Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

Aims

We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up.

This prospective study reports the 15-year survival and ten-year functional outcome of a consecutive series of 1000 minimally invasive Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women, 52%, mean age 66 years; 32 to 88). These were implanted by two surgeons involved with the design of the prosthesis to treat anteromedial osteoarthritis and spontaneous osteonecrosis of the knee, which are recommended indications. Patients were prospectively identified and followed up independently for a mean of 10.3 years (5.3 to 16.6).

At ten years, the mean Oxford Knee Score was 40 (standard deviation (sd) 9; 2 to 48): 79% of knees (349) had an excellent or good outcome. There were 52 implant-related re-operations at a mean of 5.5 years (0.2 to 14.7). The most common reasons for re-operation were arthritis in the lateral compartment (2.5%, 25 knees), bearing dislocation (0.7%, seven knees) and unexplained pain (0.7%, seven knees). When all implant-related re-operations were considered as failures, the ten-year rate of survival was 94% (95% confidence interval (CI) 92 to 96) and the 15-year survival rate 91% (CI 83 to 98). When failure of the implant was the endpoint the 15-year survival was 99% (CI 96 to 100).

This is the only large series of minimally invasive UKAs with 15-year survival data. The results support the continued use of minimally invasive UKA for the recommended indications.

Cite this article: Bone Joint J 2015;97-B:1493–99.

Periprosthetic joint infections (PJI) are challenging complications following arthroplasty. Staphylococci are a frequent cause of PJI and known biofilm producers.

Reoperations for PJI of the hip or knee between 2012 and 2015 performed at Sahlgrenska University Hospital were identified. Medical records were reviewed, and clinical parameters recorded for patients whose intraoperative bacterial isolates had been stored at the clinical laboratory. Staphylococcal strains isolated from reoperations due to first-time PJI were characterised by their ability to form biofilms using the microtiter plate test.

The study group included 49 patients (70 bacterial strains) from first-time PJI, whereof 24 (49%) patients had recurrent infection. Strong biofilm production was significantly associated with recurrent infection. Patients infected with strong biofilm producers had a five-fold increased risk for recurrent infection.

Strong biofilm production was significantly associated with increased antimicrobial resistance and PJI recurrence. This underscores the importance of determining biofilm production and susceptibility as part of routine diagnostics in PJI. Strong staphylococcal biofilm production may have implications on therapeutic choices and suggest more extensive surgery. Furthermore, despite the increased biofilm resistance to rifampicin, results from this study support its use in staphylococcal PJI.

Aims. The aim of this study was to identify factors that determine outcomes of treatment for patients with chondroblastic osteosarcomas (COS) of the limbs and pelvis. Patients and Methods. The authors carried out a retrospective review of prospectively collected data from 256 patients diagnosed between 1979 and 2015. Of the 256 patients diagnosed with COS of the pelvis and the limbs, 147 patients (57%) were male and 109 patients (43%) were female. The mean age at presentation was 20 years (0 to 90). Results. In all, 82% of the patients had a poor response to chemotherapy, which was associated with the presence of a predominantly chondroblastic component (more than 50% of tumour volume). The incidence of local recurrence was 15%. Synchronous or metachronous metastasis was diagnosed in 60% of patients. Overall survival was 51% and 42% after five and ten years, respectively. Limb localization and wide surgical margins were associated with a lower risk of local recurrence after multivariable analysis, while the response to chemotherapy was not. Local recurrence, advanced patient age, pelvic tumours, and large volume negatively influenced survival. Resection of pulmonary metastases was associated with a survival benefit in the limited number of patients in whom this was undertaken. Conclusion. COS demonstrates a poor response to chemotherapy and a high incidence of metastases. Wide resection is associated with improved local control and overall survival, while excision of pulmonary metastases is associated with improved survival in selected patients. Cite this article: Bone Joint J 2019;101-B:739–744

Infected hip prosthesis, a devastating complication of primary total hip arthroplasty (THA) can lead to a serious condition. We report here the treatment outcome of our method of two-stage revision THA for infected hip arthroplasty using a temporary antibiotic-impregnated cement spacer for the period between resection and reimplantation. Between 1996 and 2000, we performed two-stage revision THA using a temporary antibiotic-impregnated cement spacer on eight hips in eight patients with infected hip arthroplasty including hemiarthroplasty, with the infection presenting itself between four days and 19.4 years after last operation. There were four females and four males, with a mean age of 67 years (58 to 72). The mean period of follow-up was 2.5 years (0.3 to 4.3). Cementless THA was implanted as the second srage procedure. Bone defects were restored with frozen allografts. The clinical outcome was evaluated using the hip score of the Japanese Orthopaedic Association (JOA hip score). The duration of follow-up was 33.9 months (range, 8 to 55 months). The mean JOA hip score at follow-up improved from 32.6 (19 to 74) to 77.1 (59 to 96). The mean interval period was 10.3 weeks (range, 6 to 19 weeks). Seven patients with infected hip arthroplasty successfully received implantation by two-stage cement-less revision THA. One patient with MRSA infection had a recurrence after four months of revision of THA. However, the two-stage procedure using a vancomicin-impregnated bone cement spacer and beads implantation successfully treated this patient 14 months after the first revision of THA. No recurrence of infection was found at 42 months of follow-up. These results suggest that two-stage revision THA using a temporary antibiotic-impregnated cement spacer is a useful technique for infected hip arthroplasty

Aims. Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD. Methods. A total of 1,453 DM components were implanted at a single academic institution between January 2010 and December 2021: 695 in primary and 758 in revision THA. Of these, 49 presented with a dislocation of the large DM head and five presented with an IPD. At the time of closed reduction of the large DM dislocation, six additional IPDs occurred. The mean age was 64 years (SD 9.6), 54.5% were female (n = 6), and mean follow-up was 4.2 years (SD 1.8). Of the 11 IPDs, seven had a history of instability, five had abductor insufficiency, four had prior lumbar fusion, and two were conversions for failed fracture management. Results. The incidence of IPD was 0.76%. Of the 11 IPDs, ten were missed either at presentation or after attempted reduction. All ten patients with a missed IPD were discharged with a presumed reduction. The mean time from IPD to surgical treatment was three weeks (0 to 23). One patient died after IPD prior to revision. Of the ten remaining hips with IPD, the DM head was exchanged in two, four underwent acetabular revision with DM exchange, and four were revised to a constrained liner. Of these, five (50%) underwent reoperation at a mean 1.8 years (SD 0.73), including one additional acetabular revision. No patients who underwent initial acetabular revision for IPD treatment required subsequent reoperation. Conclusion. The overall rate of IPD was low at 0.76%. It is essential to identify an IPD on radiographs as the majority were missed at presentation or after iatrogenic dissociation. Surgeons should consider acetabular revision for IPD to allow conversion to a larger DM head, and take care to remove impinging structures that may increase the risk of subsequent failure. Cite this article: Bone Joint J 2024;106-B(5 Supple B):98–104

Satisfaction with care is important to both patients and to those who pay for it. The Net Promoter Score (NPS), widely used in the service industries, has been introduced into the NHS as the ‘friends and family test’; an overarching measure of patient satisfaction. It assesses the likelihood of the patient recommending the healthcare received to another, and is seen as a discriminator of healthcare performance. We prospectively assessed 6186 individuals undergoing primary lower limb joint replacement at a single university hospital to determine the Net Promoter Score for joint replacements and to evaluate which factors contributed to the response.

Achieving pain relief (odds ratio (OR) 2.13, confidence interval (CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR 2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI 2.03 to 2.68) are the domains that explain whether a patient would recommend joint replacement services. These three factors, combined with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17), drove a predictive model that was able to explain 95% of the variation in the patient’s recommendation response. Though intuitively similar, this ‘recommendation’ metric was found to be materially different to satisfaction responses. The difference between THR (NPS 71) and TKR (NPS 49) suggests that no overarching score for a department should be used without an adjustment for case mix. However, the Net Promoter Score does measure a further important dimension to our existing metrics: the patient experience of healthcare delivery.

Cite this article: Bone Joint J 2014;96-B:622–8.

Aim

The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication.

The ossific nucleus in Developmental Dysplasia of the Hip. A study of relative ossific nuceus size in hips treated in the Pavlik harness and its predictive value in treatment outcome. Purpose. To assess the value of measuring relative ossific nucleus (ON) size difference in Developmental Dysplasia of the hip (DDH) as a potential predictor of outcome of hips treated in the Pavlik Harness. Study Design. Prospective study of all unilateral cases (n=68) of DDH identified in Southampton by dynamic ultrasound and treated in a Pavlik harness studying changes in relative ON size and acetabular indices over a mean follow up period of 3.6 years. Results. All cases responding to the Pavlik harness showed a progressive correction of ON size difference. Initial ON size difference was not associated with any difference in acetabular index at the date of last follow-up. Ultrasound grading of dysplasia did not affect the rate of normalisation of ON size difference. Conclusion and clinical relevance. In patients responding to treatment of DDH in a Pavlik harness, ON size difference was not found to be a useful prognostic indicator of outcome

Dual mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a known rare complication of these implants and has reportedly decreased with modern implants. The purpose of this paper is to report the diagnosis and treatment of modern DM IPD.

1453 DM components were implanted between 2010 and 2021. 695 in primary and 758 in revision THA. 49 hips sustained a dislocation of the large head and 5 sustained an IPD at presentation. 6 additional IPD occurred at the time of reduction of large head. The average age was 64, 54% were female and the mean follow-up was three years. Of the 11 IPD, 8 had a history of instability, 5 had abductor insufficiency, 4 had prior lumbar fusion, and 3 were conversions from fracture.

The overall IPD incidence was 0.76%. Ten of the 11 DM IPD were missed at initial presentation or at the time of reduction, and all were discharged with presumed reduction. The mean time from IPD to surgical treatment was 3 weeks. One patient died with an IPD at 5 months. A DM head was reimplanted in six, two underwent revision of the acetabular component with exchange of DM head, and four were revised to a constrained liner. The re-revision rate was 55% at a mean 1.8 years. None of the patients who underwent cup revision required subsequent re-revision while half of the constrained liners and exchange of DM heads required re-revision.

The overall rate of DM dislocation or IPD is low. It is critical to identify an IPD on radiographs as it was almost universally missed at presentation or when it occurred iatrogenically. For patients presenting with IPD, the surgeon should consider acetabular revision and conversion to a constrained liner or a larger DM, with special attention to removing impinging structures that could increase the risk of re-dislocation.

In late presenting developmental Dysplasia of hip there is controversy as to the most appropriate method of treatment. The purpose of study was to determine the outcome following the non-operative and operative treatment for late presenting developmental dysplasia of hip.

Retrospective study. Inclusion criteria – (1) Unilateral DH (2) Diagnosed 6 months or more after birth (3) Minimum follow up of 2 years after treatment. 41 patients matched the inclusion criteria. 32 patients attended the follow-up clinic. Patients were divided into non-operative and operative group. Outcome instruments used include activities scale for kids (ASK), physical component of SF36 v2, centre edge angle and severin classification system, all validated scoring systems.

32 patients with mean follow-up of 7 (2–12_ years. Mean age at the time of follow-up was 9 (range 2.7 – 15) years. In our series, 15 patients received non-operative and 17 patients received operative treatment. On ASK, conservatively treated hips scored 72% and surgically treated hips scored 69%. (P-Value = > 0.05). On SF36 v2, mean value of physical function score (PFS) for both non-operative and operative group were 57.58 respectively (P Value > 0.05). Centre edge angle (CEA) of non-operative and operative group were compared with their contra-lateral normal sides (P Value > 0.05). According to Severin classification system, 7 hips were grade I, 8 were grade II in the non operative group and in operative group, 10 were grade II, 5 were grade III and 2 were grade IV. There were no major complications and only one (3%) hip developed avascular necrosis of hip.

On a medium term follow-up, despite some radiological abnormalities, most of the patients achieved good functional results following both non-operative treatments for late presenting DDH. There was no statistically significant difference in the development of hips either treated conservatively or surgically. Long term follow up studies are required in order to establish the true outcome of late presenting DDH treated either conservatively or surgically.

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Aim. was to analyze infections after bone tumour surgery. Method. 1463 patients treated from 1976 to 2007 were analized: 1036 with resection and prostheses in the lower limbs, 344 with resection and prostheses in the upper limbs, 83 with surgery for sacral tumours. Infections were analyzed for time of occurrence (“postoperative” in the first 4 weeks from surgery, “early” within 6 months, and “late” after 6 months), microbic agents, treatment, outcome. Results. In lower limbs, infections occurred in 80 cases (7.7%): generally monomicrobial, caused by gram positives, postoperative in 9, early in 12, late in 59 cases. Treatment was “two stage” in 73, “one stage” in 4, primary amputation in 3. Revisions for infection were successful in 63 patients (79%), while 17 patients were amputated (21%). In upper limbs, infections occurred in 20 cases (5.8%): generally monomicrobial, caused by gram positives (88.5%), postoperative in 2 cases, early in 7, late in 11. “Two stage” treatment was attempted in all cases, but only in 3 prosthesis was re-implanted, since the cement spacer yelded similar function. No infections were observed in 28 intralesional excisions of sacral giant cell tumours. Infection occurred in 23/52 resected sacral tumours (44%) (Three patients died postoperatively were excluded from this group): postoperative in 16 cases and early in 7, caused by gram negatives in 62% and multimicrobial in 74%. Surgical debridements associated with antibiotic therapy according to coltures cured infection in all cases. Conclusion. Infection is a severe complication in orthopedic oncology. Its incidence in the extremities (7.7% and 5.8%) is lower than after sacral surgery (44%). It is influenced by chemotherapy and by the presence of foreign bodies. Infections were mostly late, monomicrobial, gram positive in extremities, while early, multimicrobial and gram negative in sacral surgery

Aims

Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation.

CECS is an exercised induced condition that causes pain, typically in the lower limbs, and is relieved by rest. It is often seen in military personnel significantly restricting their duties. Conservative treatment is rarely successful and patients often require surgical decompression by fasciotomy or fasciectomy. All IMP (intramuscular pressure) tests (n=286) carried out between December 2007 and October 2010 on patients with suspected CECS in the anterior compartment of the lower leg were reviewed. The treatment and outcomes of those referred for surgery were analysed. Pre- and post-surgery military medical grading for leg function was extracted from the medical records system. Independent t-tests compared differences between patients that had surgery or did not. The Wilcoxon signed-rank test compared grades before and after surgery. According to the diagnostic criterion, 80% of patients undergoing IMP testing had CECS. Of these, 179 (68%) patients underwent surgery, 17 (9%) of these were for recurrent symptoms. Almost all decompressions were bilateral (95%). The majority of operations (121) were fasciectomies of the anterior compartment only and were performed by 2 surgeons. The remaining operations (58) were performed by 6 surgeons and were fasciotomies of both anterior and lateral compartments. The mean time from testing to surgery was 24 (median 11) weeks. There were 23 (13%) complications other than recurrence including 16 wound infections, 6 seromas and 1 haematoma. Pre- and post-surgery grading was available for 67% of patients. These patients had significantly better leg function after surgery (Z=−3.67, p<0.001). Of these, 47% improved, 38% showed no improvement and 15% had a poorer outcome had. Those who had a fasciectomy were significantly more likely to improve than those who had a fasciotomy (p=0.023, rho=−1.96). Our results demonstrate that patients generally improve lower limb function following surgical decompression. However, 53% showed no improvement or deteriorated in their medical grading. In addition, there is a high diagnosis rate for CECS following IMP measurement. This may reflect the poor validity of the diagnostic criterion or this could be due to good clinical selection for testing. Furthermore, fasciectomy shows a greater correlation with improved outcome than fasciotomy. There is a need to develop more accurate diagnostic criteria and to evaluate the benefits of standardising surgical technique

Purpose: Aim of this study was to analyse the incidence of infection in orthopaedic oncology after major surgical procedures for bone tumors. Materials and Methods: We included patients with primary sacral tumors treated by major surgical procedure and patients with bone tumors of the upper and lower limb treated by resection and prosthetic reconstruction. Demographic data, surgery, adjuvant treatments, type of reconstruction were analyzed. Special attention was given to the infection: incidence, classification, microbic agents, treatment and outcome. Infections in the first 4 weeks were considered “postoperative”, those in the first 6 months were judged “early”, while “late” those diagnosed after 6 months. Overall 1462 patients treated in one institution from 1076 to 2007. Were considered 1036 patients with tumors of the lower limb, 344 patients with tumors of the upper limb and 82 sacral tumors. Univariate analysis with Kaplan-Meier actuarial curves was used in evaluating risk factors and implant survival to infections. Results: In the lower limb, infection occurred in 80 cases (7.7%). Most frequent bacteria were gram positive. Infection was postoperative in 9 cases, early in 12, late in 59 cases and generally monomicrobial. Surgical treatment was “two stage” in 73 patients, “one stage” in 4 and primary amputation in 3 cases. Revisions for infection were successful in 63 pts (79%), while 17 pts were amputated (21%). In the upper limb, in 20 patients (5.8%) a revision for deep infection was required. Two infections were postoperative, 7 early and 11 late. S. Epidermidis and S. Aureo were the most frequent bacteria causing infection (45%). “Two stage” treatment of infection was performed, but a new prostheses was implanted in 3 cases. In 17 the spacer was never removed. In the sacrum, no deep infections were observed after intralesional excision for giant cell tumors. In 23/52 resections (44%) for chordoma (3 pts. died postoperatively and were excluded), infection occurred: in 16 patients postoperatively, in 7 within 6 months. Bacteria causing infection were mostly gram negative: in 74% of cases infection was multiagent. Surgical treatment consisted in one or more surgical debridements with antibiotics therapy according to coltures: infection healed in all cases. Conclusion: Infection is a severe complication in prosthetic reconstructions for tumors of the upper and lower limb. Its incidence in the extremities (7.7% and 5.8%) is lower than after sacral surgery (44%). Infections are mostly late, monomicrobial and caused by gram positive in extremities, while early, multimicrobial and caused by gram negative in the sacrum

The treatment of peri-prosthetic joint infection (PJI) of the ankle is not standardised. It is not clear whether an algorithm developed for hip and knee PJI can be used in the management of PJI of the ankle. We evaluated the outcome, at two or more years post-operatively, in 34 patients with PJI of the ankle, identified from a cohort of 511 patients who had undergone total ankle replacement. Their median age was 62.1 years (53.3 to 68.2), and 20 patients were women. Infection was exogenous in 28 (82.4%) and haematogenous in six (17.6%); 19 (55.9%) were acute infections and 15 (44.1%) chronic. Staphylococci were the cause of 24 infections (70.6%). Surgery with retention of one or both components was undertaken in 21 patients (61.8%), both components were replaced in ten (29.4%), and arthrodesis was undertaken in three (8.8%). An infection-free outcome with satisfactory function of the ankle was obtained in 23 patients (67.6%). The best rate of cure followed the exchange of both components (9/10, 90%). In the 21 patients in whom one or both components were retained, four had a relapse of the same infecting organism and three had an infection with another organism. Hence the rate of cure was 66.7% (14 of 21). In these 21 patients, we compared the treatment given to an algorithm developed for the treatment of PJI of the knee and hip. In 17 (80.9%) patients, treatment was not according to the algorithm. Most (11 of 17) had only one criterion against retention of one or both components. In all, ten of 11 patients with severe soft-tissue compromise as a single criterion had a relapse-free survival. We propose that the treatment concept for PJI of the ankle requires adaptation of the grading of quality of the soft tissues.

Cite this article: Bone Joint J 2014;96-B:772–7.

Purpose of the study

To review the primary bone tumours of the spine treated at our unit.

Liposarcomas (LPS) are the most common soft tissue malignant tumor with a reported annual incidence of 2.5 per million people. The latest histopathologic classification of liposarcomas identifies three main groups: well-differentiated LPS; myxoid-round cell LPS; pleomorphic LPS. Dedifferentiated LPS is considered as a subgroup of well-differentiated LPS where there is an area of transition from a low grade to a high grade non lipogenic lesion (typically MFH or fibrosarcoma). The purpose of the present study was a retrospective review of the data of 146 consecutive patients affected by liposarcoma, with the aim to correlate the outcome of patients with treatment modalities and prognostic factors.

There were 89 males and 57 females with an average age of 54 years (range 16–92). The tumor grading following Broders criteria showed a low grade lesion in 48% of cases and a high grade lesion in 52% of cases. The histologic pattern showed a well differentiated liposarcoma in 25 patients (17%). The most frequent histologic finding was a myxoid liposarcoma in 55 cases (38%) while a round cell component of variable rate was seen in 22 cases (15%). A pleomorphic LPS was observed in 32 cases (22%). Dedifferentiated liposarcoma occurred only in 3 cases (2%). Surgery alone was performed in 31% of cases while chemotherapy (adriamycin and ifosfamide) and/or radiationtherapy were associated in 69% of cases. Brachytherapy was performed in 50 cases. Surgical margins resulted radical in 4 (2.5%) of cases, wide in 89 (61%), marginal in 45 (31%) and intralesional in 8 (5.5%) of cases.

In 10 cases (6.8%) a local recurrence occurred and in 33 cases (22.6%) a metastatic lesion was observed. Local recurrence were treated with surgical excision in 7 cases and with amputation in 3 cases. At an average follow up of 55 months, 68.5% of patients were continuosly disease free, 6.8% were disease free after local recurrence or metastasis excision or both, 4.8% were alive with disease, 14.4% were dead of the disease, 5.5% were dead of other cause. Eleven patients (7%) underwent an amputation, in 5 cases as first surgical procedure, in 3 cases after a local recurrence and in 3 cases for complications of the radiationtherapy. Local control was significantly correlated with the type of surgery at presentation and with surgical margins. Overall survival was significantly correlated with surgical margins, with grading and with the histotype of the tumor.

In the present series of soft tissue liposarcoma the combined treatment allowed limb salvage in 93% of cases (7% of amputations). Virgin lesions at presentation and free surgical margins resulted positive prognostic factors for local control. The histotype of the tumor, grading, and surgical margins resulted significative prognostic factors in survival, with round-cell and pleomorphic and high grade lesions showing the worse prognosis.