Objectives

Current studies on the additional benefit of using computed tomography (CT) in order to evaluate the surgeons’ agreement on treatment plans for fracture are inconsistent. This inconsistency can be explained by a methodological phenomenon called ‘spectrum bias’, defined as the bias inherent when investigators choose a population lacking therapeutic uncertainty for evaluation. The aim of the study is to determine the influence of spectrum bias on the intra-observer agreement of treatment plans for fractures of the distal radius.

Introduction

Malrotation following total knee replacement is directly related to poor outcome. The knowledge of proximal and distal rotational axes and angles of the femur is therefore of high importance. The aim of the study was to determine whether the most used proximal and distal femoral angles; femoral anteversion angle (FAA) and posterior condylar angle (PCA) were different within individuals, between right, left and gender. As well, we studied whether the “inferior condylar angle” is correlated to the PCA and therefore useful in determining the rotation of the distal femur.

The aim of this study was to evaluate the long-term outcomes of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and without (N-PMF). Adult patients presenting to a single academic trauma centre in Edinburgh, UK, between 2009 and 2012 with an unstable ankle fracture requiring surgery were identified. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary measures included Euroqol-5D-3L Index (Eq5D3L), Euroqol-5D-VAS and Manchester Oxford Foot Questionnaire (MOXFQ). There were 304 patients in the study cohort. The mean age was 49.6 years (16.3–78.3) and 33% (n=100) male and 67% (n=204) female. Of these, 67% (n=204) had a PMF and 33% did not (n=100). No patient received a computed tomography (CT) scan pre-operatively. Only 10% of PMFs (22/204) were managed with internal fixation. At a mean of 13.8 years (11.3 – 15.3) the median OMAS score was 85 (Interquartile Range 60 – 100). There was no difference in OMAS between the N-PMF and PMF groups (85 [56.25 – 100] vs 85 [61.25 – 100]; p = 0.580). There was also no difference for MOXFQ (N-PMF 7 [0 – 36.75] vs PMF 8 [0–38.75]; p = 0.643), the EQ5D Index (N-PMF 0.8 [0.7 – 1] vs PMF 0.8 [0.7 – 1]; p = 0.720) and EQ5D VAS (N-PMF 80 [70 – 90] vs PMF 80 [60 – 90]; p = 0.224). The presence of a PMF does not affect the long-term patient reported outcomes in patients with a surgically managed unstable ankle fracture

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100 000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age

The purpose of this study is to analyze what kind of pattern of change in each posterior femoral condyle allows for a greater degree of flexion after total knee arthroplasty (TKA). The flexion angle was assessed pre-operatively, and at 12 months after the surgery in 98 patients (106 knees) who underwent consecutive TKA. We used a quantitative 3 dimensional technique using computed tomography for the assessment of changes in both the medial and lateral femoral condylar offset. There were no significant correlation between changes of each posterior condylar offset and post flexion angle (medial condyle; R=−0.038, p=0.70, lateral condyle; R=−0.090, p=0.36). There were no significant differences between changing patterns and increase rate of flexion (p=0.443). Additionally there were no significant differences between changing patterns and increase of flexion angle (p=0.593). Changes of each posterior condylar offset were no correlation to knee flexion after TKA in the current design prosthesis

Introduction. The treatment of trochanteric femoral fractures with the use of short femoral nails has become an established method. The fixation is required that lag screw be centered to prevent complications. But correct positioning of the device may difficult because of anatomical feature. This study evaluated the femoral morphology three-dimensionally using computed tomography (CT) images. Methods. Seventy eight patients (mean age 75)who underwent total knee arthroplasty were included. After three-dimensional reconstruction of the CT images, the anterior deviation from the femoral neck axis to proximal shaft axis was measured. The proximal shaft axis was defined as a line between center of the cross-section underneath the lesser trochanter and the center of diaphysis. The connection of center in narrow section of the neck and femoral head center was defined as neck axis. Results. The femoral neck axis and shaft axis were not coplanar. The anterior deviation of the axes was 7.5 mm (1.7 to 18.4 mm). The neck-shaft angle was 124° (110–142°). Discussion. Our results indicate that the nail and screw could not be center in current nail system, because of the non-crossing of the femoral axes. The large variation of neck-shaft angle would lead error in preoperative planning using traditional 2-D template system. Our study suggests needs for three-dimensional template system and newly femoral nail device

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning

Counter-insurgency warfare in recent military operations has been epitomised by the use of Improvised Explosive Devices (IED) against coalition troops. Emerging patterns of skeletal fractures, limb amputations and organ injuries, which are caused by these weapons have been described over recent years. This paper describes a retrospective case series of knee dislocations caused by IEDs in recent conflict. Data was obtained about military personnel from 2006 to 2011, who had sustained a knee dislocation while serving in Afghanistan from a prospectively gathered database, the Joint Theatre Trauma Registry (JTTR), maintained by the Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine. The diagnosis of knee dislocation and its associated skeletal injuries was assessed by review of all relevant plain radiographs, computed tomography scans and magnetic resonance images. The mechanism of injury, incidence of vascular injuries and other skeletal injuries was recorded. During the study period, 23 casualties sustained a knee dislocation caused by an IED. Four casualties had an associated popliteal vascular injury. Eleven injuries were caused in enclosed spaces, and 10 injuries caused by IEDs out in the open. Anterior dislocations were common in the group caused in enclosed spaces. 19/20 patients had at least one other skeletal fracture. Knee dislocations represent an uncommon but important diagnosis in modern warfare. Urgent and careful assessment for any associated vascular injuries or other skeletal injuries may help ensure timely treatment and promote future recovery. Mitigation against knee dislocation may be possible in the enclosed environment because of the predictable pattern of injury

Introduction. To introduce a new classification method and analyze related risk factor about lateral wall perforation associated with lower cervical pedicle screw and free-hand insertion technique. Methods. A Retrospective study was made to analyze 214 patients (1024 screws) with various cervical spine disorders, involved in pedicle screw instrumentation at C3-7 from July 2004 to July 2009. Researchers assessed the position of the screws in the pedicle by carefully probing intraoperatively and studying postoperative thin-slice computed tomography scan. Perforation of lateral wall was classified into two phases. Phase I refers to the burst of the pedicle by screw, which means that the length of screw threads penetrating the external cortex of pedicles on CT scan is 2 mm, whereas in Phase, the length is >2 mm. The Penetrated screws and related factors were analyzed though Backward Stepwise (Wald) Logistic regression. Results. During the follow-up, 2 screws were reported to be broken and 1 screw loosened. Of the screws inserted, total of 129 screws 12.60% have shown violated of lateral pedicle walls, included 101 screws (9.86%) causative of Phase I and 28 screws (2.73%) of Phase II. Two variance were deduced in the regression analysis, which concerned to ratio variance between inner and lateral walls, PRC 0.695, OR value = 2.003and angle difference variance between screws implanted and measurements preoperativePRC −1.542, OR value = 0.214). Conclusions. Free-hand lower cervical pedicle screw insertion in this series was comparatively safety. Phase I Penetration was believed to be safe of vertebral artery and Phase II faced to higher risk of artery damage. The main risk factor of lateral wall perforation was the ratio variance between inner and lateral wall, while the main protection factor was the angle difference variance between screws implanted and CT measurements

PURPOSE. Osteochondral talar defects (OCDs) are sometimes located so far posteriorly that they may not be accessible by anterior arthroscopy, even with the ankle joint in full plantar flexion, because the talar dome is covered by the tibial plafond. It was hypothesized that computed tomography (CT) of the ankle in full plantar flexion could be useful for preoperative planning. The dual purpose of this study was, firstly, to test whether CT of the ankle joint in full plantar flexion is a reliable tool for the preoperative planning of anterior ankle arthroscopy for OCDs, and, secondly, to determine the area of the talar dome that can be reached by anterior ankle arthroscopy. METHODS. In this prospective study, CT-scans with sagittal reconstructions were made of 46 consecutive patients with their affected ankle in full plantar flexion. In the first 20, the distance between the anterior border of the OCD and the anterior tibial plafond was measured both on the scans and during anterior ankle arthroscopy as the gold standard. Intra- and interobserver reliability of CT as well as agreement between CT and arthroscopy were assessed by intraclass correlation coefficients (ICCs) and a Bland and Altman graph. Next, the anterior and posterior borders of the talar dome as well as the anterior tibial plafond were marked on all 46 scans. Using a specially written computer routine, the anterior proportion of the talar dome not covered by the tibial plafond was calculated, both lateral and medial, indicating the accessible area. RESULTS. The distance between the anterior border of the OCD and the anterior tibial plafond ranged from −3.1 to 9.1 mm on CT and from −3.0 to 8.5 on arthroscopy. The intra- and interobserver reliability of the measurements made on CT-scans were excellent (ICC > 0.99, p < 0.001). Likewise, agreement between CT and arthroscopy was excellent (ICC=0.97; p < 0.001); only one patient showed a difference of more than 2.0 mm. The anterior 47.3 ± 6.8% (95%CI, 45.2–49.3) of the lateral talar dome, and 47.7 ± 7.0% (95%CI, 45.7–49.8) of the medial talar dome was not covered by the tibial plafond. CONCLUSIONS. Computed tomography of the ankle joint in full plantar flexion is an accurate preoperative planning method to determine the arthroscopic approach for treatment of OCDs of the talus. Almost half of the talar dome is directly accessible by anterior ankle arthroscopy

Recent advances in combat casualty care have enabled survival following battlefield injuries that would have been lethal in past conflicts. While some injuries remain beyond our current capability to treat, they have the potential to be future ‘unexpected’ survivors. The greatest threat to deployed coalition troops currently and for the foreseeable future is the improvised explosive device (IED) Therefore, the aim of this study was to conduct an analysis of causes of death and injury patterns in recent explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates. Since November 2007, UK Armed Forces personnel killed whilst deployed on combat operations undergo both a post mortem computed tomography (PMCT) scan and an autopsy. With the permission of the coroners, we analysed casualties with PMCTs between November 2007 and July 2010. Injury data were analysed by a pathology-forensic radiology-orthopaedic multidisciplinary team. Cause of death was attributed to the injuries with the highest AIS scores contributing to the NISS score. Injuries with an AIS < 4 were excluded. During the study period 227 PMCT scans were performed; 211 were suitable for inclusion, containing 145 fatalities due to explosive blast from IEDs. These formed the study group. 24 cases had such severe injuries (disruptions) that further study was inappropriate. Of the remaining 121, 79 were dismounted, and 42 were mounted (in vehicles). Leading causes of death were head CNS injury (47.6%), followed by intra-cavity haemorrhage (21.7%) in the mounted group, and extremity haemorrhage (42.6%), junctional haemorrhage (22.2%) and head CNS injury (18.7%) in the dismounted group. The severity of head trauma in both mounted and dismounted IED fatalites would indicate that prevention and mitigation of these injuries is likely to be the most effective strategy to decrease their resultant mortality. Two thirds of dismounted fatalities have haemorrhage implicated as a cause of death that may have been amenable to prehospital treatment strategies. One fifth of mounted fatalites have haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for combat casualties from point of wounding to definitive surgical proximal control alongside development and application of novel haemostatics could yield a significant survival benefit

Despite proven advantages, pulsatile lavage seems to be used infrequently during preparation in cemented total knee arthroplasty. This remains irritating, as the technique has been suggested to improve radiological survival in cemented TKA, where aseptic loosening of the tibial component represents the main reason for revision. Furthermore, there may be a potential improvement of fixation strength for the tibial tray achieved by increased cement penetration. In this study, the influence of pulsed lavage on mechanical stability of the tibial component and bone cement penetration was analyzed in a cadaveric setting. Six pairs of cadaveric, proximal tibia specimen underwent computed tomography (CT) for assessment of bone mineral density (BMD) and exclusion of osseous lesions. Following surgical preparation, in one side of a pair, the tibial surface was irrigated using 1800ml normal saline and pulsatile lavage, while in the other side syringe lavage using the identical amount of fluid was applied. After careful drying, bone cement was hand-pressurized on the bone surface, tibial components were inserted and impacted in an identical way. After curing of cement, specimen underwent a postimplantation CT analysis). Cement distrubution was then assessed using a three-dimenionsional visualization software. Trabecular bone, cement and implant were segmented based on an automatic thresholding algorithm, which had been validated in a previous study. This allowed to determine median cement penetration for the entire cemented area. Furthermore, fixation strength of the tibial trays was determined by a vertical pull-out test using a servohydraulic material testing machine. Testing was performed under displacement control at a rate of 0,5mm/sec until implant failure. Data was described by median and range. Results were compared by a Wilcoxon matched pairs signed rank test with a type 1 error probability of 5 %. Median pull-out forces in the pulsed lavage group were 1275N (range 864–1391) and 568N (range 243–683) in the syringe lavage group (p=0.031). Cement penetration was likewise increased (p=0.031) in the pulsed lavage group (1.32mm; range 0.86–1.94), when compared to the syringe irrigated group (0.79mm; range 0.51–1.66). Failure occurred in the pulsatile lavage group at the implant-cement interface and in the syringe lavage group at the bone-cement interface, which indicates the weakness of the latter. Altogether, improved mechanical stability of the tibial implant and likewise increased bone cement interdigitation could be demonstrated in the current study, when pulsed lavage is implemented. Enhanced fixation strength was suggested being a key to improved survival of the implant. If this is the case, pulsatile lavage should be considered being a mandatory preparation step when cementing tibial components in TKA

Background. Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site. Aims. Analysis of retrieved tissue-engineered bone as part of ongoing follow-up of this translational case series. Methods. With Proof-of-Concept established in vitro and in vivo, the use of a living bone composite of SSCs and allograft has been translated to four patients (five hips) for treatment of osteonecrosis of their femoral heads. Parallel in vitro culture of the implanted cell-graft construct was performed. Patient follow-up was by serial clinical and radiological examination. In one patient collapse occurred in both hips due to more advanced disease than was originally appreciated. This necessitated bilateral hip arthroplasty, but allowed retrieval of the femoral heads. These were analyzed for Type 1 Collagen production, bone morphology, bone density and mechanical strength by micro computed tomography (CT), histology (A/S stain, Collagen Type 1 immunostain, biorefringence) and mechanical testing. Representative sections of cortical, trabecular and tissue engineered bone were excised from the femoral heads using a diamond-tipped saw-blade and tested to failure by axial compression. Results. Parallel in vitro analysis demonstrated sustained cell growth and viability on the allograft. Three patients currently remain asymptomatic at up to three year follow-up. Histological analysis of the two retrieved femoral heads demonstrated, critically, Type 1 collagen production in the regenerated tissue as well as mature trabecular architecture, indicative of de novo tissue engineered bone. The trabecular morphology of regenerated bone was evident on CT, and this had a bone density of 1400 Grey scale units, (compared to 1200 for natural trabecular bone and 1800 for cortical bone). On axial compressive testing the regenerated bone on the left showed a 24.8% increase in compressive strength compared to ipsilateral normal trabecular bone, and a 22.9% increase on the left. Conclusions. Retrieval analysis data has demonstrated the translational potential of a living bone composite, while ongoing clinical follow-up shows this to be an effective new treatment for osteonecrosis of the femoral head. Regeneration of the necrotic bone may prevent subsequent collapse, thereby delaying, or possibly avoiding, the need for hip arthroplasty in early stage osteonecrosis. Evaluation of this tissue engineering construct has confirmed the potential for clinical treatment of bone defects using SSC based strategies

Background. Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR. Methods. We conducted an independent prospective study comparing VTE prevention strategies in two successive series of patients (Groups A and B) undergoing elective unilateral THR. Group A (n=253) received fondaparinux daily 2.5 mg for 10 days, followed by tinzaparin 4500 IU daily for one month. Group B (n=229) received 10 mg rivaroxaban daily for 40 days without platelet monitoring. All surgeries were performed by a single surgeon under general anesthesia using an active blood transfusion-sparing plan. In the absence of contraindications, patients received intra-operative administration of tranexamic acid to reduce postoperative bleeding. Preoperative and postoperative hemoglobin levels were recorded at regular intervals. Bleeding events were documented. The bleeding index was calculated by adding the number of red blood cell units and the difference in the hemoglobin level (in g/dL) between the first morning after the day of surgery and the seventh postoperative day (POD 7). After 5 to 10 days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at eight weeks postoperatively. Results. Baseline characteristics between the two groups were comparable. The rate of major bleeding events, proximal deep venous thrombi, and pulmonary emboli was nil in each group. The incidence of blood transfusion was 0.8% in Group A (2 of 253 hips) and 0.4% (1 of 229 hips) in Group B (p=1.0). The bleeding index analysis excluded 8 hips for which the hemoglobin value at POD 7 was not measured. The bleeding index was 1.03 (standard deviation, 0.88) in Group A and 0.8 (standard deviation, 0.80) in Group B (p<0.001). The incidence of bleeding index >2 was 10.5% (27 of 247 hips) in Group A and 3% (7 of 227 hips) in Group B (p<0.001). Discussion. We compared two series of patients treated with THR undertaken with postoperative anticoagulation to prevent VTE. The high level of success these anticoagulant treatments had at preventing VTE in our series could be attributed at least partially to the combination of an active blood-sparing transfusion plan with the use of anticoagulant molecules reported in the literature to be quite potent. Conclusions. This prospective study comparing two anticoagulant regimens in patients treated with THR did not detect any difference with regards to the efficacy of the treatments, although there was significantly less bleeding index in patients who received rivaroxaban

Aims

The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size.

Objectives

The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison.

It is becoming increasingly common for a patient to have ipsilateral hip and knee replacements. The inter-prosthetic (IP) distance, the distance between the tips of hip and knee prostheses, has been thought to be associated with an increased risk of IP fracture. Small gap distances are generally assumed to act as stress risers, although there is no real biomechanical evidence to support this.

The purpose of this study was to evaluate the influence of IP distance, cortical thickness and bone mineral density on the likelihood of an IP femoral fracture.

A total of 18 human femur specimens were randomised into three groups by bone density and cortical thickness. For each group, a defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing the appropriate lengths of component. The maximum fracture strength was determined using a four-point bending test.

The fracture force of all three groups was similar (p = 0.498). There was a highly significant correlation between the cortical area and the fracture strength (r = 0.804, p <  0.001), whereas bone density showed no influence.

This study suggests that the IP distance has little influence on fracture strength in IP femoral fractures: the thickness of the cortex seems to be the decisive factor.

Cite this article: Bone Joint J 2014;96-B:1378–84.

Patients with transfemoral amputation (TFA) often experience problems related to the use of socket-suspended prostheses. The clinical development of osseointegrated percutaneous prostheses for patients with a TFA started in 1990, based on the long-term successful results of osseointegrated dental implants.

Between1999 and 2007, 51 patients with 55 TFAs were consecutively enrolled in a prospective, single-centre non-randomised study and followed for two years. The indication for amputation was trauma in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical procedure was used to introduce a percutaneous implant to which an external amputation prosthesis was attached. The assessment of outcome included the use of two self-report questionnaires, the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) and the Short-Form (SF)-36.

The cumulative survival at two years’ follow-up was 92%. The Q-TFA showed improved prosthetic use, mobility, global situation and fewer problems (all p < 0.001). The physical function SF-36 scores were also improved (p < 0.001). Superficial infection was the most frequent complication, occurring 41 times in 28 patients (rate of infection 54.9%). Most were treated effectively with oral antibiotics. The implant was removed in four patients because of loosening (three aseptic, one infection).

Osseointegrated percutaneous implants constitute a novel form of treatment for patients with TFA. The high cumulative survival rate at two years (92%) combined with enhanced prosthetic use and mobility, fewer problems and improved quality of life, supports the ‘revolutionary change’ that patients with TFA have reported following treatment with osseointegrated percutaneous prostheses.

Cite this article: Bone Joint J 2014;96-B:106–13.

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones.

We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p < 0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05).

The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.