Summary Statement. A porcine model using Yucatan minipigs was found to be very promising for the investigation of healing around
Introduction. It is well known that blood flow is a critical key component of fracture repair. Previously, we demonstrated that
Aims. The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored,
Conventional amputation prostheses rely on the attachment of the socket to the stump, which may lead to soft-tissue complications. Intraosseous
Aim: We have carried out a prospective study to compare duplex ultrasonography and
The
Intraosseous
Introduction and Objective. Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective was to compare the analgesic efficacy and safety of a new wearable
Aims. The Intraosseous
Background: Osseointegrated amputation prostheses avoid soft tissue complications associated with traditional socket prostheses. Forces are transmitted directly to the skeleton resulting in improved function. However, approximately 50% of
We studied the effect of
Infection is the primary failure modality for
The predictive value of the pedal
A consecutive series of 31 displaced fractures of the proximal humerus were randomly selected for treatment either by closed manipulation or by
Traditional socket prosthesis (TSP) rehabilitation for amputees is associated with substantial dissatisfaction due to poor mobility and pain from soft tissue squeezing. Osseointegration (OI), eliminates skin compression and prosthesis fit issues, providing superior mobility and quality of life (QOL) for most amputees. The potential for OI to benefit patients with exceptionally poor mobility is understudied. To address this knowledge gap, this project investigated the mobility and QOL changes. A retrospective review was performed to identify transfemoral amputees who presented with wheelchair-bound mobility (K0) and had at least five years of post-osseointegration follow-up. Outcome measures included changes in mobility (K-level, daily prosthesis wear hours, Timed Up and Go (TUG), 6 minute walk test (6MWT)) and QOL (Questionnaire for persons with a Transfemoral Amputation (QTFA); Short Form Health Survey 36 (SF36). Adverse events recorded included debridement for infection, implant revision surgery, fractures, and implant failures. 9 patients with mean age 48.2±7.7 (range 34-59) years were included. The proportion of patients achieving K-level >2 improved from 0/9=0% to [9/9=100%], p<0.001. The 6MWT improved from 0±0 to 320.65±57 meters (p<0.001). The TUG improved from incapable to 10.68±2.7 seconds (p<0.001). Statistically significant QOL metrics included QTFA global score (33.33±31 vs 68.52±21, p=0.039), SF36 physical component score (30.03±6.3 vs 42.34±12, p=0.023) and the SF36 mental component score (47.89±8.8 vs 51.95±10.4, p=0.332). Six patients required operative intervention to address complications. Five developed infections: three had debridement, and 2 required implant removal and reimplantation. Osseointegration does confer significant sustained mobility and quality of life improvement for wheelchair bound transfemoral amputees. All 9 K0 patients had statistically improved mobility and QOL after osseointegrated reconstruction. This supports osseointegration as an effective rapid and long-term rehabilitation alternative for patients who have the neurologic and muscular capacity to walk but are unable due to issues related to their TSP.
In 42 amputations (28 below-knee and 14 above-knee), healing of the stump was found to correlate with the pre-operative
To try and aid the formation of a soft tissue seal to promote dermal and epidermal attachment to Intraosseous
Introduction. Following amputation, residual stumps used to attach the external prostheses can be associated with sores, infection and skin necrosis. These problems could be overcome by off loading the soft tissues. Intraosseous
Patients with above knee amputation (AKA) often experience poor socket fit exacerbated by minor weight changes, sweating, and skin problems. A
The success of long-term
The December 2022 Research Roundup. 360. looks at: Halicin is effective against Staphylococcus aureus biofilms in vitro; Synovial fluid and serum neutrophil-to-lymphocyte ratio: useful in septic arthritis?;
According to the latest report from the German Arthroplasty Registry, aseptic loosening is the primary cause of implant failure following primary hip arthroplasty. Osteolysis of the proximal femur due to the stress-shielding of the bone by the implant causes loss of fixation of the proximal femoral stem, while the distal stem remains fixed. Removing a fixed stem is a challenging process. Current removal methods rely on manual tools such as chisels, burrs, osteotomes, drills and mills, which pose the risk of bone fracture and cortical perforation. Others such as ultrasound and laser, generate temperatures that could cause thermal injury to the surrounding tissues and bone. It is crucial to develop techniques that preserve the host bone, as its quality after implant removal affects the outcome of a revision surgery. A gentler removal method based on the
Summary Statement. A novel
Summary. Osseointegrated Amputation Prostheses can be functionalised by both biological augmentation and structural augmentation. These augmentation techniques may aid the formation of a stable skin-implant interface. Introduction. Current clinical options are limited in restoring function to amputees, and are associated with contact dermatitis and infection at the stump-socket interface. Osseointegrated Amputation Prosthesis attempts to solve issues at the stump-socket interface by directly transferring axial load to the prosthesis, via a skin-penetrating abutment. However, development is needed to achieve a seal at the skin-implant interface to limit infection. Fibronectin, an Extracellular Matrix protein, binds to integrins during wound healing, with the RGD tripeptide being part of the recognition sequence for its integrin binding domain. In vitro work has found silanization of RGD to polished titanium discs up regulates fibroblast attachment compared to polished control. Electron Beam Melting can produce porous titanium alloy implants, which may encourage tissue attachment. This study aims to test whether a combination of biological RGD coatings and porous metal manufacturing techniques can encourage the formation of a seal at the skin-implant interface. Materials and Methods. We developed four different augmented
Introduction. Advantages of osseointegration have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent
Introduction. Osseointegration has emerged as a promising alternative to rehabilitating with a traditional socket mounted prosthesis. Advantages have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and better gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent
Introduction. Approximately 2,000 Skeletal
Introduction:
Introduction. Intraosseous
A high incidence of complications with wound healing in calcaneum fractures treated with open reduction and internal fixation (25 – 33% of cases) has been reported. In one study 80% of those who had wound complications required surgical treatment of these. Two recent studies have shown that the risk factors for wound complications in this injury are single layered closure, high BMI, extended time between injury and surgery, diabetes, open fractures and smoking. In our unit, out of a small sample of 56 patients undergoing calcaneal fracture fixation, all those who developed wound complications were smokers.
Problems associated with soft tissues of the stump and attachment of prosthetic devices for amputees remains a considerable problem. These problems are associated with the transmission of load through the soft tissues of the stump and difficulty in attaching the prosthetic device. Several devices have an osteointegrated
Fracture separation of the distal epiphysis of the tibia constitutes 10% of all epiphyseal fractures occurring in children. We studied 120 cases, which were treated stationary at our Department over the 10 year period between 1990 – 2000. The ratio between boys and girls was 2:1. The average age was 12,5 years (8–15 years). In 96 cases (80%) the injury occurred after a fall on the playground, in 12 cases (10%) after a roadtraffic accident and in 12 cases (10%) after a fall from a height. The average follow up is 7,2 years (2–12 years). According to the Salter-Harris classification 6 cases (5%) were Salter I, 90 cases (80%) were Salter II, 9 cases (9%) were Salter III and 6 cases (5%) were Salter IV. In all cases a closed reduction under general anaesthesia was attempted. If the reduction was succesful a whole leg plaster was applied. If the reduction was unstable a
Advances in military surgery have led to significant numbers of soldiers surviving with bilateral above knee amputations. Despite advances in prosthetic design and high quality rehabilitation not all amputees succesfully ambulate. Five patients (10 stumps) with persisting socket fit issues were selected for osseointegration (OI) using a
Introduction: Intraosseous
The prevalence of knee osteoarthritis (OA) in The United States is approximately 40 million cases, and this number is expected to rise to 60 million by the year 2020. Multiple non-operative treatment options are available for patients, including bracing. Braces can also be used for “pre-habitation” prior to total knee arthroplasty (TKA), after TKA, after traumatic sports injuries, and in neurologic patients. Although, the AAOS recommendations for brace use for treatment of knee osteoarthritis (OA) are “inconclusive”, recent studies have shown improved functional outcomes with the use of off-loader braces for the treatment of uni-compartmental knee OA. In addition, supplemental modalities such as
Introduction: Normal limb use in amputees with made to measure external prostheses can be impaired by problems at the stump – socket interface. The development of an Intraosseous
Introduction: The ‘gold standard’ currently used to assess bone quality is bone mineral density (BMD) measured by Dual Energy X-ray Absorptiometry (DEXA). However BMD accounts for no more than 60 – 70% of bone strength. X-rays are affected primarily by the mineral phase of bone; the organic phase remains essentially invisible. Yet it is known that the material strength and toughness of bone is critically dependent on its organic phase. A Raman spectroscopic technique was used that permitted visualisation of both phases of bone deep to unbroken skin by successfully removing spectral information from the overlying tissues. Hypothesis: Spectral features of both the mineral and organic phases of bone from different murine genotypes can be measured objectively through the unbroken skin using time-resolved Raman spectroscopy. Methods: We used an 800 nm probe laser (1 kHz, 1 ps pulses, focussed to 1 mm diameter) with a synchronised 4 ps optical Kerr gate that had a variable picosecond delay that effectively shuttered out photons from the overlying tissues. We measured bone spectra at a point 2mm above the carpus from two mouse genotypes: wildtype and oim/oim (matched for age, sex and weight) at a typical depth 1.1mm. We then repeated the measurements once the overlying tissues had been carefully removed to expose the bones directly. Oim/oim mice produce only homotrimeric collagen I, (á1(I)3), associated with this change in collagen is a poor mineralisation of the bone tissue, making it an ideal model for a this study. Results: We recorded the main spectral features in both phases of bone and showed that the ratios of spectral bands from the two phases were similar within each genotype, whether measured through the skin or directly from exposed bone. However, there was a significant difference in the same ratios between genotypes associated with a reduced mineralisation in the oim/oim mice; a significant difference that was apparent both directly from bone and through skin. The band associated with CH2 wag of collagen (organic phase) showed a frequency shift between the genotypes. Discussion: Measurements of the spectra and their analysis were similar whether made directly on bone or
Introduction: Tissue engineered scaffolds require vascularization to 1) enhance nutrient exchange and 2) provide cells needed to build new tissue. Cell-seeded scaffolds; bioreactors-- require rapid penetration of vessels or enhanced fluid percolation to keep their contents alive until normal nutrient exchange can be established. Bone fluid flow depends on a pumping system which drives percolation through its own matrix. Recent interest in the pumping mechanism has resulted in bone fluid flow models, which link the pumps to bending of bone by muscle contraction and compression-tension cycles from weight-bearing during locomotion. The present authors have proposed that capillary filtration, the source of the percolating fluid, is sufficiently enhanced by soliton pressure waves in blood driven by the muscle pump during exercise to provide a significant hydraulic pressure component to bone fluid percolating through bone and any bone-implanted scaffold. A proposal and some preliminary results from a pilot project suggesting enhancement of capillary filtration by the muscle pump is presented. Materials and Methods: Optical bone chambers were implanted in adult New Zealand White female rabbits. Chamber construction and implantation were as usual1. At the third week post-op, chamber ends were exposed and weekly intravital microscopy commenced.
To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation.Aims
Methods
Development of more effective diagnostic and therapeutic solutions is vital to tackling the growing challenge of bone diseases and disorders in aging societies. Spatially offset Raman spectroscopy (SORS) enables the chemical specificity of conventional Raman spectroscopy to be combined with sub-surface probing. SORS has successfully been applied to
As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30).Aims
Methods
Tourniquet use in total knee arthroplasty (TKA) is convenient for the surgeon and provides a bloodless field for expeditious surgery and a dry field for cementation, but can best be described as an orthopaedic tradition. It is logical for complex anatomy of ligament, nerve, and vessel surgery but it may not be necessary for TKA. In one recent randomised trial, the absence of the tourniquet was not found to affect the quality of cement fixation. There are numerous potential downsides to the use of a tourniquet including decrease range of motion, delayed recovery, increased pain, wound complications, micro-emboli, neuropathy, and increased VTE. There are also a number of complications associated with the use of a tourniquet including arterial thrombosis, skin irritation below the tourniquet, post-operative hyperemia, blood loss, less accurate intra-operative assessment, and it complicates intravenous drug administration. Studies of range of motion have shown that when there is a difference noted, the range of motion is consistently better without tourniquet use. When a tourniquet is utilised it has been found to be advantageous to only use the tourniquet for a minimal amount of the case, typically when cementing is performed. Functional strength has also been found to be improved without the use of a tourniquet. In a recent randomised trial, tourniquet use was associated with decreased quad strength at 3 weeks that persisted at 3 months. This was attributed to muscle damage, tourniquet-induced ischemia, and compressive injury. Increased peri-operative pain has also been reported in randomised trials associated with the use of a tourniquet. Edema, swelling, and limb girth issues have also been noted to be associated with tourniquet use. Exsanguinating a limb will result in swelling approximately 10% of the original volume half due to a return of blood, and half due to reactive hyperemia. Longer tourniquet times are also associated with increased wound drainage and more wound hypoxia as measured by
Traditionally, arthritis is a disease which generally affects the elderly population. However, the incidence in young patients is well described and is increasing with the ever-growing obese population. Currently, the non-surgical treatment of osteoarthritis consists of corticosteroid injections, hyaluronic acid injections, weight loss, physical therapy, bracing, orthotics, narcotics, and non-steroidal anti-inflammatory drugs (NSAIDS). Oral medications (NSAIDS, tramadol, and opioids) can provide effective pain relief. Improvement with NSAIDs has been reported to be 20% relative to baseline, with better improvements seen with selective cox-2 inhibitors, which also have reduced gastrointestinal and renal toxicity. Additionally, the recent AAOS guidelines strongly recommend using NSAIDs or tramadol for pain relief. Although narcotics are effective analgesics, their use in young arthritic patients can potentially predispose individuals to future opioid dependency, and thus should be used sparingly. The primary purpose of physical therapy is to improve range of motion, strengthen muscles, and improve proprioception. Currently, the AAOS strongly recommends that patients undergo self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education. Similarly, they moderately recommended that patients with a BMI ≥ 25 undergo weight loss for symptomatic arthritis. Bracing options consist of the following: off-loader braces and
This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.
The viability of three incisions for knee arthroplasty were analysed by
Chevron osteotomy for correction of symptomatic hallux valgus deformity is a widely accepted method. Full weight bearing in regular shoes is not recommended before six weeks after surgery. Low intensity pulsed ultrasound is known to stimulate bone formation leading to more stable callus and faster bony fusion. We performed a randomized, placebo-controlled, double-blinded study on 44 patients (52 feet) who underwent chevron osteotomy to evaluate the influence of daily
A new technique for the treatment of displaced fractures of the proximal humerus is described. Twelve fractures in 11 patients were managed by
Patients with above knee amputation face many challenges to mobility including difficulty with socket fit and fatigue due to high energy consumption. The aim of the Endo - Exo-Femur Prosthesis is to avoid problems at the interface between the sleeve of the socket-prosthesis and the soft tissue coat of the femur stump which often impedes an inconspicuous and harmonic gait. In 1999 we began using a
One hundred and seventy-four consecutive patients with symptoms of derangement of the knee were examined with an arthroscope under local anaesthesia using a continuous pressure-irrigation system. A 0.2 per cent prilocaine-saline solution was used as irrigation fluid. In the first 19 patients the serum level of prilocaine was monitored for six hours after the start of irrigation. Eighteen of the 174 patients had a
We have investigated whether the thigh tourniquet used during total knee replacement (TKR) influenced the development of postoperative wound hypoxia and was a cause of delayed wound healing. We allocated randomly 31 patients (31 TKRs) to one of three groups: 1) no tourniquet; 2) tourniquet inflated at low pressure (about 225 mmHg); and 3) tourniquet inflated to high pressure of about 350 mmHg. Wound oxygenation was measured using
Vertebral fracture due to a metabolic bone disease or a neoplastic disease is a common and debilitating condition. It most often is associated with either osteoporosis or metastatic bone disease. Some of the patients suffering from such fractures continue to complain of back pain and deformity despite optimal medical therapy, including radiotherapy and biphosphonates. Vertebroplasty, i.e.
Aims: Previous work at this institution has demonstrated that perfusion beneath circumferential negative pressure wound therapy (NPWT) is decreased, which conflicts with most studies on NPWT and perfusion. This study investigates perfusion beneath non-circumferential NPWT in humans and also discusses the potential methodology flaw common to all previous research in this field. Methods: Tests were conducted on both lower limbs of six volunteers (N=12). Volunteers were sequentially randomised into two groups, which would receive different suction pressures (−400 mmHg and −125 mmHg). A doughnut shaped NPWT dressing was placed over the shin of each leg. The central hole allowed for measurement of the
Skin necrosis after total knee arthroplasty can rapidly lead to infection of the prosthetic components. Risk factors for the development of skin necrosis include rheumatoid arthritis, steroid use, immunosuppression, malnutrition, peripheral vascular disease, and multiple prior scars. Vascularity of the skin over the knee will affect the rate of healing postoperatively and risk of necrosis. Johnson measured
Introduction. Kinematics tracking is the process by which the motion of the joints is studied. This motion consists of relative rotation and translation of the joint bones. Joint motion analysis is used in diagnosis of joint pathology, as well as studying the normal joint function. Currently, fluoroscopy is used in joint kinematics tracking. We are researching the use of pulse-echo A-mode ultrasound for the bone motion tracking instead of the fluoroscopy to avoid its radiation. In this work we performed feasibility study using simulation, and concluded that it is feasible to perform knee motion tracking with accuracy of 2 mm. Methods. The idea of the proposed system is to attach a number of single-element ultrasound transducers to a brace as shown in Figure 1. This brace will have a commercially available optical or electromagnetic tracking system's probe attached to it to track the global motion of the brace. The ultrasound transducers will be responsible for
INTRODUCTION: The process of ligamentization includes the histological and structural remodelling of the tendons graft to ligamentous tissue. There is little information documenting the mechanism of ligamentization process in molecular level. A number of essential genes are involved in this process and their expression can be regulated through complex biochemical pathways. Animal studies have shown that
Introduction. The interstitial fluid of bone fluid flow is supplied by flowing blood. Blood flow is determined by three kinds of muscles: cardiac, smooth, and skeletal. Cardiac muscle establishes baseline blood pressure. Smooth muscle controls vessel diameter and skeletal muscle creates intermittent intravascular pressure pulses. For the tibia the relevant skeletal muscle is the gastrocnemius which functions as a muscle pump. This study tested the hypotheses: 1) skeletal muscle-caused pressure pulses increase cortical blood flow, 2) extravasation of vascular fluid and, consequently, interstitial bone fluid flow are enhanced by resultant increased microvascular pressure and 3) bone healing is enhanced by increased bone fluid flow. Methods. Eighteen skeletally mature female New Zealand white rabbits were implanted with bone chamber windows (BCIs) as described previously. The windows were exposed at three weeks and observed weekly until Week 10 using intravital microscopy. During observation, the subject was suspended in prone position in a mesh fabric torso sling jacket so as to eliminate gravity-based reaction forces. Electrodes of a
Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation,
Introduction: Cell adhesion to titanium alloy implants is important in osseointegration [1,2] and attachment of the soft tissues to skin penetrating implants e.g. external fixator pins and Intraosseous
Introduction: Insufficiency of poroelastic bone bending as the sole mechanism driving bone interstitial fluid flow (BIFF) to account for the shear stress required to activate mechanoreceptors on osteocytes and osteoblasts, has stimulated a search for alternative or complementary mechanisms in the quest for a comprehensive bone remodeling model. Some investigators, noting that a substantial amount of interstitial fluid is exchanged with blood and lymphatic capillaries, have suggested that this exchange may play a substantial role in both microtransport through the collagen matrix and lacunar-canalicular transport. In order to accept the vascular system as a significant source of transport driving BIFF, it must first be demonstrated that capillary filtration, the proc ess by which fluid is transported from blood vasculature, is sufficiently convective to drive interstitial percolation. We have proposed that while, as shown by Otter et al., resting transmural vascular pressures are sufficient to generate streaming potentials across cortical bone, it is likely that these forces must be complemented by muscle pump contractions during exercise to generate convective percolation flows which will develop the required mechanotransducer shear stress activation threshold. To determine a minimal baseline for a muscle pump driven BIFF (MPD-BIFF) model, we have investigated the role of repetitive skeletal muscle contractions, uncoupled from gravitational loading, on blood flow and capillary filtration in cortical bone of the rabbit tibia. We tested the hypothesis that these effects increased when the muscle pump was activated. Materials &
Methods: The experimental model combined non-invasive, low magnitude
This study describes the Osseointegration Group of Australia’s
Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated
reconstruction of amputated limbs. We report clinical outcomes in 50 unilateral trans-femoral amputees
with a mean age of 49.4 years (24 to 73), with a minimum one-year
follow-up. Outcome measures included the Questionnaire for persons
with a Trans-Femoral Amputation, the health assessment questionnaire
Short-Form-36 Health Survey, the Amputation Mobility Predictor scores
presented as K-levels, 6 Minute Walk Test and timed up and go tests.
Adverse events included soft-tissue problems, infection, fractures
and failure of the implant.Aims
Patients and Methods
The purpose of this study was to evaluate the
effect of various non-operative modalities of treatment (transcutaneous
electrical nerve stimulation (TENS); neuromuscular electrical stimulation
(NMES); insoles and bracing) on the pain of osteoarthritis (OA)
of the knee. We conducted a systematic review according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines to identify
the therapeutic options which are commonly adopted for the management
of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were
the visual analogue scale and The Western Ontario and McMaster Universities
Arthritis Index pain index: all pain scores were converted to a
100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles,
seven on TENS, six on NMES, and four on bracing. The standardised
mean difference (SMD) in pain after treatment with TENS was 1.796,
which represented a significant reduction in pain. The significant
overall effect estimate for NMES on pain was similar to that of
TENS, with a SMD of 1.924. The overall effect estimate of insoles
on pain was a SMD of 0.992. The overall effect of bracing showed
a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were
found to have a significant effect on the reduction of pain in OA
of the knee. This study shows that non-operative physical modalities of treatment
are of benefit when treating OA of the knee. However, much of the
literature reviewed evaluates studies with follow-up of less than
six months: future work should aim to evaluate patients with longer
follow-up. Cite this article:
Infection of implants is a major problem in elective and trauma surgery. Heating is an effective way to reduce the bacterial load in food preparation, and studies on hyperthermia treatment for cancer have shown that it is possible to heat metal objects with pulsed electromagnetic fields selectively (PEMF), also known as induction heating. We therefore set out to answer the following research question: is non-contact induction heating of metallic implants effective in reducing bacterial load Titanium alloy cylinders (Ti6Al4V) were exposed to PEMF from an induction heater with maximum 2000 watts at 27 kHz after being contaminated with five different types of micro-organisms: Objectives
Methods
The surgical management of ankle arthritis with tibiotalar arthrodesis
is known to alter gait, as compared with normal ankles. The purpose
of this study was to assess post-operative gait function with gait
before arthrodesis. We prospectively studied 20 patients who underwent three-dimensional
gait analysis before and after tibiotalar arthrodesis. Cadence,
step length, walking velocity and total support time were assessed.
Kinetic parameters, including the moment and power of the ankle
in the sagittal plane and hip power were also recorded.Aims
Patients and Methods
Patients undergoing femoral lengthening by external fixation
tolerate treatment less well when compared to tibial lengthening.
Lengthening of the femur with an intramedullary device may have
advantages. We reviewed all cases of simple femoral lengthening performed
at our unit from 2009 to 2014. Cases of nonunions, concurrent deformities,
congenital limb deficiencies and lengthening with an unstable hip
were excluded, leaving 33 cases (in 22 patients; 11 patients had
bilateral procedures) for review. Healing index, implant tolerance
and complications were compared.Aims
Patients and Methods
The monitoring of fracture healing is a complex process. Typically, successive radiographs are performed and an emerging calcification of the fracture area is evaluated. The aim of this study was to investigate whether different bone healing patterns can be distinguished using a telemetric instrumented femoral internal plate fixator. An electronic telemetric system was developed to assess bone healing mechanically. The system consists of a telemetry module which is applied to an internal locking plate fixator, an external reader device, a sensor for measuring externally applied load and a laptop computer with processing software. By correlation between externally applied load and load measured in the implant, the elasticity of the osteosynthesis is calculated. The elasticity decreases with ongoing consolidation of a fracture or nonunion and is an appropriate parameter for the course of bone healing. At our centre, clinical application has been performed in 56 patients suffering nonunion or fracture of the femur.Objectives
Materials and Methods
Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee.
A rigorous approach to developing, delivering and documenting
rehabilitation within randomised controlled trials of surgical interventions
is required to underpin the generation of reliable and usable evidence.
This article describes the key processes used to ensure provision
of good quality and comparable rehabilitation to all participants
of a multi-centre randomised controlled trial comparing surgery
with conservative treatment of proximal humeral fractures in adults. These processes included the development of a patient information
leaflet on self-care during sling immobilisation, the development
of a basic treatment physiotherapy protocol that received input
and endorsement by specialist physiotherapists providing patient
care, and establishing an expectation for the provision of home
exercises. Specially designed forms were also developed to facilitate
reliable reporting of the physiotherapy care that patients received.Objectives
Methods
We welcome letters to the Editor concerning articles
that have recently been published. Such letters will be subject
to the usual stages of selection and editing; where appropriate the
authors of the original article will be offered the opportunity
to reply.
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was <
5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.
We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation. Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p <
0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.
We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain.
Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (>
95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.
In an interdisciplinary project involving electronic
engineers and clinicians, a telemetric system was developed to measure
the bending load in a titanium internal femoral fixator. As this
was a new device, the main question posed was: what clinically relevant
information could be drawn from its application? As a first clinical
investigation, 27 patients (24 men, three women) with a mean age
of 38.4 years (19 to 66) with femoral nonunions were treated using the
system. The mean duration of the nonunion was 15.4 months (5 to
69). The elasticity of the plate-callus system was measured telemetrically
until union. Conventional radiographs and a CT scan at 12 weeks
were performed routinely, and healing was staged according to the
CT scans. All nonunions healed at a mean of 21.5 weeks (13 to 37).
Well before any radiological signs of healing could be detected,
a substantial decrease in elasticity was recorded. The relative
elasticity decreased to 50% at a mean of 7.8 weeks (3.5 to 13) and
to 10% at a mean of 19.3 weeks (4.5 to 37). At 12 weeks the mean
relative elasticity was 28.1% (0% to 56%). The relative elasticity
was significantly different between the different healing stages
as determined by the CT scans. Incorporating load measuring electronics into implants is a promising
option for the assessment of bone healing. Future application might
lead to a reduction in the need for exposure to ionising radiation
to monitor fracture healing.
Frozen shoulder is commonly encountered in general
orthopaedic practice. It may arise spontaneously without an obvious
predisposing cause, or be associated with a variety of local or
systemic disorders. Diagnosis is based upon the recognition of the
characteristic features of the pain, and selective limitation of
passive external rotation. The macroscopic and histological features
of the capsular contracture are well-defined, but the underlying
pathological processes remain poorly understood. It may cause protracted
disability, and imposes a considerable burden on health service
resources. Most patients are still managed by physiotherapy in primary
care, and only the more refractory cases are referred for specialist
intervention. Targeted therapy is not possible and treatment remains predominantly
symptomatic. However, over the last ten years, more active interventions
that may shorten the clinical course, such as capsular distension
arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features
of frozen shoulder. We also outline the current treatment options,
review the published results and present our own treatment algorithm.
We have reviewed the literature to establish the role of lateral retinacular release in the management of disorders of the extensor apparatus of the knee. The scientific evidence for intervention is explored and reports on outcome are discussed.
A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.
The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.
In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.