retrospective study has been performed in order to evaluate the clinical and radiographic results of this arthroplasty. The preliminary results of the first 50 patients to have completed the clinical and radiographic follow-up have been evaluated. Of the 50 patients, 56 primary total hip arthroplasties were performed, in all cases the SL Plus stem was used. In 52 cases the cementless Doetz acetabular cup, made by the same manufacturer, was used. The other 4 acetabular components were: 2 long stemmed cementless components for developmental dysplasia, 1 standard cementless cup and 1 cemented cup, made by other manufacturers. All patients were reviewed clinically and radiographically. The mean follow-up time was 3 years, range 2 – 5 years. The mean Harris Hip Score was 90 (37 – 100). Patient satisfaction was: 98% satisfied, 2% dissatisfied (p <
0.001). Radiographic assessment demonstrated that all 52 (100%) Doetz acetabular cups osseointegrated, with 53 (95%) acetabular cups osseointegrating in total (p <
0.002). Of the SL Plus stems, 44 (79%) osseointegrated (p <
0.002). The following post-operative complications were observed: 2 dislocations, 2 superficial wound infections, 1 myocardial infarction, 1 sciatic nerve palsy and 1 deep vein thrombosis. The overall complication rate is high at 13%, but with no implant related failures. Nevertheless, the preliminary clinical and radiographic results of the SL Plus stem and Doetz acetabu-lar cup total hip arthroplasty are encouraging.
The average age of the of the patients that healed was 65.4yrs and 70.06 in those that lifted. Again this was significant (p=0.0078). There was no correlation between sex of the patient, seniority of the surgeon or the prosthesis type with trochanteric union.
We recommend careful planning pre-operatively to limit the change in position of the trochanter.
CSF flow was studied at 0 and 10 minutes after injection of the CSF tracer horseradish peroxidase (HRP). Vibratome sections of the spinal cord were processed using tetramethylbenzidine and sections examined under light microscopy.
Perivascular spaces were enlarged in most cases of arachnoiditis and HRP was seen to stain these spaces and the central canal within 10 minutes.
The use of distal femoral centralising devices has been advocated in order to achieve an even cement mantle. This has been shown to improve femoral component survival but it is recognised that the presence of voids in the mantle has a deleterious effect on the mechanical strength of cement at laboratory testing and in terms of implant survival. The effect of centralising devices on the mantle in relation to the timing of stem insertion has not previously been investigated. The purpose of this study is to assess the quality of the cement mantle in artificial bone using a polished taper stem with centralisation inserted at different stages of cement cure time and using different cements. Three cement types were studied, 45‘saw bone’ models were used. The cementation was carried out in an operating theatre at constant temperature of 23.2Ê°C. The cement was mixed according to the manufacturers instructions and pressurised. Early, intermediate and late stem insertion times were determined for each cement type. The late group included stems with and without centralisers. Video recordings of the stem cement interface were made with a 4 mm endoscope after stem removal. Large cement mantle defects were noted in the ‘with centraliser’ group in 7 out of 15 late insertion times and all had small defects in the mantle. None of the ‘without centraliser’ group had cement mantle defects. Based on our results we advise surgeons to be very aware of the timing of stem insertion when using centralisers.
We undertook a radiological evaluation of this technique. We assessed fracture union and strut allograft incorporation using the radiological criteria of Emerson et al. The procedure was deemed a success if the fracture had united, with evidence of graft incorporation with a stable implant. We also undertook a notes review identifying any risk factors and any previous surgery.
The relative motion between a prosthesis, the cement mantle and its’ host bone during weight bearing is not well understood. Using Radiostereophotogrammetric Analysis (RSA), we examined the dynamically inducible micromotion that exists at these interfaces when an increased load is placed through the prosthesis. Dynamically inducible micromotion was measured in the femoral components of 21 subjects undergoing total hip replacement with polished Exeter stems. Two standing RSA studies were performed, at 3 and 12 months postoperatively. Firstly in double-leg stance, and secondly fully weight bearing through the operated hip. Subjects had no signs of clinical or radiological signs of loosening at 1 year. Significant micromotion was detected at the prosthesis-cement interface at 3 months. Similar patterns of micromotion were observed at 12 months. The prosthesis appeared to bend during single-leg stance weight bearing, however this accounted for less than half of the total observed movement. Conventional RSA studies were conducted at 3 months, 6 months and 1 year to confirm that the implants showed normal migration patterns. This study demonstrates that movement exists between the prosthesis and bone during cyclical weight bearing. This dynamically inducible micromotion probably occurs at the prosthesis-cement interface. It could account for the wear that is observed on the surface of retrieved secure prostheses. This may be a mechanism by which failure eventually occurs.
The Birmingham reSurfacing Arthroplasty (BSA) is a metal on metal prosthesis with no published independent clinical studies. Despite this, it is increasing in popularity, especially as an alternative to stemmed prostheses in younger patients. This study presents the 1year migration results of the BSA femoral component using Roentgen Stereophotogrammteric Analysis (RSA). Twenty six subjects underwent a BSA, through the postero-lateral approach using CMW3G cement, with RSA marker balls placed intra-operatively. The femoral component migration was measured at intervals of 3, 6 and 12 months using the Oxford RSA system. Geometric algorhythms were used to identify the femoral component. The data was examined for distribution prior to analysis. All statistical analysis was performed using the t-test. The data was normally distributed. The 1 year migration results of the BSA femoral component are displayed below. All cemented implants migrate in vivo. The majority of cemented stemmed implant migration occurs within the first post-operative year. High rates of migration within the first post-operative year correlate with premature component failure in some instances. The BSA is a fundamentally different design to most cemented prostheses, despite this we know that very large migrations, those in excess of 2mm/year in any direction are generally regarded as poor indicators of long term outcome. These results suggest that the BSA femoral component is an inherently stable device as it does not migrate significantly within the first post-operative year. Only long-term independent clinical studies and continued RSA follow-up will enable a comprehensive evaluation of the device.
We present a review of 553 patients who underwent surgery for intractable sciatica ascribed to prolapsed lumbar intervertebral disc. One surgeon in one institution undertook or supervised all the operations over a period of 16 years. The total number of primary discectomies included in the study was 531, of which 42 subsequently required a second operation for recurrent sciatica, giving a revision rate of 7.9%. Factors associated with reoperation were analysed. A contained disc protrusion was almost three times more likely to need revision surgery, compared with extruded or sequestrated discs. Patients with primary protrusions had a significantly greater straight-leg raise and reduced incidence of positive neurological findings compared with those with extruded or sequestrated discs. These patients should therefore be selected out clinically and treated by a more enthusiastic conservative programme, since they are three times more likely to require revision surgery.
We have treated seven children with relapsed infantile Blount’s disease by elevation of the hemiplateau using the Ilizarov frame. Three boys and four girls with a mean age of 10.5 years were reviewed at a mean of 29 months after surgery. All had improved considerably and were pleased with the results. The improvements in radiological measurements were statistically significant (p <
0.001). Three-dimensional CT reconstruction was useful for planning surgery. There were no major complications. The advantages of this technique are that in addition to elevation of the hemiplateau, rotational deformities and limb-length discrepancies may be addressed.