Abstract

Shoulder replacements have evolved and current 4th generation implants allow intraoperative flexibility to perform anatomic, reverse, trauma, and revision shoulder arthroplasty. Despite high success rates with shoulder arthroplasty, complication rates high as 10–15% have been reported and progressive glenoid loosening remains a concern.

Abstract

Aim

To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain.

Introduction: Nonunion is a relatively common complication seen in orthopaedic practice. The treatment of nonunion has traditionally been revision fixation with autogenic bone grafting. Here we present our results of nonunion treatment using Osteogenic Protein -1 (OP1) and allograft paste.

Material and Methods: Forty Eight Patients with resistant nonunion including atropic, hypertrophic and infected nonunion were treated with a composite of osteogenic protein-1 and allograft paste. The series consisted of 28 males and twenty females. Average age was 54 years. The average duration of preoperative symptoms was 26 months (range 4 to 52). 28 of 48 patients had an average of three prior failed surgical attempts at union (range 1 to 6). There were thirty seven atrophic, four hypertrophic and seven infected nonunions (bone transport docking site nonunion).18 patients in the series had previous autogenic cancellous bone grafting to the fracture site for attempted union. 39 patients had revision internal fixation with application of OP-1 and allograft paste to the nonunion site. Average healing time was 6.5 months (Range 3.5–19). Three patients in this series had OP-1 insertion twice, one patient simultaneously had autogenic cancellous bone grafting with OP-1.

Results: Average follow-up was 16 months (range 4 to 38). Functional and radiological outcome was excellent in 33 patients, good in five patients and fair in three. 3 cases were ongoing. Three patients went on to non-union requiring revision surgery and are under review. One patient died during follow-up.

Conclusion: Results in our series indicate OP-1 (BMP-7) implanted with Opteform allograft paste are as effective as autogenic cancellous bone grafting in treating resistant bone nonunions.

Introduction: The Taylor spatial frame (TSF) (Smith & Nephew) is a hexapod ring fixator that utilises the Ilizarov principles. The TSFs design is based on the Stewart-Gough platform, the use of which was originally described in mechanical engineering. Due to its unique design the TSF is extremely versatile in limb reconstruction surgery, allowing six degrees of freedom bone fragment manipulation with a high degree of precision that is aided by correction planning software.

Methods: Between October 2003 and December 2008 66 consecutive patients were treated using the TSF by a single consultant surgeon. Median patient age was 45 (range 20–69). The original pathology included 18 mal-unions, 13 acute fractures, 10 medial compartment osteoarthritis (OA) of the knee with varus deformity, 8 infected nonunions, 7 limb length discrepancies, 5 nonunions, 3 ankle OA, 3 post traumatic posterolateral corner of the knee instability, 1 multiple epiphyseal dysplasia, 1 lateral compartment OA of the knee with valgus deformity, 1 deformity secondary to Polio. There were 10 ankles, 19 knees (1 femur, 18 tibiae) and 37 tibiae.

Results: The procedures performed were 16 high tibial osteotomies, 2 frame assisted platings, 8 bone transports, 32 deformity corrections, 14 Ankle arthrodesis (9 primary, 5 revision after nonunion), 9 limb lengthening and 1 derotation. The median bone transport distance and lengthening achieved is reported.

The median time spent in the frame was 21 weeks (range 9–81), including 8 patients who required 2 frames to complete their treatment.

54 cases had a satisfactory outcome in terms of union and deformity correction using only the TSF, 5 cases were ongoing. Complications included 1 below knee amputation, 2 docking site nonunions requiring ORIF, 2 nonunions after ankle arthrodesis requiring T2 nails. 2 frames were removed due to compliance issues. 2 patients developed deformity requiring Tendo-achilles lengthening. There were 2 DVTs and 2 non-fatal PEs. 1 patient suffered a fracture at a femoral pin-site after TSF removal which was treated with external fixation. The median Otterburn grade of pin-site infection was 2 (range 0–4).

Conclusion: The Taylor spatial frame was used successfully in several different pathologies ranging from acute trauma to chronic deformity. The TSF provides the surgeon with a reliable treatment strategy that is both versatile and accurate.

Introduction: The treatment of isolated medial compartment osteoarthritis (OA) in the young or physically active patient is a challenging problem for the orthopaedic surgeon.

The rationale for high tibial osteotomy (HTO) in medial compartment OA with varus deformity is to correct varus malalignment and to redistribute load to the non-diseased lateral compartment of the knee. Here we present our early to mid-term clinical and radiological findings.

Methods: Between October 2005 and April 2007 9 patients underwent HTO and TSF application. Pre-operative OA grade was recorded using the Ahlbäck classification. Radiographs were used to calculate the pre and post operative measurements for the tibiofemoral angle, the mechanical axis deviation and the tibial slope. Correction planning was carried out using the Spatialframe software package. All operations were performed by a single experienced consultant orthopaedic surgeon specialising in Ilizarov and limb reconstruction surgery. Pre and post-operative Oxford knee scores were collected for each patient.

Results: Median follow-up was 19 months (range 15–35). Median age at operation was 49 years (range 37–59). On preoperative radiographic examination eight knees were Ahlbäck grade 1 and one knee was Ahlbäck grade 2. The median time spent in the frame was 18 weeks (range 12–37). The median total angle of correction according to correction program given was 14 degrees (range 10–22) and the median duration of correction was 18 days (range 14–36) with 6 patients requiring an additional correction program.

2 patients subsequently underwent matrix induced autologous chondrocyte implant (MACI) for osteochondral defects.

In the primary OA group we found an improvement in mean Oxford knee score after HTO from 28.3 to 37.8/48 post-operatively. 1 patient was non-compliant with the correction and required a total knee replacement (TKR) for continued pain at 36 weeks post frame removal. 1 patient required fibular osteotomy during their correction.

6 (67%) of the 9 patients had a documented pin site infection. The median Otterburn grade was 3 (range 0–4). There were no cases of chronic bone infection.

Conclusions: High tibial osteotomy performed with the Taylor spatial frame presents a viable treatment option in active patients with early medial compartment OA. With TKR as an end point the survival rate of HTO for treatment of OA was 88.9% at a median of 19 months follow-up. Our results also indicate successful use of the technique in combination with MACI.

Aim: To determine the effectiveness of therapeutic lumbar facet joint injections in patients with chronic low back pain.

Methods: Eighty-six patients with refractory chronic low back pain were randomly assigned to receive facet joint injection using local anaesthetic and corticosteroid suspension under fluoroscopic guidance after clinical and radiological assessment. The main parameter for the success or failure of this treatment was the relief of the pain. Pain intensity was assessed with a visual analog scale (VAS) and changes in function and quality of life were assessed by the revised Oswestry Disability Questionnaire (ODQ) at baseline and during follow-up after injection.

Results: Patients reported lasting pain relief, better function, and improved quality of life following injection. Cumulative significant relief following injection was 91.9% up to 1 to 3 months, 81% for 4 to 6 months, 34% for 7 to 12 months, and 10% after 12 months, with a mean relief of 6.5 +/− 0.76 months. There was significant improvement noted in overall health status with improvement not only in pain relief, but also with physical, functional, and psychological status, as well as return-to-work status. No complications were noted following injection.

Conclusion: The results of this study demonstrate that intra-articular facet joint injection appear to have a beneficial medium-term effect in patients with chronic lower back pain and may therefore be a reasonable adjunct to non-operative treatment.