Introduction and Objective

Joint malleolar fractures have been estimated around 9% of all fractures. They are characterized by different both early and late complications. Among the latter, arthrofibrosis and early secondary arthrosis represent the two most common ones. Moreover, these two complications could be considered related to each other. Their real cause is still under investigation, even if residual post-operative hematoma and acute post-traumatic synovitis appear to be the most accredited. Supporting this hypothesis, joint debridement and the evacuation of the post-operative hematoma could represent a possible solution. The aim of this prospective study is to evaluate the role of arthroscopic lavage and debridement during internal fixation in order to prevent late joint complications.

Total hip arthroplasty following pelvic or femoral trauma presents the joint surgeon with challenges not dissimilar to that of revision surgery. Careful preoperative evaluation and planning, and realistic assessment of risks and expectations is necessary.

Complex acetabular fractures present the surgeon with a variety of challenges in conversion to total hip replacement (THR). Bone stock is the critical factor in achieving a stable acetabular reconstruction, particularly with regard to the posterior column. In patients who have undergone prior open reduction and internal fixation, routine radiographic examination will often be inconclusive as to the status of healing of fractures due to the presence of metal, and CAT scans will be similarly obfuscated by metal artefact. Therefore, the surgeon must be prepared for the possibility of bone stock deficiency at the time of reconstruction.

Subclinical infection following ORIF is possible; all patients should be screened for this possibility with preoperative determination of the ESR and C-reactive protein. If these studies are elevated, aspiration of the hip under x-ray or ultrasound guidance should be considered. At the time of surgery, it is suggested that cultures be obtained prior to the administration of systemic antibiotics, and consideration given to intraoperative frozen section examination of tissue if infection is suspected. Removal of internal fixation devices, debridement, and second stage reconstruction after appropriate antibiotic therapy will be necessary in these cases.

Exposure of the hip will be complicated by scar tissue. Particular care is required to avoid sciatic nerve injury during the exposure and hardware removal. Extension of the hip and knee during posterior exposure of the acetabulum and internal fixation devices will aid in retraction and avoidance of neuropraxic sciatic injury.

Stainless steel screws and plates should not contact titanium alloy implants in order to avoid the possibility of fretting wear and corrosion of dissimilar metals. Intraarticular exposure of screws or plates mandates removal of the device. In the absence of such exposure, hardware may be left in place.

Post-traumatic hip arthritis is frequently associated with avascular necrosis of the femoral head. It is not unusual to see advanced bone loss and collapse of the femoral head, with associated limb shortening. If internal fixation has been performed in the proximal femur, consideration of the appropriate femoral component length is necessary to bypass any stress risers. Calcar replacement implants will be necessary in the face of proximal femoral deficiency.

The risk of dislocation following THR in the setting of post-traumatic arthrosis is increased in the presence of soft tissue defects, abductor dysfunction, or neuromuscular deficit. Postoperative bracing may be necessary to assure stability of the reconstruction. The use of a THR orthosis set at 10–15° abduction, 30–60° flexion for 12 weeks following surgery has been successful in preventing dislocation in the setting of abnormal soft tissues.

The different spatial sideway of geodes in the same femoral head, their number, dimensions, origin, suggested to us the present document. Before now, it has already been analysed cystic hollows in primary arthrosis. Actually on our study, we relate the outcomes regarding the same phenomenon in rheumatoid arthritis.

Materials and methods. We choose femoral head previously scheduled, considering the same pre-operatory radiographic weightiness diagrams. These were undergone to a parallel and vertical planes cut among them. On three millimetres thickness slices, thanks to constant radiographic enlargement by semiautomatic images analyzator, we detected the number, site and dimensions of geodes. The data obtained, formed into a groups for quadrant (limited by two orthogonal planes crossing the centre of rotation), has been treated by statistical analysis (Anova and t-test).

Results and conclusions. According to preliminary results, it would turn out just one difference between the geodes observed in primary arthrosis and in hip arthrosis secondary to rheumatoid arthritis. This difference it consists in the dimension of cystic hollows that are bigger in rheumatoid arthritis according to the phisiopathology and anatomopathologic particularities.

Introduction and Objectives: Treatment of arthrosis secondary to massive rupture of the rotator cuff using anatomical prostheses has offered limited results. The growing use of inverted prostheses, with biomechanics completely different from anatomical prostheses, have given promising results and offer an alternative treatment for this problem as well as other functionally-similar pathologies.

Materials and Methods: This multicentre study included 25 patients with Delta III inverted prostheses (IP) from Puy®, with a minimum follow-up period ranging from 3 to 22 months. There were 23 females and 2 males in the study. Average age was 71.04 years. Pre-operative diagnoses included arthrosis secondary to massive rupture of the rotator cuff (15), prosthesis revision (4), fracture sequelae (3) and acute fracture (3). Average preoperative Constant score with secondary arthrosis was 21.

Results: Evaluation using the Constant scoring system yielded the following mean results: secondary arthrosis of less than 6 months progression: 55.75; greater than 6 months progression: 58.14; prosthetic replacement at less than 6 months of progression: 32; and fracture sequelae of more than 6 months progression: 47.66. There was one postoperative dislocation, which required corrective surgery, and one infection that required surgical cleaning.

Discussion and Conclusions: 1). Good results were achieved using inverted prostheses in the treatment of arthrosis secondary to massive rupture of the rotator cuff (average 37 point improvement in Constant score.) 2). Limited results were attained for other conditions. The most significant result was reduction in pain.

Purpose: Glucosamine-based massage cream has been developed by an Israeli company (Manon Pharmaceuticals). Prior literature indicates that a single study performed about 30 years ago has demonstrated a certain efficacy of a glucosamine containing topical formulation for the treatment of gonarthrosis.

Materials and Methods: Eighty patients suffering from grade 2–3 degenerative changes of the knee were randomized and received either a menthol based cream or a glucos-amine-containing formulation. The study was approved by the institutional Helsinki committee. Patients were evaluated pre treatment using the VAS pain measure as well as the KSS score. Standardized radiographs were evaluated as described by Ahlbeck to evaluate the stage of articular cartilage degeneration. Exclusion criteria were grade 1 and 4, inflammatory arthritis and Charcot arthropathy. Patients employed the massage cream on a tid basis for a minimum of one month. Patients were followed for a minimum of 6 months. Medication usage was evaluated during follow-up.

Results: Improvement was noted in 32 of 40 patients (defined as VAS improvement by 20 percent or more) of the experimental group and in 12 of 40 patients of the control group. KSS scores improved in 21 of 40 patients of the experimental group by 5 points or more at the 6 months time-point. Only 5 patients in the control group demonstrated similar improvement.

Conclusions: Some improvement is noted in symptoms by the use of topically applied glucosamine- containing massage cream in knee arthrosis. However many questions remain un-answered. What is the mechanism of action of topically applied glucosemamine? Does it penetrate skin and capsule to reach the cartilage and synovium? What is the role of the placebo effect in the treatment of joint symptoms in osteoarthritis, a disease typified by an undulating clinical course.

Sacroiliac joint (SIJ) fusion is a controversial yet last resort operative technique to address SIJ pain. The current study aims to determine the patient outcomes of SIJ fusions, in a single surgeon series utilising an anterior approach with 2 DC plates across the joint and iliac crest autograft.

Retrospective case series involving 11 patients who had 13 SIJ fusions performed over an 8 year period (2002–2010). Patients were identified by electronic key word search from databases at Middlemore hospital and the private sector. Dictated clinic letters and operation notes were reviewed to obtain demographic data and outcomes data including complications. Postoperative radiology reports were reviewed to document radiographic fusion status. Telephone interviews were conducted to measure clinical outcome scores via the Majeed Pelvic Score and the 12-item Short-Form Health Survey (SF-12).

10 out of 11 patients (entailing 12 SIJ fusions) responded and participated in the study, equating to over 90% follow up. 2 cases were managed at Middlemore Hospital, with the remainder in the private sector. All cases but one had a ‘post-traumatic arthritis’ etiology. Diagnosis was made by CT guided local/steroid injection into the joint in conjunction with CT/bone scan/MRI imaging. The Majeed score improved markedly for 9 of 12 SIJ fusions (75%). 10 of 12 patients stated they would have the procedure again. 7 of 12 fusions (58%) had postoperative complications including blood loss, haematoma, nerve injury (including one case of permanent foot drop), non-union, infection of the joint/metal ware, hernia and urinary retention. 5 of 12 fusions (42%) experienced altered sensation over the lateral femoral cutaneous nerve distribution. All except one patient eventually had x-rays or CT scans postoperatively that reported radiographic fusion of the joint.

In appropriately selected patients with SI joint arthrosis, 3/4 patients reported significant improvement in function and pain level after SIJ fusion. Chronic pain (from other sources) and major complications were a feature amongst those failing to benefit. Lateral femoral cutaneous nerve palsy has high incidence with the current operative technique.

Purpose: Facet joint arthrosis is an entity that can have a key role in the etiology of low back pain, especially with hyperextension, and is a key component of surgical planning, especially when considering disc arthroplasty. Plain films and MRI are most commonly utilized as the initial imaging of choice for low back pain, but these methods may not truly allow an accurate assessment of facet arthosis. Our purpose was to observe the inter- and intraobserver reliability of utilizing CT and MRI to evaluate facet arthrosis, the inter- and intraobserver reliability of the facet grading system, and the agreement of surgeons as to when to perform disc arthroplasty after the lumbar facets are evaluated.

Method: A power analysis was performed which showed we would need 6 reviewers and 43 images to have 80% power to show excellent reliability. 102 CT and the corresponding MRI images of lumbar facets were obtained from patients who were to undergo lumbar spine surgery of any type. 10 spine surgeons and 3 spine fellows reviewed the randomized images at 2 time points, 3 months apart, graded the facet arthosis as well as indicated whether they would chose to perform a disc arthroplasty based on the amount of facet arthrosis. Both interobserver and intraobserver kappa values were calculated by result comparison between observers at the two time points and between CT and MRI images from the same patient.

Results: interobserver reliability for MRI was 0.21 and 0.07(fair to slight agreement), and for CT was 0.33 and 0.27(fair agreement), for the spine surgeons and spine fellows respectively. The mean intraobserver reliability for MRI was 0.36 and 0.26 (fair agreement) and for CT was 0.52 and 0.51 (moderate agreement). The kappa value for agreement of whether to perform a disc arthroplasty after grading the facet arthrosis utilizing MRI was 0.22 (fair agreement) and utilizing CT was 0.33 (fair agreement) among the senior spine surgeons.

Conclusion: The existing grading system for facet arthrosis and of whether to perform a disc arthroplasty utilizing the grading system has at best only fair agreement. CT is more reliable for grading facet arthrosis.

Rotational acetabular osteotomy (RAO) is a circumacetabular osteotomy of the acetabulum designed to correct the dysplastic hip. In this procedure, the femoral head is covered with the articular cartilage of the acetabulum and the forces of weight-bearing are distributed more evenly. The purpose of this study was to determine whether RAO is effective in delaying the onset of arthrosis in patients with painful hip dysplasia.

We determined the outcome of 20 female patients in whom RAO was performed between 1975 and 1984; all were aged 20 to 29 years at the time of surgery. The pre-operative centre-edge angle of Wiberg was 0 or negative with proximal subluxation of the femoral head. Of these, 10 were lost to follow-up before the age of 42. In these patients, however, radiographs showed no signs of arthrosis at the last follow-up. The remaining 10 patients were examined 15 to 25 years after surgery, when they were 42 to 47 years old. Radiographs revealed findings of arthrosis in only two of them who had had the secondary acetabulum before surgery.

To evaluate the efficacy of preventive medicine, it is necessary to compare the results of intervention with the natural course of the disease. Wiberg reported on the natural history of seven female patients with severe hip dysplasia in 1939. When these patients were 13 to 34 years old, radiographs demonstrated no sign of arthrosis and the centre-edge angle was equal to or less than 12 degrees with proximal subluxation of the femoral head. These hips deteriorated to advanced arthrosis by the age of 42 years. Thus the outcome of our patients was significantly better than the natural course.

In conclusion, our study suggests that RAO is effective in delaying the onset of arthrosis in patients with painful hip dysplasia.

Between 1998 and 2007, fifteen patients with haemophilia A underwent 21 ankle arthrosco-pies+/− arthroscopic cheilectomy in order to attempt symptomatic relief of arthrosis and to increase the range of motion. All patients had severe degenerative changes radiologically.

Perioperative management was shared with our local dedicated Haemophilia service and the management algorithm will be presented.

Outcome data for pain and range of motion shows only moderate benefits.

Two patients had good relief of symptoms for 6 months. Two patients however chose to return for arthroscopies to the contralateral ankle and two had arthoscopies to the same ankle.

Follow up data is not currently available for 4 patients and the rest required fusion with a median time to fusion of 1 year.

Two patients had a documented increased range of motion, but one of these patients had an increased level of pain associated with the increased mobility.

There was 1 major complication, namely an aneurysm of the tibialis anterior artery.

Two patients had recurrent bleeds following surgery requiring ongoing and prolonged factor VIII treatment.

Average patient stay was 3.1 days, range 2 to 5 days and this stay is shorter for later years than earlier years.

The post-operative requirement for extra factor VIII ranged from 4 postoperative doses to 3 weeks ongoing treatment, median 10 doses. The average cost per dose was approximately £1128, giving a median cost of £11280 per case.

In summary, this procedure seems to be expensive in terms of QALY gains and has low rates of success in terms of function and pain relief.

Introduction: In the last ten years there is a clear favour toward internal fixation. We evaluated the technique and the clinical long term results of external fixation in a triangular frame.

Patients and Methods: From 1994 to 2001 a consecutive series of 95 patients with end stage arthritis of the ankle joint were treated. Retrospectively the case notes were evaluated. Mean age at the index procedure was 45.4 years (18–82), 67 patients were male (70.5%). In all cases the arthritic deformity was due to a posttraumatic condition. The index procedure took place on average 129 months (6–516 months) after trauma. Preoperatively 43 patients had a relevant mal-alignment. In 41 patients the range of motion (ROM) was decreased with a remaining ROM of < 20°, in further 37 cases the remaining ROM was < 10° ROM. Via a bilateral approach the malleoli and the joint surfaces were resected. An AO fixator was applied with four Steinmann-nails inserted. Follow up examination at mean 4.4 years included a standardised questionnaire and a clinical examination including the criteria of the AOFAS-Score and radiographs.

Results: In all cases the index procedure was possible although in 2 cases soft tissue contracture meant that a pes equinus position of approximately 15° was required. After mean 12.3 (8–16) weeks radiographs confirmed satisfactory union and the fixator was removed. There were no cases of DVT or PE detected in the postoperative period. In 9 cases (10.1%) we saw a reversible irritation of the dorsal cutaneous nerve. In 18 cases a pin tract infection developed (20.2%) which healed under conservative measures. In one case (1.1%) a bony infection around a pin site developed, one patient suffered a fracture of the tibia at the site of the former proximal tibial pin site due to a minor trauma. In 4 patients a non-union of the ankle arthrodesis developed (4.5%). The mean AOFAS score improved from 20.8 (Std. dev.16.2) to 69.3 at F/U (Std.dev. 21.5, p = 0,004–30, T-test). The largest improvements were found regarding to pain and walking distance. Whilst preoperatively only one patient had mild pain, at follow up 54 patients had no or only mild pain. The maximal walking distance improved from mean 675 metres to mean 3245 m (T-test, p < 0,025 –18). Analysis of the insurance status showed patients that patients insured under a workers injury compensation scheme had a mean score of 63.6 compared to 75.1 for the remaining (T-test, p=0,027).

Discussion: Non-union rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation

Methods: The complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations.

Aims

Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Purpose: The purpose of this study is to investigate the external and internal vascular anatomy of the lunate bone. The genesis of lunatomalacia requires some combination of load, vascular risk and mechanical predisposition. The findings will be correlated with the major existing theories of the cause of lunatomalacia and the most frequent fractures associated with Kienbocks disease: transverse shear fracture and midcoronal fracture. Material and methods: We studied 21 cadaver upper limbs using latex injection and Spalteholz technique. We investigated the extra- and intraosseous blood supply. In 17 wrists we evaluate the incidence and distribution of anatomic features, arthrosis, and soft tissue lesions. Results: The lunate morphology was 5 Type I (29.4%), 11 Type II (64.7%) and 1 Type III (5.9%). The lunate was found to have a separate facet for the hamate in 47.1% (Size 3–6 mm). Most frequent arthrosis was identified in the radius (88.2%) and lunate (94.1%). The triangular fibrocartilage complex (TFCC) was found torn in 47%, the lunotriquetral interosseous ligament (LTIL) was torn in 23.5%, and the scapholunate interosseous ligament (SLIL) was torn in 53% of the wrists. Statistical analysis found a correlation between the presence of arthrosis at the proximal pole of the hamate and the presence of a lunate facet. There was also a correlation between the presence of a tear in the SLIL and the presence of cartilage erosion in the scaphoid (p= 0.002). Arthrosis on the lunate was found to have a correlation with an SLIL tear or TFCC tear. The nutrient vessels entered the lunate throught the dorsal and volar poles in all the specimens. Dorsal vessels enter the bone through one or two foramina in the proximal, ulnar, and nonarticular aspect of the bone. Two to six nutrient vessels were observed entering the volar pole throught a ligament insertion: radioscapholunate ligament of Testut-Kuentz, radio-lunate-triquetrum ligament and ulnar-lunate-triquetrum ligament. Conclusions: The lunate had consistent dorsal and palmar arteries entering the bone in all the specimens. The supply blood and foramina number is more important in the volar pole of the lunate than the dorsal pole. The vascular patterns support a theory of compression fracture from repeated trauma, or anatomical predispositions as the most likely cause of Kienbocks disease

Aims

The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

Aims

The aim of this paper was to investigate the prognostic factors for local recurrence in patients with pathological fracture through giant cell tumours of bone (GCTB).

Aims

The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs.