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The Bone & Joint Journal
Vol. 106-B, Issue 8 | Pages 764 - 774
1 Aug 2024
Rivera RJ Karasavvidis T Pagan C Haffner R Ast MP Vigdorchik JM Debbi EM

Aims. Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient’s functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA. Methods. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests. Results. A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered. Conclusion. The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation. Cite this article: Bone Joint J 2024;106-B(8):764–774


The Bone & Joint Journal
Vol. 106-B, Issue 2 | Pages 128 - 135
1 Feb 2024
Jenkinson MRJ Cheung TCC Witt J Hutt JRB

Aims

The aim of this study is to evaluate whether acetabular retroversion (AR) represents a structural anatomical abnormality of the pelvis or is a functional phenomenon of pelvic positioning in the sagittal plane, and to what extent the changes that result from patient-specific functional position affect the extent of AR.

Methods

A comparative radiological study of 19 patients (38 hips) with AR were compared with a control group of 30 asymptomatic patients (60 hips). CT scans were corrected for rotation in the axial and coronal planes, and the sagittal plane was then aligned to the anterior pelvic plane. External rotation of the hemipelvis was assessed using the superior iliac wing and inferior iliac wing angles as well as quadrilateral plate angles, and correlated with cranial and central acetabular version. Sagittal anatomical parameters were also measured and correlated to version measurements. In 12 AR patients (24 hips), the axial measurements were repeated after matching sagittal pelvic rotation with standing and supine anteroposterior radiographs.


The Bone & Joint Journal
Vol. 106-B, Issue 2 | Pages 182 - 188
1 Feb 2024
Gallego JA Rotman D Watts AC

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

Methods

An independent retrospective review was conducted of a consecutive series of 21 patients with longitudinal instability injuries treated with anatomical central band reconstruction between February 2011 and July 2019. Patients with less than 12 months’ follow-up or who were treated acutely were excluded, leaving 18 patients in total. Preoperative clinical and radiological assessments were compared with prospectively gathered data using range of motion and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) functional outcome score.


The Bone & Joint Journal
Vol. 104-B, Issue 10 | Pages 1104 - 1109
1 Oct 2022
Hansjee S Giebaly DE Shaarani SR Haddad FS

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients’ performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.

Cite this article: Bone Joint J 2022;104-B(10):1104–1109.


The Bone & Joint Journal
Vol. 102-B, Issue 6 Supple A | Pages 129 - 137
1 Jun 2020
Knowlton CB Lundberg HJ Wimmer MA Jacobs JJ

Aims

A retrospective longitudinal study was conducted to compare directly volumetric wear of retrieved polyethylene inserts to predicted volumetric wear modelled from individual gait mechanics of total knee arthroplasty (TKA) patients.

Methods

In total, 11 retrieved polyethylene tibial inserts were matched with gait analysis testing performed on those patients. Volumetric wear on the articular surfaces was measured using a laser coordinate measure machine and autonomous reconstruction. Knee kinematics and kinetics from individual gait trials drove computational models to calculate medial and lateral tibiofemoral contact paths and forces. Sliding distance along the contact path, normal forces and implantation time were used as inputs to Archard’s equation of wear to predict volumetric wear from gait mechanics. Measured and modelled wear were compared for each component.


The Bone & Joint Journal
Vol. 102-B, Issue 6 Supple A | Pages 123 - 128
1 Jun 2020
Martin JR Geary MB Ransone M Macknet D Fehring K Fehring T

Aims

Aseptic loosening of the tibial component is a frequent cause of failure in primary total knee arthroplasty (TKA). Management options include an isolated tibial revision or full component revision. A full component revision is frequently selected by surgeons unfamiliar with the existing implant or who simply wish to “start again”. This option adds morbidity compared with an isolated tibial revision. While isolated tibial revision has a lower morbidity, it is technically more challenging due to difficulties with exposure and maintaining prosthetic stability. This study was designed to compare these two reconstructive options.

Methods

Patients undergoing revision TKA for isolated aseptic tibial loosening between 2012 and 2017 were identified. Those with revision implants or revised for infection, instability, osteolysis, or femoral component loosening were excluded. A total of 164 patients were included; 88 had an isolated tibial revision and 76 had revision of both components despite only having a loose tibial component. The demographics and clinical and radiological outcomes were recorded.


The Bone & Joint Journal
Vol. 102-B, Issue 5 | Pages 568 - 572
1 May 2020
McDonnell JM Ahern DP Ó Doinn T Gibbons D Rodrigues KN Birch N Butler JS

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal.

There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced.

Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described.

The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery.

Cite this article: Bone Joint J 2020;102-B(5):568–572.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1218 - 1229
1 Oct 2019
Lerch TD Eichelberger P Baur H Schmaranzer F Liechti EF Schwab JM Siebenrock KA Tannast M

Aims

Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT.

Patients and Methods

A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed.


The Bone & Joint Journal
Vol. 101-B, Issue 8 | Pages 902 - 909
1 Aug 2019
Innmann MM Merle C Gotterbarm T Ewerbeck V Beaulé PE Grammatopoulos G

Aims

This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters.

Patients and Methods

A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility.


The Bone & Joint Journal
Vol. 101-B, Issue 6 | Pages 639 - 645
1 Jun 2019
Gelfer Y Wientroub S Hughes K Fontalis A Eastwood DM

Aims

The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse.

Patients and Methods

A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery.


The Bone & Joint Journal
Vol. 100-B, Issue 5 | Pages 559 - 565
1 May 2018
Bartlett JD Lawrence JE Stewart ME Nakano N Khanduja V

Aims

The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research.

Materials and Methods

A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results’ titles, abstracts, and references were examined for relevance.


The Bone & Joint Journal
Vol. 100-B, Issue 4 | Pages 549 - 556
1 Apr 2018
Church C Ge J Hager S Haumont T Lennon N Niiler T Hulbert R Miller F

Aims. The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis. Patients and Methods. A total of 59 young adults with spastic cerebral palsy, with a mean age of 26 years (. sd.  3), were enrolled into the study in which their gait was compared with an evaluation that had taken place a mean of 12 years (. sd.  2) previously. At their visits during adolescence, the children walked with excessive flexion of the knee at initial contact and surgical or therapeutic interventions were not controlled between visits. Results. Based on the change in flexed-knee gait over approximately ten years, improvements were seen in increased Gait Deviation Index (p < 0.001) and decreased flexion of the knee at initial contact (p < 0.001). Greater popliteal angle (p < 0.001), reduced Gross Motor Function Measure section D (p = 0.006), and reduced speed of gait (p = 0.007) suggested a mild decline in function. Quality-of-life measures showed that these patients fell within normal limits compared with typical young adults in areas other than physical function. Conclusion. While some small significant changes were noted, little clinically significant change was seen in function and gait, with gross motor function maintained between adolescence and young adulthood. Cite this article: Bone Joint J 2018;100-B:549–56


The Bone & Joint Journal
Vol. 99-B, Issue 9 | Pages 1140 - 1146
1 Sep 2017
Shoji T Yamasaki T Izumi S Murakami H Mifuji K Sawa M Yasunaga Y Adachi N Ochi M

Aims

Our aim was to evaluate the radiographic characteristics of patients undergoing total hip arthroplasty (THA) for the potential of posterior bony impingement using CT simulations.

Patients and Methods

Virtual CT data from 112 patients who underwent THA were analysed. There were 40 men and 72 women. Their mean age was 59.1 years (41 to 76). Associations between radiographic characteristics and posterior bony impingement and the range of external rotation of the hip were evaluated. In addition, we investigated the effects of pelvic tilt and the neck/shaft angle and femoral offset on posterior bony impingement.


The Bone & Joint Journal
Vol. 97-B, Issue 10 | Pages 1309 - 1315
1 Oct 2015
Price AJ Erturan G Akhtar K Judge A Alvand A Rees JL

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants.

There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05).

ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant.

We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.

Cite this article: Bone Joint J 2015;97-B:1309–15.


The Bone & Joint Journal
Vol. 97-B, Issue 4 | Pages 564 - 571
1 Apr 2015
Tinney A Thomason P Sangeux M Khot A Graham HK

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

Cite this article: Bone Joint J 2015;97-B:564–71.


The Bone & Joint Journal
Vol. 95-B, Issue 8 | Pages 1088 - 1093
1 Aug 2013
Hsu W Lai L Chang H Hsu RW

It has been suggested that extracorporeal shockwave therapy is a safe and effective treatment for pain relief from recalcitrant plantar fasciopathy (PF). However, the changes in gait and associated biomechanical parameters have not been well characterised. We recruited 12 female patients with recalcitrant PF who had a mean age of 59 years (50 to 70) and mean body mass index of 25 kg/m. 2. (22 to 30). The patients reported a mean duration of symptoms of 9.3 months (6 to 15). Shockwave therapy consisting of 1500 impulses (energy flux density 0.26 mJ/mm. 2. ) was applied for three sessions, each three weeks apart. A pain visual analogue scale (VAS) rating, plantar pressure assessment and motion analysis were carried out before and nine weeks after first shock wave therapy. It was demonstrated that patients increased their walking velocity and cadence as well indicating a decrease in pain after shockwave therapy. In the symptomatic foot, the peak contact pressure over the forefoot increased and the contact area over the digits decreased. The total foot impulse also decreased as did stance duration. The duration the centre of pressure remained in the hindfoot increased in the symptomatic foot after shockwave therapy. The differences in centre of pressure trajectory at baseline decreased at final follow-up. In conclusion, shockwave therapy not only decreased the pain VAS rating but also improved the gait parameters of the symptomatic foot in PF patients. Cite this article: Bone Joint J 2013;95-B:1088–93


The Bone & Joint Journal
Vol. 95-B, Issue 2 | Pages 192 - 198
1 Feb 2013
Ackman J Altiok H Flanagan A Peer M Graf A Krzak J Hassani S Eastwood D Harris GF

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%.

There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions.

Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group.

Cite this article: Bone Joint J 2013;95-B:192–8.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 12 | Pages 1586 - 1591
1 Dec 2011
Alvand A Auplish S Khan T Gill HS Rees JL

The aim of this study was to investigate the effect of training on the arthroscopic performance of a group of medical students and to determine whether all students could be trained to competence. Thirty-three medical students with no previous experience of arthroscopy were randomised to a ‘Trained’ or an ‘Untrained’ cohort. They were required to carry out 30 episodes of two simulated arthroscopic tasks (one shoulder and one knee). The primary outcome variable was task success at each episode. Individuals achieved competence when their learning curve stabilised. The secondary outcome was technical dexterity, assessed objectively using a validated motion analysis system. Six subjects in the ‘Untrained’ cohort failed to achieve competence in the shoulder task, compared with one in the ‘Trained’ cohort. During the knee task, two subjects in each cohort failed to achieve competence. Based on the objective motion analysis parameters, the ‘Trained’ cohort performed better on the shoulder task (p < 0.05) but there was no significant difference for the knee task (p > 0.05). . Although specific training improved the arthroscopic performance of novices, there were individuals who could not achieve competence despite focused training.These findings may have an impact on the selection process for trainees and influence individual career choices


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 10 | Pages 1442 - 1448
1 Oct 2010
Thompson N Stebbins J Seniorou M Wainwright AM Newham DJ Theologis TN

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation.

The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups.

We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 9 | Pages 1262 - 1266
1 Sep 2010
Carda S Molteni F Bertoni M Zerbinati P Invernizzi M Cisari C

This study assessed if transfer of the extensor hallucis longus is a valid alternative treatment to split transfer of the tibialis anterior tendon in adult hemiplegic patients without overactivity of the tibialis anterior.

One group of 15 patients had overactivity of tibialis anterior in the swing phase, and underwent the split transfer. A further group of 14 patients had no overactivity of tibialis anterior, and underwent transfer of extensor hallucis longus. All patients had lengthening of the tendo Achillis and tenotomies of the toe flexors. All were evaluated clinically and by three-dimensional gait analysis pre- and at one year after surgery. At this time both groups showed significant reduction of disability in walking. Gait speed, stride length and paretic propulsion had improved significantly in both groups. Dorsiflexion in the swing phase, the step length of the healthy limb and the step width improved in both groups, but only reached statistical significance in the patients with transfer of the extensor hallucis longus. There were no differences between the groups at one year after operation.

When combined with lengthening of the tendo Achillis, transfer of the extensor hallucis longus can be a valid alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot deformity in patients without overactivity of tibialis anterior.