Aims

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data.

Introduction

A 68 year old female patient underwent a left total hip replacement for primary osteoarthritis in March 2004. She was referred back by her GP 5 years as she was struggling with mobility and felt there were mice in her hip. It was squeking so loudly that it could be hear at a distance of 25 metres. There was no history of any falls or dislocation in the last 5 years. The implant used was an Exeter/ABG ceramic total hip prosthesis with Palacos cement. This ladies discomfort in her hip had been always there. She never described herself as being satisfied with the THR. However, her discomfort had worsened terribly over the last year.

Introduction

Revision surgery is generally recommended for recurrent dislocation following Total hip arthroplasty (THA). However, dislocation following revision THA continues to remain a problem with further dislocation rates upto 28% quoted in literature.

We present early results of one of the largest series in U.K. using dual mobility cemented acetabular cup for recurrent hip dislocation.

Purpose: To present results of a series of patients treated with Trapeziectomy, Ligament Reconstruction and Tendon Interposition for treatment of 1st CMC joint arthritis.

Methods: 59 patients (65 thumbs) from Single surgeons’ practice were prospectively followed by 2 independent observers who did not participate in the study. Patient demographics, occupation, handedness, symptoms and clinical findings were recorded. Objective assessment including pinch and grip strength was carried out by the Occupational therapists. Functional outcome assessment was done using questionnaire designed by senior author. Patients were asked to evaluate the operation using the subjective assessment component of Buck-Gramcko score. Radiographs were studied for Trapezial space and arthroplasty space. Analysis was carried out using SPSS statistical software.

Results: A total of 59 patients at an average age of 62 years were followed up for an average of 25 months. Six patients had bilateral procedures. Average follow up was 3.5 years with minimum follow up being 3 years. Osteoarthritis was the commonest diagnosis accounting for 53 (91%) patients and rheumatoid arthritis in 6 (9%) of patients. 48 cases (82%) were Stage IV and 15 cases (18%) Stage V. Mean duration of symptomsbefore the surgical intervention was 36 months. 3 patients developed superficial wound infection and 4 patients developed reflex sympathetic dystrophy. The results suggested pinch strength and grip strength improved to 50% and 22.5% respectively, as compared to pre-operative value.

Conclusion: Treatment options for 1st CMC joint arthritis have evolved over time. Many prospective randomized studies have shown lack of advantage of LRTI as compared to trapeziectomy alone, but these studies are not free from limitations. The present study is one of the largest reported single surgeon series and benefits from aprospectively maintained database with minimum 3 years follow up. The study rises above the existing limitations in the literature and reinforces concept of Ligament Reconstruction and Tendon Interposition.

Level of Evidence: Level II (Prospective study)

Introduction: Osteoarthritis of thumb CMC joint is a common pathology. Several non-prosthetic surgical options exist. There is abundant literature both in favour of and against combining trapeziectomy with ligament reconstruction and/or tendon interposition (LRTI). This study provides qualitative and quantitative outcomes assessment of a single surgeon series of consecutively operated 65 patients with trapezio-metacarpal joint arthritis using Trapeziectomy with LRTI.

Methods: 50 female and 15 male patients at an average age of 63 at the time of surgery were followed up for a mean of 3 years, 4 months. Radial half of flexor carpi radialis is dissected using a Carroll tendon retriever and passed through a transosseous hole in the thumb metacarpal base to exit on its dorsum. Patients were put in a full below elbow cast for a period of 4 weeks following which hand therapy was instituted. Patients were evaluated using quick DASH score and objective data like thumb opposition, radiographic scaphometacarpal mobility and gap, pinch and grasp strength. All operations were carried out by senior author.

Results: Good to excellent results were obtained in 59 cases with satisfactory opposition. Pinch strength was 4.3 Kg being 1 to 2 Kg less than reference range. Scoring with quick DASH did not decrease with the longevity of follow up. No complications were encountered. No correlation was found between variables like age, sex, dominance, occupation, primary diagnosis, reduced space on follow up radiographs, severity of arthritic changes and final outcome.

Discussion: Present study is one of the largest consecutive single surgeon series reported recently. All efforts were made to eliminate confounding factors like multi surgeons, modifications of technique, different patient populations etc. The study supports the concept of interposition arthroplasty in the treatment of basal joint arthritis of thumb provided strict attention to the details of surgical technique is observed.

Introduction: The C-Stem was introduced in the endeavour to achieve greater stability, improved fixation, minimise subsidence and improve loading of the proximal femur to maintain bone quality and avoid stress shielding. Since promising early results in 2001, no studies including a large patient population from a single surgeon series have been published.

Methods: Health records and imaging modalities of 260 patients, operated between 2001 and 2004 were retrospectively evaluated by 2 independent reviewers. All patients had antero-lateral approach in supine position. Clearing of the calcar was carried out to allow adequate cement mantle proximally and posteromedially. Tip of the stem was allowed to penetrate in to the intramedullary bone block. All patients were followed up regularly with clinical and radiological information being updated.

Results: 90 men and 170 women, 30 bilateral cases were identified. Mean age at the time of surgery was 61.8 years (50–91). Commonest diagnosis was primary OA (56%) followed by secondary OA due to AVN or childhood pathology (30%) and previous trauma. 43 patients had previous operations in the form of failed internal fixation, osteotomy or hemiarthroplasty. Assessment included oxford hip score. Radiographs digitalised on DICOM software were analysed for subsidence (0.7 mm), alignment (94% satisfactory), bone-cement interface changes (35% progressive improvement) and proximal femur stress shielding (2.1%). At the time of final follow up 89% were independently mobile. 4 % thigh pain, 3 revisions for recurrent dislocations, 3 nonfatal and 2 fatal pulmonary embolism. Taking death or revision for any reason as endpoints, 97.8% survivorship was noted using Kaplan-miere analysis.

Discussion: The strength of the study includes large patient population, completeness of follow up and single surgeon series eliminating compounding factors. Bone cement interface improvement was noted in younger patients with high activity level. The study consolidates the soundness of the concept of C-Stem.

Between May 1992 and April 1997, there were 20 452 births in the Blackburn District. In the same period 1107 infants with hip ‘at-risk’ factors were screened prospectively by ultrasound. We recorded the presence of dislocation and dysplasia detected under the age of six months using Graf’s alpha angle. Early dislocation was present in 36 hips (34 dislocatable and 2 irreducible). Of the 36 unstable hips, 30 (83%) were referred as being Ortolani-positive or unstable; 25 (69%) of these had at least one of the risk factors. Only 11 (31%) were identified from the ‘at-risk’ screening programme alone (0.54 per 1000 live births). Eight cases of ‘late’ dislocation presented after the age of six months (0.39 per 1000 live births). The overall rate of dislocation was 2.2 per 1000 live births.

Only 31% of the dislocated hips belonged to a major ‘at-risk’ group. Statistical analysis confirmed that the risk factors had a relatively poor predictive value if used as a screening test for dislocation. In infants referred for doubtful clinical instability, one dislocation was detected for every 11 infants screened (95% confidence interval (CI) 8 to 17) whereas in infants referred because of the presence of any of the major ‘at-risk’ factors the rate was one in 75 (95% CI 42 to 149).

Routine ultrasound screening of the ‘at-risk’ groups on their own is of little value in significantly reducing the rate of ‘late’ dislocation in DDH, but screening clinically unstable hips alone or associated with ‘at-risk’ factors has a high rate of detection.