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Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_18 | Pages 16 - 16
1 Dec 2023
Saghir R Watson K Martin A Cohen A Newman J Rajput V
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Introduction

Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.

Methods

At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 58 - 58
7 Aug 2023
Saghir R Watson K Martin A Cohen A Newman J Rajput V
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Abstract

Introduction

Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.

Methods

At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_13 | Pages 67 - 67
1 Dec 2022
Cohen D Le N Zakharia A Blackman B Slawaska-Eng D de SA D
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To determine in skeletally mature patients with a traumatic, first-time, patellar dislocation, the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes.

Three online databases MEDLINE, EMBASE and PubMed were searched from database inception (1946, 1974, 1966 respectively), to August 20th, 2021, for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative kujala score as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS and Detsky scores.

Overall, there were a total of 22 studies and 1705 patients included in this review. The pooled mean redislocation rate in 18 studies comprising 1409 patients in the rehabilitation group was 31% (95% CI 25%-36%, I2 = 65%). Moreover, the pooled mean redislocation rate in five studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2%-17%, I2 = 70%). The pooled mean postoperative Kujala anterior knee pain score in three studies comprising 67 patients in the reconstructive group was 91 (95% CI 84-97, I2 = 86%), compared to a score of 81 (95% CI 78-85, I2 = 78%) in 7 studies comprising 332 patients in the rehabilitation group. The reoperation rate was 9.0% in 936 patients in the rehabilitation group and 2.2% in 322 patients in the reconstruction group.

Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation and a higher Kujala score, as well as noninferiority with respect to complication rates compared to nonoperative treatment. The paucity of high-level evidence warrants further investigation in this topic in the form of well-designed and high-powered RCTs to determine the optimal management option in these patients.


The Bone & Joint Journal
Vol. 103-B, Issue 6 Supple A | Pages 45 - 50
1 Jun 2021
Kerbel YE Johnson MA Barchick SR Cohen JS Stevenson KL Israelite CL Nelson CL

Aims

It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.

Methods

We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_9 | Pages 38 - 38
1 Oct 2020
Johnson MA Kerbel YE Barchick SR Cohen JS Stevenson K Israelite CL Nelson CL
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Introduction

Previous research has indicated that preoperative modification of risk factors associated with obesity may reduce complications after TKA. However, the optimal method is still debated. This study aims to investigate whether a preoperative Risk Stratification Tool (RST) devised by our institution to optimize obese patients can reduce unexpected ICU transfers, and 90-day ED visits, readmissions, and reoperations.

Methods

We retrospectively reviewed 1,724 consecutive risk stratified patients undergoing primary unilateral TKA. The mean age was 64.8 years and average body mass index (BMI) was 34.2 kg/m2. All patients underwent preoperative optimization using the RST. We first compared our primary variables of interest between obese (BMI>30, n=1,189) and non-obese patients (n=535). Patients were then divided into 3 groups (I-non-obese, II-obese (30–39.9 kg/m2) and III-morbidly obese ((>40 kg/m2)) and logistic regression was used to evaluate outcomes among the groups adjusted for age, sex, smoking history and diabetes.


Bone & Joint Research
Vol. 9, Issue 7 | Pages 341 - 350
1 Jul 2020
Marwan Y Cohen D Alotaibi M Addar A Bernstein M Hamdy R

Aims

To systematically review the outcomes and complications of cosmetic stature lengthening.

Methods

PubMed and Embase were searched on 10 November 2019 by three reviewers independently, and all relevant studies in English published up to that date were considered based on predetermined inclusion/exclusion criteria. The search was done using “cosmetic lengthening” and “stature lengthening” as key terms. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.


The Bone & Joint Journal
Vol. 102-B, Issue 4 | Pages 485 - 494
1 Apr 2020
Gu A Malahias M Selemon NA Wei C Gerhard EF Cohen JS Fassihi SC Stake S Bernstein SL Chen AZ Sculco TP Cross MB Liu J Ast MP Sculco PK

Aims

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_9 | Pages 17 - 17
1 Sep 2019
Reddington M Walters S Cohen J Baxter S Cole A
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Purpose of the study

To investigate the feasibility of undertaking a definitive Randomised Controlled Trial (RCT) to determine the effectiveness of early physiotherapy for sciatica.

Methods

Patients over 18 presenting to their G.P with sciatica were eligible to participate in the study, those without a clear understanding of English or had co-morbidities preventing rehabilitation were ineligible. Process and patient reported outcomes including self-rated disability, pain and general health, were collected at baseline, 6,12 and 26 weeks post randomisation.

Participants were randomised into either early physiotherapy, receiving treatment within 2 weeks after randomisation or usual care with physiotherapy commencing 6 weeks post randomisation. Both groups received up to 6 treatment sessions of a patient-centred, goal orientated physiotherapy programme specific to their needs.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_9 | Pages 18 - 18
1 Sep 2019
Reddington M Walters S Cohen J Baxter S Cole A
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Purpose of the study

The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision.

Methods

This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_3 | Pages 52 - 52
1 Apr 2018
Huish E Coury J Ummel J Casey J Cohen J
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Introduction

Management of the patellofemoral surface in total knee arthroplasty (TKA) remains a topic of debate. Incidence of anterior knee pain and incidence of repeat operation have been the focus of several recent meta-analyses, however there is little recent data regarding patients” subjective ability to kneel effectively after TKA. The purpose of this study was to compare patient reported outcomes, including reported ability to kneel, after total knee arthroplasty with and without patellar resurfacing.

Methods

Retrospective chart review of 84 consecutive patients who underwent primary TKA with patella resurfacing (56 knees) or without patella resurfacing (28 knees) having a minimum of 2.5 year follow up was performed. Oxford knee scores (OKS), visual analog pain scores (VAS), and questionnaires regarding ability to kneel were evaluated from both groups. Inability to kneel was defined as patients reporting inability or extreme difficulty with kneeling. Shapiro-Wilk test was used to determine normality of data. Mann Whitney U test was used to compare the OKS and VAS between groups. Chi square test was used to compare kneeling ability between groups. Statistical analysis was performed with SPSS version 23 (IBM, Aramonk, NY).


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_4 | Pages 53 - 53
1 Apr 2018
Lum Z Ummel J Coury J Huff K Cohen J Casey J
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Introduction

Infections in total joint arthroplasty (TJA) are a burden to the healthcare system. An infection in total joint arthroplasty costs nearly $60,000–80,000 to the system. 3 major tenets to decrease surgical site infections, focus on patient preoperative optimization, intraoperative techniques, and postoperative care. Intraoperative vancomycin powder been successful in lowering infection rates in other areas of orthopaedics.

The purpose of our study was to investigate whether topical intraoperative vancomycin powder had any effect on surgical site infection, complication rate, or reoperation rate. Our hypothesis was vancomycin powder may decrease the rate of surgical site infections without any effect on wound complications.

Materials & Methods

208 consecutive patients undergoing either total hip or total knee arthroplasty (THA or TKA) were given intraoperative vancomycin powder or none. 64 patients received vancomycin poweder compared to 164 patients who did not. All preoperative, intraoperative and postoperative management was similar. Preoperative data including age, sex, BMI, diabetes status and comorbidities were recorded. Surgical techniques included medial parapatellar or subvastus for TKA, posterolateral for THA. 90-day culture positive infection and reoperation rates were recorded.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_3 | Pages 59 - 59
1 Feb 2017
Campbell D Sharpe K Cohen R
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Introduction

Cementless tapered wedge stems have shown excellent results over the last decade. Distal potting with inadequate proximal fit, as well as failure to achieve biologic fixation has led to thigh pain, loosening and implant failure. To support a variety of patient morphologies a novel tapered wedge stem was designed with reduced distal morphology, maximizing the proximal contact of the grit blasted surface. The objective of the study was to analyze the clinical outcomes of this stem design.

Methods

Three hundred and nineteen patients enrolled into prospective, post-market multicenter studies received a novel tapered wedge stem. Clinical and patient-reported outcomes including the Harris Hip Score (HHS), Lower Extremity Activity Scale (LEAS), Short Form 12 (SF12), and Euroqol 5D Score (EQ-5D) were evaluated preoperative through two years postoperative.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_3 | Pages 85 - 85
1 Feb 2017
Cruz A Perona P Cohen R Campbell D
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Background

Instability and dislocation are some of the most important postoperative complications and potential causes of failure that dual mobility total hip arthroplasty (THA) systems continue to address. Studies have shown that increasing the relative head size provides patients implanted with smaller and larger cups increased stability, greater ROM and a lesser incidence of impingement, without compromising clinical results. The purpose of the current study was to review clinical outcomes in three groups of primary THA patients receiving a dual mobility acetabular shell.

Methods

In two US based, post-market, multicenter studies, 450 patients received a primary cementless dual mobility THA. Patients were split into three groups based on cup size: ≤ 50mm, 52mm–56mm, and ≥ 58mm. Harris Hip Scores (HHS), Short Form 12 Physical Components (SF12 PCS), Lower Extremity Activity Scores (LEAS), and Euroqol 5D Score (EQ-5Ds) were collected preoperatively and through 2 years postoperative.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_7 | Pages 76 - 76
1 May 2016
Duplantier N Rivere A Cohen A Chimento G
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Background

Joint replacement surgery has been shown to be successful in post solid organ transplantation patients. However, complication rates, revision rates, and overall mortality can be higher in this population compared to patients who have not undergone solid organ transplantation. Many transplant patients have a decreased life expectancy. Therefore, literature suggests that joint replacement surgery be offered to qualifying patients early on when symptomatic. This study compares the outcomes of patients who have undergone solid organ transplantation as well as a joint replacement to patients that have only undergone joint replacement surgery.

Methods

We retrospectively gathered 42 transplant (T) patients over a ten year period, 2003–2013, that underwent a liver (21) or kidney (21) transplant as well as primary total knee arthroplasty (TKA) (23) or total hip arthroplasty (THA) (19). We then gathered 42 non-transplant (NT) patients matched for procedure, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and age adjusted Charlson co-morbidity index (ACCI) score who only underwent TKA or THA with no transplant. We used Chi-Square, T test, and multivariate analysis to compare the two groups with regard to number of complications (NOC), readmissions at 30 and 90 days post surgery, length of stay (LOS), number of intensive care unit (ICU) admissions, and total direct cost (TDC) per hospital stay.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 45 - 45
1 Dec 2015
Finelli C Dell Aquila A Miki-Rosario N Fernandes H Dos Reis F Cohen M Abdalla R Da Silva C Murça M Nigro S Salles M
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Intramedullary nailing (IMN) has been frequently indicated to treat long bone open and closed fractures, but infection following internal fixation may have devastating consequences, with higher costs. Treatment of intramedullary nail-associated infections (IMNI) is challenging and based upon surgery and adequate antibiotic administration, which requires the correct identification of causative microorganisms. However, there have been difficulties for the microbial diagnosis of IMNI, as the peri-prosthetic tissue cultures may show no microbial growth, particularly in patients with previous use of antibiotics. Sonication have shown higher sensitivity and specificity for microbial identification on a variety of orthopedic implant-associated infections. Aim: To compare clinical and microbiological results and sensitivity for the pathogen identification obtained by conventional peri-implant tissue culture samples with culture of samples obtained by sonication of explanted IMN implants, among patients presenting IMNI of long bones.

Methods: Longitudinal prospective cohort study performed at a tertiary public hospital, ongoing since August 2011. We analyzed all patients with indication for IMN implant removal, and orthopedic-implant associated infections was defined according to previous publications addressing osteosynthesis-associated infections (Yano 2014). Minimal of 2 samples from the peri-implant tissue were taken and sent under sterile conditions to the laboratory for culture. Statistical analysis was performed McNemar's test for related proportions.

Results: We included 26 patients presenting clinical signs of IMNI, of which tissue and sonication cultures were performed for 26 (100%) and 20 (77%) patients, respectively. Among them, 88% were male, with mean age was 35.9 years (range, 19–59 yo). Causes of trauma were mainly motorcycle crashes accounting 54% of accidents; tibia and fibula were affected in 65% and 27%, respectively. Gustilo open fracture classification was grade II (35%) and IIIA (35%). First stage management with external fixation for fracture stabilization was performed in 75% of trauma patients. Sensitivity of peri-prosthetic tissue culture and sonication was 80.7% (21/26), and 95% (19/20) (p< 0.05), respectively. Only one infected patient presented negative tissue and fluid cultures. Gram-positive cocci were isolated in 75% and 79% in tissue and sonication fluid cultures, respectively. Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus sp., were isolated from tissue and sonication culture in 43.5% and 36.3%, 8.7% and 22.7%, 13% and 13.7%, respectively. Polymicrobial infection was diagnosed in 3.8% (1/26) and 15.8% (3/19), patients by tissue and sonication fluid cultures (p< 0,01), respectively.

Conclusion: Sonication of retrieved infected intramedullary nails has the potential for improving the microbiological diagnosis of IMNI.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 105 - 105
1 Dec 2015
Metsemakers W Emanuel N Cohen O Reichart M Schmid T Segal D Richards R Zaat S Moriarty T
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One of the most challenging complications in orthopedic trauma surgery is the development of infection. Improved infection prophylaxis could be achieved by providing local delivery of antibiotics directly to the tissue-implant interface. Especially implant-associated bone infections caused by antibiotic-resistant pathogens pose significant clinical challenges to treating physicians. Prophylactic strategies that act against resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), are urgently required.

The objective of this experimental study was to determine the efficacy of a biodegradable Polymer-Lipid Encapsulation MatriX (PLEX) loaded with the antibiotic doxycycline as a local prophylactic strategy against implant-associated osteomyelitis in a humeral non-fracture rabbit model.

Activity of the PLEX-doxycycline-coating was tested against both a doxycycline susceptible (doxyS) methicillin-susceptible S. aureus (MSSA) as well as a doxycycline-resistant (doxyR) MRSA. In a rabbit intramedullary (IM) nail-related infection model, twelve rabbits received an inoculum of a doxyS MSSA direct into the medullary cavity of the humerus. After inoculation, animals received either a PLEX-doxycycline-coated nail, or an uncoated nail. The animals were observed for four weeks. Upon euthanasia, quantitative bacteriology was performed to determine bacterial load in tissues and biofilm formation on the implant. A second study was performed with sixteen rabbits receiving a DoxyR MRSA inoculum, again in coated and uncoated groups.

In vitro elution studies revealed that 25% of the doxycycline was released from the PLEX-coated implants within the first day, followed by a 3% release per day up to day 28. Quantitative bacteriology revealed the presence of osteomyelitis in all animals receiving an uncoated nail in both the MSSA and the DoxyR MRSA studies (figure). All rabbits receiving a PLEX-doxycycline-coated nail were culture negative in the doxyS MSSA-group and the surrounding bone displayed a normal physiological appearance in both histological sections and radiographs. In the doxyR MRSA inoculated rabbits, a statistically significant reduction in the number of culture-positive samples was observed for the PLEX-doxycycline-coated group when compared to the animals that had received an uncoated nail, although the reduction in bacterial burden did not reach statistical significance.

Improved prophylaxis against infection in trauma and orthopedic implant surgery is clearly required today. In this study, we investigated a PLEX-doxycycline-coated IM nail in a humeral non-fracture rabbit model. The PLEX-doxycycline coating on titanium alloy implants provided complete protection against implant-associated MSSA osteomyelitis, and resulted in a significant reduction in the number of culture positive samples when challenged with a doxycycline-resistant MRSA.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_13 | Pages 12 - 12
1 Nov 2015
Cohen B
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The primary goals of successful rTSA (Reverse Total Shoulder Arthroplasty) are pain relief, improved shoulder motion and function with the restoration of patient independence. These goals can be achieved by optimal prosthesis design and surgical technique.

Historically there have been two predominant reverse shoulder design philosophies: the traditional valgus 155-degree neck-shaft angle with a medialised center of rotation introduced by Dr. Grammont, and the more recent varus 135-degree neck-shaft angle with a lateralised center of rotation, developed by Dr. Frankle. The latter design has reported lower incidences of scapular notching, coupled with improved adduction and external rotation. Over time, an understanding of the factors which resulted in clinical complications and those that contributed to the clinical success of both these design philosophies has been analyzed and widely publicised. With the currently available reverse prostheses the surgeon is required to be committed to one design philosophy or the other. This commitment to one singular design may hinder surgeons from the ability to individualise each case regardless of patient anatomy, rotator cuff condition, arthritic state and post-operative expectation.

Recently, a system has been launched which offers both design philosophies in one system, providing unsurpassed intra-operative flexibility. This allows the surgeon to adapt to each individual case and choose either design philosophy based on patient condition and anatomy, thus optimizing patient outcome.

The treatment of proximal humeral fractures has historically included Hemi Arthroplasty (HA) or Total Shoulder Arthroplasty (TSA). However, rTSA has recently become the surgery of choice for many fracture treatments based on more reproducible results. Certain implant characteristics are gaining favor in the treatment of proximal humerus fractures namely:

Press fit humeral stems - which avoid the risks of cement in-between the tuberosities which has been reported to compromise healing.

Proximal ‘box-shape’ geometry - which enables rotational stability especially in cases with proximal bone loss to promote reconstruction leading to improved healing.

135-degree neck-shaft angle - allowing a higher and more anatomic tuberosity position for more stable fixation maintains anatomical integrity of the tuberosities which has been reported as a critical factor for retaining rotator cuff function.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_11 | Pages 251 - 251
1 Jul 2014
Emanuel N Rosenfeld Y Cohen O Estrada R Applbaum Y Barenholz Y Gustilo R David S
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Bacterial infection of bone may result in bone destruction which is difficult to cure due to poor accessibility to bone of systemically-administrated antibiotic and poor performance of currently available local antibacterial treatments. PolyPid Ltd developed a novel local drug delivery system based on self-assembly of pharmaceutically approved lipids and polymers that encapsulate doxycycline (Doxy). The formulation is self-assembled lipid matrix via the interaction of the lipids (cholesterol and synthetic phospholipids) and biocompatible - biodegradable polymer (poly-lactic-co-glycolic).

The entrapped Doxy is located within the anhydrous environment and therefore fully protected from both enzymatic and long-term water-exposure-related degradation. The fine coating of the tri-calcium phosphate (TCP) bone filler by this Doxy-containing formulation (BonyPid™) is capable of releasing intact and active drug at zero-order kinetics for a predetermined period of up to 30 days. The coating of the TCP granules with the polymer-lipids-Doxy formula (BonyPid™) did not change the granules’ macroscopic shape, but altered its color from white to pale yellow, which resemble the color of the entrapped Doxy. The average sizes of the non-coated TCP granules and the coated granules BonyPid™ were similar, as determined by measuring the widest dimension of each granule (1135±241 µm and 1072±242 µm, respectively, P=0.16). The MIC for Doxy that was released from BonyPid™ at different time points was similar to the non-encapsulated Doxy, suggesting full bioavailability of the released drug. BonyPid™ formulation structure was characterised by different physical methods including wide angle X-ray analyses (WAXS), differential scanning calorimetric (DSC) and SEM. WAXS analyses of BonyPid™ samples show a strong signal in the range of 1.3–1.8 2θ°, suggesting that the polymer and lipid TCP coating is a highly organised nano-substructure.

The principle lipid in BonyPid™ formulation is phosphatidylcholine, which constitutes more than 85% of the overall lipid mass. It was found that the length of the acyl chains (14, 16 and 18 carbons, respectively) can significantly alter the release rate of Doxy during the prolonged (30 days), zero-order release phase, but did not alter the release profile. The anti-infection activity of BonyPid™ was tested in the rabbit tibia model contaminated with 5×105S. aureus. Both acute and chronic infection models were tested. Only BonyPid™ treatment demonstrated a statistically significant reduced bone absorption over the infected group (P<0.04 for day 7, 14 and 21) and significantly lower bacterial bone concentration (p>0.05) on day 21 following the bone grafting and the bacterial inoculation. In addition it was found that BonyPid™ did not reduce the osteo-conductivity as compared to non-coated TCP bone-filler. The first-in-man study for the treatment of contaminated / infected severe open long-bone fractures of BonyPid™ completed its 6 months follow-up. The results demonstrated high safety profile and significant efficacy; early bone callus formation and 0% infections in the BonyPid™ target bone fracture.

Conclusion

Results demonstrate that BonyPid™ nan-technology that allow one month release of doxycycline in a controlled manner provides a new way for treating open fractures. This new local antibiotic delivery system is applicable in other medical situations associated with localised infections.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_11 | Pages 268 - 268
1 Jul 2014
Doornberg J Bosse T Cohen M Jupiter J Ring D Kloen P
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Summary

In contrast to the current literature, myofibroblasts are not present in chronic posttraumatic elbow contractures.

However, myofibroblasts are present in the acute phase after an elbow fracture and/or dislocation. This suggests a physiological role in normal capsule healing and a potential role in the early phase of posttraumatic contracture formation.

Introduction

Elbow stiffness is a common complication after elbow trauma. The elbow capsule is often thickened, fibrotic and contracted upon surgical release. The limited studies available suggest that the capsule is contracted because of fibroblast to myofibroblast differentiation. However, the timeline is controversial and data on human capsules are scarce.

We hypothesise that myofibroblasts are absent in normal capsules and early after acute trauma and elevated in patients with posttraumatic elbow contracture.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 267 - 267
1 Dec 2013
Cohen R
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Cementless biologic fixation surfaces on total joint replacement devices, such as those used in total hip and knee procedures, have evolved over the decades. Historically, various surfaces to allow bone ingrowth or ongrowth have been applied as a coating to a pre-formed solid metal substrate. As shown in Figure 1, from left to right, representative coating surfaces include sintered beads, diffusion-bonded fiber metal, and plasma sprayed titanium. In certain applications, tantalum porous metal (Fig 1, left) can be used without a solid metal substrate, but its most widespread usage is in a modular acetabular cup design with the porous metal diffusion-bonded to a solid metal substrate similar to other coatings. Each of these examples of biologic fixation surfaces has limitations. With comparatively low porosity, bead, fiber metal and plasma spray coatings are simply a surface enhancement onto a rigid machined, forged or cast metal substrate. Furthermore, the thermal process to apply the coatings can adversely affect the mechanical properties of the metal substrate. Released in the 1990's, tantalum porous metal is considered a ‘highly porous metal’ with twice the porosity of the applied surface coatings. With that greater porosity comes lower strength that requires engineers to make standalone tantalum porous metal shapes more bulky. The chemical deposition process to produce tantalum porous metal shapes has also limitations on geometry possibilities. Where bonding the tantalum porous metal to a solid metal substrate is necessary for adequate strength, that diffusion bonding process pressure can diminish the surface coefficient of friction necessary for initial stability.

A new class of manufacturing processing, referred to as ‘additive manufacturing’, allows engineers to create unique porous configurations. These configurations can be fabricated with beneficial properties to a specific implant application. One such enabling additive manufacturing process is called direct metal laser sintering (DMLS). This process utilizes a laser that travels over a fine powder bed. The laser path is determined by a program that mimics a computer model. Where the laser contacts the powder bed, the powder consolidates. Layer by layer, a scaffold porous metal is fabricated. Figure 2 shows a titanium alloy porous metal structure produced by DMLS. This formed biomaterial has 65% porosity, a high coefficient of friction, low stiffness, and strength that is 2 to 3 times that of tantalum porous metal. From a design versatility perspective, with greater strength, relatively thinner and more bone conserving geometries can be developed. When a solid metal surface interface to secure a modular polymer bearing is required, the DMLS process can produce the solid surface and the porous metal at the same time. With no secondary bonding thermal cycle needed, the construct's mechanical integrity is not compromised. Advancing biologic fixation necessitates bone conserving implant designs that have the properties to achieve immediate mechanical stability and longer term bone ingrowth. This novel use of DMLS in this particular porous metal geometry allows engineers to meet those criteria.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 331 - 331
1 Mar 2013
Cohen R Skrepnik N
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Various reports confirm that elevations in serum markers associated with skeletal muscle injury exist and can occur after orthopaedic surgery in the absence of overt clinical manifestations of myocardial injury. The purpose of this study is to measure the influence surgical approach on these serum markers following primary Minimally Invasive THA. Consecutive enrollment of 30 patients into three different groups of 10 was performed. The MIS Modified Watson Jones THA is an approach using an inter-muscular plane, the Mini Posterior is a trans-muscular approach with some muscle detachment and repair, while the MIS II Incision THA is an inter-muscular approach anteriorly and a trans-muscular approach posteriorly. Blood samples for total creatine kinase (CK), creatine phospho-kinase (CPK), and serum myoglobin were obtained at screening and the morning before surgery as a baseline, immediately post-operatively in the recovery room and 8, 16, 24, 36, 48, and 72 hours post-operatively. Hemoglobin and hematocrit was obtained pre-operatively, 16, 36, and 72 hours (±6 hours) post-operatively. Cardiac troponin-I was measured the morning before surgery (pre-operatively) and 16 hours following surgery to monitor any contributory effect of myocardial injury. We report measurable and reproducible trends in serum enzyme levels consistent with skeletal muscle damage due to THA. Troponin-I remained normal in all but one case throughout the entire study indicating no myocardial contribution to measured serum enzyme levels. While these trends may have slight correlation with surgical approach, they were not statistically significant. We conclude that all three procedures do affect serum enzyme markers and are safe from this standpoint, but no surgical approach appears to affect the degree of muscle trauma more or less than another.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 41 - 41
1 Mar 2013
Cohen R Skrepnik N Katz J Maltry J Housman LR Slagis S Eberle R
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The purpose of this study was to compare the clinical, radiographic, and DEXA results of Epoch® Femoral Component for primary THA with other non-cemented femoral components. The Epoch and Epoch 14+ (Zimmer, Warsaw, IN) Composite Femoral Components were studied in conjunction with the VerSys® Fiber Metal Taper, Fiber Metal Mid coat and Beaded Fullcoat Femoral Components (Zimmer, Warsaw, IN). All patients were randomized into one of five component groups and followed prospectively. All patients across the five groups were matched with respect to demographics and body mass index (BMI) (Table 1). Diagnoses were evenly distributed across all study groups. There was no significant change in BMD at 5-years when compared to the baseline (6 month) DEXA measurements for all component groups except for the Beaded Fullcoat component subset which had significant decreases in BMD in proximal zones 1, 6 and 7, The Fiber Metal Taper showed similar decreases in BMD in zones 1 and 7, and the Epoch Component had a significant decrease in BMD in zone 7 only. Additionally, our DEXA findings complement and support the subjective radiographic interpretations performed for this study cohort. The results from this prospective, randomized controlled clinical trial showed that the Epoch Composite Femoral Component for primary THA can achieve results equal to standard alloy components of varying design. Based on these early results, the Epoch and Epoch 14+ Femoral Components for primary THA are justified for continuance of further prospective study.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 42 - 42
1 Mar 2013
Cohen R
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Modularity of femoral components has been widely accepted at the head neck junction, most commonly combining two unlike metals with only sporadic reporting of compatibility issues and corrosion. The development and introduction of a new and improved modular neck junction (Rejuvenate Modular Femoral component, Stryker Orthopedics) provided the option of fine-tuning leg lengths, offset and stability. The surgical technique did indeed provide the desired endpoints, however, the early recognition of problems with the junction causing corrosion and Adverse Local Soft Tissue Reaction (ALTR) and subsequent revision has led to the product being voluntarily withdrawn from the market. My experience as an early user of this stem is described in this manuscript providing a better early recognition and treatment of this potentially very destructive process.

Methods

A retrospective review of one hundred and ninety one Rejuvenate Stems that were implanted between January 2010 and January of 2012. However, after March 2011, this stem was only used on those patients who had a rejuvenate stem on the contralateral side. They were all implanted through a mini posterior incision with the first 82 patients receiving a Tritanium cluster hole cup (Stryker Orthopedics) with between two and three screws. The remaining 109 patients had an ADM (Anatomic Dual Mobility, Stryker Orthopedics). All patients were allowed to bear weight as tolerated and were followed up with Xrays at six weeks and one year. Clinical visits were recorded at 2 weeks and 6 months postop. Additional follow up was scheduled every two years following the first annual visit.

Results

One hundred and seventy four of the 191 hips were available for review at the one-year follow-up. Fourteen patients have undergone revision of the hip due to increased pain and formation of an avascular pseudo capsule due to corrosion at the neck stem junction. All patients have demonstrated a black flaky residue at the taper junction and all have had a large, tense effusion with a milky colored fluid. A neo caspsule has formed in all patients that appeared avascular and thickened. Seven of the eight tritanium cups in the revision cases were loose and required revision, while none of the ADM cups were loose. One patient has undergone two revisions since the initial cause of failure was not recognized and she subsequently developed pain within three months following placement of a new modular neck at the initial revision. One patient who underwent revision developed a deep infection and is currently on antibiotics but has not cleared the infection as of this writing.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_13 | Pages 4 - 4
1 Mar 2013
McCarthy I Kostic D Hu X Tan W Sathiananda S Cohen H Wolman R
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We have studied patients with Joint Hypermobility Syndrome (JHS) admitted to the Royal National Orthopaedic Hospital (RNOH) for a three-week in-patient rehabilitation programme. Ten patients were investigated at the start and end of this programme, and so far eight patients have been followed up at three months review. Postural stability was measured using a force plate, and the path of the centre of force (CoF) was tracked while patients were asked to attempt a series of more challenging tasks: double leg stance with eyes open and then with eyes closed, followed by single leg stance with eyes open and closed. Patients also completed a number of questionnaires at the same time points. We found the results of the double stance eyes closed test of postural stability to be the most informative. The ellipse area (EA) containing 95% of the points of the path of the CoF decreased from 21.5 + 14.8 cm2 to 9.0 + 11.5 cm2 over the course of the in-patient programme. In the eight patients followed up at three months, EA has remained the same (9.6 + 14.6 cm2). We conclude that the effects of the exercise programme and advice on subsequent exercise can be maintained over three months.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_12 | Pages 1 - 1
1 Mar 2013
Leeper A Brandon P Morgan A Cutts S Cohen A
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Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 126 - 126
1 Sep 2012
Nich C Nich C Langlois J Marchadier A Vidal C Cohen-Solal M Petite H Hamadouche M
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Osteoporosis following ovariectomy has been suggested to modulate bone response to polyethylene wear debris. In this work, we evaluate the influence of estrogen deficiency on experimental particle-induced osteolysis. Polyethylene (PE) particles were implanted onto the calvaria of wild-type (WT), sham-ovariectomized (OVX), OVX mice and OVX mice supplemented with estrogen (OVX+E2) (12 mice per group). Sham-implanted mice served as internal controls. After 14 days, seven skulls per group were analyzed with a high-resolution micro-computed tomography (CT) and by histomorphometry, and for tartrate-specific alkaline phosphatase. Five calvariae per group were cultured for the assay of IL-1, IL-6, TNF- and RANKL secretion using quantitative ELISA. The expression of RANKL and OPG mRNA were evaluated using real-time PCR. As assessed by CT and by histomorphometry, PE particles induced an extensive bone resorption and an intense inflammatory reaction in WT, sham-OVX and OVX+E2 mice. In OVX mice group, these features appeared considerably attenuated. In WT, sham-OVX and OVX+E2 mice, PE particles induced an increase in serum IL-6, in TNF-and RANKL local concentrations, and resulted in a two-fold increase in RANKL/OPG mRNA ratio. Conversely, these parameters remained unchanged in OVX mice after PE implantation. The combination of two well-known bone resorptive mechanisms ultimately attenuated osteolytic response, suggesting a protective effect of estrogen deficiency on particle-induced osteolysis. This paradoxical phenomenon was associated with a downregulation of pro-resorptive cytokines. It is hypothesized that excessive inflammatory response was controlled, illustrated by the absence of increase of serum IL-6 in OVX mice after PE implantation.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 134 - 134
1 Sep 2012
Lindau T Bainbridge C Cohen B Kushner H Smith T Nguyen D Szczypa P Gerber R
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Introduction

Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC.

Methods

JOINT I and II were multicenter, 9-month, open-label studies in which DC patients with primary flexion deformities ?20° received ?3 CCH (0.58 mg) injections/joint (?5 injections/patient) at 30-day intervals into joints prioritized by extent of contracture. After the first injection, patients could opt to receive up to 2 additional injections in same cord or other cords regardless of outcome for the first joint. The primary endpoint was reduction in contracture to ?5° 30 days after the last injection. Data from JOINT I and II were pooled.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 157 - 157
1 Sep 2012
Singhal R Perry D Khan F Cohen D Stevenson H James L Sampath J Bruce C
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Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Method

All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 72 - 72
1 Sep 2012
Cohen D Cartwright-Terry M Pope J Davidson J Santini A
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Purpose

To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure.

Methods

Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVI | Pages 11 - 11
1 Aug 2012
Singhal R Perry D Khan F Cohen D Stevenson H James L Sampath J Bruce C
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Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Method

All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5 degrees C. The definition of SA was based upon microscopy and culture of the joint fluid collected at arthrotomy.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIX | Pages 106 - 106
1 Jul 2012
Cartwright-Terry M Cohen D Pope J Davidson J Santini A
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Purpose

To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure.

Methods

We prospectively analysed all patients who required MUA post TKA performed by 2 surgeons using the same prosthesis from 2003 to 2008 and compared them to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. In addition risk factors were identified including warfarin and statin use, diabetes and body mass index.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 11 | Pages 1556 - 1561
1 Nov 2011
Singhal R Perry DC Khan FN Cohen D Stevenson HL James LA Sampath JS Bruce CE

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 299 - 299
1 Jul 2011
Dawson-Bowling S Cohen A Ritchie J Fordyce M
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Introduction: Osteoarthritis of the first metatarsopha-langeal joint (MTPJ) is common. A range of surgical treatment options is described, including different designs of total arthroplasty. The MOJE is a ceramic-on-ceramic press fit arthroplasty. We present a maximum 8 year follow up of 32 procedures.

Methods: 32 MOJE arthroplasties were undertaken by the senior author (MF) in 30 patients (9 male, 21 female; mean age 61.9, range 37–76) over six years. Patients were followed up in special clinics where symptoms, levels of function and radiographs were subjectively and objectively scored using the SF-36, modified Kitaoka and AOFAS systems.

Results: 100% follow-up was achieved, with mean time since surgery 58 months (range 25–97). Mean scores were: Kitaoka 53.8 (15–75, maximum possible 75), AOFAS score was 61.3/100 (range 18–100, maximum 100), SF-36 physical score 48.6 (27.6–58.7) SF-36 mental score 52.2 (19.5–62.2). Eight implants had required revision; two for component fracture.

Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection.

Discussion: Although several previous studies have suggested favourable initial outcomes with this implant, all focus only on early results. The longest follow-up we found was 29 months; these authors quote excellent early outcomes but acknowledge the need for longer-term follow-up. In our series, the reoperation rate of 25% up to 8 years is worryingly high. Whilst a cohort of patients clearly have satisfactory results with the MOJE, we would suggest that surgeons contemplating its use give due consideration to these outcomes before proceeding.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 31 - 31
1 Jan 2011
Cohen D Chapman E Sarkar S Manning M
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Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were admitted to our Trauma Unit to identify if the NICE guidance was being followed.

Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Nice guidance from 2005 is clearly not being implemented in our area. A minority of patients will have contraindications or allergies to bisphosphonates (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 456 - 456
1 Jul 2010
Goshen Y Kornreich L Stein J Ash S Cohen I Feinmesser M Yaniv I
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The detection of hepatic nodules during follow-up of survivors of solid tumors in childhood raises a diagnostic dilemma. Focal nodular hyperplasia (FNH) is an uncommon, benign tumor and must be differentiated from late hepatic metastasis.

We retrospectively analyzed patients, treated for pediatric solid tumors between January 1990 and December 2007, and performed abdominal imaging as part of the follow-up.

Four survivors with FNH were detected, out of 450 who received chemotherapy with/out irradiation including patients who underwent autologous bone marrow transplantation (ABMT). Case 1: A 23 years(y) adolescent, presented at age 10y with acute abdomen due to embryonal sarcoma of liver, she received VACAIEx4, relapsed locally, and underwent ABMT with high-dose carboplatin/melphalan and radiotherapy. Asymptomatic multiple liver lesions were disclosed by US and MRI 5y later, biopsy proved FNH. Case 2: A 21y adolescent who at age 3y had alveolar rhabdomyosarcoma of the calf with positive inguinal nodes. She received VACAIE x6, and VP16/carboplatin x3 with local radiation. She developed ovary disorder and received oral contraceptive (OC) at age 14.5y, routine US 1.5y later disclosed nodular lesions in liver, diagnosed as FNH by CT, pills were stopped. At follow-up some lesions reduced in size and few disappeared. Case 3: A 9y old girl, operated for choroid plexus carcinoma at age 1.5y, received VP16/carboplatin x16 and underwent ABMT preceded by thiotepa/melphalan. Abdominal US at age 5.5y disclosed multiple liver lesions, biopsy proved FNH, that disappeared 2y later. Case 4: An 11y old girl operated at age 8 months for retroperitoneal germ cell tumor, received VIP/BVPx4, routine US at 10y disclosed 2 liver lesions diagnosed by CT as FNH.

We conclude that FNH can be differentiated from late metastasis by imaging; in questionable cases by biopsy, close follow-up is recommended, alkylating agents especially during ABMT, and OC may be risk factors.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 458 - 458
1 Jul 2010
Ash S Cohen I Goshen Y Toledano H Yaniv I
Full Access

Increased intensity of therapy for osteosarcoma in the last 30 years has improved prognosis. 70–80% of patients with non metastatic osteosarcoma can now be cured, but late side effects occur. Fertility of survivors is becoming of greater importance.

We retrospectively studied all consecutive female long term survivors of localized osteogenic sarcoma of childhood and adolescence treated at the Schneider Children‘s Medical Center of Israel. Patients were treated with 3 different protocols including the use of Methotrexate, Adriamycin, Cisplatin, Bleomycin, Cytoxan, Vincristine, Actinomycin D, Melphalan and Ifosfamide.

Sixteen female survivors of non metastatic osteogenic sarcoma were treated from 1/1977 to 12/2001, with a minimum follow up of 6.3 years (max. 29 years) from the end of therapy. Median age at diagnosis was 11.7 (range 9.0–16.8) years. Twelve out of 16 (75%) are married and have between them 31 children, mean 2.7 (range 1–7) children. Of these 11 have children and one is currently pregnant with her first child. None of the females reported difficulties in conceiving their first child. The maximum interval from marriage to first delivery was 2.5 years. Two females had 3 spontaneous abortions between the 2nd–4th pregnancies. Four out of 9 female survivors who received > 360mg/m2 of adriamycin were treated with cardiomimetic drugs and/or ACE inhibitors during pregnancy. All four had 2–4 children/ female survivor. The children of survivors are healthy with no birth defects. Mean length of pregnancy was 38.6 weeks and mean birth weight was 2865 grams. No survivors had undergone invasive fertility preservation procedure and only one unmarried patient was using GnRH analogs.

Despite reports of transient disturbances in menstruation, all married females were fertile. Our results question the need for fertility preservation using GnRH analogs or invasive procedures such as ovary or egg preservation for non metastatic osteogenic sarcoma female patients.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_II | Pages 331 - 331
1 May 2010
Cohen D Chapman E Sarkar S Manning M
Full Access

Introduction: Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87).

We prospectively reviewed the medication of such patients who were discharged from our Trauma Unit to identify if the NICE guidance was being followed.

Method: Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture.

We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one.

Results: 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate.

6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Conclusions: Nice guidance from 2005 is clearly not being implemented in our area. Some patients will have contraindications or allergies to bisphosphonates, however, they will be a minority (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society).

We believe the results demonstrate a lack of health promotion opportunities to prevent future fracture. Although there is clear focus and impetus for developing falls prevention services nationwide, this enthusiasm has not been translated across to bone health, despite the potential savings in terms of morbidity, mortality and healthcare costs.

Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care.

This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 9 - 9
1 Mar 2010
Wysocki RW Cohen MS
Full Access

Purpose: The purpose is to evaluate the clinical outcome of patients who underwent excision of motion-limiting radioulnar heterotopic ossification (HO) as a complication of a distal biceps tendon repair. The hypothesis is that there are no measurable clinical losses that persist after excision.

Method: Between 1996 and 2005, eight consecutive patients were identified. All were treated with heterotopic ossification excision using a standard surgical technique, a single dose of postoperative radiation, four weeks of indomethacin, and a standard rehabilitation protocol. These individuals were studied and compared to a matched cohort of eight patients who underwent a distal biceps tendon repair with a similar surgical technique that was uncomplicated. At minimum follow-up of one year, all patients in both groups completed the Disabilities of the Arm, Shoulder and Hand (DASH) outcomes questionnaire, were tested for range of motion in elbow flexion/extension and forearm supination/pronation, and underwent biceps isokinetic dynamometry strength testing including elbow flexion and forearm supination. Both peak strength as well as muscle fatigue were quantified. Range of motion and strength comparisons were made both between groups and side-to-side within each group.

Results: There were no patients lost to follow-up. At mean follow-up of 56 months, there were no cases of nerve palsy, recurrence, or other complications. All patients in the HO group returned to their original occupation without restrictions. Mean arc of forearm rotation in this group increased from 19 to 151 degrees (p=0.01), but pronation (65 degrees) was less than the unaffected arm (p=0.01). There were no side-to-side differences in motion within the control group, or differences in peak strength or fatigue within either group. When comparing the two groups, there was a trend towards worse functional outcomes on DASH in the HO group than the controls (p=0.09). No differences were identified between the HO and control groups with respect to isokinetic torque, endurance strength or range of motion.

Conclusion: When patients develop motion-limiting heterotopic ossification after distal biceps tendon repair, surgical resection can safely lead to a functional recovery of elbow and forearm strength and motion. Level III Evidence, Case-control


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 24 - 24
1 Mar 2010
Katz JA Skrepnik NV Cohen RG Wild JJ Slagis SV Robertson MF
Full Access

Purpose: The purpose of this study was to report one year follow-up of clinical and economic results using minimally invasive versus standard techniques for primary TKA. A multi-surgeon, prospective study assessed the one year clinical and economic benefits of MIS versus standard approaches for primary TKA.

Method: Six surgeons, from September 2005 to January 2006, performed a total of 129 TKA cases with 63 patients in the MIS-SV group and 66 patients in the STD group. Data collected included demographic information with BMI, length of hospital stay, hospital cost, discharge disposition, rehabilitation outcomes and Knee Society Scores. Data was collected preoperatively, and at 10 days, six weeks, three months, six months and one year postoperatively

Results: Average LOS was significantly shorter (2.2 days) for MIS-SV group then 3.3 days for STD group. Preoperative range of motion was 1120 for both groups and improved to 1220 (MIS-SV) and 1230 (STD) at one year. Preoperative KSS Functional Scores were 44 for each and improved to 87.6 (MIS-SV) and 86.6 (STD) at one year. Preoperative KSS Knee Scores were 44 (MIS-SV) and 52 (STD). At one year post-operatively, the KSS Knee Score improved to 91.4 (MIS-SV) and 77 (STD). Economically, the MIS-SV procedures averaged $25,076±1,772 and the STD procedure’s mean was $29,928±6,587.

Conclusion: Clinically, no difference between MIS-SV TKA and STD TKA were observed in ROM and KSS Functional score at one year. MIS-SV TKA had a cost savings over STD TKA and KSS Knee Score was significantly better at one year for MIS-SV group


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 463 - 463
1 Sep 2009
Dakhil-Jerew F Haleem S Jadeja H Bowman N Shah D Cohen A El-Metwally A Guy R Selmon G Shepperd J
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Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 476 - 476
1 Sep 2009
Dakhil-Jerew F Jadeja H Bowman N Shah D Cohen A El-Metwally A Guy R Selmon G Shepperd J
Full Access

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 8 | Pages 1069 - 1073
1 Aug 2009
Hamid N Loeffler BJ Braddy W Kellam JF Cohen BE Bosse MJ

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (sd 13.59) in the intact screw group, 92.40 (sd 12.69) in the broken screw group, and 85.80 (sd 11.33) in the removed screw group (p = 0.0466).

There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 118 - 118
1 Mar 2009
Cohen D Olivier O Jahraja H Kemp G Hunter J Waseem M
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Introduction: We present a double blinded prospective randomized controlled trial between viscoseal and intraarticular diamorphine injection in shoulder arthroscopy.

Materials & Methods: Twenty adult patients undergoing arthroscopic subacromial decompression were randomised into two groups. The Viscoseal group received 10ml of Viscoseal and 10ml of 0.5% bupivacaine injected into the subacromial bursa at completion of the procedure (n=10). The matched control group received 10mg diamorphine and 10mls of 0.5% bupivacaine (n=10). All procedures were performed by the senior author. The patients were blinded to the injections given. Post-operative regimes were standardised and all patients were assessed by visual analogue pain scores at recovery and 1, 2, 6, 12 & 24 hours post-operative. The presence or absence of nausea and time to discharge were also noted.

Results: The mean age of the Viscoseal group was 53 (range 34–70) years and in the control group 59 (32–85) years. In the Viscoseal group 40% of patients were discharged on the same day, while there were no early discharges in the diamorphine group this difference did not reach statistical significance (P=0.054 by Fisher’s exact test). There were no significant differences in post-operative pain score or the fraction pain-free between the two groups or in supplementary analgesic drug doses given (all P> 0.08). Only 10% of the Viscoseal group were nauseous post-operatively compared to 60% of the control group (P=0.03 by Fisher’s exact test).

Discussion: Arthroscopic surgery has never been more popular. Patients like smaller scars, early discharge and quick return to daily life and work; for surgeons arthroscopic surgery is skilful, satisfying and digitally recordable; and the NHS benefits from reduced hospital stay and post-operative complications.

Review of the literature involving the use of viscoseal in shoulder surgery revealed no direct comparison with diamorphine, but only to bupivacaine alone.

Many methods of post-arthroscopic pain relief are available. In our hospital diamorphine with bupivacaine is standard, at £2.57 per treatment. In the present study nausea was significantly lower in the Vicoseal group, but no significant intervention was required and oral anti-emetics sufficed. Pain was not significantly different, and there were no significant differences in supplementary analgesia or in early discharge. In our opinion, the significant improvement in nausea alone is not enough to justify the high price of £52.88 per Vicoseal treatment. We believe that the benefits for routine use have not been demonstrated.


Introduction: Pharmacological and mechanical methods are recommended to prevent venous thromboembolism (VTE) following hip replacement (THR). However, data on mechanical methods such as graduated compressive stockings (GCS) are limited. This study examined the efficacy and safety of GCS when added to fondaparinux.

Methods: The randomised treatments were 2.5 mg fondaparinux for 5–9 days starting postoperatively alone or with GCS for 42±7 days. The primary efficacy outcome was VTE or sudden death prior to Day 42±7. All patients were to have duplex USS at day 42 + 7. VTE was defined by verified symptomatic VTE or asymptomatic proximal DVT. The main safety outcomes were major and minor bleeding and VTE death.

Results: 856 patients were randomised, of which 799 were THR patients. Of these 756 (95%) were evaluable, 377 in the fondaparinux and 379 in the fondaparinux plus GCS groups. Risk factors for thrombosis were recorded (age > 75 in 20%, history of obesity in 21%, cancer in 6% and VTE in 3%). Compliance with GCS was high, with 85% wearing them continuously. The primary efficacy outcome of VTE or sudden death in THR patients was similar in each treatment group, the results were 5.5% in the fondaparinux only group and 5.3% in the fondaparinux with GCS group; odds ratio was 0.96, 95% confidence interval 0.50–1.83, p=0.91. Outcomes were not different for long-length and short-length stockings. Major bleeding occurred in one patient (< 1%), minor bleeding in 6.7%. No VTE deaths were reported.

Discussion: The addition of GCS to fondaparinux showed no benefit in thromboprophylaxis over fondaparinux alone in this large study of THR patients. Therefore GCS may not be indicated in patients receiving fondaparinux. Graduated compression stockings are time consuming to measure and fit, inconvenient and expensive; therefore we recommend a reconsideration of this current and commonly used practice in THR.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 11 | Pages 1536 - 1536
1 Nov 2008
COHEN AT SKINNER JA WARWICK D BRENKEL I


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 513 - 513
1 Aug 2008
Geftler A Katz T Mercado E Atar D Cohen E
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Background: Fractures of the distal femur include metadiaphyseal fractures and physeal injuries. Treatment with cast alone is often excluded because of the inability to achieve and maintain reduction, polytrauma, and pathological fractures. Furthermore, operative treatment can also be challenging as the physis is still open and can be damaged by the fracture itself or by the fixation device, the metaphyseal fragment is short and problematic to fixate, and some of the fractures are intraarticular.

The goal of the study was to review the pattern of these fractures and report the midterm outcomes of various treatment options.

Study design: Inclusion criteria for this retrospective study were: age 9–16 years, fracture in the distal third of the femur treated surgically, growth plates open and availability to follow-up. From 2003–2006, fourteen children (mean age 11.5 years) met inclusion criteria. Over the same period, a search based on ICD-9 codes identified 49 patients with femur fractures that had undergone surgery.

Patient charts and radiographs were reviewed and the children were evaluated by an orthopedic surgeon not involved in the patient management. Parameters recorded included: time to union, time to achieve 0–110° knee range of motion (ROM), and emergency surgery, limited knee ROM and premature physeal arrest.

Results: Fractures of the distal femur were frequent among teenagers accounting for 28% of all femoral fractures. a) Injury was related to sport activities (n=10), motor vehicle accidents (n=3) and blast injury (n=1). b) Fracture types: Salter-Harris physeal injuries (n=6) and metaphyseal fractures (n=8). Three of the meta-diaphyseal fractures were pathological fractures through bone cysts.

Treatment: The following methods were employed: a) external fixators (n=2), b) screws, pins and cast (n=6), c) Plates (n=5), and d) Titanium elastic nails (n=1). The mean follow-up was 16 months (range 3–38 months). d) There were no major complications. The knee ROM at 6 weeks was 35° after pins and cast, and 80° after other methods. The knee ROM was at least 110° at 3 months after plate fixation and at six months after pins and cast.

Conclusions: We identified two main subgroups of treatment in teenagers: plates in 5, and screws or Kirschner wires with cast augmentation in 6. The teenagers treated with plates had better short-term outcomes but, at 6 months, there was no difference between the groups. It appears that, if fracture configuration allows, the percutaneous locking plates should be the first treatment option. Bone cysts appear to be a significant risk factor in this age group. The midterm outcome of distal femur fractures was overall good without physeal arrest or malalignment.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 511 - 511
1 Aug 2008
Cohen E Haim A Fruchtman Y Atar D Wiessel Y
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Introduction: Congenital insensitivity to pain and anhydrosis (CIPA) is a rare genetic disease transmitted through an autosomal recessive mode. It is known also as HSAN (Hereditary Sensory and Autonomic Neuropathy) type 4. Affected patients suffer from: anhydrosis, mental retardation, poikilothermia and musculo-skel-etal anomalies. The actual knowledge on musculo-skel-etal aspects in CIPA is based on case reports.

Aim of the study: To describe systematically the musculo-skel-etal aspects related to CIPA in a large group of patients followed over the years.

Material and Methods: 40 patients with CIPA were followed in our institution. The age range was 3 months to 19 years of age, and the mean follow up was 8 years. There was some degree of relationship between the parents Their charts were reviewed, radiographs, and bacterial cultures were examined.

Results: The main features that we observed: a) Joint instability with a spectrum that varies from positive provocative test to recurrent dislocation. b) Bone and Joint infection-often with high production of purulent discharges and associated with subluxation of affected joint or with pathologic fractures. Infections can be multimicrobial, are difficult to eradicate and lead to bacteremia episodes. c) Wound healing problems. Wounds hardly heal in CIPA patients. The scar is formed slowly if at all. Chronic sinus drainage and frequent wound dehiscence is the rule. d) Radiological abnormalities: osteomyelitis, pathological fractures with giant callus formation, vanishing bones, heterotrophic ossification, and pseudo-arthrosis were observed.

Conclusions: There is a wide spectrum of musculo-skel-etal pathologies in CIPA affected children. Their orthopedic conditions determine ambulation capacity, life quality and life expectancy and influence dramatically on their families. Complications both mechanical and infectious are very often. A multidisciplinary approach to this chronic illness is needed.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 7 | Pages 887 - 892
1 Jul 2007
Cohen AT Skinner JA Warwick D Brenkel I

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 346 - 346
1 May 2006
Dabby D Patisch H Blumberg N Cohen I Jakim I
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The proper management of radial head fractures is difficult and controversial. The radial head is intra-articular, part of the forearm ring and participates in both flexion and extension as well as in pronosupination. Our main goal in treating those fractures is anatomic restoration of the joint surface and early mobilization. Excision of the radial head, a well described procedure, may result in elbow instability and proximal migration of the radius. In this work we tried to avoid those complications by either conserving the head (ORIF) or by using a Radial head prosthesis.

Material and Methods: 20 Patients were enrolled into the study between 2003–2004. They were divided into 2 groups. 10 patients had ORIF and in patients the Corin Radial head prosthesis was used. Post-op all patients started immediate CPM. All patients were followed-up for 12–28 months (average 18.6). XR were taken each time and clinical examination was done, ROM was noted as well as muscle strength. Elbow stability was tested only on the 2nd month post op. Patient satisfaction was noted based of their function ability, and the amount of pain. Pain was rated on a scale of 1–10.

Results: Both groups passed the surgery uneventfully. No neurovascular damage nor infection were noted. In clinical examination the elbow was found to be stable in both groups. Decreased ROM in compare with the other elbow was found in both groups, but was more prominent in he ORIF group. One patient in the ORIF group in which biodegradable rod was used developed moderate synovitis that passed without intervention after 9 weeks. XR reveled that one patient in the ORIF group developed Heterotopic ossification, no dislocation or subluxation of the prosthesis was seen. Regarding to pain, in the ORIF group the patients rated their pain as milder in compare to those in the prosthetic group.

Conclusions: Both methods result in stable elbow but the ORIF group showed tendency to experience less pains and the prosthesis group showed tendency to better ROM.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 348 - 348
1 May 2006
Mercado E Cohen E Alkrinawi N Atar D
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Introduction: Fracture of the lateral condyle of distal humerus in the pediatric population is a common problem. In children less than 13 year the distal humerus is only partially ossified and it is sometimes impossible to assess whether a fracture extends to the articular surface of distal humerus and whether or not there is a step off. Classic recommendations were to perform an open reduction in order to ensure perfect reduction. There are sporadic reports on use of arthrography or MRI studies

Aim of the Study: Retrospective study- intended to evaluate the clinical and radiographic outcome in children in whom the articular surface of distal humerus was evaluated by arthrography . Uppon arthrography results undisplaced fractures were percutaneously pinned and displaced fractures underwent formal open reduction and internal fixation.

Patients and Methods: 11 children mean age 7.8 (1.5–15) were enrolled in the study. Inclusion criteria was a fracture of lateral condyle of humerus suspected to be type II according to Jakob (the fracture is complete but is not diplaced out of the elbow joint). The mean follow up was 2.4y (13m-5.2y). Range of motion. Carrying angle were and neurovascular status were noted and compared with controlateral elbow. Actual X-rays were reviewed.

Results: The patient sample represent around 8% of the whole number of children treated in our Institution during 2000–2005. In 7 patients we were able to avoid open reduction and still to achieve excellent results. In 4 cases that were finally managed by open reduction the intraoperative findings fitted the arthrographic findings.

In Conclusion: Arthrography may prevent unnecessary open reductions for lateral condyle fractures in children.