Introduction

Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation

Introduction

The purpose of this research is to compare the quality of life in children during gradual deformity correction using external fixators with intramedullary lengthening nails.

Background

Inpatient physiotherapy is routinely provided after total knee replacement (TKR) surgery to enhance recovery prior to discharge. However, the provision of outpatient physiotherapy is variable in the UK, and the longer-term benefits of outpatient physiotherapy are unclear. This study aimed to evaluate the feasibility of conducting a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of group-based outpatient physiotherapy after TKR.

Background

There is a paucity of long term data concerning the pre and postoperative patient reported function of total knee replacement. The aim of this study was to determine the mortality, implant survivorship, patient reported function and satisfaction in a cohort of 114 patients, from a single centre, who received a Kinemax total knee replacement more than 15 years ago.

The technique of Matrix Induced Autologous Chondrocyte Transplantation (MACI) is well established with satisfactory outcomes up to five years in the knee. Fewer series describe the outcomes of this technique in the ankle. We present the functional outcomes of the technique for a single surgeon series in a general hospital setting.

Twenty-seven patients, mean age 41, were reviewed at 3.7 (range, 1 to 5) years. Patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scale, Tegener activity score and University of California lower extremity activity scale. MRI findings were also reviewed.

While most patients report a significant improvement in symptoms with full return to activities of daily living, 36% of those under 40 and 78% of those over 40 reported restricted recreational activity. Of the patients under 40 years of age, 86% were able to run compared with 23% of those over 40. Of patients over 40, 64% continued to have moderate or severe pain.

Careful preoperative counselling is required for patients of all ages regarding likely outcomes. In patients over 40 the procedure is unlikely to give good pain relief and alternative options should be considered.

Heterotopic ossification is a recognised complication of surgery on the hip joint that can adversely affect the outcome. The aim of this study was to determine the incidence of heterotopic ossification following surgical hip dislocation and debridement for femoro-acetabular impingement using Ganz trochanteric flip osteotomy approach. We also compared the incidence of heterotopic ossification between two subgroups of patients; in the first group, a shaver burr was used to reshape the femoral head and in the second group, an osteotome was used.

Methods: We reviewed postoperative radiographs of all patients who underwent surgical hip dislocation and debridement during the period between March 2003 and July 2007. We excluded patients with radiographic follow-up of less than one year. Brooker classification was used to grade heterotopic ossifications.

Results: Ninety eight patients (mean age 35 years, range 12–65 years) were included with a mean radiological follow-up of 23 months (range 12–61 months). The overall incidence of heterotopic ossification was 31%. None of the patients developed Brooker grade III or IV heterotopic ossifications. The incidence of heterotopic ossifications in the shaver burr group (n=57) and in the osteotome group (n=41) was 30% and 32%, respectively.

Conclusions: Heterotopic ossification of minor grade is a common complication of surgical hip dislocation using trochanteric flip osteotomy approach. The use of a shaver burr did not result in higher rates of heterotopic ossifications despite the formation of large amounts bone debris.

The aim of Femoro-Acetabular Impingement (FAI) surgery is to improve femoral head-neck clearance by resection of the osseous bump deformity. The purpose of this study was to investigate whether osseous bumps will re-grow and to compare two instruments used for resection osteoplasty; a shaver burr and an osteotome.

We reviewed records of patients who underwent surgical hip dislocation and debridement via Ganz flip osteotomy between March 2003 and July 2007. We excluded patients with less than one-year radiographic follow-up.

Ninety-five patients (95) underwent 98 surgical hip dislocations and were included (mean radiological follow-up 23 months, range 12–61 months). Bump re-growth occurred in 16 cases (16%). Pre and postoperative Non-Arthritic Hip Scores (NAHS) were available for 12 of the 16 patients. The mean pre- and postoperative NAHS were 62 (range 26–95) and 83 (range 41–104) respectively (p= 0.02). In the shaver burr group (n=57), there were 6 cases of bump re-growth (12%) compared to 10 cases in the osteotome group (n=41) (32%).

In this study, recurrence of osseous bumps did not affect the outcome. Using shaver burrs resulted in lower rates of bump re-growth than using osteotomes. This could be related to heat osteonecrosis at the femoral head-neck junction.

We report a 10% failure rate for aseptic loosening and overall revision rate of 15% at 5 years mean follow up in 190 patients using the Cormet 2000 Dual coat ace-tabular component.

Between April 2001 and March 2004, this cup was used in our region by 4 surgeons. It was peripherally expanded and comprised a cobalt chrome shell, plasma sprayed with a further layer of cobalt chrome which was then coated with hydroxyapatite. This backing has since been abandoned in favour of a titanium plasma coat beneath the hydroxyapatite because of a higher than expected incidence of early loosening.

There were 190 cups implanted in 174 patients, 142 with resurfacing heads. The average age was 54 and 99 were male.

Revision for aseptic loosening was required in 20 cups (10%) at a mean interval of 23 months including five within 2 months, Of the early revisions three developed a deep infection. Undiagnosed groin pain in four further patients appeared at revision to arise from an inflamed bursa secondary to impingement of psoas tendon on the rim of the cup. There was one primary infection, one infection following revision of a trochanteric osteotomy and two neck fractures. Persistent unexplained groin pain was seen in three patients who have declined further surgery

Failure of this backing to integrate with bone led to an unacceptably high early loosening rate. Positioning of the larger resurfacing cups is critical to avoid painful irritation of psoas. Early revision carries a high risk of infection.

Between January 2003 and December 2004, 14 patients underwent bilateral resurfacing arthroplasty via a Ganz trochanteric osteotomy. This bilateral group was mobilised fully weight-bearing with crutches. During the same period 139 Ganz trochanteric osteotomies were performed for unilateral hip resurfacing. These patients were mobilised with crutches, weight-bearing up to 10 kg on the operated leg.

Nine osteotomies (32%) in the bilateral group subsequently developed a symptomatic non union requiring revision of fixation. This compares with 10 patients (7%) in the unilateral group. Applying the Fisher’s exact test, the difference reached significance (p=0.0004). In 2 patients a second revision was required to achieve union. In 1 patient, revision of trochanteric fixation precipitated a deep infection.

Protected weight-bearing following a Ganz trochanteric osteotomy is important to the success of the procedure. Simultaneous bilateral hip arthroplasty through a Ganz approach should be avoided. If it is undertaken, we recommend that patients should be non weight-bearing for 6 weeks following surgery. Non union following a Ganz trochanteric osteotomy for arthroplasty carries a significant morbidity.

Collecting outcome scores in paper form is fraught with difficulty. We have assessed the feasibility of and patient’s attitude towards entering scores using a touchscreen.

A touchscreen was installed in the orthopaedic outpatient clinic. If relevant, patients were asked to complete either an Oswestry Disability Index (ODI) or Oxford Shoulder Score (OSS) using the screen. Patients were given written instructions and their hospital number by the receptionist who had no further input. Scores were completed with two identifiers. A paper questionnaire was used to assess computer experience and attitude towards the touchscreen.

Results: 1377 patients, average age 51 successfully completed a score in the first 12 months. 1/3 were over 60. 93% correctly entered their hospital number and date of birth, falling to 85% in patients over 70. All patients were identifiable. The average time to complete the scores was 4 minutes rising with age.

Of 170 patients completing the questionnaire, 1/3 had little or no experience of computers and 1/3 were over 60. 93% of patients were willing to repeat the score using the touchscreen to monitor progress. 2/3 found it easier to use than expected. Only 10% would prefer a paper score. These results were maintained among patients over 60. Only 2 were unable to complete the score and 80 % of those potentially eligible did so. The remainder were called to clinic before the touchscreen was free.

Conclusion: Orthopaedic outcome scores can be collected in very large volumes using a touchscreen. Data is then in an immediately usable form. The method is acceptable to the patients, independent of age and computer experience. Even in the oldest patients the accuracy is higher than for paper versions of the score. Combined with operative data, this simple method has the potential to provide a very powerful audit tool indeed.

The long-term survival of total knee arthroplasty (TKA) has been well established; however, functional outcome remains inconsistent. More normal postoperative TKA kinematics have been shown to produce better knee function. Improved kinematics can be obtained by using implants with optimised surface geometry. Hence a TKA with an appropriate surface geometryis likely to provide superior long-term functional outcome. The Advance-Medial Pivot TKA (Wright Medical) is a fixed bearing prosthesis with a conforming medial compartment and a non-conforming (flat on flat) lateral compartment. This surface geometry is designed with the intention of replicating the normal knee motion of sliding or pivoting medially and rolling back laterally.

Aim: To investigate the sagittal plane kinematics of Advanced Medial Pivot Knee and compare with those of “flat on flat” fixed bearing TKA and normal knees

18 patients who had undergone primary TKA for osteoarthritis were recruited at an average of 18 months post operation. These patients performed flexion and extension exercises against gravity and a step up exercise. Video fluoroscopy of these activities was used to obtain the patellar tendon angle (PTA). This is a previously validated method for assessing sagittal plane kinematics of a knee joint. The kinematic profile of the Advance Medial Pivot Knee was compared to the profile of 14 normal knees and 30 flat on flat, fixed bearing TKA’s.

The sagittal plane kinematics of the Advance TKA differed from the normal knees. However, similarly to normal knees, a linear relationship was observed between PTA and knee flexion angle throughout knee flexion range. The kinematics of the Medial Pivot Knee were similar to normal when the knee was in a highly flexed position.

Functional plane kinematics of the Advance Medial Pivot TKA appear to meet the design criteria in that a linear relationship between PTA and flexion angle is maintained. Further work is required to establish if these improved sagittal plane kinematics translate into improved functional outcome.

Study Design: Prospective Cohort Study.

Summary of Background Data: It has previously been suggested that fulcrum bending radiographs (Cheung et al Luk 1997) and traction radiography under anaesthetic (Davis et al 2003) predict the flexibility and correction obtained following surgery better than conventional supine bending radiographs.

Objective: To compare fulcrum bending radiographs and traction radiographs for the prediction of surgical correction of idiopathic scoliosis.

Subjects: The study was based on 16 patients with a diagnosis of idiopathic scoliosis who underwent corrective surgery.

Outcome measures: The Cobb angle of the major curve was compared on the standing AP and fulcrum bending radiograph taken in the pre-op assessment clinic, the traction film undertaken under anaesthetic immediately prior to surgery and the first post operative standing radiograph taken. The post operative correction of the major curve was analysed using regression techniques and adjusted for the base line curve angle of the major curve.

Results: The results were presented as an estimate of the parameter coefficient in the model associated with 95% confidence intervals. The median pre-operative Cobb angle of the major curve was 69 degrees, on the fulcrum bending film was 47 degrees, on the traction film was 30 degrees, and on the first post operative film was 30 degrees. There was no evidence to suggest that the fulcrum Cobb had an effect on the post operative correction of the major curve. There was however evidence to suggest that the traction Cobb angle had an effect on the post operative correction of the major curve (parameter estimate 0.87) 95% CI (0.174, 1.399), T value = 2.83, P = 0.016.

Conclusion: Traction radiographs under anaesthetic better predict the surgical correction obtained in adolescent idiopathic scoliosis compared to fulcrum bending radiographs. These two techniques have not been directly compared before.

Surgical outcome has been linked to frequency of the surgical procedure with increased complications among surgeons with low volume. Shoulder arthroplasty is a relatively low volume procedure compared to hip or knee replacement. A recent papers has shown that in 1999 only 3% of surgeons perform 10 or more shoulder arthroplasties in New York State (Hasan SS et al). We postulated that the situation in England and Wales may be similar and examined data on frequency for shoulder hip and knee arthroplasty.

Hospital Episode Statistics(HES) data for the year April 2002 to April 2003 was analysed for Total hip replacement, Elbow replacement and Total and Hemi- shoulder arthroplasty. Consultant codes were matched for surgical codes for the procedures.

338 (61%) of surgeons doing shoulder arthroplasty performed 2 or less procedures during the study year. 13 surgeons (2.4%) performed more than 20 shoulder arthroplasties. This contrasted with shoulder and knee arthroplasty where volumes per consultant were higher (vide infra).

The majority of surgeons who performed shoulder arthroplasty during the year 2002/2003 did 2 procedures or less. The authors raise concern about the outcome of surgery among surgeons with such low volumes.