Acromioclavicular joint injuries are one of the most common injuries in the shoulder girdle complex. Surgical management is considered based on patient profile, level of activity, pain, and classification of injury. To date, a vast array of surgical techniques have been proposed and described in the literature, a possible reason being that the optimal solution is still uncertain. The aim of this study is to determine the efficacy of an alternative surgical technique. This study is a retrospective case series of 80 patients that have been operated by a single surgeon over a period of 6 years. A novel surgical technique, the ‘BiPOD method’, was applied where a synthetic artificial ligament (LARS®) is used to reconstruct and reduce the acromioclavicular joint. The technique is done in a reproducible manner, where a single continuous artificial ligament is used to reduce and reconstruct both, the coracoclavicular and acromioclavicular ligament complexes to achieve bidirectional stability. Patients were followed-up postoperatively, either clinically where possible or telephonically. The Acromioclavicular Joint Instability Score (ACJI) and radiographic measurements were used to determine the clinical and surgical outcome of the surgery. Radiographic parameters, measuring the reduction of the coracoclavicular- and acromioclavicular joint, were analysed and documented. The results showed marked improvement in both, the coracoclavicular distance and acromioclavicular distance. Clinically, using the ACJI scoring system, the patients reported substantial improvement in pain and function. Complications were recorded but were insignificant. The BiPOD surgical technique, making use of an artificial LARS® ligament, has proven acceptable outcomes in the surgical management of acromioclavicular joint dislocations.
We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN. This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs. We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types. Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%). Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94). Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients.
Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.
The Accolade®TMZF is a taper-wedge cementless metaphyseal coated femoral stem widely utilized from 2002-2012. In recent years, there have been reports of early catastrophic failure of this implant. Establishing a deeper understanding of the rate and causes of revision in patients who developed aseptic failure in stems with documented concerns about high failure rates is critical. Understanding any potential patient or implant factors which are risk factors for failure is important to inform both clinicians and patients. We propose a study to establish the long-term survival of this stem and analyze patients who underwent aseptic revision to understand the causes and risk factors for failure. A retrospective review was undertaken of all patients who received a primary total hip arthroplasty with an Accolade® TMZF stem at a high-volume arthroplasty center. The causes and timing of revision surgery were documented and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to minimize loss to follow-up. Survivorship analysis was performed with use of the Kaplan-Meier curves to determine the overall and aseptic survival rates at final follow-up. Patient and implant factors commonly associated with aseptic failure were extracted and Cox proportional hazards model was used. A consecutive series of 2609 unilateral primary THA patients implanted with an Accolade®TMZF femoral hip stem were included. Mean time from primary surgery was 12.4 years (range 22 days to 19.5 years). Cumulative survival was 96.1% ± 0.2 at final follow-up. One hundred and seven patients underwent revision surgery with aseptic loosening of the femoral component was the most common cause of aseptic failure in this cohort (33/2609, 1.3%). Younger age and larger femoral head offset were independent risk factors for aseptic failure. To our knowledge, this is the largest series representing the longest follow-up of this taper-wedge cementless femoral implant. Despite early concerns, the Accolade® TMZF stem has excellent survivorship in this cohort. Trunnionosis as a recognized cause for revision surgery was rare. Younger age and larger femoral head offset were independent risk factors for aseptic failure.
During total knee arthroplasty (TKA), a tourniquet is often used intraoperatively. There are proposed benefits of tourniquet use including shorter duration of surgery, improved surgical field visualization and increased cement penetration which may improve implant longevity. However, there are also cited side effects that include increased post-operative pain, slowed recovery, skin bruising, neurovascular injury and quadriceps weakness. Randomized controlled trials have demonstrated no differences in implant longevity, however they are limited by short follow-up and small sample sizes. The objective of the current study was to evaluate the rates of revision surgery among patients undergoing cemented TKA with or without an intraoperative tourniquet and to understand the causes and risk factors for failure. A retrospective cohort study was undertaken of all patients who received a primary, cemented TKA at a high-volume arthroplasty centre from January 1999 to December 2010. Patients who underwent surgery without the use of a tourniquet and those who had a tourniquet inflated for the entirety of the case were included. The causes and timing of revision surgery were recorded and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to reduce the loss to follow-up. Survivorship analysis was performed with the use of Kaplan-Meier curves to determine overall survival rates at final follow-up. A Cox proportional hazards model was utilized to evaluate independent predictors of revision surgery. Data from 3939 cases of primary cemented TKA were available for analysis. There were 2276 (58%) cases in which a tourniquet was used for the duration of the surgery and 1663 (42%) cases in which a tourniquet was not utilized. Mean time from the primary TKA was 14.7 years (range 0 days - 22.8 years) when censored by death or revision surgery. There were 150 recorded revisions in the entire cohort, with periprosthetic joint infection (n=50) and aseptic loosening (n=41) being the most common causes for revision. The cumulative survival at final follow-up for the tourniquetless group was 93.8% at final follow-up while the cumulative survival at final follow-up for the tourniquet group was 96.9% at final follow-up. Tourniquetless surgery was an independent predictor for all-cause revision with an HR of 1.53 (95% CI 1.1, 2.1, p=0.011). Younger age and male sex were also independent factors for all cause revision. The results of the current study demonstrate higher all-cause revision rates with tourniquetless surgery in a large cohort of patients undergoing primary cemented TKA. The available literature consists of short-term trials and registry data, which have inherent limitations. Potential causes for increased revision rates in the tourniquetless group include reduced cement penetration, increased intraoperative blood loss and longer surgical. The results of the current study should be taken into consideration, alongside the known risks and benefits of tourniquet use, when considering intraoperative tourniquet use in cemented TKA.
Overall, hip and knee total joint replacement (TJR) patients experience marked benefit, with reported satisfaction rates of greater than 80% with regard to pain relief and improved function. However, many patients experience ‘nuisance’ symptoms, an annoyance which may cause discomfort, which can negatively impact postoperative satisfaction. The purpose of this study was to evaluate the prevalence of nuisance symptoms among TJR patients and impact on overall patient satisfaction. A prospective survey study to assess type and prevalence of primary hip/knee TJR related nuisance symptoms, and impact on patient satisfaction at six-months to one-year post-TJR was conducted. The survey was administered over a one-year period at one academic arthroplasty centre. Survey questions tapped occurrence of commonly reported nuisance symptoms (e.g. localized pain, swelling, stability, incision appearance/numbness, stiffness, clicking/noise, ability to perform activities of daily living), and impact of the symptom on overall hip/knee satisfaction rated on a 10-point visual analogue scale (VAS), (0=no impact, 10=to a great extent). Overall VAS satisfaction with TJR was also assessed (0=not at all satisfied, 10=extremely satisfied). Survey responses were analysed using descriptive statistics. The sample comprised of 974 primary TJR patients, including 590 knees (61%) and 384 hips 39%) who underwent surgery over a one-year period. Among knees, the most commonly reported nuisance symptoms and associated impact to satisfaction per mean VAS scores included: difficulty kneeling (78.2%, mean VAS 4.3, ±3.3), limited ability to run or jump (71.6%, VAS 3.3, ±3.3), numbness around incision (46.3%, VAS 3.8, ±3.3), clicking/noise from the knee (44.2%, VAS 2.7, ±2.7) and stiffness (43.3%, 3.3, ±2.7) following knee arthroplasty. Overall, 88.1% of knee patients surveyed experienced at least one self-reported nuisance symptom at one-year postoperative. Mean overall VAS satisfaction with knee TJR was reported as 9/10 (±1.7). Among hip TJR patients, the most commonly reported nuisance symptoms and associated impact to satisfaction per VAS scores were: limited ability to run or jump (68.6%, VAS 3.4, ±3.4), muscular pain in the thigh (44.8%, VAS 3 ±2.7), limp when walking (37.6%, VAS 4.1, ±3.2), hip stiffness (31%, VAS 3.1, ±2.4), and new or worsening low back pain (24.3%, VAS 2.9, ±2.5). Overall, 93.7% of patients experienced at least one self-reported nuisance symptom at one-year postoperative. Mean overall VAS satisfaction following total hip arthroplasty at one year was reported as 8.9/10 (±1.7). Nuisance symptoms following primary total hip and knee arthroplasty are very common. Despite the high prevalence of such symptoms, impact of individual symptoms to overall TJR satisfaction is minimal and overall TJR patient satisfaction remains high. Careful preoperative counselling regarding the prevalence of such symptoms is prudent and will help establish realistic expectations following primary hip and knee TJR.
Prosthetic joint infections (PJI) are amongst the most feared postoperative complication of total joint replacement (TJR). PJIs are associated with significant morbidity ranging from functional impairment to amputation. Staphylococcus aureus (S. aureus) is one of the most common causative organisms involved in PJI. More than one quarter of the general population are S. aureus carriers, and carrier status has been shown to increase the risk of developing surgical site infections including PJIs. Decolonization of S. aureus carriers prior to surgery has demonstrated promising results in general surgery, however, solid evidence supporting decolonization in orthopaedic patients is lacking. We aimed to seek further evidence supporting pre-operative screening and S. aureus decolonization in patients undergoing primary or revision hip and knee TJR. A quasi-experimental quality improvement study was conducted to compare the 5-year baseline rates of deep PJIs to a one-year screening and decolonization intervention period. All consecutive patients who underwent primary or revision TJR at one tertiary care hospital in Hamilton, ON, Canada were included in both study periods. Nasal and throat screening for S. aureus carriage of all eligible TJR patients in the preoperative clinic was implemented as standard of care. Patients who tested positive were contacted and provided with details on the S. aureus decolonization protocol. Decolonization included a standardized treatment protocol of 2% intranasal mupirocin twice daily for five days prior to surgery date (excluding day of surgery), and chlorhexidine gluconate wipes (2%) to be used once daily for 4 days prior to surgery date and on the morning of surgery. Regardless of the colonization status at the visit in the preoperative clinic, all patients were re-swabbed on the day of surgery. Primary outcome of interest was the rate of deep PJI as per CDC/NHSN at one-year postoperative follow-up. Secondary outcomes included rate of deep PJIs due to S. aureus, adherence to the decolonization protocol, proportion of S. aureus carriers successfully decolonized, and the proportion of patients deemed as non-carriers following preoperative swab subsequently identified as carriers on the day of surgery. A total of 8,505 patients were included in the 5-year control group, and 1,883 during the intervention period, of which 424 (22.5%) were identified as S. aureus carriers. The deep PJI rate was similar in the two groups, 0.4% (7/1,883) in the intervention group and 0.5% (42/8,505) in the control group (OR 0.75, 95%CI 0.34–1.67, p=0.58). More importantly, we found a significant reduction in PJI due to S. aureus to only one case in the intervention period (0.05%) as compared to 29 cases (0.3%) in the historic control (OR 0.15, 95%CI 0.004–0.94, p=0.0376). We found a significant reduction in PJIs due to S. aureus by decolonizing S. aureus carriers prior to surgery. However, no significant difference in overall infection rates was observed. In conclusion, routine implementation of active screening for S. aureus and decolonization of carriers before TJR is feasible and helps to reduce PJI due to S. aureus.
The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR. A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year VAS pain. PCS-magnification CRC sub-domain was also identified as a significant predictor of KSS/HHS at one-year (median difference 1.3, 95% CI −5.23–0.11, p=0.041). Preoperative VAS pain, Oxford and HHS/KSS scores were significantly inferior in patients who had CRC PCS, abnormal HADS-A, and abnormal HADS-D scores compared to patients with normal scores. At one-year, PCS CRC patients also had significantly inferior VAS pain (p=0.001), Oxford (p < 0 .0001) and KSS/HHS (p=0.025). Abnormal HADS-A and HADS-D patients experienced significantly inferior postoperative VAS pain (HADS-A p=0.025, HADS-D p=0.030), Oxford (HADS-A p=0.001, HADS-D p=0.030), but no difference in KSS/HHS (HADS-A = 0.069, HADS-D = 0.071) compared to patients with normal PCS/HADS scores. However, patients with CRC PCS experienced significantly greater improvement in preoperative to postoperative VAS pain (p < 0 .0001), Oxford (p=0.003) and HHS/KSS (p < 0 .0001). Similarly, patients with abnormal HADS scores showed significant improvement in preoperative to one-year postoperative change scores, as compared to normal patients in VAS pain (HADS-A p=0.011, HADS-D p=0.024), KSS/HHS (HADS-A p=0.017, HADS-D p=0.031), but not Oxford (HADS-A p=0.299, HADS-D p=0.558). Patients who are anxious, depressed or who pain catastrophize have worse preoperative function and pain. Postoperatively, pain and functional outcomes are also inferior in such patients, however they do experience a significantly greater improvement in outcomes. Furthermore, it appears that rumination and anxiety traits predict pain levels postoperatively. Although these patients report higher levels of pain postoperatively, as compared to preoperative, great improvement can be expected following hip and knee TJR.
The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics. A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and Lawrence (K-L) scale. Logistic regression was used to assess pattern of relationship between preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% confidence interval (CI) were reported. A secondary quantile regression analysis examined whether a model not restricted to pre-defined PCS and HADS categories would yield comparable results to the logistic regression model described in the primary analysis. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). VAS pain (OR 1.23,95%CI 1.04–1.45) and Oxford score (OR 1.13,95%CI 1.07–1.20) were identified as significant predictors for PCS. The same two variables were the strong predictors for all sub-domains of PCS excluding rumination. Oxford Score was the only significant predictor for abnormal HADS-A (OR 1.10,95%CI 1.04–1.17) while VAS pain (OR 1.27,95%CI 1.02–1.52) and Oxford (OR 1.09,95%CI 1.01–1.17) were significant predictors for abnormal HADS-D. Similar pattern of association for PCS and HADS was observed in the quantile regression model, where larger VAS pain and Oxford scores significantly increased median PCS across all domains. Female gender, younger age or having a higher ASA grade were associated with higher median HADS-A, but unlike in the logistic regression, this association was statistically significant. Pain catastrophising and emotional disorders generally result in poor functional outcomes in TJR patients. The most important predictor of catastrophising, anxiety/depression is pain and subjective function. At risk patients include those with high preoperative pain with generally good preoperative function, as well as younger females with significant comorbidities. Such patients should be identified, and targeted psychological therapy implemented preoperatively to optimise coping strategies and adaptive behaviour to mitigate inferior TJR outcomes including pain and patient dissatisfaction.
The Latarjet procedure utilises the coracoid as a vascularised bone autograft to augment the glenoid in patients with shoulder dislocation, especially where there is a bony lesion affecting the glenoid. A modification of the Latarjet procedure, pioneered in Cape Town, South Africa, rotates the coracoid so that its curved under-surface matches that of the glenoid. The aim of this study was to measure the radii of curvature of the glenoid and the coracoid to see how well the curved under-surface of the coracoid matches the glenoid’s surface curvature. An initial study of 210 cadaveric scapulae was performed in which the radii of curvature of the surface of the glenoid and the curved under-surface of the coracoid were measured. We found that the curves are very similar. The glenoid’s surface had a median curvature of 30mm (inter-quartile range from 25mm to 30mm) and the coracoid had a median curvature of 22.5mm (inter-quartile range from 20mm to 25mm). The curvature of the glenoid in these dry specimens was slightly larger than the corresponding coracoid curvature. In life this difference would be minimised by articular cartilage, labrum and the attachment of capsule (another Cape Town modification). A further parallel CT based study was set up at Derbyshire Royal Infirmary in England. The same radii of curvature where measured and compared using 3D CT reconstruction on a further 20 scapulae from living patients. These measurements also support the cadaveric similarities with a mean glenoid curvature of 23.9mm and coracoid of 25.4mm respectively. Using a paired t-test no statiscally significant difference was found between the corresponding data (p=0.2488) This study confirms the native anatomy of the coracoid is perfectly suited for this modification of the Latar-jet procedure.
Total hip arthroplasty (THA) allows patients to return to an active lifestyle. Unfortunately one of the more common complications of cementless THA is a fracture of the greater trochanter (GT) or the calcar. These may compromise the outcomes of THA, but there are no large studies looking into this hypothesis. Between September 1998 and August 2005 the Hamilton Arthroplasty group performed 2282 THA operations. Demographic and outcome data on these patients was collected and tabulated in a prospective database. Radiographs were available on a picture archiving system for 1075 of the patients, 85% of which were primary THAs. GT and calcar fractures were identified. Statistical comparisons on the normal distributed outcome data were made using the Student’s T-test comparing repaired and missed fractures. A total of 60 GT fractures were found in the review of 1075 radiographs, giving an incidence of 5.6%. This included 19 isolated GT fractures and 10 GT fractures with associated calcar fractures that were found in primary hip arthroplasties, 48% of the total. Revision hip surgeries had 14 isolated GT fractures and 17 GT fractures with associated calcar fracture. We found that 23 (40%) of all GT fractures were missed intra-operatively and did not receive any fixation. All calcar fractures were noted and repaired, even if the associated GT fracture was not. 106 isolated calcar fractures were noted, 10% of all arthroplasties, only one of which did not receive fixation. Of this, 85 (80%) were from primary total hip arthroplasty and 21 (20%) from revision hip arthroplasty. Evaluation of the outcome data showed no significant difference between repaired and missed GT fractures. Reported outcomes compared favourably with the average for all THA in that time period. Adoption of cementless total hip arthroplasty in North America undoubtedly increases the rate of GT and calcar fractures. Most calcar fractures were noted and fixed but only 50% of GT fractures were discovered intraoperatively, an area of potential improvement. Greater trochanter and recognized calcar fractures may not have long-term detrimental effects.
The association between obesity and sleep apnea syndrome (SAS) is well known, as is the fact that TJR patients are often obese. Based on review of 5819 primary TJR patients at our institution, 53% of patients presenting for TJR were obese (mean BMI 31), and of those obese patients 61.3% were female. The potential impact of SAS, diagnosed and undiagnosed, on TJR outcomes has not been well described. In the literature it has been suggested that such patients may be at increased risk of prolonged hospital length of stay (LOS), increased risk of postoperative MI, and risk of postoperative respiratory compromise requiring unplanned transfer to a special care unit (SCU). At our institution, unless deemed required for preoperatively identified co-morbidities, all TJR patients are managed acutely on an orthopaedic ward with no formal step down unit available for enhanced monitoring, even when receiving PCA or epidural for postoperative pain control. We undertook a prospective non-randomised survey of 1927 primary TJR patients over a fifteen-month period to screen for a preoperative diagnosis of SAS, or symptoms suggestive of SAS using the self-report Epworth Sleep Apnea Questionnaire. In addition, we evaluated impact of SAS on LOS, risk of postoperative MI, risk of postoperative respiratory compromise and unplanned transfer to SCU. Of our sample, 88/1927 patients (4.6%) had a confirmed preoperative diagnosis of SAS. An additional 74/1927 patients (3.8%) had 3/3 symptoms suggestive of undiagnosed SAS. SAS patients were younger; mean sixty-six years, p=0.005, and predominantly male; 58%, p<
0.0001, as compared to non-SAS patients comprised of 60% females and mean age sixty-nine years. Mean BMI was higher in the SAS group; 32.3 versus 30, p<
0.0001. There was no correlation between SAS and risk of postoperative MI, LOS (mean 5.2 days, both groups), nor unplanned SCU admission. Despite concerns expressed in the literature, we found that SAS, both diagnosed and suspected, was not associated with prolonged LOS, increased risk of postoperative MI, postoperative respiratory compromise, or unplanned postoperative transfer to a SCU.
Prior to TJR, clinical cardiovascular risk assessment is typically limited by severe exercise restrictions. Noninvasive pharmacological cardiovascular stress tests may predict major perioperative cardiovascular events in patients undergoing orthopaedic surgery. We undertook a pilot study to inform the feasibility of a large prospective cohort study. Patients were eligible if they were aged >
forty-five, undergoing elective TJR, and had known atherosclerotic disease or risk factors for atherosclerotic disease. We recruited patients at the Hamilton Health Sciences, Henderson Hospital. Prior to surgery patients underwent dipyridamole stress perfusion imaging and dobutamine stress echocardiography. For both tests the interpreters evaluated seventeen myocardial segments and were blinded to information about patients’ clinical risk factors. The attending surgeons and research personnel following patients after surgery were blinded to results of the noninvasive pharmacological cardiovascular stress tests. All patients had an ECG performed and troponin T drawn six to twelve hours postoperatively and on the first, second and third days after surgery. Starting in November 2005 we recruited thirty patients over six months; seventeen (57%) patients were male, twenty-one (70%) underwent TKA, and nine (30%) underwent THA. The length of surgery was seventy-two (SD 38) minutes and the length of hospital stay was five (SD 3) days. We successfully followed all patients to thirty days after surgery. Three patients (10%; 95% CI, 3–26%) suffered a perioperative myocardial infarction. Twenty nine patients underwent dipyridamole stress perfusion imaging prior to surgery; a reversible defect involving 30–50% of the myocardium increased the likelihood of a perioperative myocardial infarction (likelihood ratio [LR] 4.0; 95% CI, 1.2–13.3). Twenty-six patients underwent dobutamine stress echo-cardiography; a reversible defect increased the likelihood of a perioperative myocardial infarction (LR 4.0; 95% CI, 0.7–22.9). This pilot study demonstrates the need for, and feasibility of, a large prospective cohort study to determine if preoperative noninvasive pharmacological cardiovascular stress testing has additional predictive value, beyond clinical variables, for the occurrence of myocardial infarction in patients undergoing major hip and knee surgery.
Digital radiography has replaced traditional radiography in many hospitals yet little is known regarding the accuracy of this new technology in THA templating. Our study analyzed the reproducibility and reliability of computer templating in primary uncemented THA as compared to standard on-lay templating techniques with hardcopy radiographs from a digital source. In December 2004 our hospital converted from standard hardcopy radiography to digital radiography. Patients undergoing THA had preoperative digital radiographs taken which included an AP pelvis with a 50mm magnification marker place in the groin, AP hip, and a cross-table lateral. Forty patients were selected that met our inclusion criteria to begin the templating process, including adequate placement of the magnification marker and optimal hip implant positioning on the postoperative films. Cases that did not have a marker, had significant deformity or mal-positioned implants were excluded. Hardcopies of digitised radiographs were printed and a traditional templating technique using 120% magnified on-lay transparent templates was performed (Capello, 1984). Digital templating was performed using OrthoView Software (Bono, 2004). Templating was conducted by two staff surgeons and one resident. Intra-observer and inter-observer effects were calculated using an Intraclass Correlation Coefficient (ICC). Digital templating showed good inter-observer and intra-oberserver reliability with ICC values >
0.7. Using computer templating, the femoral stem was accurately predicted to within one size in 85% of the cases, and the acetabular cup was accurately predicted to within one size in 80% of the cases.Using on-lay templating, the femoral stem was accurately predicted to within one size in 85% of the cases, and the acetabular cup was accurately predicted to within one size in 60% of the cases. There was a significant difference between the accuracy of acetabular cup templating between techniques, likely as a result of the ability of computer templating to adjust for magnification error. Computer templating was able to accurately predict postoperative leg-length discrepancy, abduction angle and horizontal offset. Overall, computer templating was found to be a reproducible and reliable technique for uncemented THA. Problems and lessons learned in the implementation of a digital templating system will be discussed.
There were more than 574,000 primary lower limb total joint arthroplasties performed in the United States in 2002 and 48,000 in Canada over approximately the same period. The incidence of clinically apparent myocardial infarction following lower limb arthroplasty has been previously reported at 1.8% (Gandhi et al, 2006). The functional outcome of patients suffering post-operative myocardial infarctions has never been reported to our knowledge. Our hypothesis is that functional scores of patients undergoing total joint arthroplasty that suffer peri-operative myocardial infarction will be lower than in our control patients. Patients were retrospectively identified from a prospectively collected database of total joint arthroplasties performed at one center. Six surgeons performed 3320 primary lower limb arthroplasties over a period of seven years. Patients of interest were identified via discharge summaries to have suffered a myocardial infarction diagnosed clinically and confirmed by biochemical assay. These patients were then case matched for demographics, risk factors and pre-operative functional score. Sixty-two patients (twenty six hips and thirty six knees) were identified as having suffered a post-operative myocardial infarction. There was an overall mortality of 13% and only thirty-four of the sixty-two (55%) completed follow-up to one year. The clinical course of the remaining patients remains uncertain. Statistically significant differences have been observed in Oxford hip scores at six weeks post operatively. Any differences disappear by six months. No statistically significant differences in outcomes were seen in knee outcomes. It would appear that those patients who are well enough to return for follow-up do just as well as those patients who did not suffer myocardial infarctions. There may be some differences in the rate of recovery from the surgery, but it appears that overall functional outcome of the patients that survive remain good.
Controversy exists surrounding best practice for antibiotic prophylaxis in TJR. Practicing orthopedic surgeons performing TJR in Canada were surveyed to inform regarding the most common antibiotic prophylaxis practice. Cross-sectional survey of five hundred and ninety practicing Canadian orthopaedic surgeons was conducted. Three orthopaedic surgeons, and one infectious disease specialist established face and content validity of the survey. The survey was mailed to surgeons, and re-mailed to non-responders at twelve-weeks. Survey included questions pertaining to prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision setting, as well as postoperative wound drainage investigation and management. Response rate after two mail-outs was 410/590 (69.5%). 96.6% indicated routine use of systemic prophylactic antibiotics for uncomplicated primary TJR. Cefazolin was most commonly prescribed (97.3 %), with 1gm Cefazolin the most common dosage (70.2%). Vancomycin was prescribed 26% of the time as first line. 48.5% administer the antibiotic in the operating suite, and 90% administer within <
sixty minutes prior to skin incision. 47.8% routinely use antibiotics in acrylic cement, and 50% use it in a commercially prepared form. Postoperative prophylaxis duration varied widely with 42% preferring twenty-four hours. 33% routinely culture serous wound drainage within one-week postoperative in the absence of redness or fever. 19.8% prescribe antibiotics if wound drainage persists beyond hospital stay. 15.6% would conduct intraoperative wound exploration if drainage persists beyond postoperative day four. 63.9% stated they routinely withhold antibiotics until they have obtained a deep tissue culture specimen in revision TJR. 74% use the same antibiotic prophylaxis regimen for both primary and revision procedures. Of responding surgeons, 47/410 (11.8%) were categorised as high volume performing >
two hundred TJR’s per year, and 40/410 (9.8%) were categorised as low volume performing <
twenty-five per year. Comparative results to be discussed. Opinions vary widely amongst surgeons in Canada, illustrating the controversy in what constitutes ‘best practice’. Despite available published data, a large proportion of Canadian surgeons may fall short in meeting optimal standards of care in some domains such as the dose prescribed and timing of administration. This survey also illustrates the lack of available information to guide current management of postoperative wound drainage in the face of shorter patient hospital stays. Much work is needed in this area to determine risks and benefits of these costly tests and interventions in treating arthroplasty patients.
To evaluate the mechanism by which orthopedic implant wear particles induce apoptosis in immature osteoblasts in an in-vitro setting. Stromal cells from femurs of thirty day-old Swiss Webster Mice were isolated, cultured in-vitro, and incubated with orthopedic wear particles in the micrometer size range. After incubation with wear-particles, the cells were assessed for Caspase three expression and activity in the presence or absence of specific inhibitor(s) in order to delineate potential mechanism for cellular changes previously reported. Here we report the induction of caspase three protein expression and activity with incubation of stromal cells with titanium wear particles. Caspase three activity however was not demonstrated to be up regulated in a time dependent manner or at lower concentration of particles (2 x 107 particles/ml). However, there was a significant (P<
0.05) increase in caspase three activity with titanium particle at higher concentration (4 x 107 particles/ml) that was not reversible when the extrinsic arm of the apoptotic pathway was blocked with anti-TNFƒa antibodies. Our previous studies have suggested that aseptic loosening of orthopedic implants may be independent of inflammatory processes, and may be associated with induction of programmed cell death. Our current results would strengthen this idea by demonstrating induction of expression and activity of caspase three involved in apoptosis in cells incubated with wear particles. In addition, titanium wear particles may induce apoptosis through direct cellular effects rather than through the extrinsic TNFƒa pathway. Delineating the mechanism by which wear particles induce apoptosis in immature osteoblasts will allow for the selection and/or development of inhibitors to the process of asceptic loosening by targeting a specific pathway.
The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded.
As a result of the increased popularity of metal-on-metal bearings for total hip arthroplasty, concerns have been expressed about patient exposure to increased serum metal ion levels. We therefore performed a retrospective review of patients with metal-on-metal, uncemented Ring total hip replacements with a minimum follow up of thirty years. After allowing for prosthesis revision and patient mortality, 6 hips in 5 patients were reviewed and serum ion levels measured. Similar cohorts of patients with other combinations of bearings were compared with an age-matched osteoarthritic control group. Serum cobalt and chromium levels in the metal-on-metal hip arthroplasty group were significantly higher than in all other groups and approximately five and three times greater respectively than in the group with no implants. Unlike the stainless steel-on-plastic group, the cobalt/chrome-on-plastic group showed significantly raised serum cobalt levels compared with the control group. It is of interest that patients who have had their metal-on-metal hip replacements revised to metal-on-plastic, have metal ion levels that are not statistically different to those of the osteoarthritic control group. Though we acknowledge the small numbers of patients studied, no identifiable harmful effects were found. We conclude that serum metal ions remain elevated throughout the life of the metal-on-metal articulation. Metal bearing hip arthroplasty is being used in ever younger patients and together with increased life expectancy we are exposing our patients to potentially harmful levels of metal ions throughout the life of the implant.
The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings.
A ligament tensioning device was used during total knee arthroplasty procedures to determine the effective stiffness of the soft tissue envelope around osteoarthritic knees. This information was used to calculate the resting forces on polyethylene components in well balanced knees. Various patient and implant factors were investigated to see if they correlated with the stiffness of the soft tissues around arthritic knees. The effective stiffness of the soft tissues was found to be higher when the posterior cruciate ligament was preserved compared to when it was sacrificed. The purpose of this study was to determine, in vivo, the effective stiffness of the soft tissue envelope around the knee and to estimate the resting force on the implanted polyethylene component during total knee arthroplasty (TKA). A ligament tensioning device was used to measure displacement between the tibia and the femur versus load during eighty-six consecutive TKA procedures. A maximum of five measurements were made in both flexion and extension. The measurements were taken after bone cuts were made and soft tissue balancing was performed. The effective stiffness of the knee soft tissue envelope was determined in flexion and extension. Post- operative range of motion was measured while the patient was still under anesthetic. There was no significant difference in the average effective stiffness between men and women or between flex-ion and extension. Age did not appear to correlate with effective stiffness. The average effective stiffness was significantly higher in posterior cruciate retaining knees compared to those in which the posterior cruciate was sacrificed. There was no statistical significance between the average resting force on the polyethylene in men versus women, in flexion versus extension, or in posterior cruciate retaining knees versus posterior cruciate sacrificing knees. The immediate post-operative range of motion did not correlate with the resting force on the implanted polyethylene
Retrospective analysis of three hundred and seventy-one obese (BMI _ 30) and two hundred and forty-nine non-obese (BMI <
30) primary unilateral TKA patients with minimum one-year follow-up to determine influence of obesity versus non-obesity on clinical outcomes following primary unilateral total knee arthroplasty (TKA) for osteoarthritis. Obese patients fare just as well as non-obese patients, experiencing a greater degree of improvement in observed and self-reported outcome measures. Multiple factors determine outcome of TKA. This study aimed to determine influence of obesity versus non-obesity, as measured by body mass index (BMI), on clinical outcomes following primary unilateral total knee arthroplasty (TKA) for osteoarthritis. Compared to non-obese patients, obese patients had inferior preoperative clinical scores, but achieved comparable ultimate clinical outcomes. Despite inferior preoperative clinical scores, obese patients undergoing primary TKA for osteoarthritis can expect the same ultimate clinical outcome as non-obese patients. Statistically significant differences for; mean age of obese 69.2 ±9 and non-obese 73±8 (p<
0.0001), with a higher preponderance of obese females, 70.2% vs. 30% male (p=0.033). Despite statistically significant differences among all preoperative clinical outcomes including; KSS clinical (p=0.019), KSS function (p=0.02), Oxford (p=0.02), and flexion (p=0.001), there were no statistically significant differences among these outcomes at one-year postoperative. No statistical difference among surgical outcomes, hospital length of stay, pain scores or stair climbing ability at any interval. Retrospective analysis of three hundred and seventy-one obese (BMI _ 30) and two hundred and forty-nine non-obese (BMI <
30) primary unilateral TKA patients with minimum one-year follow-up. Statistical analysis to determine differences in demographics, surgical time, intraoperative complications, hospital length of stay, and clinical outcomes including; flexion, KSS and Oxford score, pain-level and stair climbing ability at six-week, six-month, and one-year postoperative. Patients with previous high tibial osteotomy, ORIF, or receiving associated WSIB benefits were excluded. Obese patients fare just as well as non-obese patients, experiencing a greater degree of improvement in observed and self-reported outcome measures.
To evaluate the effect of implant articular geometry on postoperative range of motion (ROM) after primary total knee arthroplasty for osteoarthritis, we conducted a retrospective case-control study of one hundred and twenty patients (sixty in each group) comparing Scorpio® Posterior Cruciate Substituting implant using Superflex® versus traditional tibial insert. Cases and controls were matched 1:1 for surgeon and gender. Both groups had similar baseline characteristics. Except for KSS Clinical Score at six months (mean: 92.8 for Superflex® versus 87.6 for traditional insert; p=0.029), there was no statistically significant difference between the two groups in knee scores or ROM up to one-year postoperatively. To evaluate the effect of implant articular geometry on postoperative range of motion (ROM) after primary TKA. Despite the advent of high flexion knee designs, surgical technique and patient driven factors remain the overriding determining factors for ultimate flexion range achieved following TKA. One hundred and twenty patients (sixty in each group) were included. Both groups had similar baseline characteristics. Except for KSS Clinical Score at 6 month (mean ± SD: 92.8 ± 5.8 for Superflex® versus 87.6 ± 14.6 for traditional insert; p=0.029), there was no statistically significant difference between the two groups in knee scores or ROM. Flexion at one year for Superflex® was 113.5° ± 10.5 compared with 113.2° ± 11.9 for traditional tibial insert (p=0.869). Retrospective cohort study of a prospectively gathered database of TKA’s performed at a high-volume arthroplasty center from 1998 to 2003. Inclusion Criteria: primary TKA for osteoarthritis using Scorpio® Posterior Cruciate Substituting implant with Superflex® tibial insert versus traditional insert. Exclusion Criteria: WSIB, prior history of septic arthritis, and previous knee surgery. Cases and controls were matched 1:1 for surgeon and gender. Postoperative care was standardized. Data points included demographics, operative details, pre- and post-operative Knee Society Score (KSS), Oxford Knee Score and range of motion at six weeks, six months and one year postoperatively. P<
0.05 was considered statistically significant. Despite improvements in knee prostheses design, patient factors and surgical technique remain the most important determinants of outcome in primary TKA, particularly ROM.
Retrospective review of four thousand two hundred and fifty-two patients undergoing TJR at a single high-volume arthroplasty centre to determine prevalence and timing of myocardial infarction (MI) following TJR. The incidence of peri-operative MI was 1.5%, with a mean of three days to time of MI. This cohort was comprised of 55% females with a mean age of seventy-five years. We found poor correlation between pre-operative risk assessment using the Modified Multifactorial Index score. Our findings suggest that there is a minimum length of stay compatible with patient safety given the inadequacy of currently available preoperative risk assessment tools. This study was undertaken to evaluate the prevalence and timing of peri-operative myocardial infarction in patients undergoing total joint replacement (TJR). Despite the pressure toward decreasing length of stay following TJR surgery, we suggest that there is a minimum length of stay compatible with patient safety given the inadequacy of currently available preoperative risk assessment tools. The prevalence rate of peri-operative MI was 63/4252(1.5%), with a mean time of three days (range 0–18) to MI. Furthermore, there was a predominance of females (55%) and a mean age of seventy-five years among this cohort. We found poor correlation between pre-operative risk assessment using the Modified Multifactorial Index score. Patients who suffered an acute MI following elective TJR surgery between April 1998 and April 2003 were abstracted from the Hospital CIHI database of four thousand two hundred and fifty-two patients. The role of preoperative risk assessment and risk reduction strategies were also evaluated. The previously reported rate of MI is 0.3 % and 0.9% following unilateral and bilateral TJR respectively. The reported frequency of MI tends to increase with older age (>
70 yrs) and male gender. There is emerging information that these rates may be grossly under-estimated. Prosthetic arthroplasty is major surgery and regardless of the surgical technique, patients remain at risk for complications.
Historically, cemented THA femoral stems inserted in varus have yielded poor clinical results. Very few studies to date have addressed the question of the effects of varus alignment on uncemented stems. We have conducted a retrospective review of one hundred and twenty-five uncemented THA femoral stems implanted by a single surgeon from 1994 to 1999. Within this single surgeon group we were able to identify sixteen stems implanted in varus and thus proceeded to analyze the effect of varus alignment on functional outcome. To assess functional and radiographic outcome of uncemented primary THA femoral stems implanted in varus. After four-years of follow-up, there have been no radiographic or clinical problems associated with implanting uncemented femoral stems in varus. Although it is not recommended to implant stems in varus, radiographic and clinical problems associated with implanting uncemented femoral stems in varus appear to be non-consequential. Of the study sample, one hundred and sixteen hips were in neutral alignment as compared to sixteen varus hips. We could not show any significant difference in Harris Hip scores between the varus and non-varus hips (p>
0.5). No cases showed evidence of radiographic loosening, or subsidence (p=0.3) at four-year follow-up. Retrospective radiographic review of one hundred and twenty-five uncemented primary THA femoral stems implanted by a single surgeon (now retired) from 1994 to 1999, using the Watson-Jones approach, identified sixteen femoral stems implanted in varus. These sixteen stems were matched 1:1 for demographics and preoperative diagnosis to a cohort of sixteen non-varus uncemented stems implanted by the same surgeon over the same study period. Functional outcome included Harris Hip score and range of motion at four-years postoperative. Radiographic signs of loosening and subsidence, defined as >
2mm, were measured. Varus alignment was defined as ≥ 5°. Paired t-tests were conducted on all outcome variables, p<
0.05 was considered statistically significant. Study results suggest there to be no consequence of varus femoral alignment in uncemented stems. Patients will need to be followed for a longer duration to further examine the effects of varus implantation of unce-mented femoral stems.
A prospective evaluation was undertaken utilizing the SF12 score, Oxford Knee score, Knee Society Score (KSS), visual analog pain score, and a non-validated questionnaire to determine patient self-perception of leg alignment after knee arthroplasty, and impact of satisfaction with alignment on clinical outcomes. 21/84 (25%) patients were dissatisfied with their new leg alignment and this group subsequently reported greater pain scores (p<
0.001) and lower SF12 scores (p<
0.002). Oxford Scores and KSS showed no difference between groups. We suggest that patient satisfaction with postoperative lower extremity alignment is an important issue affecting subjective outcomes in total knee arthroplasty (TKA). This study was undertaken to determine how patients perceive their leg alignment after knee arthroplasty and whether their level of satisfaction with alignment affects clinical outcomes. The results of this study suggest that there may be some benefit to preoperative counselling on what to expect in regard to leg alignment following surgery. Additionally, given the adverse impact of dissatisfaction with limb alignment on subjective outcomes, we suggest that patient satisfaction regarding leg alignment should be considered for inclusion in the design of subjective outcomes measures for total knee arthroplasty. 21/84(25%) patients were dissatisfied with their new leg alignment while all but one had an anatomic axis between 4–100 valgus radiographically. This group subsequently reported greater pain scores (p<
0.001) and lower SF12 scores (p<
0.002). At six months follow-up, there was no difference between groups on the Oxford Knee or KSS (p>
0.05). A non-validated questionnaire was utilized to prospectively ask patients to self-rate their alignment, their satisfaction with their alignment, and their pain scores on a visual analog scale (VAS). Additional outcome measures included pre and postoperative SF-12, Oxford Knee and KSS. There is still no consensus regarding any one single scoring system with regard to clinical outcomes of primary TKA. Also, it has been widely reported that surgeons often perceive outcomes of TKA with more success than patients. 21/84 of our patients were dis-satisfied with their alignment while all but one had an anatomic axis between 4–100 valgus radiographically.
It is known that activity level correlates with wear in total joint arthroplasty. UCLA activity score surveys were sent to four hundred and sixty-seven knee and hip arthroplasty patients with good/excellent clinical outcomes as determined by one-year postoperative Knee Society (KSS) and Harris Hip (HHS) scores. The UCLA activity score was correlated with clinical outcomes and demographic data. Average UCLA score was 6.2 for hips, 6.3 for knees, indicating moderate activity levels. Hip arthroplasty UCLA score significantly correlated with age, gender and one-year Oxford score. Knee arthroplasty UCLA score significantly correlated with gender, one-year functional KSS and Oxford score. Arthroplasty patients are often warned to avoid high level activities for fear of implant loosening, failure or increased polyethylene wear. Patients with good/excellent clinical outcomes may however be inclined to participate in higher demand activities. There is need for specific information regarding patient profile and activity level following TJR. Current recommendations for activity among TJR patients may not be justified. Longer-term follow-up will elucidate specific activities which may be permissible or detrimental to implant survivorship. Survey response rate was 70.2% among THA patients at mean 40.7months. Mean UCLA score was 6.2/10, indicating moderate activity. Mean outcome scores; one-year HHS 94.8, Oxford 6.6. UCLA score significantly correlated with age, gender and one-year Oxford. Survey response rate was 81.8% among TKA patients at mean 36.6months. Mean UCLA score was 6.3/10, indicating moderate activity. Mean outcome scores; one-year KSS clinical 95.9, KSS function 95, Oxford 18.2. UCLA score significantly correlated with gender, one-year KSS function and Oxford. No significant differences among clinical outcomes and survey non-respondents. UCLA activity score survey of two hundred and twenty-five primary TKA and two hundred and forty-two primary THA patients. Patients abstracted from prospective database and pre-selected for good/excellent outcomes based on KSS and HHS at one-year. Clinical outcomes included Oxford Hip/Knee scores. UCLA, demographics and clinical outcomes correlated using Pearson’s correlation. UCLA scores indicate the average TJR patient maintains a moderate activity level. Younger male patients with low Oxford can be expected to participate in higher level activities. One THA patient underwent subsequent revision despite moderate activity level.
A radiographic review of sixty-nine lateral closing wedge high tibial osteotomies and forty-two medial opening wedge osteotomies was conducted. Patellar height and tibial slope were measured. The Blackburne-Peel (BP) and Insall-Salvati (IS) ratios were used to measure patellar height. Our results show that 18.8% and 47.6% of the lateral closing wedge group had patella-infera (PI) according the the BP and IS ratios respectively. No opening-wedge cases demonstrated patella infera with either ratio. Tibial slope was found to be significantly more neutral in the closing wedge group versus the opening wedge (−2.2° vs. −7.28° respectively). Patients undergoing HTO typically require a definitive arthroplasty procedure at an average of six years post-HTO. Total knee arthroplasty can be complicated by the presence of PI which compromises exposure and increases the risk of patellar tendon avulsion leading to suboptimal results. The current study compares the incidence of PI between lateral closing and medial opening wedge HTO’s. Conversion of opening wedge HTO to TKA should have less technical challenge and improved outcomes as compared to lateral closing wedge HTO conversions. This is attributable to the absence of PI. Of the closing wedge group, 18.8% and 47.6% were found to have PI according to the BP and IS ratios respectively. Of the opening wedge group there were no cases of PI found with either ratio. Tibial slope was found to be significantly more neutral in the closing wedge compared to the opening wedge group (−2.2° vs. −7.28° respectively). The study cohorts were abstracted from surgeon records. Sixty-nine closing wedge and forty-two opening wedge HTO’s were identified. Lateral 30° flexion x-rays were measured for patellar height and tibial slope. Both the Blackburne-Peel (BP) and Insall-Salvati (IS) patellar height measurements were used. From this data we can conclude that in our study population the incidence of PI in the opening wedge group was 0% thus negating the potential deleterious effects of PI at the time of knee arthroplasty.
A retrospective review was conducted to evaluate short-term (one year) outcomes of primary total knee arthroplasty (TKA) patients receiving Ontario Worker’s Safety and Insurance Board Benefits (WSIB) compared to a matched cohort of non-WSIB patients. Postoperatively, WSIB patients had higher pain scores, poorer self-perceived functional outcomes and lower flexion range. WSIB patients required more postoperative clinic visits and were more reluctant to answer questions regarding functional outcome. All differences were statistically significant. The short-term outcomes of primary TKA in patients receiving WSIB benefits are inferior to those obtained by non-WSIB patients. Retrospective review to evaluate short-term outcomes of primary TKA patients receiving WSIB as compared to non-WSIB patients. Short-term outcomes of primary TKA in WSIB patients are inferior both subjectively and objectively to non-WSIB patients. WSIB patients are seen more frequently for postoperative follow-up which we would attribute to the persistence of subjective complaints following primary TKA. Short-term outcomes of primary TKA in WSIB patients are inferior to those obtained by non-WSIB patients. WSIB patients undergoing primary TKA require more postoperative visits with a greater prevalence of subjective postoperative complaints. Thirty-eight WSIB patients who underwent primary TKA were matched to thirty-eight non-WSIB patients. There were no statistical differences in preoperative Knee Society (KSS) and Oxford Score. Six-week total KSS (p=0.011), pain as measured by KSS (p=0.015), and flexion (p=0.012) were significantly different between the groups. At six-months similar results were noted among KSS function (p=0.027) and pain (p=0.024), Oxford Score (p=0.027), and flexion (p=0.035). One-year Oxford Score (p=.011) and flexion (p=0.013) were statistically significant, as were the McGrory Modified Knee Score (p=0.001), patient expectations (p=0.030), perceived quality of life (p=0.009), and number of postoperative clinic visits (p=0.024). Retrospective review on successive WSIB patients undergoing primary TKA, at a single arthroplasty centre, matched to a cohort of non-WSIB patients for demographics and preoperative diagnosis. Outcomes included Knee Society, Oxford Knee, and McGrory et al Modified Knee scores, patient satisfaction, and number of postoperative clinic visits. Unpaired t-tests were used to determine differences in outcomes. There are few reports but many allusions regarding inferior outcomes of TKA in WSIB patients. Our study provides further evidence to support this view. Multiple factors may account for this variance, including psychosocial factors. Further prospective studies are needed to address this burgeoning issue.
Metal-on-metal bearings for total hip replacement (THR) are becoming increasingly popular. Improved wear characteristics mean that these articulations are being inserted into younger patients in the form of THR and resurfacing procedures. This has led to concerns regarding potential carcinogenicity because of the increased exposure to metal ions that the procedure brings. We have studied the serum cobalt and chromium concentrations in patients who had primary, well-fixed Ring metal-on-metal THRs for more than 30 years. The levels of cobalt and chromium were elevated by five and three times, respectively compared with those in our reference groups. Metal-on-metal articulations appear to be the source of metal ions throughout the life of the prosthesis. In three patients who had undergone revision of a previous metal-on-metal THR to a metal-on-polyethylene replacement the levels of metal ions were within the normal range. The elevations of cobalt and chromium ions seen in our study were comparable with those in patients with modern metal-on-metal THRs.
Treatment of OA of the shoulder in young and active patients remains a problem. Present treatment options are debridement, microfracturing, arthrodesis or shoulder replacement. We report the preliminary results of soft-tissue interposition arthroplasty with an acellular allograft skin-derived collagen matrix (Graft Jacket®, Wright Medical). Between July and December 2003 five men and one woman with severe glenohumeral OA had a soft-tissue interposition arthroplasty of the shoulder. The mean age of the patients was 47 years (34 to 58). In four patients the procedure was done arthroscopically. The Graft Jacket® was sutured to the labrum with a minimum of five sutures. The mean postoperative follow-up was 6.2 months. Four patients experienced notable pain relief after the operation. Preoperatively the mean visual analogue pain score was 7.2 and postoperatively it was 2.6. One patient had no improvement and elected to wait before having further treatment. One patient needed a hemi-arthroplasty. The range of motion improved in only one patient. The mean Constant score improved 14 points, from 45 to 59. There were no complications peroperatively or postoperatively. While the long-term results are still unknown, soft-tissue interposition arthroplasty with the Graft Jacket® shows promising results.
External rotation of the shoulder is commonly measured in two ways, with the arm adducted or with the arm abducted to 90°. The measurement forms an important part of the assessment of shoulder function, but has been shown to be unreliable. Following the observation that, with the arm adducted, the range of external rotation alters according to the exact position of the arm in the sagittal plane, we conducted a study to quantify the effect on the range of external rotation of a small increment in forward flexion (15°). With the arm first in a vertical position and then in 15° of forward flexion, external rotation was measured in 40 asymptomatic and 20 ‘frozen’ shoulders. With forward flexion, the range of external rotation decreased by a mean of 16.9° in the asymptomatic and 13.5° in the ‘frozen’ shoulders. We postulate that some of the variation is a function of scapular positioning. With arm flexion, the scapula protracts, resulting in alteration in glenoid version. However, some difference is due also to alteration in soft tissue tension in the two arm positions. The sagittal position of the arm affects the range of external rotation of the adducted shoulder. This variation in measurement may affect the scores of certain outcome measures.
Little has been written about the results of isolated acromioclavicular joint (ACJ) resection using the superior approach. We report the results of our large series. Between June 1994 and October 2003, a single surgeon performed 155 isolated ACJ resections, using the direct superior approach. Exclusion criteria were previous ipsilateral shoulder surgery, simultaneous arthroscopic procedures and OA. We asked 90 of the patients (94 shoulders) to complete the Simple Shoulder Test questionnaire by telephone. The median age of the 72 males and 18 females was 38 years (16 to 62). The dominant shoulder was involved in 54 patients. There was a history of trauma in 44 patients, with 11 rugby injuries. The median follow-up period was 29 months (6 to 118). One portal infection resolved with debridement and antibiotics. Five revision procedures were done, four open revision Mumfords and one subacromial decompression. The mean postoperative Simple Shoulder score was 11.5 (6 to 12). Patients rated outcome as excellent in 63 shoulders, good in 22, moderate in five and poor in four. The technique provides consistently good or excellent results (90%) and allows rapid return to normal function. There was complete resolution of pain in 73 of the 94 shoulders. All rugby players returned to the same level of play.
The shape of the glenoid can vary between pear and oval, depending on the presence of a glenoid notch. We measured the glenoid notch angle (the angle between the superior and inferior part of the anterior glenoid rim) in 53 embalmed cadavers and investigated its relationship with the labral attachment to the glenoid at that point. The attachment of the anterosuperior labrum at the site of the glenoid notch was classified as tight or loose or, in some cases, there was a sublabral foramen. The anterior labrum was then removed and digital images perpendicular to the glenoid notch were taken. Using a digital image analysis program, the angle of the glenoid notch was measured. In 37 shoulders (70%) the attachment of the labrum at the site of the glenoid notch was assessed as tight and in eight (15%) as loose. In eight shoulders (15%) a sublabral foramen was found. The mean glenoid notch angle was 153° in the loosely attached group, 159° in the sublabral foramen group and 168° in the group with a tight attachment. The presence of a glenoid notch was noted only when the glenoid notch angle was less than 170°. The glenoid notch angle is related to the attachment of the labrum. In the presence of a glenoid notch, there is more likely to be a loosely attached labrum or sublabral foramen. The loose attachment of the anterosuperior labrum may be a predisposing factor in traumatic anterior instability.
The management of bony lesions associated with glenohumeral instability is the subject of debate. Invariably some time elapses between injury and surgery, during which atrophy may reduce both size and quality of the bone. The main purpose of our study was to assess the viability of the bone. Histomorphometric bone analyses were prospectively performed on glenoid fragments harvested from 21 male patients during modified Latarjet operations. Their median age was 21 years (16 to 50). Rugby was the main sport of 64% and water sports (surfing, water polo, water skiing) of 21%. The mean glenoid bone loss on CT scan was 17% (10% to 50%). In 33% of patients, bone loss exceeded 20%. Gross morphology of glenolabral fragments identified a single large fragment in 11 patients, a dominant large fragment with smaller fragments in seven, and multiple fragments in the remaining patients. The mean volume of bony fragments was 2.18 ml (1 to 3) and the mean mass was 1.64 gm (0.43 to 2.8). Histological examination revealed that there was no bone in three of the 21 specimens. Bony necrosis was present in eight of the 18 specimens that contained bone (44%). Given the histopathological findings, attempts to reattach these devitalised bone fragments by screws or anchors may fail and lead to recurrent instability.
Calcific tendinitis of the shoulder is a common cause of shoulder pain and is usually treated conservatively initially. We evaluated the ultrasound-guided needling procedure for calcium deposits in the rotator cuff. Between 2002 and 2003 eight men and 18 women (mean age 49 years) with calcific tendinitis of the shoulder were treated this way. The mean duration of symptoms was 29 months. Before the procedure, the skin and subacromial bursa were infiltrated with local anaesthetic. The calcium deposit was perforated and aspirated when possible. With saline, a lavage was done to wash out the calcium. Eleven patients (42.3%) had marked improvement in pain and needed no further treatment. Four patients required a reneedling procedure, and four patients needed repeated subacromial injections during the absorption phase of the calcium. In six patients arthroscopic calcium removal was needed. The mean visual analogue pain score during the procedure was 2.63. There were no complications. The ultrasound-guided needling procedure is an effective and well-tolerated method of treatment of calcific tendinitis of the shoulder and in 77% of our cases there was no need for surgical removal. Where there is incomplete dissolution, the procedure can be repeated.
The research question was: can Arthroscopic or open biopsies were obtained, with informed consent and institution-approved review protocol, from patients undergoing total shoulder replacement or orthopaedic interventions for end-stage rotator cuff deficiency or arthropathy. Chondrocytes were isolated from eight biopsies and cells cultured over 4-weeks. In the first week post-digestion, validation studies showed cell counts varying from 30 000 to 400 000 (mean 126 666) and viability ranging from 30% to 100% (mean 75.2%). No primary culture failures were observed. One of the eight had an unexplained lower cell count and viability. Viability exceeded 80% in six of the eight cultures (75%). Alcian Blue stains and flow cytometry (Facscan) confirmed stable cultures with matrix formation. Aggrecan studies are in progress. The fact that
With widely reported co-existence of impingement syndrome and acromioclavicular joint (ACJ) disease, some surgeons recommend that ACJ resection be combined with subacromial decompression. From 1998 to 2003, 201 patients with symptomatic ACJs were taken to theatre. Bursoscopy was performed on 129 males and 54 females, those patients who had previously undergone ipsilateral shoulder surgery or had sonographically-proven rotator cuff tears being excluded. The mean age was 41 years (16 to 72). The preoperative diagnosis was isolated ACJ disease in 136 patients and combined ACJ disease and impingement in 47. Bursoscopy revealed no abnormalities in 124 of the 136 patients in whom isolated ACJ disease was diagnosed. In two patients, minimal bursal fraying was noted but no decompression was performed. Significant ‘impingement lesions’ were seen in 10 patients, all of whom were over age 35 years. Symptomatic ACJ disease coexisted with impingement (lesion or signs) in only 57 of 183 patients (31%) patients. With careful preoperative evaluation, unnecessary surgery is avoidable.
Immunosuppression following intra-articular injections of steroid into the hip may interfere with asepsis in a subsequent total hip arthroplasty (THA). We have undertaken a retrospective, matched, cohort study of infective complications after THA, in 40 patients who had received such an injection and 40 who had not. In the injection group there were five revisions, four of which were for deep infection. There were none in the matched group. The overall rate of revision in our database of 979 primary THAs was 1.02%. Six additional patients who had received injections underwent investigation for infection because of persistent problems in the hip as compared with one in the control group.
The operative method was similar in all cases: the non-union was exposed through a delto pectoral approached and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone a T-plate could then be applied to the humerus with the screws directed into the intramedullary fibular peg. Cortico-cancellous bone from the Iliac crest was supplemented.
Pre-operative constant scores: Average 26 Post-operative constant scores: Average 75 The most significant increase in constant score was the ability to actively elevate the arm. Decrease in pain levels did play a role but was not as dramatic as the increase in function.
This study was to evaluate the stability of a delta keel tibial tray using a block prosthesis and to determine whether a long intramedullary stem is a necessary adjunct to augment construct stability. An experimental technique was used employing strain gauges and deflection transducers to assess the stiffness and principle strains conferred to human cadaveric tibiae under various axial loading conditions. As a control measure, tests were conducted in the absence of any bone loss, and repeated in a simulated bone defect treated with a metal block. The latter was analysed with and without augmentation of the tibial tray with an intramedullary stem. With axial loading of 2000N, the tray and block configuration resulted in 21% less proximal bone strain than the tray alone. The combined tray, block and stem resulted in 35% less proximal bone strain than the tray alone. Using the tray and block produced 1.06 times more deflection of the tibial tray and using the tray, block and stem 1.03 times more deflection of the tibial tray than the tray alone in the absence of a bony defect. There was no statistical difference in overall construct stability (p <
0.05) despite the large strain-offsetting effect recorded using the tibial tray in conjunction with the block and stem These results suggest that isolated bone defects that can be dealt with using a single block and modern standard tibial tray may not require additional supplementation with a long intramedullary stem.
This paper looks at technical details and other issues in 30 primary total hip arthroplasty procedures performed through a direct lateral exposure in which the skin incision was limited according to the preoperatively templated acetabular component external diameter (D), using a formula D/2 + 1cm. All patients were positioned in the lateral decubitis position and stabilised with a vacuum beanbag. Unpaired t-tests were used to determine difference in outcome between these patients and those operated on conventionally. No differences were noted between the two groups with regard to preoperative diagnosis, Oxford Hip Score, Harris Hip Score, demographic details, and body mass index. No statistically significant differences were noted with regard to operation time, blood loss, postoperative narcotic requirements, time to mobilise, length of hospital stay, postoperative complications and six-week postoperative Harris Hip and Oxford Hip functional outcome scores. The mini-incision technique does not appear to carry short-term advantages for the patients. We did not encounter technical problems, but the mini-exposure does create technical challenges that could potentially have an adverse effect on the ultimate outcome. We do not advocate its use.
This paper retrospectively reviews the type and outcome of shoulder surgery in 61 professional rugby players (mean age 24.7 years). All competed at provincial level or higher, with 20 competing internationally. Forty-three of the patients played the position of forward, while 33 played back. Most shoulders (41) were on the dominant side. Ten players had multiple procedures and over a seven-year period 76 procedures were performed. The procedures included 16 Latarjets, four arthroscopic stabilisations, four SLAP repairs, four arthroscopic shoulder decompressions, three biceps tenodeses, three HAGL repairs, two revision Latarjets, one posterior Bankart, one pectoralis major repair, one Weaver-Dunn and four combination procedures. All but two players returned to their previous level of competition. The mean time to return to full contact participation was 3.6 months (1 to 12). The time to return was one month for an arthroscopic Mumford and six months for a stabilisation procedure.
The outcome of the shoulder Delta prosthesis in 22 men and nine women was prospectively studied. The mean age was 74 years (62 to 86). Indications for surgery were cuff deficient arthritis (18), fracture malunion (three), ‘pseudo-paralysis’ (six) and failed total prostheses (four). The mean preoperative Constant score of 39 increased to 69 (10 to 39) at 33 months postoperatively, with the major increases in the scores for active forward elevation and pain relief. The subjective satisfaction was 79%. Although this was a small series with a short follow-up, early results seem satisfactory.
In this prospective study of partial articular supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically by an ‘all inside’ method, 12 patients (nine men and three women) with a mean age of 31 years (22 to 36) were followed up for a mean of 16 months (8 to 32). The deep partial rotator cuff tears were usually viewed from the glenohumeral joint side. Viewing the subacromial space usually revealed an entirely normal cuff with no sign of subacromial impingement. With the arthro-scope in the glenohumeral joint, the footprint area of the supraspinatus tendon was prepared and one or two anchors, each preloaded with two sutures, were passed through the rotator cuff into the footprint area of the greater tuberosity. The sutures attached to these anchors were passed through the tendon and tied in the subacromial space. The Constant score improved from a preoperative mean of 72 to a postoperative mean of 91. The greatest increase was in power and overhead motion, especially abduction and external rotation. PASTA lesions are difficult to diagnose, even with MRI. The ‘all inside’ method of arthroscopic repair obviates the need to detach intact fibres.
This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function.
In a retrospective review, 38 consecutive Workers’ Compensation (WC) patients undergoing primary total knee arthroplasty (TKA) were matched to a cohort of non-WC patients for demographics and preoperative diagnosis. Outcome measures included the Knee Society Score (KSS), the Oxford Knee Score, the McGrory Modified Knee Score (MMKS), patient satisfaction and number of postoperative clinic visits. Unpaired t-tests were used to determine differences in outcomes. Pre-operative KSS, pain and flexion range as measured by KSS, and Oxford scores displayed no statistical differences. The differences in the two groups at six weeks was significant in respect of KSS (p =0.0005) pain as measured by KSS (p =0.015), and flexion range (p =0.012). At six months similar results were noted in pain as measured by KSS (p =0.018), Oxford scores (p =0.005) and flexion range (p =0.035), but KSS function was not significant (p =0.073). One-year Oxford scores (p =0.013) and flexion range (p =0.013) were statistically significant, as were MMKS (p =0.001), patient expectations (p =0.030), perceived quality of life (p =0.009), and number of postoperative clinic visits (p =0.003). The short-term outcomes of primary TKA in patients receiving workers’ compensation benefits are inferior to those obtained by non-workers’ compensation patients. Workers’ compensation patients are seen more often for postoperative follow-up, which we would attribute to the persistence of subjective complaints following primary TKA.
The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure. In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively. In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results.
In this study, 40 patients who underwent total hip arthroplasty (THA) and had a history of previous steroid injections were compared retrospectively with 40 carefully matched patients who underwent THA in the same period but had never received steroid injections. The development of sepsis under standard care was one of the outcome measures. This occurred in 20% of steroid patients within the first 36 months after THA, compared to 0% in the control group. Further, in a detailed analysis of Harris and Oxford scores, patients treated with steroid had a higher incidence of night pain, more severe pain, and greater loss of function in activities of daily living at one year. There were two revisions for deep infection in the steroid and control groups. Based on the incidence of pain and infectious complications in the first postoperative year, and pending completion of the study, we provisionally suggest that steroid injection of hips may be ill advised in patients who are likely candidates for future THA.
The proximity of neural structures to the coracoclavicular ligaments limits the amount of coracoid process that can be harvested. The purpose of this study of 100 dry human scapulae was to define the anatomic limitations. We found the mean measurement of the horizontal arm of the coracoid process anterior to the conoid tubercle was 21.5 mm (SD 0.9 mm). In 10% of the scapulae, it was larger than 30 mm. In 66%, the posterior aspect of the conoid fused with the vertical ramus and the lateral lip of the suprascapular notch. This amount of coracoid appears to be large enough to expand the glenoid vault, and to hold two AO small fragment screws. It can be safely harvested if the conoid ligament is respected. Partial sacrifice of the trapezoid ligament is unavoidable, but does not compromise coracoclavicular stability. If the coracoid osteotomy is extended medial to the conoid tubercle it encroaches on the vertical ramus of the coracoid and can damage the suprascapular nerve. Posterior advancement of the osteotomy can extend onto the anterosuperior glenoid.
We evaluated the clinical outcome of arthroscopic labroplasty in 56 patients treated for shoulder instability owing to ligamentous laxity. In our technique, the antero-inferior labral capsular complex is detached and mobilised from the glenoid. It is advanced superiorly and plicated to create a new labrum, retensioning the capsule and decreasing the articular volume. Usually, a rotator interval plication is also added. Postoperatively, patients wear an adduction sling for three weeks, but movement is permitted within pain limits. The mean time to follow-up, when patients were clinically reviewed and assessed on the Walch-Du Play score, was 26 months (12 to 74). No intra-operative complications or nerve injuries were encountered. There was a single failure with frank redislocation. The mean Walch-Du Play score was 88/100 (10 to 100). Redundant capsule and a hypoplastic labrum are common in unstable shoulders owing to ligamentous laxity. The labroplasty creates a ‘bumper’ and addresses the excess of capsule. In our short-term experience, this arthroscopic technique is superior to the open capsular shift.
Between 1996 and 2001 we used a modification of the Latarjet procedure to treat 70 patients with bony insufficiency of the glenoid. Our modification involves detaching a long piece of coracoid and rotating it to match its concave inferior surface with the surface of the glenoid. The coracoid graft is placed extra-articularly and the capsule repaired with bone anchors to the edge of the glenoid. Postoperatively no sling is applied and rehabilitation is started early. At a mean of 24 months (9 to 72) patients were clinically reviewed and assessed on the Walch-Du Play score. The results were excellent in 68%, moderate in 6% and poor in 1%. There were no redislocations. The results were most satisfactory in this group of patients, most of whom participated in contact sports, where soft tissue procedures (e.g., open and arthroscopic Bankarts) carry unacceptable failure rates.
The capsular shift procedure is done to treat instability due to ligamentous laxity. Usually there is no traumatic avulsion of the labroligamentous tissues. In surgical repair the anterior labrum is separated from the glenoid. The labrum and attached ligaments are shifted superiorly and attached with bone anchors to the decorticated glenoid. The labrum and ligaments are rolled into a soft tissue ‘bumper’ (we refer to this as labroplasty). Arthroscopic rotator interval plication is added to the procedure. For six months to six years we followed up 67 patients treated between 1994 and 2000. There were two cases of recurrent subluxation (3%). Patient satisfaction was high.
The acromion is a bony process that juts out from the lateral end of the scapular spine. It is continuous with the blade and the spinous process. The process is rectangular, and carries a facet for the clavicle. Inferiorly is sited the subacromial bursa. Inferior encroachment or displacement of the acromion can result in impingement. The aim of this osteological study was to assess the presence of acromial displacement and variations predisposing to compaction of the subacromial space. Using the method described by Morrison and Bigliana, we assessed the scapulae of 128 men and women ranging from 35 to 92 years of age. We found a flat acromion in 30%, no hook in 48%, a small hook in 18% and a large hook in 4%. The presence of a hook was associated with a subacromial facet and a large hook with glenoid erosion. This study confirms the presence of four types of acromion.
We discuss aspects of glenohumeral instability and rotator cuff tears in a clinically orientated approach, presenting a new way of quantifying structural bone loss from the anterior glenoid and defining the Glenoid Index as an indicator of the appropriate surgical approach to address anterior instability. Repair of the rotator cuff depends on viable and functional muscular tissue. We discuss the potential for repair of the supraspinatus tendon in relation to the tangent sign, fat infiltration and retraction. Comparing MRI and arthroscopic findings, we highlight pitfalls in the diagnosis and repair of the subscapularis tendon.
Painful conditions of the acromioclavicular (AC) joint are common in South Africa, particularly among sportsmen. These conditions are often treated by open excision of the distal end of the clavicle, but an arthroscopic procedure offers many advantages. From February 1994 to February 2000, we performed 138 procedures. The mean age of patients ({71% men and 29% women) was 29 years (19 to 53). In cases of rotator cuff impingement, arthroscopic acromioplasty was followed by clavicular excision via the subacromial route. With a normal acromion and rotator cuff the AC joint was approached through two superior AC portals, avoiding removal of the AC ligaments. In all cases a standard 3.5-mm arthroscope was placed in one portal for viewing and the mechanical shaver inserted through the other. About 7 mm to 8mm of bone was removed from the clavicle. Patients were in hospital for about a day and 87% were discharged the same day. The mean follow-up time was 34 months (2 months to 4 years). Patient satisfaction was high in 32%, fair in 60% and poor in 8%. Most patients (92%) returned to all previous sports and activities. We concluded that the arthroscopic Mumford procedure is at least as successful as its open equivalent. It can be done as an outpatient procedure and permits a rapid return to activities. Cosmesis is excellent and stability of the AC joint is preserved.
The rotator cuff is sited on the anatomical neck of the humerus and is formed by the insertion of the supraspinatus (SP), infraspinatus (IS), teres minor (TM) and subscapularis. All play a vital role in the movement of the glenohumeral joint, and the anatomy is of critical importance in arthroscopic rotator cuff repair. We undertook an osteological and gross anatomical dissection study of the insertion mechanism of these tendons, in particular the SP . The SP inserts by a triple or quadruple mechanism. The ‘heel’ (medial) and capsule fuse, inserting into the anatomical neck proximal to the anterior facet of the greater humeral tubercle. The ‘foot arch’ inserts as a strong, flat, fibrous tendon into the facet. This area is cuboidal, rectangular, or ellipsoid, and measures 36 mm2 to 64 mm2. In about 5%, the insertion is fleshy (pitted), rendering it weaker than a tendinous attachment. The ‘toe’ lips over the edge of the facet laterally and fuses with the periosteum, fibres of the inter-transverse ligament and the IS. A proximal ‘hood’ of about 4 mm stretches down inferiorly and fuses with the periosteum of the humeral shaft. The subacromial or subdeltoid synovial bursa are sited laterally. The IS and TM insert into the middle and posterior facets (225 mm and 36 mm2) at respective angles of 80° and 115°. The inferior portion of the TM facet is not fused with the shoulder capsule. The subscapularis inserts broadly into the lesser tubercle, and the superior fibres fuse with the shoulder capsule and intertransverse ligament. The insertion of the subscapularis does not contribute directly to the formation of the ‘hood’, which belongs exclusively to the SP, IP and TM. This study confirms the complexity of the SP insertion and suggests that an unfavourable attachment or biomechanical anatomical malalignment may lead to eventual tendon/cuff degeneration.
We have long suspected that patients treated at our institution have narrower femoral canals than the literature suggests. This has implications when it comes to nail size and the question of using reamed or unreamed nails. Using CT analysis, we studied the morphology of the femoral isthmus. We prospectively evaluated 30 men with a mean age of 26 years (20 to 35). Patients with previous femoral fractures were excluded from the study. A scanogram determined the level of the isthmus and axial cuts at this level accurately revealed canal size and shape. We found a canal size of less than 12 mm in 62%. In a third of these, canal size was less than 11 mm. Axial cuts showed three types of femoral canals: 14 patients had thick femoral cortices and a narrow canal, seven had thin cortices and a wider canal, and nine had an oval canal, with the larger diameter in the sagittal plane. If one adheres to the principle of reaming until cortical clutter is heard, the recommended 12-mm or 13-mm reamed femoral nail is not suitable for the majority of non-Caucasian men in our population. Larger nails may cause such complications as delayed union, nonunion and fracture. Smaller nails of 10-mm and 11-mm diameter result in satisfactory clinical and radiological outcomes.
The supraspinatus tendon (SP) often ruptures. Gray established that the tendinous insertion always attaches to the highest facet of the greater tubercle of the humerus. Our osteological study of 124 shoulders in men and women between the ages of 35 and 94 years refocuses on the humeral insertion of the SP in relation to infraspinatus (IS) and teres minor (TM). We found type-I SFs (cubic) in 53 shoulders (43%) and type-II SFs (rectangular or oblong) in 21 (17%). Type-III (ellipsoid) SFs were present in 20 shoulders (16%) and type-IV (angulated or sloping) in 11 (9%). SFs were type V (with tuberosity) in 12 shoulders (10%) and type VI (pitted) in three (2%). The facet area of the SP, IP and TM varied from 49 mm, 225 mm and 36mm2. Of the three muscles, the IS facet was consistently the largest (p <
0.05) and shaped rectangularly. The SP inserted in a cubic or rectangular facet format in 75% of people. SP facet-size may relate to tendon strength, degeneration and rupture. This information may contribute to the understanding of tears of the rotator cuff.
Traumatic atlanto-axial subluxation is a rare injury which may not be revealed on routine radiographs, especially when there is muscle spasm. We report on seven patients with atlanto-axial subluxation as a result of neck injury; only two of them had significant head injuries. Three patients presented with a neurological deficit attributable to the injury, one immediate and two with delayed onset. Traumatic atlanto-axial instability, occurring in an otherwise healthy patient, has a potential for neurological disaster; early consideration of operative treatment is indicated.
Isolated traumatic dislocation of the radial head in children is not as rare as sometimes supposed. Attention to detail in radiographic interpretation is the key to diagnosis. Early closed reduction and immobilisation in an above-elbow plaster in 90 degrees of flexion and full supination for three to six weeks is recommended. Seven cases are presented, two of which were treated operatively and had unsatisfactory results. The applied anatomy, management and complications are discussed.