We report the case of a 13-year-old obese child presenting with bilateral stable slipped capital femoral epiphyses, which were managed by percutaneous single screw fixation
The ABG I cementless hip prosthesis has demonstrated unacceptably high rates of wear and osteolysis in our patients. We performed a retrospective study of 97 hips implanted between 1992 and 1998. Radiographic analysis revealed high rates of wear of the polyethylene liner with marked periacetabular osteolysis. Clinical examination indicated that many of these patients were initially asymptomatic. Wear-related problems have required ten hips to be revised and a furher 13 are awaiting revision. This gives a failure rate of 24% at a mean follow-up of 69 months. Contributing factors are likely to include poor wear characteristics of the polyethylene liners which were gamma irradiated in air, and increased wear debris caused by a poor fit of the polyethylene liner within the shell. We believe that all ABG I implants should be immediately reviewed and remain under careful, long-term follow-up.
We found the ABG cementless hip has excessive acetabular wear and premature failure due to osteolysis. In 60 patients implanted at mean age 56 years, 66 hips (mean follow up 48 months), 7 were revised and 7 have severe acetabular osteolysis. In some this is entirely asymptomatic. There was significant association with osteolysis, length of follow up and wear but no correlation between wear and acetabular component position, age, liner thickness, and use of ceramic or CoCr heads. We recommend regular lifelong radiological review of these hips and suspension of use of this prosthesis until a wider review is undertaken.
We wished to determine the most accurate and reliable technique for insertion of tibial prostheses, with tibial resection guided by either intramedullary (IM) or extramedullary (EM) alignment jigs. 135 consecutive AGC cemented total knee replacements in 126 patients in a single unit were performed by, or directly supervised by, four consultant surgeons. Ethical approval and patient consent was obtained. Intramedullary alignment was used for the femoral cuts and patients were randomised at the time of operation to have either IM or EM guides for resection of the proximal tibia, cut with a zero degree posterior slope in both. The protocol only entered patients into the trial if their knees were suitable for use with both IM and EM tibial alignment although, in the event, no patients were excluded. Long leg radiographs (standing hip to ankle) were taken by a standardised method three months after the surgery. A blinded assessor, unaware of the alignment method used, evaluated acceptable films and measured tibial component alignment. The proportion of tibial prostheses aligned within two degrees of 90 was the endpoint of the study. Of the 135 knees 100 suitable x-rays were assessed. Correct tibial alignment was more likely in the IM group (85%) than the EM group (65%), p=0. 019. Though mean alignment was similar, variation (standard deviation) was less in the IM group (2. 0 vv 2. 2). In the AGC knee, intramedullary alignment guides are superior to extramedullary guides for alignment of the tibial prosthesis. We recommend the routine use of intramedullary tibial alignment.
The aim of this study was to evaluate the morbidity associated with carpal tunnel syndrome and the outcome following surgical treatment using the Nottingham Health Profile (NHP). Between 1994 and 1996 we performed a prospective study of the effect of carpal tunnel release on the health status of 96 patients. The Nottingham Health Profile, a validated generic scoring system was used to assess quality of life, before and after surgery. 96 patients with 103 symptomatic hands were studied over this two year period. The patients completed a questionnaire before and 4 months after surgery. The notes were reviewed by an independent assessor and data collected with regard to duration and nature of symptoms, associated conditions, patients’ satisfaction and complications. 72 patients were satisfied with the results of surgery and 24patients were dissatisfied despite in the main clinical improvement. There was a significant improvement in the scores for pain, physical mobility and sleep 4 months following surgery in all patients. We observed that those patients with a significantly high pre-op NHP score fared less well than cohorts, developing more frequent complications and overall were more likely to be dissatisfied with the results of surgery. This group of dissatisfied patients had previously been indistinguishable from their cohorts and were as it were invisible. The high NHP scores provided an objective way of identifying this group of individuals. Carpal tunnel syndrome had a notable impact on the health status of our patients. There was a significant improvement in the NHP scores 4 months following surgery. Our findings show that outcome assessment tools have predictive value in identifying patients who may not benefit from surgery or in whom a poor result might be anticipated.
We undertook a prospective, randomised study of 135 total knee arthroplasties to determine the most accurate and reliable technique for alignment of the tibial prosthesis. Tibial resection was guided by either intramedullary or extramedullary alignment jigs. Of the 135 knees, standardised postoperative radiographs suitable for assessment were available in 100. Correct tibial alignment was found in 85% of the intramedullary group compared with 65% of the extramedullary group (p = 0.019). We conclude that intramedullary guides are superior to extramedullary instruments for alignment of the tibial prosthesis.
We report the medium term results using an extensively porous coated cementless femoral stem for revision hip arthroplasty in 129 cases. 166 femoral revisions were performed using the Solution cementless stem between 1991 and 1997 in 4 hospitals within our region. 30 patients had died and 7 were lost to follow up leaving 122 patients ( 129 hips ) available for assessment. All were independently reviewed, questioned about thigh pain, and scored using the Charnley modification of the Postel-D’Aubigne Hip Score. Post operative complications and need for further surgery were noted. Radiographs were assessed to identify component subsidence, osteolysis and stress shielding. At mean 5 year follow up (range 2–8 yrs), 9 stems (7%) had been revised and a further 4 stems (3%) were subsiding. Of the remaining components, 8 stems (7%) showed fibrous union and 108 stems (92%) bone ingrowth. Mild to moderate stress shielding was common but did not seem to affect fixation. Our findings indicate that satisfactory medium term stability can be achieved using diaphyseal fixation in the mechanically or biologically proximally deficient femur. Failure due to subsidence occurs due to undersizing, occurs early and progresses.
Between 1992 and 1994 we performed a prospective study of the effect of total knee replacement (TKR) on the health status of 119 patients over the age of 80 years who had had a primary unilateral TKR. The Nottingham Health Profile was used to assess this before and at three and 12 months after operation. We found a significant improvement in the scores for pain, emotional reaction, sleep and physical mobility at three months. After 12 months, the scores for pain and sleep were well maintained. The other factors had deteriorated slightly but remained better than before operation. Our findings show that TKR leads to a significant improvement in the general health status of the very elderly.
