The primary aim of this study was to analyse the position of
the acetabular and femoral components in total hip arthroplasty
undertaken using an anterior surgical approach. In a prospective, single centre study, we used the EOS imaging
system to analyse the position of components following THA performed
via the anterior approach in 102 patients (103 hips) with a mean
age of 64.7 years (Aims
Patients and Methods
We present a series of 16 patients who have had a failed ankle arthroplasty converted to an ankle arthrodesis using a surgical technique of bone grafting with internal fixation. We describe our technique using tricortical autograft from the iliac crest to preserve length and an emphasis is placed on maintaining the malleoli and subtalar joint. A successful fusion was achieved in all cases with few complications. Our post operative AOFAS improved to a mean of 70 with good patient satisfaction and compares well to other published series. From this series and an extensive review of the literature we have found fusion rates following failed arthroplasty in patients with degenerative arthritis to be very high. In this group of patients a high fusion rate and good clinical result can be achieved when the principles of this surgical technique are adhered to. It would appear that a distinction should be made between treating patients with poor quality bone and more extensive bone loss, as is often the case with rheumatoid patients; and the patients with a non inflammatory arthropathy and better bone quality. The intramedullary nail would appear to be the preferred option in patients with inflammatory polyarthropathy where preservation of the subtalar joint is probably not of relevance as it is usually extensively involved in the disease process, and a higher rate of complications can be anticipated with internal fixation.
This controlled study uses gait analysis to evaluate patients' pre- and post-ankle arthroplasty, post-ankle arthrodesis and compares the results with a healthy control group to assess whether these theoretical benefits are borne out in clinical practice. Five patient groups (arthrodesis, arthroses, arthroplasty after 6 and 12 months and control) each consisting of 12 patients were analysed in our gait laboratory and the following parameters obtained at two different walking speeds: velocity, cadence, step length, stride length, the timing of toe off and the duration of stance phase. In addition, the ground reaction force during the whole gait cycle was recorded, as well as the range of movement of the knee and of the foot in relation to the tibia in walking and functional tests.Aim
Method
Long folllow up showed that main complications were pain and bone cysts, which required arthrodesis in 8 cases. Survivorship analysis at 108 months were 83% [IC5%: 72–95]. At follow up, clinical AOFAS ankle score was significantly raised (31% preoperative to 84% at follow up). A SF36 quality of life score was available for 85 patients. Physical score was 60, mental score 66 and total score was 64.
This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).
We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.
Spinal deformities are a common feature of Marfan’s syndrome and can be a significant cause of morbidity. The morphology of the scoliosis associated with this condition was previously described by Sponseller, but no correlation with the pelvic parameters has been seen. We performed a retrospective radiological study of 58 patients with scoliosis, secondary to Marfan’s syndrome and related the findings in the thoracolumbar spine to the pelvic parameters, including pelvic version (tilt), pelvic incidence and sacral slope. Our results showed marked abnormalities in the pelvic values compared with those found in the unaffected population, with increased retroversion of the pelvis in particular. In addition we found a close correlation between the different patterns of pelvic parameters and scoliosis morphology. We found that pelvic abnormalities may partially dictate the spinal disorders seen in Marfan’s syndrome. Our results supplement the well-established Sponseller classification, as well as stressing the importance of considering the orientation of the pelvis when planning surgery.
Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings.
We report the results of a prospective study of 140 consecutive cases of acetabular revision using large frozen femoral head allografts and cemented all polyethylene acetabular components. The mean follow-up time was 10 years (5 Ð 16). Thirty patients died, seven were lost to follow-up and 26 had failed and undergone further surgery. Nineteen failures were due to aseptic failure and collapse of the graft. Kaplan-Meier survival analysis calculated a mean survival at 10 years of 88.5% for revision for any reason. We compare all reported techniques of acetabular reconstruction for similar defects and recommend a surgical strategy based on the available evidence, but weighted towards a preference to reconstitute bone stock rather than removing further bone in the revision situation.
The functional objectives (walking for 31 patients, verticalisation for ten, comfort for one) were achieved in all patients except five. There was one taluseversus, one anterior subluxation of the talus, one persistent stepping. For two patients underlying neurological disorders did not allow fulfilment of the contract. There were also three cases of claw toes with moderate functional impact.
The cryopreserved graft (femoral head bone bank) was used to reconstruct the acetabular defect. The graft was adapted to the size of the defect to fashion a congruent construct aimed at achieving primary stability. We did not use any supporting material in addition the primary osteosynthesis with one or two screws. A poly-ethylene cup was cemented in the graft. Most of the cement was applied onto the graft which was reamed to the size of the acetabulum. We retained a theoretical 6-year follow-up for review. All patients were seen for follow-up assessment using the Postel-Merle-d’Aubigné (PMA) clinical score and standard x-rays analysed according to the Oakeshott method. Kaplan-Meier survival curves were plotted taking change in status, revision for clinical failure as the endpoint.
We evaluated the use of a hemipelvic acetabular transplant in twenty revision hip arthroplasties with massive acetabular bone defects (Paprosky IIIB) at a mean follow-up of 5-years (4–10 years). These defects were initially trimmed to as geometric a shape as possible by the surgeon. The hemipelvic allografts were then cut to a geometric shape to match the acetabular defects and to allow tight stable positioning of the graft between the host ilium ischium and pubis. The graft was further stabilised with screw fixation. A cemented cup (without a reinforcement ring) was entirely supported by the allograft in all procedures. We report 65% good intermediate-term results. There were seven failures (five aseptic loosening and two deep infections). Radiographic bone bridging between the graft and host was evident in only one of these cases. Aseptic graft osteolysis began radiographically at a mean of 14 months and revision occurred at a mean of 2 years in the 5 aseptic failure cases. All 5 cases could be reconstructed again due to the restoration of bone stock provided by the hemipelvic graft. One infected case was able to be reconstructed using impaction allografting and the other was converted to a Girdlestone hip. Thirteen of twenty acetabular reconstructions did not require revision. Radiographic bone bridging between the graft and host was evident in 12 cases. In 2 cases, ace-tabular migration began early (at 5 and 27 months) but stopped (at 35 and 55 months). These 2 cases have been followed for 6 and 9 years respectively, with no further migration. Two dislocations occurred but did not require acetabular revision. The function of these hips is good with a mean Postel Merle D’Aubigne score of 16.5. We feel that these are satisfactory intermediate term results for massive acetabular defects too large for reconstruction with other standard techniques.
We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow. We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months. All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head.