Aim: Cementation of tibial implants in total knee arthroplasty is a gold-standard considering the high loosening rates of cementless implants. In contrast, only sparse data exist regarding unicondylar arthroplasty due to limited use. In this study, we compare cemented with cementless unicondylar knee arthroplasty and aim to define both clinical and radiological differences in treatment outcome.

Materials and Methods: In a retrospective study, 106 patients who had undergone a medial unicondylar replacement were examined after a mean postoperative period of 8 years. Of these, 42 patients (median age 81±7 years) had received a cemented and 64 (median age 73±7 years) a cementless knee arthroplasty by the same surgeon while 7 patients were deceased or could not be reached. Well-established clinical (VAS, HSS, KSS, UCLA, WOMAC) and quality of life (SF-36) scores were used to evaluate treatment outcome. X-rays were performed to evaluate periprosthetic loosening zones, according to Ewald’s criteria.

Results: The cementless patient group presented significantly better clinical scores (HSS, KSS, UCLA, WOMAC), except in the Visual Analogue Scale (VAS) for pain assessment. The quality of life was significantly better in the cementless group except in the subgroups concerning physical function, vitality and social role, which resembled normal population. Moreover, radiographic analysis using antero-posterior X-rays revealed significantly more and larger periprosthetic loosening areas in tibial zone 2 in the cementless group.

Conclusion: The inferior clinical results characterising the cemented group could be attributed to the higher mean age. Regarding the radiological loosening zones, we did not detect any differences in the techniques of fixation, although physical activity and mechanical stresses were higher in the cementless group.

Aims. The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA). Methods. The original cohort consisted of 145 consecutive THAs performed by a single surgeon in 138 patients. A total of 37 patients (40 hips) survived a minimum of 30 years, and are the focus of this review. The femoral component used in all cases was a first-generation Taperloc with a non-modular 28 mm femoral head. Clinical follow-up at a minimum of 30 years was obtained on every living patient. Radiological follow-up at 30 years was obtained on all but four. Results. Seven femoral components (18%) required revision, and none for septic loosening. Four well fixed stems were removed during acetabular revision and three were revised for late infection. One femoral component (3%) was loose by radiological criteria. The mean Harris Hip Score improved from 47 points (SD 4.62) preoperatively to 83 points (SD 9.27) at final follow-up. With revision for any reason as the endpoint, survival of the femoral component was 80% (95% confidence interval (CI) 61% to 90%) at 32 years. With revision for aseptic loosing femoral component, survival was 99% (95% CI 93% to 99%). Conclusion. With regards to aseptic loosening, the Taperloc femoral component provides excellent fixation at a mean follow-up of 32 years. Cite this article: Bone Jt Open 2023;4(2):79–86

The management of comminuted metaphyseal fractures is a technical challenge and satisfactory outcomes of such fixations often remain elusive. The small articular fragments and bone loss often make it difficult for standard fixation implants for proper fixation. We developed a novel technique to achieve anatomical reduction in multiple cases of comminuted metaphyseal fractures at different sites by employing the cantilever mechanism with the help of multiple thin Kirschner wires augmented by standard fixation implants. We performed a retrospective study of 10 patients with different metaphyseal fractures complicated by comminution and loss of bone stock. All patients were treated with the help of cantilever mechanism using multiple Kirschner wires augmented by compression plates. All the patients were operated by the same surgeon between November 2020 to March 2021 and followed up till March 2023. Surgical outcomes were evaluated according to the clinical and radiological criteria. A total of 10 patients were included in the study. Since we only included patients with highly unstable and comminuted fractures which were difficult to fix with traditional methods, the number of patients in the study were less. All 10 patients showed satisfactory clinical and radiological union at the end of the study with good range of motion. One of the patient in the study had post-operative wound complication which was managed conservatively with regular dressings and oral antibiotics. Comminuted metaphyseal fractures might differ in pattern and presentation with every patient and there can be no standard treatment for all. The cantilever technique of fracture fixation is based on the principle of cantilever mechanism used in bridges and helps achieve good anatomical reduction and fixation. It provides a decent alternative when standard modes of fixation don't give desired result owing to comminuted nature of fractures and deficiency of bone stock

Acetabular retroversion (ARV) is a cause of femoroacetabular impingement leading to hip pain and reduced range of motion. We aimed to describe the radiological criteria used for diagnosing ARV in the literature and report on the outcomes of periacetabular osteotomy (PAO) and hip arthroscopy (HA) in its management. A systematic review using PRISMA guidelines was conducted on the MEDLINE, CINAHL, EMBASE, COCHRANE database in December 2022. English-language studies reporting outcomes of PAO, or open or arthroscopic interventions for ARV were included. From an initial 4203 studies, 21 non-randomised studies met the inclusion criteria. Eleven studies evaluated HA for ARV, with average follow-up ranging from 1 to 5 years, for a cumulative number of 996 patients. Only 3/11 studies identified ARV using AP standardized pelvic radiographs. The most frequent signs describing ARV identified were: Ischial Spine Sign (98% of patients), Posterior Wall Sign (PWS, 94%) and Crossover Sign (COS, 64%); with mean Acetabular Retroversion Index (ARI) ranging from 33% to 35%. 39% of HA patients had all three radiographic signs. Clinically significant outcomes were reached by 33–78% of patients. Eight studies evaluated PAO for ARV, with a follow-up ranging from 2 to 10 years, for a cumulative number of 379 patients. Five of the eight studies identified ARV using standardized radiographs. ISS, COS and PWS were positive in 54%, 97% and 81% of patients, respectively with 52% of PAO patients having all three radiographic signs. Mean ARI ranged from 36–41%. Clinically significant results were reported in 71%–78% of patients. The diagnostic criteria for ARV is poorly defined in the literature, and the quality of evidence is low. Studies on HA are more likely to have used lenient diagnostic criteria. It remains difficult to recommend which cases maybe more suitable for treatment by HA rather than PAO

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

Aims. Intra-articular (IA) tumours around the knee are treated with extra-articular (EA) resection, which is associated with poor functional outcomes. We aim to evaluate the accuracy of MRI in predicting IA involvement around the knee. Methods. We identified 63 cases of high-grade sarcomas in or around the distal femur that underwent an EA resection from a prospectively maintained database (January 1996 to April 2020). Suspicion of IA disease was noted in 52 cases, six had IA pathological fracture, two had an effusion, two had prior surgical intervention (curettage/IA intervention), and one had an osseous metastasis in the proximal tibia. To ascertain validity, two musculoskeletal radiologists (R1, R2) reviewed the preoperative imaging (MRI) of 63 consecutive cases on two occasions six weeks apart. The radiological criteria for IA disease comprised evidence of tumour extension within the suprapatellar pouch, intercondylar notch, extension along medial/lateral retinaculum, and presence of IA fracture. The radiological predictions were then confirmed with the final histopathology of the resected specimens. Results. The resection histology revealed 23 cases (36.5%) showing IA disease involvement compared with 40 cases without (62%). The intraobserver variability of R1 was 0.85 (p < 0.001) compared to R2 with κ = 0.21 (p = 0.007). The interobserver variability was κ = 0.264 (p = 0.003). Knee effusion was found to be the most sensitive indicator of IA involvement, with a sensitivity of 91.3% but specificity of only 35%. However, when combined with a pathological fracture, this rose to 97.5% and 100% when disease was visible in Hoffa’s fat pad. Conclusion. MRI imaging can sometimes overestimate IA joint involvement and needs to be correlated with clinical signs. In the light of our findings, we would recommend EA resections when imaging shows effusion combined with either disease in Hoffa’s fat pad or retinaculum, or pathological fractures. Cite this article: Bone Joint J 2023;105-B(6):696–701

Aims. We present the clinical and radiological results at a minimum follow-up of 20 years using a second-generation uncemented total hip arthroplasty (THA). These results are compared to our previously published results using a first-generation hip arthroplasty followed for 20 years. Methods. A total of 62 uncemented THAs in 60 patients were performed between 1993 and 1994. The titanium femoral component used in all cases was a Taperloc with a reduced distal stem. The acetabular component was a fully porous coated threaded hemispheric titanium shell (T-Tap ST). The outcome of every femoral and acetabular component with regard to retention or revision was determined for all 62 THAs. Complete clinical follow-up at a minimum of 20 years was obtained on every living patient. Radiological follow-up was obtained on all but one. Results. Two femoral components (3.2%) required revision. One stem was revised secondary to a periprosthetic fracture one year postoperatively and one was revised for late sepsis. No femoral component was revised for aseptic loosening. Six acetabular components had required revision, five for aseptic loosening. One additional acetabular component was revised for sepsis. Radiologically, all femoral components remained well fixed. One acetabular was judged loose by radiological criteria. The mean Harris Hip Score improved from 46 points (30 to 67) preoperatively to 89 points (78 to 100) at final follow-up. With revision for aseptic loosening as the endpoint, survival of the acetabular component was 95% (95% confidence interval (CI) 90 to 98) at 25 years. Femoral component survival was 100%. Conclusion. The most significant finding of this report was the low prevalence of aseptic loosening and revision of the femoral component at a mean follow-up of 22 years. A second important finding was the survival of over 90% of the hemispheric threaded ring acetabular components. While these shells remain controversial, in this series they performed well. Cite this article: Bone Jt Open 2021;2(1):33–39

Aim. To investigate self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK and investigate the relationship between QoL and BACH classification. Method. All patients newly referred to a specialist bone infection clinic at a single tertiary centre within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available.1 Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value set of 41 chronic health conditions within the UK.2. Results. 201 patients were referred during the study period, with 159 (79.1%) patients diagnosed with long-bone osteomyelitis and 16 (8.0%) with osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D: 0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the 40th and 41st lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke, chronic obstructive pulmonary disease, kidney disease, liver disease and malignancy. Patients classified as having uncomplicated long-bone osteomyelitis reported significantly higher QoL compared to those classified as complex osteomyelitis (EQ-5D: 0.527 vs. 0.401, p<0.05; VAS: 66.9 vs. 58.4, p<0.05). Patients who were not fit for surgery due to co-morbidity reported similar QoL scores compared to those patients with complex osteomyelitis (EQ-5D: 0.293, p=0.07; VAS: 46.6, p=0.06). Patients with stable disease who did not require surgery, gave significantly better QoL scores when compared to the other classifications of osteomyelitis (EQ-5D: 0.746, p<0.01; VAS: 81.9, p<0.01). Conclusions. Patient reported QoL in osteomyelitis correlates with disease complexity as classified according to the BACH classification system. Patients with pelvic and long-bone osteomyelitis rate their QoL lower than patients with other chronic diseases

Introduction. This study assesses self-reported quality of life (QoL) in patients with osteomyelitis referred to a specialist centre in the UK. Materials and Methods. All patients newly referred to a specialist tertiary bone infection clinic within the UK between January 2019 and February 2020 were prospectively included. Diagnosis of osteomyelitis was made according to the presence of clinical and radiological criteria for ≥6 months. An EQ-5D-5L questionnaire and visual analogue score (VAS) were completed during the initial clinic appointment. Long-bone osteomyelitis was classified by the attending orthopaedic surgeon using the BACH classification system as either uncomplicated, complex or with limited options available. Patients managed non-operatively were subclassified into those who were (i) unfit to receive an operation or (ii) fit and well with stable disease. EQ-5D index scores were compared to a published UK value-set of 41 chronic health conditions within the UK. Results. 201 new patients were referred during the study period. 159 (79.1%) met the criteria for long-bone osteomyelitis and 16 (8.0%) for osteomyelitis of the pelvic bones. Patients with pelvic osteomyelitis reported lower EQ-5D index scores compared to long-bone osteomyelitis (EQ-5D:0.097 vs. 0.435, p<0.001) but similar VAS (60.2 vs. 54.6, p=0.37). Long-bone and pelvic osteomyelitis gave the lowest EQ-5D scores respectively when compared to 41 other chronic health conditions including stroke, chronic obstructive pulmonary disease, kidney disease, liver disease and malignancy. Patients classified as having uncomplicated long-bone osteomyelitis reported significantly higher QoL compared to those classified as complex osteomyelitis (EQ-5D:0.527 vs. 0.401, p<0.05; VAS: 66.9 vs. 58.4, p<0.05). Patients not fit for surgery due to co-morbidity reported similar QoL scores compared to those patients with complex osteomyelitis (EQ-5D: 0.293, p=0.07; VAS: 46.6, p=0.06). Patients with stable disease who did not require surgery, gave significantly better QoL scores when compared to the other classifications of osteomyelitis (EQ-5D: 0.746, p<0.01; VAS: 81.9, p<0.01). Conclusions. Patient reported QoL in osteomyelitis correlates with disease complexity as classified according to the BACH classification system. Patients with pelvic and long-bone osteomyelitis rate their QoL lower than patients with other major chronic diseases

Purpose: A lack of consensus regarding the radiologic criteria to diagnose spinal non-union limits inferences from clinical research. This systematic review aimed to examine the spectrum of radiologic investigations used to assess lumbar spinal fusion and the definitions of successful spine union used in the spine literature. Method: We comprehensively searched three electronic databases from 1950 to 2009 (MEDLINE, Embase and the Cochrane Central Register of Controlled Trials) for clinical studies involving posterolateral fusion of the lumbar spine. English-language studies including adult patients and reporting a definition of successful fusion were included. Studies examining the reliability and validity of radiologic investigations were also identified. Key measures included. radiologic investigations,. definition of successful lumbar fusion and. reliability, sensitivity and specificity of the investigations used to assess the spinal fusion. Results: Among 1165 potentially eligible studies, 91 met our inclusion criteria. Of the studies 78% (n = 71) used plain radiographs to diagnose non-union, 4% (n = 4) used CT scans and 18% (n = 16) used both. Fifty-one studies used both static (xray or CT) and dynamic (flexion-extension xray) images, 35 used only static images and five used only dynamic radiographs. In total, we identified fifty-two different radiographic definitions of successful fusion. More than half of the studies (n = 50, 55%) failed to provide a reference for the definition used. The most common definition of fusion (7 studies) used static radiographs and defined fusion as continuous intertransverse bony bridging with this quality of fusion at all intended levels. Seven studies evaluated reliability of xray criteria but no studies provided complete validation of the definitions. Only 3 studies provided some validation and reliability estimates of thin-slice CT scanning in diagnosing spinal non-union. Significant variability in reliability, sensitivity and specificity exists for all radiologic investigations in the diagnosis of spinal non-union. Conclusion: The radiologic investigations and definitions of successful posterolateral fusion used in the spine literature vary substantially. Choice of radiologic criteria should be based upon reliability and validity testing. Studies using fusion criteria that have not been shown to be reliable or valid should be interpreted with caution

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Cite this article: Bone Joint J 2024;106-B(3):227–231.

The April 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic Bankart repair in athletes: in it for the long run?; Functional outcomes and the Wrightington classification of elbow fracture-dislocations; Hemiarthroplasty or ORIF intra-articular distal humerus fractures in older patients; Return to sport after total shoulder arthroplasty and hemiarthroplasty; Readmissions after shoulder arthroplasty; Arthroscopic Bankart repair in the longer term; Bankart repair with(out) remplissage or the Latarjet procedure? A systematic review and meta-analysis; Regaining motion among patients with shoulder pathology: are all exercises equal?

Aims

Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis).

Aims

To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Aim: This study was carried out in order to clarify the causes that are mainly responsible for the necessity of reoperation after the initial correction of the deformity in congenital talipes equinovarus. The cases, which had been treated surgically with the same method and recurred later, were studied retrospectively in order to be ascertained epidemiological data related to the disease, to be isolated operative findings related to its pathology and to be estimated the surgical results based on clinical and radiological criteria. Material-Methods: During the 15-year-period from 1990 to 2004, 123 infants (196 feet) with congenital talipes equinovarus have been treated operatively. There were 88 males and 35 females. Seventy three patients (59.3%) had the deformity bilaterally, 20 patients in right foot and 30 in left. Family history was positive in 5 infants. Other congenital anomalies coexisted in 12 infants (9.7%). Preoperative application of successive plasters was started into the first week for 93 infants (75.6%) and its duration was 3 months for 83.7% of cases. All the patients have been operated on with posteromedial approach, extensive ligament division and generous release of soft tissues during the first year of age. Two thirds of cases (67.4%) were treated surgically into the first 6 months of age. Results: Anatomical variations were revealed during the operation in 14 feet (7.1% of the cases). The clinical results as well as the radiological signs into the first 6 postoperative months were satisfactory, but a reoperation was necessary in 21 feet (in 14 infants) for correction of part of the initial deformity into the following 2–5 years. The clinical criteria were related to the manner of standing and walking, the range of motion of the foot joints and block test. The radiological criteria were related to anteroposterior and lateral talocalcaneal angles and the angle between the longitudinal axis of the talus and that of the first metatarsal in the anteroposterior view as well as the position of the calcaneus in the lateral view. The causes that led to recurrence were related to imperfect correction with the plasters, to incomplete release of soft tissues during the initial operation and to some likely predisposing congenital and environmental factors. Conclusions: The prevention of recurrence of the initial deformity, in the operative correction of congenital talipes equinovarus, is mainly related to the attentive pre-operative application of plasters, the careful lege artis surgical technique and the early diagnosis and treatment of the predisposing factors

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

We reviewed 123 second-generation uncemented total hip replacements performed on 115 patients by a single surgeon between 1993 and 1994. The acetabular component used in all cases was a fully porous-coated threaded hemispheric titanium shell (T-Tap ST) with a calcium ion stearate-free, isostatically compression-moulded polyethylene liner. The titanium femoral component used was a Taperloc with a reduced distal stem. No patient was lost to follow-up. Complete clinical and radiological follow-up was obtained for all 123 hips at a mean of 14 years (12 to 16). One femoral component was revised after a fracture, and three acetabular components for aseptic loosening. No additional femoral or acetabular components were judged loose by radiological criteria. Mild proximal femoral osteolysis was identified in two hips and minor acetabular osteolysis was present in four. The mean rate of penetration of the femoral head was 0.036 mm/year (0.000 to 0.227). These findings suggest that refinements in component design may be associated with excellent long-term fixation in cementless primary total hip replacement

A total of 92 patients with symptoms for over six months due to subacromial impingement of the shoulder, who were being treated with physiotherapy, were included in this study. While continuing with physiotherapy they waited a further six months for surgery. They were divided into three groups based on the following four clinical and radiological criteria: temporary benefit following steroid injection, pain in the mid-arc of abduction, a consistently positive Hawkins test and radiological evidence of impingement. Group A fulfilled all four criteria, group B three criteria and group C two criteria. A total of nine patients improved while waiting for surgery and were excluded, leaving 83 who underwent arthroscopic subacromial decompression (SAD). The new Oxford shoulder score was recorded pre-operatively and at three and 12 months post-operatively. A total of 51 patients (group A) had a significant improvement in the mean shoulder score from 18 (13 to 22) pre-operatively to 38 (35 to 42) at three months (p < 0.001). The mean score in this group was significantly better than in group B (21 patients) and C (11 patients) at this time. At one year patients in all groups showed improvement in scores, but patients in group A had a higher mean score (p = 0.01). At one year patients in groups A and B did better than those in group C (p = 0.01). Arthroscopic SAD is a beneficial intervention in selected patients. The four criteria could help identify patients in whom it is likely to be most effective

Background. In young patients with femoral neck non-union it is desirable to preserve the femoral head. The objective of this study was to assess the outcome results of revision internal fixation and nonvascular fibular bone grafting. Patients and Methods:. Ten patients with non united fracture neck femur were included in this prospective study. Fixation was done with two cancellous screws leaving behind a space between two screws for fibular strut graft. Assessment of union was done by both clinical and radiological criteria. Results:. union was achieved in 8 cases in an average time of 16 weeks (range 12–20 weeks). There was no infection, thromboembolic complications, donor site morbidity or implant failure in our series. Conclusion:. Nonvascularized fibular strut graft along with cancellous screws provides a biological and mechanically sound method of treatment. Fibula being cortical provides mechanical strength besides stimulating union and getting incorporated as biological graft

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Neural axis anomalies in idiopathic scoliosis (AIS) are well documented, with prevalence of 7% in adolescents; 20% in early-onset and up to 40% in congenital, the case for pre-operative MRI of brainstem to sacrum is well made in these groups. SK is rarer than AIS and the prevalence of anomalies is not defined. The case for routine MRI scan is unclear. A recent report concluded that routine MRI was not indicated, although this was based on only 23 MRI scans in 85 patients. At our institution all patients are undergo whole spine MRI following a diagnosis of SK. We aimed to assess the incidence of significant neural anomalies in Scheuermann's Kyphosis. Using a keyword search for “Scheuermann”, we reviewed all SK patients' MRI reports over the past 6 years. 117 MRI scans were identified. 13 patients did not fulfil the radiological criteria for SK and thus 104 (73M: 31F) scans were reviewed. 14 (13%) of 104 scans showed unexpected Significant abnormal findings. There were 8 (8%) with neural axis anomalies: 4 syrinxes; 1 cord anomaly; 2 cerebellar descents and 1 cerebellar tumour. All these patients had normal neurological examination except one with examination consistent with a known diagnosis of Parkinson's. A further 6 patients had non-neural anomalies. The presence of neural axis anomalies may influence the management of a patient with SK. Neurological compromise during correction is higher in patients with neural axis anomalies and this risk can often be partially mitigated by a preceding neurosurgical procedure (such as foramen magnum decompression or shunt). Furthermore it is well described that these anomalies often occur in patients who demonstrate a normal neurological examination. This study confirms this. Given that MRI is widely available and considering the devastating life implications of neurological injury, we advise pre-operative MRI scan in all SK patents

Isolated fractures of the anterior column and anterior wall are a relatively rare subgroup of acetabular fractures. We report our experience of 30 consecutive cases treated over ten years. Open reduction and internal fixation through an ilioinguinal approach was performed for most of these cases (76.7%) and percutaneous techniques were used for the remainder. At a mean follow-up of four years (2 to 6), 26 were available for review. The radiological and functional outcomes were good or excellent in 23 of 30 patients (76.7%) and 22 of 26 patients (84.6%) according to Matta’s radiological criteria and the modified Merlé d’Aubigné score, respectively. Complications of minor to moderate severity were seen in six of the 30 cases (20%) and none of the patients underwent secondary surgery or replacement of the hip

Aims

The aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement.

Introduction. Two randomised trials concluded cast type (above or below elbow) makes no significant difference in the re-displacement rate of paediatric forearm fractures involving the distal third of the radius. This has not, however, led to the universal use of below elbow casts. In particular we noted one trial reported significant re-displacement in 40% or more of cases, which was much higher than we would expect. To review the radiological outcomes and need for re-manipulation of paediatric distal forearm fractures treated with closed manipulation under anaesthesia in our institution, in part for subsequent comparison with published results. All forearm fractures treated at a specialist children's hospital in one year were reviewed retrospectively. Based on the methodology of one trial, we included all fractures involving the distal third of the radius, with or without an ulna fracture, which underwent closed manipulation. Outcomes were radiological alignment using existing radiographs and need for re-manipulation. Cast type was at the discretion of the treating surgeon. The radiological criteria for re-displacement were based on published methodology. 79 children underwent manipulation, 71 receiving above elbow casts and 8 below elbow casts. Radiologically 21% of injuries treated in an above elbow cast re-displaced (15/71) compared to 38% of those in below elbow plasters (3/8). In 2 cases the re-displacement was treated with re-manipulation. The preference in our institution was clearly for above elbow casts in this injury pattern. The small number of below elbow casts in our series limits any comparisons. Our rate of re-displacement using above elbow casts was half that of one of the published studies, so the existing literature is not consistent with our experience

We describe the association between post-operative femoral stem radiological appearances and aseptic failure of THA (total hip arthroplasty) following a retrospective review of records and radiographs of all patients attending for follow-up between August 2002 and August 2003 who had a cemented Charnley femoral stem and either a cemented polyethylene acetabular cup inserted. Femoral stem aseptic loosening was defined either by findings at revision surgery, the definite radiographic loosening criteria of Harris or progressive endosteal cavitation across zones as described by Gruen. Well-fixed control THAs were defined as those that demonstrated none of the radiographic features of aseptic loosening or ‘at risk’ signs as described by Wroblewski. Parameters measured were: Alignment, Barrack grade of cementation, cement mantle width of the cement mantle and the presence and width of any radiolucent lines. Sixty-three hips were entered into the aseptic failure group and 138 into the control group. The alignment of the femoral stem was not associated with failure (p=0.283). Thickness of the cement mantle was statistically associated with failure in Gruen zones 6 (p=0.040) and Gruen zone 7 (p=0.003). A significant association for the presence of radiolucent lines was found for Gruen zones 3 (p=0.0001) and 5 (p=0.0001). The grade of cementation as measured by the Barrack grade was strongly associated with failure for grades C (p=0.001) and D (p=0.001). This study has demonstrated that easily applied radiological criteria can be used to identify ‘at risk’ Charnley THAs from the immediate post-operative AP radiograph

The aim of this study was to obtain detailed long-term data on the cement-bone interface in patients with cemented stems, implanted using the constrained fixation technique. A total of eight stems were removed together with adjacent bone during post-mortem examinations of patients with well-functioning prostheses. Specimens were cut at four defined levels, contact radiographs were obtained for each level, and slices were prepared for histological analysis. Clinical data, clinical radiographs, contact radiographs and histological samples were examined for signs of loosening and remodelling. The mean radiological follow-up was 9.6 years and all stems were well-fixed, based on clinical and radiological criteria. Contact radiographs revealed an incomplete cement mantle but a complete filling of the medullary canal for all implants. Various amounts of polyethylene particles were evident at the cement-bone interface of seven stems, with no accompanying inflammatory reaction. Cortical atrophy and the formation of an ‘inner cortex’ were confirmed in six of eight stems by contact radiographs and histology, but were only visible on two clinical radiographs. Our results confirm that a complete cement mantle is not essential for the survival of Müller straight stems into the mid term, and support our hypothesis that no benefit to long-term survival can be expected from modern cementing techniques

Introduction: Foot and ankle involvement in rheumatoid arthritis is common. Pain and disability secondary to planovalgus deformity and the arthritic process are difficult to control with conservative measures. Arthroplasty of the ankle is associated with high failure rates and does not completely correct the deformity. Arthrodesis of the hindfoot is a good option to alleviate pain, correct the deformity and improve functional ability, however has not been well reported in the literature. Aims: To determine change in quantitative measures of patient health, pain and functional ability following hindfoot arthrodesis in patients with rheumatoid arthritis, and to assess patient satisfaction postoperatively. Methods: 24 consecutive additive hindfoot arthrodeses were performed by a single surgeon on 22 patients with rheumatoid arthritis. Patients were assessed preoperatively using the Short Form-12 Health Survey (SF-12), Manchester-Oxford Foot Questionnaire (MOXFQ) and pain scores. These assessments were repeated at 6 and 12 months postoperatively, with an additional satisfaction questionnaire. Results: There was a marked and sustained improvement in the post-operative SF-12, MOXFQ and pain scores, with 71% of patients reporting no pain at 12 months. 19 out of 22 patients reported being satisfied or very satisfied with the operation. Bony union was achieved in all patients, both on clinical and radiological criteria. Most patients returned to normal footwear, some with slight modification to facilitate a more normal gait cycle. Conclusions: This study shows that additive hindfoot arthrodesis can be a very effective procedure in the management of moderate to severe ankle and hind-foot disease in rheumatoid arthritis. Patients should be counselled regarding the considerable recovery period; however significant improvement in the patient’s general health, foot function and pain can be expected

We describe the association between immediate postoperative radiological appearances and early aseptic failure of THA having compensated for the methodological flaws in previous similar studies. 63 hips were entered into the aseptic failure group and 138 into the control group. Alignment of the femoral stem was not associated with failure (p=0.283). Thickness of the cement mantle was associated with failure in Gruen zones 6 (p=0.040) and 7 (p=0.003). A significant association for the presence of radiolucent lines was found for Gruen zones 3 (p=0.0001) and 5 (p=0.0001). Grade of cementation was associated with failure for Barrack grades C (p=0.001) and D (p=0.001). This study has demonstrated that easily applied radiological criteria can be used to identify at risk THAs from the immediate post-operative AP radiograph

1. The literature of primary or idiopathic protrusio acetabuli is reviewed with particular reference to familial and racial influence on pathogenesis. 2. The radiological criteria of a "deep" acetabulum and of a "protruded" acetabulum are discussed. 3. Four generations of a family are presented in which all three members of the second generation showed marked protrusio acetabuli. In the remaining generations most members appeared to have abnormally deep acetabuli. 4. It is concluded that this family shows a strong familial tendency to deep or intruded acetabuli. The family tree, though incomplete, suggests a genetic influence ofa dominant type

Aims

Tibial cones are often utilized in revision total knee arthroplasty (TKA) with metaphyseal defects. Because there are few studies evaluating mid-term outcomes with a sufficient cohort, the purpose of this study was to evaluate tibial cone survival and complications in revision TKAs with tibial cones at minimum follow-up of five years.

Background: Intraarticular loose bodies following simple dislocations can lead to early degeneration. Non concentric reduction may indicate retained loose bodies and offer a method to identify patients requiring exploration to avoid this undesirable outcome. Methods: 117 consecutive simple dislocations of the hip presenting to the hospital from January 2000 to June 2006 were assessed for congruency after reduction by fluoroscopy and good quality radiographs. Patients with non concentric reduction underwent open exploration to identify the etiology and removal of loose bodies. The post operative results were analyzed using Thomson and Epstein clinical and radiological criteria. Results: 12 of the 117 (10%) dislocations had incongruent reduction which was identified by a break in Shenton’s line and an increase in medial joint space in seven patients, superior joint space in three patients or a concentric increase in two patients. CT scan performed identified the origin of the osteocartilagenous fragment to be from the acetabulum in six patients, femoral head in four, from both in one and one patient had inverted posterior labrum. In addition to this a patient had posterior capsular interposition. Following debridement, congruent reduction was achieved in all patients. At an average follow up of four years and nine months (4.9 years), the functional outcome evaluated by Thompson and Epstein criteria was excellent in 11 cases and good in one case. Conclusions: Intra articular loose bodies were identified by non-concentric reduction in 12 out of 117 patients with simple hip dislocation. Careful evaluation by immediate post reduction fluoroscopy and good quality radiographs are a must following reduction of hip dislocations

We studied a consecutive series of 285 uncemented total hip replacements in 260 patients using the Taperloc femoral component and the T-Tap acetabular component. The outcome of every hip was determined in both living and deceased patients. A complete clinical and radiological follow-up was obtained for 209 hips in 188 living patients, followed for a mean of 14.5 years (10 to 18.9). They were divided into two groups, obese and non-obese, as determined by their body mass index. There were 100 total hip replacements in 89 patients in the obese cohort (body mass index ≥ 30 kg/m. 2. ), and 109 in 99 non-obese (body mass index < 30 kg/m. 2. ) patients. A subgroup analysis of 31 patients of normal weight (body mass index 20 kg/m. 2. to 25 kg/m. 2. ) (33 hips) and 26 morbidly obese patients (body mass index ≥ 35 kg/m. 2. ) (30 hips) was also carried out. In the obese group five femoral components (5%) were revised and one (1%) was loose by radiological criteria. Femoral cortical osteolysis was seen in eight hips (8%). The acetabular component was revised in 57 hips (57%) and a further 17 (17%) were loose. The mean Harris hip score improved from 52 (30 to 66) pre-operatively to 89 (49 to 100) at final follow-up. Peri-operative complications occurred in seven patients (7%). In the non-obese group six (6%) femoral components were revised and one (1%) was loose. Femoral cortical osteolysis occurred in six hips (6%). The acetabular component was revised in 72 hips (66%) and a further 18 (17%) were loose. The mean Harris hip score increased from 53 (25 to 73) prior to surgery to 89 (53 to 100) at the time of each patient’s final follow-up radiograph. No statistically significant difference was identified between the obese and non-obese patients with regards to clinical and radiological outcome or complications. The subgroup analysis of patients of normal weight and those who were morbidly obese showed no statistically significant difference in the rate of revision of either component. Our findings suggest there is no evidence to support withholding total hip replacement from obese patients with arthritic hips on the grounds that their outcome will be less satisfactory than those who are not obese

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Between 1999 and 2002 14 children with femoral shaft fractures were treated with closed, locked intramedullary nailing. There were 11 male and 3 female patients, aged 11–16 years (mean 14.4 years). All fractures were closed. There were 9 transverse, 1 pathologic, 1 bipolar, 1 malunited and 2 spiral fractures. The fractures occurred following MVA or falls from height. All fractures were reduced and closed locked intramedullary nailing was performed using small diameter titanium nails without reaming. The entrance of point of the nail was created at the tip of the greater trochanter and no traction was used intraoperatively. The mean hospital stay was 2 days and immediate partial weight-bearing was permitted. All fractures united according to clinical and radiological criteria within 9 weeks. The maximum patient follow-up was 24 months (mean 17 months). Hip and knee mobility was full and no case of femoral head osteonecrosis, infection or malunion was ascertained. Closed, locked intramedullary nailing in adolescent patients provides immediate fracture immobilization combining safety and limited morbidity. Meticulous adherence to the surgical technique is necessary respecting the developing upper part of the femur

Objective: The main treatment for unstable distal radius fracture in Québec consists in pinning and cast, with secondary shortening and displacement responsible for lack of motion. The goal of the study is to compare clinical and radiological results after treatment with non-bridging external fixator compared to pinning and cast, with restoration of grip strength as main clinical outcome. Method: Between June 2003 and June 2005, 120 consecutive patients admitted for unstable extra-articular distal radius fracture were randomized in the 2 groups. Early mobilisation was allowed in the group with external fixator, and patients in the other group had pins and cast for 6 weeks. Follow-up was completed after 6 months with determination of clinical and radiological data for the both wrists. 110 patients completed the study, with 2 comparative groups for epidemiologic and radiological criteria (n = 63 for pins and 57 for external fixator). Results: Grip strength was significantly better in the fixator group at 3 months (68,36%;p< 0,001) and 6 months (98,26%;p< 0,001). Active ROM was better and obtained earlier in the fixator group in all directions (p< 0,001). Fixator prevent shortening and secondary displacement in a highly significant way (p< 0,001). No difference in pain medication, but fixator group could begin occupation earlier (p< 0,001). Conclusion: Non-bridging external fixator is a treatment of choice for unstable extra-articular distal radius fractures. The immediate stability allows in all patients (without influence of age, bone quality or fracture displacement) early mobilisation, prevent secondary displacement, and gives earlier and better functional results

Purpose: The main treatment for unstable distal radius fracture in Québec consists in pinning and cast, with secondary shortening and displacement responsible for lack of motion. The goal of the study is to compare clinical and radiological results after treatment with non-bridging external fixator compared to pinning and cast, with restoration of grip strength as main clinical outcome. Method: Between June 2003 and June 2005, 120 consecutive patients admitted for unstable extra-articular distal radius fracture were randomized in the 2 groups. Early mobilisation was allowed in the group with external fixator, and patients in the other group had pins and cast for 6 weeks. Follow-up was completed after 6 months with determination of clinical and radiological data for the both wrists. 110 patients completed the study, with 2 comparative groups for epidemiologic and radiological criteria (n = 63 for pins and 57 for external fixator). Results: Grip strength was significantly better in the fixator group at 3 months (68,36%;p< 0,001) and 6 months (98,26%;p< 0,001). Active ROM was better and obtained earlier in the fixator group in all directions (p< 0,001). Fixator prevent shortening and secondary displacement in a highly significant way (p< 0,001). No difference in pain medication, but fixator group could begin occupation earlier (p< 0,001). Conclusion: Non-bridging external fixator is a treatment of choice for unstable extra-articular distal radius fractures. The immediate stability allows in all patients (without influence of age, bone quality or fracture displacement) early mobilisation, prevent secondary displacement, and gives earlier and better functional results

Aims

The most important complication of treatment of developmental dysplasia of the hip (DDH) is avascular necrosis (AVN) of the femoral head, which can result in proximal femoral growth disturbances leading to pain, dysfunction, and eventually to early onset osteoarthritis. In this study, we aimed to identify morphological variants in hip joint development that are predictive of a poor outcome.

The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction. Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the EuroQol-5D questionnaire were documented over a median period of follow-up of 40 months (12–206). Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5 years (16–80). Half of them were posterior-wall fractures, 21.6% bicolumn, 14.7 %posterior-wall and column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases. Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome

Purpose: The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction. Patients & Methods: Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the Euro-Qol-5D questionnaire were documented over a median period of follow-up of 40months (12–206). Results: Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5years (16–80). Half of them were posterior-wall fractures, 21.6% both column, 14.7% posterior-wall and posterior-column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intraoperative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At final follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases. Discussion/Conclusion: Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome

Basilar impression is a well-recognised though rare complication of osteogenesis imperfecta. Three patients, all members of the same family, with advanced basilar impression complicating osteogenesis imperfecta tarda, are described. The clinical features in these cases illustrate the natural history of this condition: from asymptomatic ventricular dilatation, through the foramen magnum compression syndrome, to death from brain-stem compression. The radiological criteria on which the diagnosis is based, are defined. Review of the literature reveals only seven previously documented cases, all in patients with mild forms of osteogenesis imperfecta. The unusually low incidence of basilar impression in osteogenesis imperfecta and its apparent restriction to patients with mild forms of the disease is discussed. The examination of close relatives of patients with basilar impression and osteogenesis imperfecta is emphasised in order to anticipate the onset of severe neurological complications

Out of a total of 91 patients with traumatic posterior dislocation of the hip treated between 1936 and 1974 in the Mansfield area, 81 patients were reviewed. The average follow-up period was 12.5 years, although there was a large number of cases with a follow-up of more than 15 years and a smaller number with a follow-up of 30 years. The overall results were surprisingly poor despite early reduction of the dislocation in the majority of cases. We found that 15 years after simple dislocation 24 per cent of the cases had a poor result by both clinical and radiological criteria, but in the more severe grades of initial injury the results became worse, with 73.3 per cent of the patients graded as fair and poor, and only 26.7 per cent graded excellent or good

Aims

Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology.

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77). At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two. Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis

Purpose: The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction. Patients and Methods: Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the Euro-Qol-5D questionnaire were documented over a median period of follow-up of 40months (12–206). Results: Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5years (16–80). Half of them were posterior-wall fractures, 21.6%bicolumn, 14.7%posterior-wall and column, 6.8%transverse, 5.7%anterior-column, 1.1%anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases. Conclusion: Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome

Radiological evaluation is crucial for interpretation of experimental osteomyelitis studies. Current scoring systems for radiologic evaluation of experimental osteomyelitis have limitations to demonstrate differences among treatment groups. Response of bone tissue to infection is a dynamic process; each radiological sign of osteomyelitis becomes prominent at different time points of disease. Analysing radiological criteria separately at different stages of the disease may provide better quantification of the response to treatment in experimental osteomyelitis rather than summation of these grades together. Osteomyelitis was induced with S.aureus in left tibias of 72 adult, wistar albino rats. Rats were assigned into six different treatment groups. Their radiograms were graded according to previously defined scoring systems, and each radiological criterion separately, at the third week of induction, and at the third and sixth week after treatment. Although periosteal reaction and diaphyseal widening demonstrate significant differences with three weeks of treatment, previously defined scoring systems could not find significant differences. At the sixth week of treatment, only one of the previously defined grading scales was able to differentiate significance among the treatment groups. Individual values of diaphyseal widening, osteolysis, BMC values were pointed out differences among the groups in the presence of osteomyelitis, confirmed by osteomyelitis. Formulation of radiological grading scales requires evaluation of periosteal elevation, diaphyseal widening, bone deformation, osteolysis, and osteosclerosis, individually. However, evaluation of these scores separately will multiply interpretations of future studies, and will make them more meaningful

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed

Background: In a recent publication from the National Joint Registry it was suggested that prosthesis type influenced patient satisfaction at one year following knee arthroplasty. In this report Unicondylar Replacement (UKR) was associated with lower levels of patient satisfaction when compared to cemented TKR. The unicondylar group did however have a significantly lower Oxford Knee Score (OKS) than the TKR group and this occurred irrespective of patient age. A common perception is that UKR is only offered to patients with lesser disease, with a decreased clinical profile. This may explain their higher levels of dissatisfaction as the overall change in their OKS from pre to post operation would be relatively smaller than for TKR. Aim: We hypothesised that patients listed for UKR have less severe disease and therefore a lower preoperative OKS when compared to TKR. Methods: After sample size calculation we retrospectively analysed 76 patients who underwent either UKR or TKR under the care of a single surgeon. OKS was recorded at a dedicated pre-assessment clinic. The decision to offer UKR was based on clinical and radiological criteria as outlined by the Oxford group. Results: There were 38 patients in either group. The mean pre-operative OKS was 39.5 (26–56, SD 7.6) in the UKR group and 41.6 (31–51, SD 5.7) in the TKR group. There was no statistical difference between these two groups (p=0.18). Discussion: Patients listed for knee replacement have significant pain and functional impairment. In our population those suitable for UKR have similarly severe symptoms to those who do not meet the criteria for UKR and are only eligible for TKR. It remains unclear why patients undergoing UKR should be less satisfied when they have better post operative patient reported outcome scores. It emphasizes the need for careful patient selection and counselling in patient undergoing UKR

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures

We report a prospective study of gait and tibial component migration in 45 patients with osteoarthritis treated by total knee arthroplasty (TKA). Migration was measured over two years using roentgen stereophotogrammetry. We used the previously established threshold of 200 μm migration in the second postoperative year to distinguish two groups: a risk group of 15 patients and a stable group of 28 patients. We performed gait analysis before operation and at six months and at two years after TKA. On all three occasions we found significant differences between the two groups in the mean sagittal plane moments of the knee joint. The risk group walked with higher peak flexion moments than the stable group. The two groups were not discriminated by any clinical or radiological criteria or other gait characteristics. The relationship which we have found between gait with increased flexion moments and risk of tibial component loosening warrants further study as regards the aetiology of prosthetic loosening and possible methods of influencing its incidence

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator. Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

Introduction and purpose: Rhizarthrosis of the thumb is the most common form of osteoarthritis of the hand. In some cases it courses with intense pain and severe functional limitation of the thumb or the entire hand. The purpose of this study is to compare the results of treating rhizarthrosis with a total ARPE trapezio-metacarpal prosthesis and trapezectomy, whether or not associated with tendon interposition and ligament repair. Materials and methods: A retrospective comparative study in which we reviewed cases of rhizarthrosis treated surgically in our hospital between 1994 and 2004. We found 75 cases, of which 28 were treated with resection arthroplasty (group A), 32 with ARPE prosthesis (group B) and 15 with bone fusion (not included in this study). The mean age was 58.85 for group A and 63.16 for group B. Mean follow-up time was 39.5 months. We used the DASH questionnaire for the subjective clinical examination and the Jamar dynamometer for the objective examination. For radiological assessment we used the Eaton classification and Walch radiological criteria. Results: We analysed the results using SPSS statistical software and found no significant differences between the two groups, although the subjective assessment showed better results in terms of mobility and pain remission in group B and strength in group A. Conclusions: The aim of surgical treatment of rhizarthrosis is to achieve a stable, pain-free thumb. Several procedures are available, the success of which depends on correct indication and meticulous surgical technique

Introduction: Ankle syndesmotic injury is currently assessed by radiographic criteria defined by Pettrone. These indices are based on the assumption that the ankle is in the correct rotation when the radiographs are taken. This study shows that computerized tomographic (CT) scans of an ankle in its mortice orientation demonstrate a greater range of values for the tibio-fibular overlap (TFO), and the tibial clear space (TCS) than that proposed by Pettrone. This study also demonstrates how rotation of the ankle in the transverse axis changes the values for the TFO and TCS. Materials and Method: 20 uninjured ankle CT scans were studied to evaluate the syndesmosis. The images were orientated so that measurements were taken 1cm above the tibial plafond with the ankle in a mortice orientation. Each image was rotated 5° from 15° external rotation to 20° internal rotation. Bony landmarks were confirmed prior to taking measurements. These were taken by 2 orthopaedic surgeons on 2 separate occasions. Results: The range for the TFO is 0–11.6mm; the range for the TCS is 2–6.1mm. The range for the values is greater than that proposed by previous studies. The TFO and TCS change with rotation of the leg. Conclusion: On the AP radiograph syndesmotic disruption is indicated by a TCS > 5mm, a TFO < 10mm and on the mortise view a TFO < 1mm. A normal ankle should therefore have a TCS less than 5mm and TFO greater than 10mm on the AP and greater than 1mm on the mortise view. There is a greater normal range of syndesmotic width found on CT scans than suggested by previous studies. Values change with rotation of the leg in its transverse plane. Syndesmotic injury cannot be reliably diagnosed using the current radiological criteria

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator. Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred. Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire. Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Introduction: The problems of the differential diagnosis (d.d.) between musculoskeletal infections and tumours are generally uncommon because both pathologies are quite rare. This is not the experience at the G. Pini Orthopaedic Institute where there are two Units specialized on bone infections and bone tumours and their clinicians often consult each other for difficult cases. Material and Methods: On the basis of this experience, the A.A. revised clinical and radiological criteria of d.d. between acute or chronic osteomyelitis and different histotypes of musculoskeletal tumours. In particular they examined the type and the course of the symptoms, the laboratory data, the site of the lesions and the characteristics of the imaging, both for bone damages and for soft tissues invasion. Afterwards they compared this revision whit the experience of the cases consulted each other. Results: D.d. of acute osteomyelitis include Ewing sarcoma, Osteosarcoma and Eosinofilìe granuloma, especially in children; d.d. of chronic and deep lesions (axial skeleton) in adults include lymphoma and metastasis; in the epiphysis d.d. can involve also benign lesions. This work allowed the A.A. to identify some guidelines that they consider suitable. Time, possibilities and limits of the imaging techniques like bone scans, CT and MRI are outlined, likewise time and types of direct examination of the lesions by puncture or biopsy, that was necessary in many cases, are proposed. Conclusions: The A.A. think that these personal guidelines can help them to face easier, in the future, the difficult cases, minimizing both diagnostics and therapeutics delays and mistakes

Introduction: We describe the association between postoperative femoral stem radiological appearances and aseptic failure of THA (total hip arthroplasty). Methods: A retrospective review of records and radiographs of all patients attending for follow-up between August 2002 and August 2003 who had a cemented Charnley femoral stem and either a cemented polyethylene acetabular cup inserted. Femoral stem aseptic loosening was defined either by findings at revision surgery, the definite radiographic loosening criteria of Harris or progressive endosteal cavitation across zones as described by Gruen. Well-fixed control THA’s were defined as those that demonstrated none of the radiographic features of aseptic loosening or ‘at risk’ signs as described by Wroblewski. Parameters measured were: Alignment, Barrack grade of cementation, cement mantle width of the cement mantle and the presence and width of any radiolucent lines. Results: 63 hips were entered into the aseptic failure group and 138 into the control group. The alignment of the femoral stem was not associated with failure (p=0.283). Thickness of the cement mantle was statistically associated with failure in Gruen zones 6 (p=0.040) and Gruen zone 7 (p=0.003). A significant association for the presence of radiolucent lines was found for Gruen zones 3 (p=0.0001) and 5 (p=0.0001). The grade of cementation as measured by the Barrack grade was strongly associated with failure for grades C (p=0.001) and D (p=0.001). Discussion and conclusion: This study has demonstrated that easily applied radiological criteria can be used to identify ‘at risk’ Charnley THA’s from the immediate post-operative AP radiograph

Objectives: To determine if high quality, thin slice (1–3)mm CT scan images would allow proper evaluation of interbody fusion through titanium cages in view of the fact that there are no universally accepted radiological criteria. . 1. Design: Patients undergoing interbody lumbar fusion were prospectively evaluated with a CT scan and plain radiographs six months following surgery. These were blindly and independently evaluated by a consultant radiologist and a research fellow. They were assessed for bridging bony trabeculation both through and surrounding the cages as well as for changes at the cage endplate interface. Subjects: Fifty-three patients (156 cages) undergoing posterior lumbar interbody fusion using titanium inter-body cages were evaluated. Posterior elements were used to pack the cages and no graft was packed outside the cages. Outcome Measures: Kappa co-efficient and chi-squared analysis. Results: On the CT scan both observers noted bridging trabeculation in 95%of the cages-Kappa 0.85, while on radiographs they were present in only 4%-Kappa 0.74. Both observers also identified bridging trabeculation surrounding the cages on the CT scans in 90%-Kappa 0.82, while on the radiographs this was 8%-Kappa 0.86. Radiographs also did not identify all the loose cages. Conclusions: High quality CT scan images can demonstrate bridging bony trabeculation following the use of titanium interbody cages. It also demonstrated consistent bone growth outside the cages inspite of not using any bone graft

Introduction: A subjective observation suggests that a significant percentage of patients offered a TKR could benefit from a relatively more conservative, less invasive unicompartmental knee arthroplasty. We set out to challenge this hypothesis. Materials & Methods: 1147 TKRs were performed between 2002 and 2005 at Ravenscourt Park Hospital. 50 consecutive knee x-rays of patients who underwent a TKR were reviewed by three independent observers. Medial and lateral articular cartilage height, varus angulation, and femero-tibial anteroposterior and mediolateral translation were measured on antero-posterior and lateral weight bearing radiographs. Skyline views were analysed for patellofemoral disease. The most appropriate procedure according to local radiological criteria was recorded for all three observers. Unicompartmental arthroplasty was considered when the following criteria was met 1) anteromedial disease with preservation of posterior slope, 2) preservation of the tibial spines, 3) no anteroposte-rior or mediolateral translation, 4) normal tibiofemoral alignment and 5) preservation of patellofemoral joint. Osteophytes were disregarded. Tricompartmental disease merited a TKR while isolated patellofemoral (PFJ) disease considered for PFJ replacement. Patients were not formally examined. Preoperative Knee Society Scores (KSS) and WOMAC scores were noted. Results: The three observers indicated that 26 (52%), 21 (42%) and 22 (44%) patients respectively could potentially benefit from a unicompartmental arthroplasty given the right clinical setting. Consensus was reached for unicompartmental replacement in 16 (31.2%) and for TKR in 18 (36%) of cases. There was no correlation between the operation performed and operation proposed (42% ± 8) suggesting that the surgeon’s preference is a dominating factor. Interestingly within the proposed unicompartmental group Knee Society Scores were higher (100 ± 22 vs 71 ± 26) giving an indication to the disease severity. Conclusion: The clinical benefit and economic value of opting for a unicondylar knee arthroplasty when indicated is considerable. None the less it was only considered by a minority of surgeons who undertake knee arthroplasty

Purpose of the study: Static metatarsalgia is a common complaint in podology surgery. Most cases are related to the great toe, but in certain cases, isolated metatarsal disharmony, without hallux vlgus, can be observed. We report 45 such cases. Material and methods: This was a retrospective analysis of isolated metatarsal disharmony observed in patients who underwent metatarsal surgery between 1986 and 2003. There were 36 women and 9 men, mean age 49 years. Three subgroups were distinguished: posttraumatic disharmony, isolated disharmony of the second ray, iatrogenic disharmony. Conditions related to rheumatoid disease, aseptic osteonecrosis of the metatarsal heads, and rear foot disorders were excluded. Surgical treatment was osteotomy of the base of the metatarsal for 24 patients, and Weil’s osteotomy for 21. Clinical and radiological assessment used the Kitaoko and Maestro criteria. Results: Mean preoperative score was 38 (range 21–58). Mean gain one year after osteotomy was 35 points. The score was 76 after osteotomy of the metatarsal base and 79 after Weil osteotomy. The less favorable results were observed in the group of posttraumatic metatarsalgias. Outcom was less satisfactory in the male population where residual metatarsalgia was noted in 75%. Reflex dystrophy occurred in 15% of the patients who had multiple osteotomies. Radiographically, The SM4 line was centered with progressive geometry in 50%. Discussion: While the short-term results obtained with these two surgical methods were similar, osteotomy of the metatarsal base offers better long-term outcome. The osteotomy improved the functional score, even without improvement of radiological criteria. Initial treatment of metatarsal fractures should attempt to restore correct alignment of the metatarsals because of the poor results obtained with corrective osteotomy for posttraumatic misalignment. Conclusion: When metatarsal disharmony is symptomatic, we propose osteotomy of the base of the metatarsals for the median rays in order to avoid transfer metatarsalgia. Complementary osteotomy of the fifth metatarsal is not always necessary

Introduction: Isolated compressive fractures of the scaphoid and lunate fossa of the distal radius are rare injuries and their closed reduction is almost impossible. Frequently the displacement becomes accepted and conservative treatment was applied which in the long-term could have catastrophic consequences concerning the fate of articular cartilage. Material and Methods: Seven patients (6 males and 1 female) of mean age 30 years old (range 18–42) were studied with compressive fracture of scaphoid (4 patients) or lunate (3 patients) fossa. All patients (except one with compressive fracture of the lunate fossa who was treated early), were initially treated conservatively. Mean delay of surgical treatment was 36 days (3 patients) while two patients were operated 2 and 2, 5 years postinjury. One patient with fractured lunate fossa had concomitant fracture of the lunate. The vast majority of the patients underwent supplementary imaging techniques (CT scan, MRI, 3D-CT scan). The majority of patients were approached both intraarticularly and extraarticularly. Results: Results were estimated after an average follow-up of 12 months (range, 6 months – 3 years) according to clinical and radiological criteria. Six patients revealed excellent or good result while one had a fair result. Conclusion: In conclusion, operative treatment of these intraarticular fractures should be attempted independently of the time elapsed from injury on the premise that there are no arthritic changes and an adequate pre-operative planning has done

The object of this work was to retrospectively study the recommendations and the results of cruent reduction of idiopathic congenital displacement of the hip following ineffective orthopaedic treatment. From 1993 to 2001, 15 cruent reductions were performed in 11 children (seven girls and four boys). Initially, the 15 hips were treated by orthopaedic techniques (Pavlik harness and/or slow reduction according to the Sommerville-Petit method). Four of these have benefitted from surgical treatments after orthopaedic treatment proved to be ineffective (psoas tenotomy, Salter osteotomy). At the time of the cruent reduction the mean age was 24 months (range 9 months to 5 years). For the surgical reduction, always associated with a shortening-derotation osteotomy of femur, the Smith-Petersen antero-medial approach was used. In five of these cases, the cruent reduction was complemented by Salter osteotomy. The mean post-surgical follow-up is 5.6 years (from 1 to 9 years). In none of the hips studied was recurrence of the dislocation observed. The functional outcome, studied by Mackay criteria, is good for all the hips. No significant dysmetria of the lower limbs was present. According to the radiological criteria in the classification of Severin outcome was good or excellent in 12 hips and average in three hips. According to the Bucholz and Ogden classification, six hips showed signs of necrosis as a result of the orthopaedic treatment. The surgical treatment did not cause necrosis in the remaining nine hips. Recourse to a surgical procedure can result because of the anatomical obstacles typical of specific dislocations. Surgical reduction must be considered as an operation to preserve the hip; this operation is suitable at about 1 year of age if progressive orthopaedic practices are ineffective. Before 2 years of age, the cotyloid cavity can continue to develop after femoral head reduction, whereas, after this age, it is preferable to integrate a Salter osteotomy with the cruent reduction

Aims

Aneurysmal bone cysts (ABCs) are locally aggressive lesions typically found in the long bones of children and adolescents. A variety of management strategies have been reported to be effective in the treatment of these lesions. The purpose of this review was to assess the effectiveness of current strategies for the management of primary ABCs of the long bones.

Fracture of the lateral humeral condyle accounts for approximately 15% of all elbow fractures in children. We studied 68 fractures of the lateral humeral condyle, which were treated surgically over a period of six years during 1994 to 2000. There were 49 boys and 19 girls. The average age was 6,5 years (2,5 – 13 years). All cases were treated with open reduction and internal fixation with two divergent K-wires for safer stabilisation of the fracture. Subsequently a cast was applied for 4–6 weeks to the radiological union of the fracture, where the K-wires were removed. The patients were evaluated with clinical and radiological criteria. Sixty-five cases were classified as Milch type II fractures and three were Milch type I fractures. According to the Jacob classification, which records the degree of displacement, 23 cases were type II fractures and 45 cases were type III fractures. The mean follow up was 4 years (2–8 years). Analysis of the postoperative radiographs showed that radiological union was achieved in all cases. The mean time to radiological union of the fracture was 4,5 weeks (3–8 weeks). At latest follow up we observed abnormalities of the shape of the distal humerus due to overgrowth of the lateral humeral condyle in 40% of the cases. In 4 patients we observed pseudocubitus varus due to overgrowth of the lateral humeral condyle and in 3 patients we observed mild cubitus varus (< 5°). Clinically in all cases there was painless free movement of the elbow. We conclude that satisfactory anatomical reduction of the fracture gives good clinical results. The radiological abnormalities observed seem not to play an important role in the final result

These fractures are usually caused from high energy road accidents and sports injuries and are accompanied by meniscal and collateral ruptures. Aim the study is to present the surgical treatment of these fractures in relation to quality and technique of the reduction and the evaluation of results with base clinical and radiological criteria. From 1996 until 2001. 30 patients with mean of age 48.5 years mainly men, we have treated with tibial plateau fractures, that main cause had the road accident. According to the classification of AO, were predominate of type A and associated injuries had 12 patients. The diagnosis became with simple radiographs, tomographies and in 5 with computed tomography. All patients were operated on average 5 days after the injury and were used in 16 with lag screw {8 with subcutaneous technique } and in 14 with buttress plate and screws In the 1/3 of patients were used bone grafts and in 12 were observed rupture of lateral meniscus. They were re-examined 27/30 patients 1–7 years after the injury and the result it was satisfactory in 24/27. A radiologic control revealed arthritic changes in 17 patients and painful only 5 of them. while all patients had been operated with subcutaneous technique of lag screws had excellent result.. 23 came back in their work while serious instability of the Knee was not observed. As shown in the bibliography in this fractures the quality of reduction and atraumatic technique in combination with stable fixation and early range of motion they constitute strategical goals of treatment that it ensures a good result. The arthritic changes are asymptomatic when do not exist serious{ cruciate -meniscal damage -} instability of the Knee

The purpose of this study is to evaluate the results of the treatment of displaced greater-tuberosity fractures by open reduction and stable fixation with heavy non absorbable sutures and early passive motion. Thirty-six patients, 21 male (average age 50 years) and 15 female (average age 62 years) underwent open reduction and internal fixation for a displaced greater-tuberosity fracture of the proximal humerus, between 1992–2000. Main indication for operative treatment was at least 1 cm displacement of the tuberosity. Reduction and stable fixation of the greater tuberosity with its rotator-cuff attachments, was performed by a lateral approach using heavy transosseous nonabsorbable sutures. Passive motion was started at the second postoperative day followed by active range of motion after the fifth postoperative week. All patients were examined periodically using clinical and radiological criteria. All fractures were healed without any displacement within 3 months. Final assessment was performed according to Neer’s criteria for pain, motion, function, strength and patient’s satisfaction, in a mean follow-up period of 4 years. Twenty seven patients (75%) rated excellent, without pain, showing active forward elevation at 160 to 180°, external rotation at 60 to 80° and internal rotation up to tiq level. Nine patients (25%) rated very good, had only minor pain problems. We conclude that, if displaced fractures of the greater tuberosity are not diagnosed and treated promptly, may result in limitation of motion and functional disability. To our experience open reduction and stable fixation with transosteal suturing, allowing early passive motion of the joint, gives excellent to very good final results

Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

Introduction: There are approximately 50000 hip and knee arthroplasties performed in the UK every year. With this increasing number the prevalence of periprosthetic fractures is also rising. These are often challenging problems with increased morbidity and mortality. The use of cortical strut allografts in periprosthetic fractures was first reported in the early 90’s with favourable results.The aim of this study was to assess the radiological outcome of cortical strut allografts used as the treatment for periprosthetic fractures of the femur in patients presenting to our institution. Patients & Methods: 17 patients with who had received strut allografts as part of their treatment for a periprosthetic fracture of the femur were identified. 13 fractures were around a total hip replacement and 4 around other femoral implants (2 long stemmed TKR’s and 2 fracture fixation devices). We undertook a radiological evaluation of this technique. We assessed fracture union and strut allograft incorporation using the radiological criteria of Emerson et al. The procedure was deemed a success if the fracture had united, with evidence of graft incorporation with a stable implant. We also undertook a notes review identifying any risk factors and any previous surgery. Results: Two patients died in the early post-operative period. 15 patients were available for analysis. The average length of radiographic review was 16 months. 11/15 procedures (73%) were deemed a success. All these showed evidence of graft incorporation which was time dependent. There were four failures. In one patient the struts fractured at two months. There were three cases of deep sepsis, this required amputation in one and excision arthroplasty in two. Conclusion: Cortical strut allografts are a good technique for the management of periprosthetic fractures of the femur. As well as providing initial support they also become incorporated which improves the host bone stock

We present a unique prospective study which estimates the median sustained stage related improvement in pain and hand function predicting symptomatic relief period with high accuracy with a single steroid injection. Patients were grouped into stages, I to IV according to the Eaton and Glickel radiological criteria. The steroid injection contained 40mg triamcelone and 1% lido-caine. The response was assessed by DASH and a visual analogue score before and at six-week interval. We used the Kaplan-Meier method to estimate median length of sustained improvement by grade of disease, with 95% confidence interval. All the patients were injected by an upperlimb physiotherapist (DD). Post injection review was carried out by an independent observer(MK). Forty patients were studied: 33 females and 7 males. The age ranged from 53 to 81 years, (mean 65years). No patient was lost to follow-up. Mean duration of symptoms were 36 months. Six patients has stage I disease(15%), eighteen patients had stage II disease (45%), ten patients had stage III disease (25%) and six patients has stage IV disease (15%). Pain score ranged from 4 to 9 on visual analogue score. Reduction in pain visual analogue score was noticed in all but 3 patients. With the exception of Grade III patients, DASH scores decreased significantly at 6 weeks (Grade I 14.9, Grade II 19.3, Grade III 6.2 and Grade IV 10.0.). With the exception of Grade IV patients, pain scores decreased significantly at 6 weeks. In Grade II patients, over half had sustained symptomatic relief at 6 months. So on average, we can expect grade I patients to sustain symptomatic relief for an average of 17 weeks. The true average is likely to be between 13 and 21 weeks. For grade II patients, most will still have improved at 6 months. Grade III and IV patients have an identical prognosis of 4 weeks, though the true prognosis may be between 2 and 6 weeks. In conclusion it is possible to predict the period of symptomatic improvement in each of the four disease stages. This allows the treating clinician to discuss the outcome of treatment with reasonable accuracy

The purpose of this study is to determine the indications and effectiveness of hybrid external fixation in the treatment of tibial plateau fractures and to evaluate the patient’s functional recovery. Twenty-seven patients with 28 intra-articular fractures of the proximal tibia were surgically treated with hybrid external fixation in a two years period (1999–2001). There were 25 patients (19 men and 6 women) available for the last follow up evaluation. The mean age was 35 years (17–76). According to Schatzker classification, there were 6 fractures type V and 22 type VI. Three of them were open fractures. The method included, indirect reduction based on ligamentotaxis and compression of the fractured segments with olive pins, in most patients. Additional limited internal fixation with free screws was also performed in 5 cases. Open reduction was necessary in 6 patients. Mobilization of the injured articulation was started at the third postoperative day, while full weight bearing was allowed after three months. The fixator was removed in average 12th week. Final evaluation was done according subjective, functional, clinical and radiological criteria. Mean follow up period was 14 months. All fractures except one united at an average time of 13, 5 weeks. Twenty-two patients (77.6%) graded as excellent and good, hi detail, subjective results were acceptable in 72%, functional in 84%, clinical in 70% and radiological in 80%. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and superficial pin path infections. The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow quick mobilization and functional recovery of the knee joint. Moreover it is an application rather atraumatic because, only occasionally requires open reduction

Purpose of the study: This prospective anatomic study was conducted to analyze meniscal healing after arthroscopic repair. Material and method: Two preliminary studies (a radio-anatomic study and a comparative arthroscan-arthros-copy study) were conducted to define strict radiological criteria (contiguous slices or spiral acquisition)which could be interpreted by all observers. Sixty-five vertical meniscal lesions were included in the study and divided into four groups according to localization (medial or lateral) and knee stability (stable or associated ligamentoplasty). Arthroscopic repair was performed in all cases. Mean length of the lesions was 20.31±6 mm. Minimum follow-up was six months. The work-up included an arthroscan and the IKDC function score. Results: The work-up could be interpreted for 62 knees. The overall outcome according to Henning was: 42% complete healing, 31% incomplete, 27% failure. Healing outcome was similar for lesion in a red-red zone (73%) or a red-white zone (70%). The healing surface could be assess for 43 knees: 37% complete healing, 21% partial healing of more than half of the initial tear, 12% partial healing of less than half of the tear, and 12% failure. The analytic results of 17 medial repairs on stable knees yielded: 9 complete, 2 partial, 4 failure, with IKDC (79, 68, 73 points) having no significant influence. For the 24 medial repairs on unstable knees outcome was: complete healing in 10, partial in 6 and a good IKDC score (80.85 points). Functional outcome was poor for the eight failures (67 points). Lateral repairs on 11 stable knees yielded: complete healing in 2 (IKDC 76 points), partial in four (IKDC 94 points) and failure in five (IKDC 82 points). For the ten unstable knees, complete healing was achieved in five and partial healing in five with good patient satisfaction (IKDC 80.70 points). Conclusion: Methodologically, arthroscan provided a good assessment of healing. The notion of the healing surface appears to be more appropriate than thickness, since partial healing can transform an unstable knee into a stable one. Clinically, in one third of the knees, meniscal healing could not be achieved. This failure was more frequent and less well tolerated for the medial lesions. For the lateral lesions, incomplete healing was more frequent, perhaps in relation to meniscal mobility and the associated ligamentoplasty which apparently protected the meniscal repair. In this series, meniscal healing did not have a significant influence on the functional outcome

Conservative treatment is not always possibile because it needs anatomic reduction of the fractures and to prevent the functional difficulties. There’s inherent tendency loss of reduction after non-operative treatment. According to criteria of instability of Cooney et al. as dorsal angulation > 20° degrees, loss radial length> 10 mm, intraarticular extension, etc. or if we had fractures A3, B, C of A.O. classification, open, bilateral fractures in polytrauma, will be useful to operate with internal or external fixation. We need to respect the morphology of three columns. We compare two different types of devices usually used in the last ten years in our hospital as the external fixation with Pennig and the plates and screws in internal fixation, underlining the advantages and the disadvantages. Between January 1997 and December 2006 215 patients with comminuted and unstable fractures complicated with different clinical aspects of exposure or vasculopathy or neurological acute entrapment or lesion, of severe displacement were treated by external fixator of Pennig. They were evaluated according to Gartland e Werley system, Sarmiento modified. Pain, disability and functional disease of articulation, radiological criteria of instability. To follow up average 12,4 months (range 5 to 24 months) the patients were distinguished as excellent, good, in 76% and fair good and bad in 24%. Complications of treatment were 3 osteitis and trombosis. In the same period we applied 142 plates the most in the volar side as DCP, LCP in association when it needs with graft, pinning and platelet gel after centrifugation of blood of the patient useful to bone healing. These patients were evaluated regarding to anatomy and function after reduction as strength of punch by Jamar dynamometer, pain, range of motion. After three months the patients operated with plates showed a ROM and a strength of punch better than those operated by external fixator. On the contrary after six months, more and more after twelve months the clinical and radiological results that is anatomical and functional outcomes were the same. At one year the Dash score was the same in the both of groups and there was not a difference between them. So we are authorized to use the external fixator of Pennig in unstable fracture A3 of wrist after failure of closed reduction, higher energy fractures and dislocations, unstable articular methaepiphiseal and comminuted fractures, exposed fractures, bilateral and complicated in politrauma. We applied volar plate and screws when there are extraarticular displaced fractures (A3.3), articular displaced fracture (B, C), corrected osteotomies, particularly in fracture type B (internal osteosintesis with plate + eventual volar graft), type C (internal osteosintesis volar plate associated with dorsal approach and pinning) + possible graft

Aims

The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT.

Introduction: Operative fixation is the mainstay of treatment for displaced ankle fractures. Results however can be variable, with patients complaining of residual pain and stiffness of the ankle joint. In addition, metalwork can be problematic giving rise to symptoms in up to 25% of patients. We undertook a retrospective study to evaluate outcome in terms of functional and radiological criteria in a cohort of patients. Aim: To assess outcome in a cohort of patients following operative treatment of ankle fractures. Materials and Methods: Patients with suitable injuries sustained were identified from the hospital HIPE database. Data was collated from hospital records including demographic details, mechanism of injury, details of the initial injury and surgical treatment. Patients were invited to attend for clinical and radiological examination of the injured ankle. Patients completed the SF12, the Olerud ankle score and a visual analogue pain scale (VAS) on arrival at the clinic. The range of motion of both the injured and uninjured ankle were examined. Finally, the patient’s injured ankle was evaluated on plain X-rays using Cedell’s scoring system. Comparison was made with initial roentgens at the time of injury. Results: From 106 patients treated over a four-year period, 63 were successfully followed up. Mean time of follow up was 3.5 years. Older patients had a poorer recovery, as had those with more severely displaced fractures. Pain was not a major problem for patients with 58 complaining of no pain, or pain only after prolonged exercise. 43% of patients complained of occasional swelling of the affected limb. The majority of patients (89%) had returned to their previous occupations at the time of follow up. 16% of patients (10) had their metalwork removed post operatively. In seven cases, this was due to skin problems or pain adjacent to the metalwork. Conclusion: Older age at presentation, and severity of initial injury appear to have a significant effect on long-term outcome, which may be attributable to poorer osteosynthetic ability in an elderly osteoporotic patient. Our study underlines the importance of accurate anatomical reduction of ankle fractures in order to minimise subsequent arthrosis

The purpose of this paper is the overview of 92 cases with slipped capital femoral epiphysis (S.C.F.E.), treated in inic within the last 18 years (1985–2003).The paper reports the method of treatment and early complications concerning ischaemic necrosis and chondrolysis. During this time, 80 children with S.C.F.E. aged 10–14 years, were treated in our clinic.Of our patients, 50 were boys and 30 girls.With regard to the degree of the slippage, 59 cases 1st degree, 32 were 2nd degree and 1 was 3rd degree;as regards the type, 63 cases were chronic, 17 acute and 12 chronicacute.They were treated surgically by pinning (use of 2 or 3 Moore-Knowls, Steinmann pins and cannulated screws) while in one case osteotomy of the femoral neck was performed.In 11 cases with 2nd degree slippage, total or partial reduction took place on the surgical table,with mild traction and strong internal rotation of the limb.In addition, in 20 cases cannulation was performed. There has been a follow-up period of 1–10 years after surgery. Complications: In 11 hips (in most of which Steinmann pins had been used) occurred slippage of the material inside the joint and the pin was removed (within 2 weeks).During follow-up no signs of either vascular necrosis or chondrolysis were present, with the exception of one case with 2nd degree S.C.F.E. where reduction was also attempted. In total, 2 cases of chondrolysis occurred, in one of which signs of chondrolysis were present even before surgery, and 2 cases of vascular necrosis.The results were evaluated on clinical criteria (limping, pain, reduction in length, range of movement of hip joint) and radiological criteria (articular space, appearance of the femoral head, neck-femoral angle). Conclusion: It seems to be that any attempt of reduction, even with mild traction, is responsible for serious complications. On the contrary, pin slippage inside the joint does not seem to lead to a poor result, provided that there is early diagnosis and immediate removal of the pin. Finally, it must be stressed that the complications in the 4 cases of either chondrolysis or vascular necrosis, occurred in patients whose weight exceeded by 25–30 % what is normally expected at their age and height

Aims

To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention.

We have reviewed 70 patients with bilateral simultaneous total hip arthroplasties to determine the rate of failure and to compare polyethylene wear and osteolysis between an implant with a cobalt-chrome head and Hylamer liner with that of a zirconia head and Hylamer liner. The mean thickness of the polyethylene liner was 11.0 mm (8.8 to 12.2) in the hip with a zirconia head and 10.7 mm (8.8 to 12.2) in that with a cobalt-chrome head. At follow-up at 6.4 years no acetabular or femoral component had been revised for aseptic loosening and no acetabular or femoral component was loose according to radiological criteria in both the cemented and cementless groups. The mean rate of linear wear and annual wear rate were highest in the 22 mm zirconia femoral head (1.25 mm (SD 1.05) and 0.21 mm (SD 0.18), respectively) and lowest in the 22 mm cobalt-chrome femoral head (0.70 mm (SD 0.39) and 0.12 mm (SD 0.07), respectively). The mean volumetric wear was highest in the 28 mm zirconia femoral head (730.79 mm. 3. ) and lowest in the 22 mm cobalt-chrome femoral head (264.67 mm. 3. ), but if the results were compared by size of the femoral head and type of material there was no statistical difference (p > 0.05). Sequential measurements of annual wear showed that the zirconia femoral head had a relatively higher rate of penetration than the cobalt-chrome head over the first three years; thereafter the rate of wear was reduced and compared favourably with that of cobalt-chrome heads. There was a statistically significant relationship between the wear of the polyethylene liner and the age of the patient, male gender and the degree of abduction angle of the cup, but not diagnosis, weight, hip score, range of movement, or amount of anteversion. Osteolysis was identified on both sides of the acetabulum in six patients (9%). Of 12 hips with acetabular osteolysis, six had a 28 mm cobalt-chrome femoral head and the remaining six a 28 mm zirconia head. Osteolysis was observed in zones 1A and 7A of the femur in two hips (3%) with a 28 mm zirconia head (cemented hip) and in four (6%) with a 28 mm cobalt-chrome femoral head (cementless hip). Our findings suggest that although the performance of a zirconia femoral head with a Hylamer liner was not statistically different from that of a cobalt-chrome femoral head and Hylamer liner, there was a trend for the zirconia head to be worse than the cobalt-chrome femoral head

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.

The purpose of the study is to evaluate the outcome of two methods: Posterolateral fusion and instrumentation versus posterolateral fusion, instrumentation and interbody fusion using clinical and radiological criteria in demographically similar groups. This is a prospective cohort study of sixty-four patients randomized to two therapeutic strategies (Level II study). Sixty-four patients were randomized to either instrumented posterolateral fusion (control) or combined instrumented posterolateral and interbody fusion (study) in one level degenerative disorders of the lumbar spine. Demographics of the groups were similar including age, gender and other variables. The demographics of the groups were similar for one level degenerative disorders—disc herniation, spondylolisthesis and spinal stenosis. The primary outcome was measured by the Oswestry Disability Index at two years. There was no statistically significant difference. Secondary outcomes (SF36, VAS, fusion rate, disc height maintenance, maintenance of deformity correction, adjacent segment degeneration) were statistically similar in both groups. In conclusion, no clinical advantage with interbody fusion versus posterolateral fusion alone. Analysis of the correlation between the pedicle shape and the spinal canal anatomy in scoliotic anatomic specimens. S. Parent1, H. Labelle, W. Skalli, J. de Guise,. 13175 Côte Ste-Catherine, Montréal, Québec H3T 1C5. The objective of the present study was to analyze the correlation between the pedicle shape and spinal canal anatomy in scoliotic specimens. Vertebral canal anatomy was evaluated in a series of thirty anatomic scoliotic specimens and compared to thirty normal specimens. Spinal canal enlargement inversely correlated with pedicle width modifications on the concavity of scoliotic curves. These findings suggest that changes in pedicle anatomy are secondary to local changes in spinal cord position. Recent studies have demonstrated the close relationship between the spinal cord and the pedicle on the concavity of the scoliotic curve of patients with scoliotic deformities. The hypothesis of the present study is that changes in spinal canal shape are related to spinal cord position and resulting bone remodeling. This study evaluated the characteristic changes of spinal canal shape in anatomic scoliotic specimens. Posterior elements morphology is closely related to the local spinal cord anatomy and its relationship with the bony architecture. The characteristic posterior element changes seen in scoliosis are likely the result of local bone remodeling. Spinal asymmetry was observed in scoliotic specimens when compared to normal specimens. Spinal canal was enlarged asymmetrically on the concavity of thoracic scoliotic curves (p < 0.01). Overall, canal surface was greater in scoliotic specimens when compared to normal specimens (p < 0.01). These changes were more important at the apex of the curve. Spinal canal characteristic shape was evaluated in thirty scoliotic anatomic specimens and thirty normal anatomic specimens using twelve parameters representing measures of right and left hemi-canal length, width or surface area. The 3-D coordinates of eight points taken at the periphery of each spinal canal were recorded. The results of this study support the hypothesis that spinal canal shape is modified by the spinal cord position and that posterior element changes seen in scoliosis are in part due to bone remodeling in response to local neural anatomy modifications. Funding: Fonds de Recherche en Santé du Québec

Aims

Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making.

Purpose: Publications reporting compression flexion fractures are rather old and rarely individualise this type of fracture. There is a consensus on anterior plate fixation which generally provides good outcome. We propose a retrospective analysis of our series to revisit the classification system and analyse outcome after surgical treatment. Material and methods: From January 1983 to November 2001, 96 fractures of the lower extremity of the radius with anterior displacement were treated in our unit. There were 95 patients (50 men and 45 women), mean age 42.7 years (15–88). The fracture resulted from a traffic accident in 52 patients. Twenty-seven patients had associated injuries. For lateral simple or complex anterior marginal fractures, the Castaing and Cauchoix classification was modified to take into account the importance of the fragment, relative to the middle of the radial glenoid, with or without associated lesion of the radial borders on the lateral and AP views (types I and II fractures). Type III factures were Goyrand fractures and type IV associated Goyrand fractures with one or more joint fracture lines. Our series thus included 43 anterior marginal fractures including 27 type II fractures where more than 50% of the joint surface was displaced, 53 Goyrand fractures (25 type III and 28 type IV). Plate fixation was used for 90 wrists, associated with complementary fixation in 17. Outcome was assessed with Laulan clinical criteria and Mouilleron radiological criteria. Results: Bone healing was achieved in all cases, without changing the initial fixation in 85 wrists. There were 49 men and 35 women, mean age 40.7 years (20–87). Type I/II fractures were found in 40 wrists, simple Goyrand fracture (type III) in 23 and comminuted Goyard fracture (type IV) in 22. At three months, reduction was good in 57 cases (67%), fair in 23 and poor in five.There were eleven secondary displacements in eight women and three men, mean age 57.7 years. They had four type I/II fractures and seven Goyrand fractures (1 type III, and 6 type IV). Plate fixation used for eight wrists had to be completed with pinning or a fixator. Radiological reduction was good in two cases (18%), fair in three and poor in six (55%). Twenty-five patients (30%) presented residual pain (10 patients), carpal tunnel syndrome (7 patients), wrist or finger stiffness (4 patients), radiocarpal osteoarthritis (3 patients), and cutaneous palmar neuroma (1 patient). At mean 61 follow-up (12–204), clinical outcome was good for 70 wrists; 78 wrists were pain free. The radiological outcome was good in 64 wrists, fair in 18 and poor in five. Discussion: Better radiographic analysis distinguishing type II and IV fractures, which were the cause of three-quarters of the displacements, improves identification of wrists which must have complementary fixation with pins or fixator in addition to the anterior plate which in these cases should be prebent. For the other wrists, initial reduction was satisfactory in 67%, explaining the good functional tolerance demonstrated subjectively (89%) and objectively (80%). There were only rare sequelae in this series and complications were limited: painful wrist in 10%, secondary to reflex dystrophy in two. Conclusion: Good interpretation of the radiographs enables prediction of difficult reduction where complementary fixation in addition to the anterior plate can be useful for type II and IV fractures

Aims

The aim of the current study was to assess the reliability of the Ottawa classification for symptomatic acetabular dysplasia.

Aims

The aims of this study were to determine the change in the sagittal alignment of the pelvis and the associated impact on acetabular component position at one-year follow-up after total hip arthroplasty (THA).

Aims

Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone.

Aims

Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation

Aims

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

Introduction: We present our experience in the treatment of the aseptic necrosis of the femoral head with a vascularized iliac crest graft by means of a retrospective analysis of 25 hips (22 patients) subjected to surgery in our hospital between June 1993 and September 2002. Materials and methods: There was a predominance of male patients (20 cases). In most patients the necrosis appeared in the left side. The most common predisposing factor was alcohol abuse (8 cases). All patients were subjected to a clinical (Harris score) and a radiological evaluation, and the evolution of their necrosis was assessed using the Ficat-Arlet system (as modified by ARCO) with a mean follow-up of 4 years. Results: The average functional evaluation was of 87 points, with 76% of results in the excellent and good categories and 24% fair and poor. 40% of the hips underwent some kind of radiological deterioration (mean: 5.2 years). On the basis of the radiological evaluation criteria, 66% of patients evolved satisfactorily. Conclusions: Our results are in line with those published in the literature. 60% of patients operated on showed no evidence of a radiological progression of the necrosis of the femoral head

The purpose of the study is to evaluate the retrospective results of 92 surgically treated spastic hips. Twenty-one patients were able to walk in the community with aids, 19 were able to walk about the house, and 13 were wheelchair bound. The mean age at the time of the operation was 7 yrs (3–18) and the average follow-up was 5. The cohort of the study included 45 tetraplegic patients, 6 diplegic, and 2 hemiplegic. The dislocated hips were 25 and the subluxated ones 67. The surgical treatment included soft tissue and bone procedures. The 53 patients were divided into two age groups: those less than 7yrs old and those older than 7yrs. The cohort was also divided into 39 patients operated in one setting, and 14 operated in more than one. Clinical evaluation was based on the joint range of motion, the ambulatory status and the pain. The radiological evaluation criteria were based on Reimer's migration index, the center-edge angle, Sharp's angle, and neck-femoral angle. We used the interclass correlation coefficient to measure our interobserver reliability for MI 0,93, for CE angle 0,95 and for Sharp's angle 0,81, as the interobserver difference for MI averaged 9% for CE angle 7and for Sharp's angle 3. Statistical analysis of continuous variables was done by Student's t-test or the Wilcoxon rank sum test. Categorical variables were evaluated by Fisher's test. Concerning the walking ability, from the 13 severe quadriplegic patients, none improved his functional level but they achieved better sitting balance. The walking ability of the rest of the patients improved one level in 78% of the cases. The mean preoperative abduction was improved from 24,7 to 33,5, the mean flexion was slightly reduced from 123 preoperatively to 114 postoperatively and the mean extension reduced from −20 preoperatively to −8 postoperatively. Reimer's index reduced from 67,2 to 21,7 postoperatively, the CE angle increased from −10,6 to 20,5, the Sharp's angle increased from 36,9 to 40,5 and the neck-shaft angle increased from 119,7 to 157,5post-operatively. Of greater significance were MI and CE at p<0.05. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year post-operatively. 46 hips were evaluated as good, 30 as satisfactory, and 16 as poor. The severe tetraplegic with small-negative CE angle and Reimer's migration index > 50%, as well as the small age of the patients (<7 yrs) were negative prognostic factors. Better results were observed when patients were operated at age <7yrs by soft tissue procedures and MI<30%, while patients >7yrs had satisfactory results only after combined bony and soft tissue procedures and MI <50%. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year postoperatively

Introduction: In the attempt to improve fusion rates in spondylodesis surgery, focus has been applied on numerous factors, including surgical strategies, instrumentation-devices and –material, technical preparation of the fusion bed, stringency of radiological outcome criteria, patient-related factors such as age, sex, tobacco consumption, and severity of underlying pathology. In recent years the development of new techniques for exploring mechanisms in cellular and molecular biology have further directed focus toward more advanced biological techniques and considerations. To the authors’ knowledge, little or no attention has been focused on one of the basic and important factors in the attempt to achieve fusion, ie the impact of bone graft quantity placed at the fusion bed. The aim of this study was to investigate the influence of autologous bone graft quantity in posterolateral instrumented spinal fusion (PLF) in respect to fusion rates. Methods and results: A prospective clinical study in 76 patients, in which CD-instrumented posterolateral lumbar or lumbosacral spine fusion surgery was performed. The quantity of autologous bone graft applied at the fusion bed was recorded peroperatively. Spinal fusion rates were assessed by AP/lateral radiographs at one-year follow-up by two independent observers, according to our strict classification system. The impact of bone graft quantity, tobacco consumption, age and sex of the patients were analysed in respect to fusion-rates by logistic regression. According to our classification “fusion” was seen in 76% of the patients, “non-union” in 12.7% and “doubtful”fusion in 11.3%. In “fusion” segments, the median amount of bone used was 24.4 (13–53) g and 14.7 (12.5–23.4) g in “non-union” segments. The “non-union” rate was 7.1% for non-smokers in contrast to 21.4% for patients who smoked during the first six post-operative months. The impact on fusion rates by graft quantity and cigarette smoking were significant, p< 0.006 respectively 0.035. Age and gender did not influence fusion rates. Thirty-three percent of patients with “non-union” had a corresponding failure of the implant. Conclusions: The quantity of graft used at the fusion bed is critical for successful fusion. Based on the results presented here, we recommend a minimum of 24 g of autogenous bone graft at each intervention segment in auto-grafted posterolateral spinal spondylodesis surgery. In addition, this study underlines the importance of tobacco arrest, in at least the first six post-operative months. The data presented here strongly support the importance of quantifying or optimally standardising the amount of graft placed at each intervention segment

Aims

This study reports the mid-term results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing.

Aims

This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

Aims

Periprosthetic joint infection (PJI) remains a challenging complication following total hip arthroplasty (THA). It is associated with high levels of morbidity, mortality and expense. Guidelines and protocols exist for the management of culture-positive patients. Managing culture-negative patients with a PJI poses a greater challenge to surgeons and the wider multidisciplinary team as clear guidance is lacking.

Aims

Promising medium-term results from total shoulder arthroplasty (TSA) have been reported for the treatment of primary osteoarthritis in young and middle-aged patients. The aim of this study was to evaluate the long-term functional and radiological outcome of TSA in the middle-aged patient.

Objectives

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.