We have studied 105 patients with 107 acute,
A
Infected nonunion of a long bone continues to
present difficulties in management. In addition to treating the infection,
it is necessary to establish bony stability, encourage fracture
union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in
66 patients treated in a multidisciplinary unit. The operative treatment
of patients suitable for limb salvage was performed as a single
procedure. Antibiotic regimes were determined by the results of
microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%)
had an infection-free united fracture in a functioning limb. Seven
others required amputation (three as
We compared lower limb coronal alignment measurements
obtained pre- and post-operatively with long-leg radiographs and
computer navigation in patients undergoing
Although gradual bone transport may permit the
restoration of large-diameter bones, complications are common owing
to the long duration of external fixation. In order to reduce such
complications, a new technique of bone transport involving the use
of an external fixator and a locking plate was devised for segmental
tibial bone defects. A total of ten patients (nine men, one woman) with a mean age
at operation of 40.4 years (16 to 64) underwent distraction osteogenesis
with a locking plate to treat previously infected post-traumatic
segmental tibial defects. The locking plate was fixed percutaneously
to bridge proximal and distal segments, and was followed by external fixation.
After docking, percutaneous screws were fixed at the transported
segment through plate holes. At the same time, bone grafting was
performed at the docking site with the external fixator removed. The mean defect size was 5.9 cm (3.8 to 9.3) and mean external
fixation index was
13.4 days/cm (11.8 to 19.5). In all cases,
Satisfactory selection criteria are essential for the successful outcome of unicompartmental knee arthroplasty (UCA). We report the frequency of revision of the Oxford medial unicompartmental arthroplasty in knees previously treated for anteromedial osteoarthritis by high tibial osteotomy (HTO). The combined results from three sources were used to allow statistical analysis of this uncommon subgroup. In the combined series of 631 knees (507 patients) which had medial unicompartmental replacement, 613 were
The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with
We reviewed 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean age at operation was 57 years, 2 months (20 to 86 years). The indication for operation was post-traumatic osteoarthritis in 67,
The results of primary total knee replacement performed on a group of haemophiliac patients in a single institution by the same surgeon using the same surgical technique and prosthesis are reported. A total of 35
We reviewed, retrospectively, 13 patients who had undergone open anterograde autologous bone grafting of the talus for symptomatic osteochondral defects of the dome of the talus. The mean age of the seven men and six women was 38.4 years. The defects included the full thickness of articular cartilage, extended through the subchondral plate and were associated with subchondral cysts. Six patients (46%) were clinical failures requiring further surgery. Of the remaining seven, functional outcome results were obtained at a mean of 51.9 months after surgery. The mean outcome scores for the Musculoskeletal Outcomes Data Evaluation and Management System foot and ankle questionnaire and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were 87.0 and 84.3, respectively. There was an overall 46.2% patient satisfaction rate. We believe that the technique of autologous bone grafting presented should be used with extreme caution, when considered as the
During a six-year period (January 1996 to January 2002 ), we re-explored 60 interspaces (49 patients, 49 feet) for recurrence or persistent symptoms after one or more previous procedures for excision of an interdigital neuroma. Ten patients underwent concomitant excision of a
Of 111
Deep vein thrombosis is a common complication
of immobilising the lower limb after surgery. We hypothesised that
intermittent pneumatic compression (IPC) therapy in outpatients
who had undergone surgical repair of acute ruptures of the Achilles
tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of
the Achilles tendon were randomised to either treatment with IPC
for six hours per day (n = 74) under an orthosis or treatment as
usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively,
the incidence of deep vein thrombosis was assessed using blinded, double-reported
compression duplex ultrasound. At this point, IPC was discontinued
and all patients were immobilised in an orthosis for a further four
weeks. At six weeks post-operatively, a second compression duplex ultrasound
scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in
the treated group and 37% in the control group (p = 0.042). Age
over 39 years was found to be a strong risk factor for deep vein
thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI)
2.14 to 10.96). Treatment with IPC, corrected for age differences
between groups, reduced the risk of deep vein thrombosis at the
two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks,
the incidence of deep vein thrombosis was 52% in the treated group
and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC
appears to be an effective method of reducing the risk of deep vein
thrombosis in the early stages of post-operative immobilisation
of outpatients. Further research is necessary to elucidate whether
it can confer similar benefits over longer periods of immobilisation
and in a more heterogeneous group of patients. Cite this article:
Although patients with a history of venous thromboembolism
(VTE) who undergo lower limb joint replacement are thought to be
at high risk of further VTE, the actual rate of recurrence has not
been reported. The purpose of this study was to identify the recurrence rate
of VTE in patients who had undergone lower limb joint replacement,
and to compare it with that of patients who had undergone a joint
replacement without a history of VTE. From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR,
243 revision THR, 152 revision TKR) in 5967 patients (68% female,
mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively
identified 118 consecutive treatment episodes in 106 patients (65%
female, mean age 70; 51 to 88,) who had suffered a previous VTE.
Despite mechanical prophylaxis and anticoagulation with warfarin,
we had four recurrences by three months (3.4% of 118) and six by
one year (5.1% of 118). In comparison, in all our other joint replacements
the rate of VTE was 0.54% (35/6528). The relative risk of a VTE by 90 days in patients who had undergone
a joint replacement with a history of VTE compared with those with
a joint replacement and no history of VTE was 6.3 (95% confidence
interval, 2.3 to 17.5). There were five complications in the previous
VTE group related to bleeding or over-anticoagulation. Cite this article:
The treatment of infected nonunions is difficult.
Antibiotic cement-coated (ACC) rods provide stability as well as delivering
antibiotics. We conducted a review of 110 infected nonunions treated
with ACC rods. Patients were divided into two groups: group A (67
patients) with an infected arthrodesis, and group B (43 patients)
with an infected nonunion in a long bone. In group A, infected arthrodesis,
the success rate after the first procedure was 38/67 (57%), 29/67
(43%) required further surgery for either control of infection or
non-union. At last follow-up, five patients required amputation,
representing a limb salvage rate of 62/67 (93%) overall. In all,
29/67 (43%) presented with a bone defect with a mean size of 6.78
cm (2 to 25). Of those with a bone defect, 13/29 (45%) required
further surgery and had a mean size of defect of 7.2 cm (3.5 to
25). The cultures were negative in 17/67 (26%) and the most common
organism cultured was methicillin-resistant Cite this article:
To conduct a pilot randomised controlled trial to evaluate the
feasibility of conducting a larger trial to evaluate the difference
in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores
at six months between patients with Achilles tendinopathy treated
with a platelet-rich plasma (PRP) injection compared with an eccentric
loading programme. Two groups of patients with mid-substance Achilles tendinopathy
were randomised to receive a PRP injection or an eccentric loading
programme. A total of 20 patients were randomised, with a mean age
of 49 years (35 to 66). All outcome measures were recorded at baseline,
six weeks, three months and six months.Objectives
Methods
We hypothesised that adjuvant intermittent pneumatic
compression (IPC) beneath a plaster cast would reduce the risk of
deep-vein thrombosis (DVT) during post-operative immobilisation
of the lower limb. Of 87 patients with acute tendo Achillis (TA)
rupture, 26 were prospectively randomised post-operatively after
open TA repair. The treatment group (n = 14) received two weeks of
IPC of the foot for at least six hours daily under a plaster cast.
The control group (n = 12) had no additional treatment. At two weeks
post-operatively all patients received an orthosis until follow-up
at six weeks. At two and six weeks the incidence of DVT was assessed
using colour duplex sonography by two ultrasonographers blinded
to the treatment. Two patients withdrew from the study due to inability
to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both
the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p
= 0.18). No significant differences in incidence were detected at
two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction
of the IPC leading to a second plaster cast was found to correlate
with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading
to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a
plaster cast for outpatient DVT prevention during post-operative
immobilisation, owing to a high incidence of DVT related to malfunctioning
of this type of IPC application. Cite this article:
We investigated the fracture-free survival of long bones stabilised by a telescopic intramedullary rod (TIMR) in patients with osteogenesis imperfecta with respect to the remodelling status of fracture or osteotomy sites and TIMR regions, in order to identify risk factors for fracture. A total of 44 femora and 28 tibiae in 25 patients with a mean age of 5.0 years (1.9 to 10.5) at presentation were studied. There were six patients with Sillence type I, five with type III, 13 with type IV and one with type V osteogenesis imperfecta. All received bisphosphonate treatment at the same stage during the mean follow-up of 7.3 years (0.5 to 18.1). The fracture-free survival was estimated at 6.2 years (95% confidence interval 5.1 to 7.3) by Kaplan-Meier analysis. More than half the fracture or osteotomy sites remained in a less-remodelled state at the latest follow-up or time of fracture. Of the 33 fractures, 29 (87.9%) occurred in long bones containing a less-remodelled site, and these fractures were located at this site. The relative fracture risk at the rod tip was significantly greater than in any other TIMR region (p <
0.001), and this was higher in bone segments having a less-remodelled site. This study shows a persistent fracture risk in TIMR-stabilised long bones, especially at less-remodelled fracture or osteotomy sites and at the rod tip.
We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient’s age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.
A silver-containing hydroxyapatite (Ag-HA) coating has been developed using thermal spraying technology. We evaluated the osteoconductivity of this coating on titanium (Ti) implants in rat tibiae in relation to bacterial infection in joint replacement. At 12 weeks, the mean affinity indices of bone formation of a Ti, an HA, a 3%Ag-HA and a 50%Ag-HA coating were 97.3%, 84.9%, 81.0% and 40.5%, respectively. The mean affinity indices of bone contact of these four coatings were 18.8%, 83.7%, 77.2% and 40.5%, respectively. The indices of bone formation and bone contact around the implant of the 3%Ag-HA coating were similar to those of the HA coating, and no significant differences were found between them (bone formation, p = 0.99; bone contact, p = 0.957). However, inhibition of bone formation was observed with the 50%Ag-HA coating. These results indicate that the 3%Ag-HA coating has low toxicity and good osteoconductivity, and that the effect of silver toxicity on osteoconductivity depends on the dose.